TL;DR: If mediastinal staging is improved, more patients should receive optimal treatment and might survive longer and the current post hoc analysis evaluated survival in ASTER.
Abstract: Five-Year Survival After Endosonography vs Mediastinoscopy for Mediastinal Nodal Staging of Lung Cancer Lung cancer accounts for the highest cancer-related mortality rate worldwide.1 Accurate mediastinal nodal staging is crucial in the management of non–small cell lung cancer (NSCLC) because it directs therapy and has prognostic value.2,3 The Assessment of Surgical Staging vs Endosonographic Ultrasound in Lung Cancer (ASTER) trial compared mediastinoscopy (surgical staging) with an endosonographic staging strategy (which combined the use of endobronchial and transesophageal ultrasound followed by mediastinoscopy if negative).4 The endosonographic strategy was significantly more sensitive for diagnosing mediastinal nodal metastases than surgical staging (94% endosonographic strategy vs 79% surgical strategy). If mediastinal staging is improved, more patients should receive optimal treatment and might survive longer. The current post hoc analysis evaluated survival in ASTER.
TL;DR: Transvascular endosonographic-guided biopsy is an important adjunct to conventional endoscopic techniques and allows the thoracic endoscopist to obtain biopsy specimens from intrathoracic lesions that are not accessible without vascular puncture.
TL;DR: Although adherence to the European NSCLC mediastinal staging guideline on initial use of endosonography was good, 30% of endOSonography procedures were performed insufficiently and unforeseen N2 rates following staging by endos onography with or without confirmatory mediastinoscopy were comparable.
TL;DR: In this paper, the authors assess current guideline adherence and consequent unforeseen unforeseen N2 disease (uN2) in NSCLC patients having various indications for mediastinal staging.
TL;DR: The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions and the results from the most recent studies and current international guidelines are explained and revised.
Abstract: The staging of mediastinal lymph nodes for lung cancer is crucial for planning treatments or reinterventions. In potentially curable patients the aim of mediastinal staging is to exclude the presence of malignancy in mediastinal lymph nodes with a high level of accuracy while also considering clinical factors and the balance of the benefits and risks of tissue sampling techniques. Mediastinal staging is based on computed tomography (CT) and positron emission tomography (PET) and can be sufficient when no mediastinal abnormalities are present and the probability of unforeseen N2 disease is low. In the case of bulky lymph nodes with a high probability of malignancy in PET-CT, tissue confirmation is not normally required. If mediastinal sampling is needed it can be achieved by endosonographic techniques, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or a combination of the two. Positive results do not need further confirmation. In the case of negative results, surgical techniques still play a role in the selected cases discussed by multidisciplinary lung cancer committees. New mediastinal surgical techniques including video-assisted cervical mediastinoscopy (VACM), video-assisted mediastinoscopic lymphadenectomy (VAMLA), and transcervical extended mediastinal lymphadenectomy (TEMLA) have been shown to be useful in selected patients. Final pathological staging is based on lymph node removal during surgery and can be achieved by taking one of two approaches: lymph node sampling or systematic lymph node sampling. The accuracy of PET-CT and mediastinal endosonography is lower for mediastinal restaging than it is for surgical techniques; their false positive and false negative (FN) rate is high and so, they require histological confirmation. Here we explain and revise the results from the most recent studies and current international guidelines.
TL;DR: The authors realizar una revision actualizada de la literatura, acerca del uso de la mediastinoscopia in el diagnostico del cancer pulmonar.
Abstract: La exploracion mediastinal comienza desde la epoca de Galeno. Su desarrollo se alcanzo en la segunda mitad del siglo XX, utilizada para el estudio de los ganglios y tumores mediastinales. En la actualidad su uso se ha ampliado no solo como diagnostico, sino con fines terapeuticos, al lograr realizar resecciones pulmonares. El objetivo es realizar una revision actualizada de la literatura, acerca del uso de la mediastinoscopia en el diagnostico del cancer pulmonar. Se realizo una revision de la literatura medica donde se utilizaron las bases de datos Scopus, Medline y Cochrane bajo los criterios de sus revisores. Se emplearon las palabras claves en idioma espanol e ingles. El metodo de analisis y sintesis se uso para la interpretacion de la bibliografia. Se revisaron 173 articulos, de los cuales, se escogieron 58, que cumplian con los criterios de seleccion, entre ellos, 6 meta analisis, 11 articulos de revision y 41 articulos originales. La videomediastinoscopia constituye una herramienta valida para el diagnostico, asi como para el estadiamiento de enfermedades dentro y fuera de la cavidad toracica y mediastino. Por otra parte, permite el tratamiento de algunas enfermedades.
