Showing papers on "Mediastinoscopy published in 2016"

Risk Factors for Predicting Occult Lymph Node Metastasis in Patients with Clinical Stage I Non-small Cell Lung Cancer Staged by Integrated Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography

Abstract: Lymph nodes in patients with non-small cell lung cancer (NSCLC) are often staged using integrated 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). However, this modality has limited ability to detect micrometastases. We aimed to define risk factors for occult lymph node metastasis in patients with clinical stage I NSCLC diagnosed by preoperative integrated FDG-PET/CT. We retrospectively reviewed the records of 246 patients diagnosed with clinical stage I NSCLC based on integrated FDG-PET/CT between April 2007 and May 2015. All patients were treated by complete surgical resection. The prevalence of occult lymph node metastasis in patients with clinical stage I NSCLC was analysed according to clinicopathological factors. Risk factors for occult lymph node metastasis were defined using univariate and multivariate analyses. Occult lymph node metastasis was detected in 31 patients (12.6 %). Univariate analysis revealed CEA (P = 0.04), SUVmax of the primary tumour (P = 0.031), adenocarcinoma (P = 0.023), tumour size (P = 0.002) and pleural invasion (P = 0.046) as significant predictors of occult lymph node metastasis. Multivariate analysis selected SUVmax of the primary tumour (P = 0.049), adenocarcinoma (P = 0.003) and tumour size (P = 0.019) as independent predictors of occult lymph node metastasis. The SUVmax of the primary tumour, adenocarcinoma and tumour size were risk factors for occult lymph node metastasis in patients with NSCLC diagnosed as clinical stage I by preoperative integrated FDG-PET/CT. These findings would be helpful in selecting candidates for mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration.

Identification of false-negative and false-positive diagnoses of lymph node metastases in non-small cell lung cancer patients staged by integrated (18F-)fluorodeoxyglucose-positron emission tomography/computed tomography: A retrospective cohort study.

Abstract: Background The aim of this study was to evaluate the diagnostic accuracy of integrated 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in hilar and mediastinal lymph node (HMLN) staging of non-small cell lung cancer (NSCLC), and to investigate potential risk factors for false-negative and false-positive HMLN metastases. Methods We examined the data of 388 surgically resected NSCLC patients preoperatively staged by integrated FDG-PET/CT. Risk factors for false-negative and false-positive HMLN metastases were analyzed using univariate and multivariate analyses of clinicopathological factors. Results The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of integrated FDG-PET/CT in detecting HMLN metastases were 47.4%, 91.0%, 56.3%, 87.7%, and 82.5%, respectively. On multivariate analysis, the maximum standardized uptake value (SUVmax) of the tumor ( P = 0.042), adenocarcinoma ( P = 0.003), and tumor size ( P = 0.017) were risk factors for false-negative HMLN metastases, and history of lung disease ( P = 0.006) and tumor location (central; P = 0.025) were risk factors for false-positive HMLN metastases. Conclusions The present study identified risk factors for false-negative and false-positive HMLN metastases in NSCLC patients staged by preoperative integrated FDG-PET/CT. These findings would be helpful in selecting appropriate candidates for mediastinoscopy or endobronchial ultrasound-guided transbronchial needle aspiration.

Five-Year Survival After Endosonography vs Mediastinoscopy for Mediastinal Nodal Staging of Lung Cancer

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.

Convex-probe Endobronchial Ultrasound: A Decade of Progress.

Abstract: Ever since the invention of the flexible bronchoscope, perhaps no other innovation in the field of interventional pulmonology has caused so much excitement the world over, as the convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA). While it took over a decade from 1992 to 2004 for the radial EBUS to evolve into the commercial convex probe EBUS scope, another exciting decade has gone by with the technology being thoroughly researched and appraised. The current evidence suggests that EBUS-TBNA can replace mediastinoscopy as the first investigation in the mediastinal staging of lung cancer. The use of EBUS-TBNA has been extended to several other areas including the diagnosis of undefined mediastinal lymphadenopathy, evaluation of intra-parenchymal lesions and others. In fact, EBUS-TBNA is the preferred modality for accessing mediastinal lesions in contact with the airways. The procedure not only has a high diagnostic efficiency (80%-90% for most indications) but is also safe compared to alternative options, such as image-guided fine needle aspiration and mediastinoscopy in the diagnosis of mediastinal lymphadenopathy. Apart from the traditional use of EBUS to perform TBNA, the last decade has seen the evolution of its transoesophageal use, development of novel EBUS-TBNA needles to obtain better histological specimens and a smaller EBUS scope. This review summarises the developments made in this field over the years since its inception.

