The Efficacy of Restaging Endobronchial Ultrasound in Patients With Non-Small Cell Lung Cancer After Preoperative Therapy

Nasir, Basil S.; Bryant, Ayesha S.; Minnich, Douglas J.; Wei, Ben; Dransfield, Mark T.; Cerfolio, Robert J.

doi:10.1016/j.athoracsur.2014.04.091

Cited by 28 publications

(31 citation statements)

References 15 publications

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“…In addition, a false negative rate has been reported for nearly one quarter of patients undergoing redo mediastinoscopy, emphasizing the need to investigate other possible mediastinal staging modalities [11]. So far, data on the role of endobronchial ultrasonography in the postinduction setting are sparse [8,9]. The procedure is also operator dependent, and may not be universally available across all institutions in the United States.…”

Section: Commentmentioning

confidence: 98%

“…In most patients, however, mediastinoscopy before induction therapy often makes repeat mediastinoscopy hazardous and inaccurate. Endobronchial ultrasonography and nodal fine needle aspiration in this setting are operator dependent and are not universally applicable across institutions [8,9]. Therefore, a noninvasive model predictive of persistent N2 disease may be invaluable in this setting and has significant prognostic value.…”

mentioning

confidence: 98%

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Clinical Predictors of Persistent Mediastinal Nodal Disease After Induction Therapy for Stage IIIA N2 Non-Small Cell Lung Cancer

Kamel

Rahouma

Ghaly

et al. 2017

The Annals of Thoracic Surgery

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Section: Commentmentioning

confidence: 98%

mentioning

confidence: 98%

Clinical Predictors of Persistent Mediastinal Nodal Disease After Induction Therapy for Stage IIIA N2 Non-Small Cell Lung Cancer

Kamel

Rahouma

Ghaly

et al. 2017

The Annals of Thoracic Surgery

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“…This is thought to be attributable to LN necrosis and fibrosis (101)(102)(103)(104). However, the procedure is safe with no complications reported.…”

Section: Ebus-tbna and Med-role In Lung Cancer Diagnosismentioning

confidence: 96%

“…Both Med and EBUS-TBNA have been used for mediastinal restaging (41,(96)(97)(98)(99)(100)(101)(102). However, performance of both Med and EBUS-TBNA in restaging is worse than in original staging.…”

Section: Ebus-tbna and Med-role In Lung Cancer Diagnosismentioning

confidence: 99%

The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer

Czarnecka‐Kujawa¹,

Yasufuku²

2017

J. Thorac. Dis.

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This review provides an update on the current role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and mediastinoscopy (Med) in assessment of patients with non-small cell lung cancer (NSCLC). Invasive mediastinal lymph node (LN) staging is the major application for both of these techniques. Up until recently, Med was the gold standard for invasive mediastinal LN staging in NSCLC. However, EBUS-TBNA has shown to be equivalent, and in some studies better than Med for invasive staging of lung cancer. EBUS-TBNA offers access to N1 LNs and development of the thin convex probe EBUS (TCP-EBUS) will expand EBUS-TBNA access from the paratracheal region and central airways to more distal parabronchial regions allowing for more extensive N1 LN assessment and sampling more distal lung tumors. EBUS-TBNA is more cost-effective than Med and it is currently recommended as the test of first choice for invasive mediastinal LN staging in lung cancer. ConfirmatoryMed should be performed selectively in patients with high pretest probability of metastatic disease. Addition of esophageal ultrasound fine needle aspiration (EUS-FNA) may increase diagnostic yield of EBUS-TBNA mediastinal staging. Both Med and EBUS-TBNA can be used in primary lung cancer diagnosis, restaging of the mediastinum following neoadjuvant therapy and in diagnosis of lung cancer recurrence. In the future, a combination of EBUS-TBNA with or without EUS-FNA and Med is most likely going to provide the most optimal invasive assessment of the mediastinum in patients with lung cancer. The decision on test choice and sequence should be made on a case-by-case basis and factoring in local resources and expertise.

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“…Yet, this requires important forethought when patients undergo initial evaluation and staging, something that is often disregarded. Moreover, since EBUS is both operator dependent and still not universally available nationwide, we feel a non-invasive staging modality such as PET scanning could provide a gap for those institutions (1,2).…”

mentioning

confidence: 99%

PET scan avidity and its role in surgical resection for IIIa N2 disease

Pupovac

Lee

2017

J. Thorac. Dis.

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the relationship between reduction in PET scan avidity (SUVmax) in mediastinal nodes and the presence of persistent N2 disease after induction therapy as a means to provide an additional tool for risk stratifying prospective surgical patients.Dr. Martin and Mehran expressed concern that our publication appears to advocate for the use of serial PET scanning to establish persistence of nodal disease as the sole determination of operability. This was not the intention of the article. We simply wanted to show that assessing the postinduction metabolic activities of the tumor and mediastinal nodes may help surgeons modify their management strategy to more appropriately fit their patient's risk profile.It was also noted that our paper was done in an era where endobronchial ultrasound (EBUS) was not routinely used prior to induction therapy. As mentioned in the limitations of the article, we recognized that the vast majority of the cohort studied had preinduction mediastinoscopy, whereas the recent trend is towards the use of EBUS. Using EBUS in this setting would allow for the use of mediastinoscopy following induction therapy, theoretically removing the significant hazards and false negative rate of a redo mediastinoscopy. However, the data on the role that EBUS plays in the postinduction setting are scant. The initial results appear slightly better than the 25% false negative rate of repeat mediastinoscopy, but the number of studies is limited and it still needs be determined whether or not these results hold up when they include less cautiously selected patients and centers.Since postinduction primary mediastinoscopy performs well in comparison to primary mediastinoscopy in general, we agree that in an ideal world, EBUS should be the initial choice in preinduction lymph node staging. Yet, this requires important forethought when patients undergo initial evaluation and staging, something that is often disregarded. Moreover, since EBUS is both operator dependent and still not universally available nationwide, we feel a non-invasive staging modality such as PET scanning could provide a gap for those institutions (1,2).Dr. Martin and Mehran queried as to why not operate regardless of nodal status, if patients who underwent resection while not achieving mediastinal downstaging still revealed substantially better survival rates than those seen with definitive chemotherapy. This is an important question, as the utility of observing PET scan avidity lie not only in the ability to downstage patients, but the capacity to accurately upstage patients with stage IIIa NSCLC as well.We acknowledge that many centers have adopted an approach that favors resection regardless of persistent N2 or downstaged N2 disease; however, this is not our methodology. If a patient has histologically proven single station or non-bulky multistation IIIa N2 disease, it is our preference to offer induction chemotherapy and surgical

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The Efficacy of Restaging Endobronchial Ultrasound in Patients With Non-Small Cell Lung Cancer After Preoperative Therapy

Cited by 28 publications

References 15 publications

Clinical Predictors of Persistent Mediastinal Nodal Disease After Induction Therapy for Stage IIIA N2 Non-Small Cell Lung Cancer

Clinical Predictors of Persistent Mediastinal Nodal Disease After Induction Therapy for Stage IIIA N2 Non-Small Cell Lung Cancer

The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer

PET scan avidity and its role in surgical resection for IIIa N2 disease

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