6 citations
Cites background from "Five-Year Survival After Endosonogr..."
...Por otra parte, la TEP es superior a la TAC para identificar los ganglios linfáticos malignos, con una sensibilidad de 58-91 % y una especificidad de 78-90 %.((39,40,41)) Una situación especial se presenta en aquellos pacientes que en la TAC tienen ganglios mayores de 1cm y sin embargo muestran ganglios que no captan la glucosa marcada en la TEP, situación tal, en la que está indicado el estadiamiento invasivo, que demuestra en un 13 % la presencia de ganglios linfáticos malignos....
[...]
...es_E S manos expertas es segura, con una aceptable morbilidad y mortalidad.((37,38,39,40)) Además, muestra una mayor rentabilidad en la obtención de muestras histológicas, si la comparamos con la punción transbronquial broncoscópica, la punción transesofágica y la punción con aguja guiada por ecografía torácica....
TL;DR: A substantial portion of cancer cases and deaths could be prevented by broadly applying effective prevention measures, such as tobacco control, vaccination, and the use of early detection tests.
Abstract: Cancer constitutes an enormous burden on society in more and less economically developed countries alike. The occurrence of cancer is increasing because of the growth and aging of the population, as well as an increasing prevalence of established risk factors such as smoking, overweight, physical inactivity, and changing reproductive patterns associated with urbanization and economic development. Based on GLOBOCAN estimates, about 14.1 million new cancer cases and 8.2 million deaths occurred in 2012 worldwide. Over the years, the burden has shifted to less developed countries, which currently account for about 57% of cases and 65% of cancer deaths worldwide. Lung cancer is the leading cause of cancer death among males in both more and less developed countries, and has surpassed breast cancer as the leading cause of cancer death among females in more developed countries; breast cancer remains the leading cause of cancer death among females in less developed countries. Other leading causes of cancer death in more developed countries include colorectal cancer among males and females and prostate cancer among males. In less developed countries, liver and stomach cancer among males and cervical cancer among females are also leading causes of cancer death. Although incidence rates for all cancers combined are nearly twice as high in more developed than in less developed countries in both males and females, mortality rates are only 8% to 15% higher in more developed countries. This disparity reflects regional differences in the mix of cancers, which is affected by risk factors and detection practices, and/or the availability of treatment. Risk factors associated with the leading causes of cancer death include tobacco use (lung, colorectal, stomach, and liver cancer), overweight/obesity and physical inactivity (breast and colorectal cancer), and infection (liver, stomach, and cervical cancer). A substantial portion of cancer cases and deaths could be prevented by broadly applying effective prevention measures, such as tobacco control, vaccination, and the use of early detection tests.
TL;DR: Urinary albumin excretion is a predictor of all-cause mortality in the general population and the excess risk was more attributable to death from CV causes, independent of the effects of other CV risk factors.
Abstract: Background— For the general population, the clinical relevance of an increased urinary albumin excretion rate is still debated. Therefore, we examined the relationship between urinary albumin excretion and all-cause mortality and mortality caused by cardiovascular (CV) disease and non-CV disease in the general population. Methods and Results— In the period 1997 to 1998, all inhabitants of the city of Groningen, the Netherlands, aged between 28 and 75 years (n=85 421) were sent a postal questionnaire collecting information about risk factors for CV disease and CV morbidity and a vial to collect an early morning urine sample for measurement of urinary albumin concentration (UAC). The vital status of the cohort was subsequently obtained from the municipal register, and the cause of death was obtained from the Central Bureau of Statistics. Of these 85 421 subjects, 40 856 (47.8%) responded, and 40 548 could be included in the analysis. During a median follow-up period of 961 days (maximum 1139 days), 516 deat...
TL;DR: It is demonstrated that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings, and evidence suggests that more complete staging improves patient outcomes.
TL;DR: The risks of mortality, myocardial infarction, and progression to kidney failure associated with a given level of eGFR are independently increased in patients with higher levels of proteinuria.