Impact of the introduction of EBUS on time to management decision, complications, and invasive modalities used to diagnose and stage lung cancer: a pragmatic pre-post study

Abstract: Utilisation of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and guide sheath (EBUS-GS) for diagnosis and staging of lung cancer is gaining popularity, however, its impact on clinical practice is unclear. This study aimed to determine the impact of the introduction of endobronchial ultrasound-guided procedures (EBUS) on time to management decision for lung cancer patients, and on the utilisation of other invasive diagnostic modalities, including CT-guided trans-thoracic needle aspiration (CT-TTNA), bronchoscopy, and mediastinoscopy. Hospital records of new primary lung cancer patients presenting in 2007 and 2008 (Pre-EBUS cohort) and in 2010 and 2011 (Post-EBUS cohort) were reviewed retrospectively. The Pre-EBUS cohort included 234 patients. Of the 326 patients in the Post-EBUS cohort, 90 had an EBUS procedure (EBUS-TBNA for 19.0 % and EBUS-GS for 10.4 % of cases). The number of CT-TTNAs and bronchoscopies decreased following the introduction of EBUS (p = 0.015 and p 28 days; EBUS was not a predictor of time to management decision. The introduction of EBUS led to fewer CT-TTNAs and bronchoscopies and did not impact on the time to management decision. EBUS-TBNA or EBUS-GS alone provided sufficient information for diagnosis and/or regional staging in half of the lung cancer patients referred for this investigation.

Negative EBUS-TBNA Predicts Very Low Prevalence of Mediastinal Disease in Staging of Non-Small Cell Lung Cancer.

Abstract: Background Confirmation of mediastinal disease (N2/3) in non-small cell lung cancer (NSCLC) generally precludes curative surgical management. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a routine first test in mediastinal staging of NSCLC; however, it remains unclear whether a negative EBUS-TBNA should be followed by mediastinoscopy before proceeding to surgery. Understanding the prevalence of metastases in lymph nodes with benign findings on EBUS-TBNA will inform decision making following negative EBUS-TBNA. Methods We examined a retrospective cohort of patients who underwent EBUS-TBNA before resection with mediastinal lymph node sampling for NSCLC between December 2009 and June 2014 in 3 hospitals in Melbourne, Australia. All patients had integrated positron emission tomography/computed tomography (PET/CT) before EBUS-TBNA. Results Eighty-two matched mediastinal lymph node stations were sampled in 57 patients by both EBUS-TBNA and surgical resection, 47 nodes in patients staged cN0/1 by PET/CT and 35 nodes in patients staged cN2/3. All patients had a negative EBUS-TBNA. Four malignant nodes were identified surgically (4.9% of lymph nodes). The mean size of malignant deposits was 5.5 mm. Per-node negative predictive value was 78/82=0.95. All malignant nodes were located in patients with moderate-high risk disease (cN2/3), giving a disease prevalence in cN2/3 patients of 11%, and 0% in cN0/1. In patients staged cN2, per-node NVP was 0.89. Conclusion The prevalence of mediastinal nodal disease following negative EBUS-TBNA is very low, at 4.9%. The per-node NVP of EBUS-TBNA is 0.95, decreasing to 0.89 in moderate-high risk patients. We suggest that a negative EBUS-TBNA of mediastinal nodes does not need to be confirmed by mediastinoscopy of those nodal stations, regardless of PET/CT findings.

FDG PET/CT for assessing the resectability of NSCLC patients with N2 disease after neoadjuvant therapy.