Abstract: Context The current staging system for chronic kidney disease is based primarily on estimated glomerular filtration rate (eGFR) with lower eGFR associated with higher risk of adverse outcomes. Although proteinuria is also associated with adverse out- comes, it is not used to refine risk estimates of adverse events in this current system. Objective To determine the association between reduced GFR, proteinuria, and ad- verse clinical outcomes. Design, Setting, and Participants Community-based cohort study with partici- pants identified from a province-wide laboratory registry that includes eGFR and pro- teinuria measurements from Alberta, Canada, between 2002 and 2007. There were 920985 adults who had at least 1 outpatient serum creatinine measurement and who did not require renal replacement treatment at baseline. Proteinuria was assessed by urine dipstick or albumin-creatinine ratio (ACR). Main Outcome Measures All-cause mortality, myocardial infarction, and progres- sion to kidney failure. Results The majority of individuals (89.1%) had an eGFR of 60 mL/min/1.73 m 2 or greater. Over median follow-up of 35 months (range, 0-59 months), 27959 participants (3.0%)died.Thefullyadjustedrateofall-causemortalitywashigherinstudyparticipants with lower eGFRs or heavier proteinuria. Adjusted mortality rates were more than 2-fold higher among individuals with heavy proteinuria measured by urine dipstick and eGFR of 60mL/min/1.73m 2 orgreater,ascomparedwiththosewitheGFRof45to59.9mL/min/ 1.73 m 2 and normal protein excretion (rate, 7.2 (95% CI, 6.6-7.8) vs 2.9 (95% CI, 2.7- 3.0)per1000person-years,respectively;rateratio,2.5(95%CI,2.3-2.7)).Similarresults were observed when proteinuria was measured by ACR (15.9 (95% CI, 14.0-18.1) and 7.0 (95% CI, 6.4-7.6) per 1000 person-years for heavy and absent proteinuria, respec- tively;rateratio,2.3(95%CI,2.0-2.6))andfortheoutcomesofhospitalizationwithacute myocardial infarction, end-stage renal disease, and doubling of serum creatinine level. Conclusion The risks of mortality, myocardial infarction, and progression to kidney failure associated with a given level of eGFR are independently increased in patients with higher levels of proteinuria.
TL;DR: Among patients with (suspected) NSCLC, a staging strategy combining endosonography and surgical staging compared with surgical staging alone resulted in greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies.
Abstract: CONTEXT Mediastinal nodal staging is recommended for patients with resectable non-small cell lung cancer (NSCLC). Surgical staging has limitations, which results in the performance of unnecessary thoracotomies. Current guidelines acknowledge minimally invasive endosonography followed by surgical staging (if no nodal metastases are found by endosonography) as an alternative to immediate surgical staging. OBJECTIVE To compare the 2 recommended lung cancer staging strategies. DESIGN, SETTING, AND PATIENTS Randomized controlled multicenter trial (Ghent, Leiden, Leuven, Papworth) conducted between February 2007 and April 2009 in 241 patients with resectable (suspected) NSCLC in whom mediastinal staging was indicated based on computed or positron emission tomography. INTERVENTION Either surgical staging or endosonography (combined transesophageal and endobronchial ultrasound [EUS-FNA and EBUS-TBNA]) followed by surgical staging in case no nodal metastases were found at endosonography. Thoracotomy with lymph node dissection was performed when there was no evidence of mediastinal tumor spread. MAIN OUTCOME MEASURES The primary outcome was sensitivity for mediastinal nodal (N2/N3) metastases. The reference standard was surgical pathological staging. Secondary outcomes were rates of unnecessary thoracotomy and complications. RESULTS Two hundred forty-one patients were randomized, 118 to surgical staging and 123 to endosonography, of whom 65 also underwent surgical staging. Nodal metastases were found in 41 patients (35%; 95% confidence interval [CI], 27%-44%) by surgical staging vs 56 patients (46%; 95% CI, 37%-54%) by endosonography (P = .11) and in 62 patients (50%; 95% CI, 42%-59%) by endosonography followed by surgical staging (P = .02). This corresponded to sensitivities of 79% (41/52; 95% CI, 66%-88%) vs 85% (56/66; 95% CI, 74%-92%) (P = .47) and 94% (62/66; 95% CI, 85%-98%) (P = .02). Thoracotomy was unnecessary in 21 patients (18%; 95% CI, 12%-26%) in the mediastinoscopy group vs 9 (7%; 95% CI, 4%-13%) in the endosonography group (P = .02). The complication rate was similar in both groups. CONCLUSIONS Among patients with (suspected) NSCLC, a staging strategy combining endosonography and surgical staging compared with surgical staging alone resulted in greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00432640.