Abstract: Neoadjuvant chemoradiotherapy (CMRT) is the most effective treatment of stage III non-small-cell lung cancer (NSCLC). The present study aimed at assessing FDG PET/CT for defining the response of N2 disease to neoadjuvant CMRT, as surgical resection after such therapy significantly improves 5-year survival in responding N2 disease. Forty-five patients with locally advanced NSCLC underwent both pre-neoadjuvant therapy FDG PET/CT and post-neoadjuvant therapy FDG PET/CT followed by anatomical resection of lung and ipsilateral mediastinal lymph nodes (LN). Seventeen of these patients who had PET/CT studies in our institution and were operated after CMRT were retrospectively included in the study group (12 males, ages 43–78 years; stage IIIA: 14 patients, stage IIIB: 3 patients). PET/CT response in N2 was visually scored per-lymph node station and per patient. Quantitative N2 response was evaluated by SUVmax and total lesion glycolysis (TLG) measurements after therapy alone and in comparison with pre-therapy values. PET/CT N2 response was confirmed at surgery. Seventeen NSCLC patients with 29 metastatic N2 lymph nodes (LN) were assessed. Histopathology confirmed 14 responders and 3 non-responders, and was available in 20/29 metastatic LN, showing complete response in 17 and residual disease in 3 LN. LN-based visual analysis of N2 response on PET/CT defined 3 TP, 16 TN and 1 FP, for sensitivity, specificity, accuracy, negative and positive predictive values (NPV and PPV) of 100, 94, 95, 100 and 75 %, respectively. Patient-based visual analysis defined 3 TP, 13 TN and 1 FP study, for sensitivity, specificity, accuracy, NPV and PPV of 100, 93, 94, 100 and 75 %, respectively. Nodal-based quantitative analysis of FDG uptake in N2 nodes revealed a significant difference between responding and non-responding LN only of SUVmax post-therapy (2.5 ± 1.21 vs. 3.5 ± 2.36, P = 0.04). FDG PET/CT after neoadjuvant therapy accurately defined response in metastatic N2 nodes of NSCLC patients, presenting very high sensitivity and NPV for detecting responding nodes. PET/CT may enable selection of candidates for curative resection of stage III NSCLC. Mediastinoscopy may not be mandatory in patients with a negative PET/CT after neoadjuvant therapy.

Evaluation of the diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration for metastatic mediastinal tumors

Abstract: Background and Objectives: The mediastinum is a relatively uncommon site of distant metastases, which typically appear as peripheral lung nodules. We chose to assess the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of distant metastases to the mediastinum. Materials and Methods: Over the period 2008–2013, a total of 446 patients with concurrent or previously diagnosed and treated extrathoracic malignancies were evaluated. Results: Surgical treatment was carried out in 414 patients (156 women and 237 men aged 26–68 years, mean age of 56.5 years) presenting with distant metastases to the lungs: Thoracoscopic wedge resection was completed in 393 patients and lobectomy and segmentectomy were performed in 7 and 14 patients, respectively. The median time from primary tumor resection was 6.5 years (range: 4.5 months to 17 years). Thirty-two of these patients underwent EBUS-TBNA for mediastinal manifestation of the underlying disease. EBUS-TBNA specimens were aspirated from the subcarinal or right paratracheal lymph node stations in 26 (81%) patients and from the hilar lymph nodes in 6 (18.8%) patients only. Metastases to lymph nodes were confirmed in 14 of these patients (43.8%). Primary lung cancer was diagnosed in seven patients. Mediastinoscopy was performed in two patients to reveal either lymph node metastasis or sarcoidosis. Thoracotomy for pulmonary metastases resection and mediastinal lymph node biopsy was performed in nine patients. Lymph node metastasis was confirmed in five patients (15.6%). The diagnostic efficacy, sensitivity, specificity, and negative predictive value (NPV) of EBUS-TBNA were 78.8%, 93.3%, 100%, and 87.5%, respectively. Conclusion: EBUS-TBNA is a valuable diagnostic tool in a selected group of patients with secondary tumors in the mediastinum and lungs.

The Feasibility of EBUS-Guided TBNA Through the Pulmonary Artery in Highly Selected Patients.

Abstract: BACKGROUND The use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for diagnosis and staging of benign and malignant thoracic disease has rapidly evolved into the standard of care. The lymph node stations that can be reached by EBUS and EUS are substantially more than those that can be accessed by mediastinoscopy. In rare cases, the clinician is faced with extraordinary circumstances in which a minimally invasive approach to the lymph nodes in station 5 is required. We present our findings in 10 cases, at 7 different institutions, where EBUS was instrumental in reaching a diagnosis. METHODS We retrospectively collected 10 cases where EBUS-TBNA was performed through the pulmonary artery in an attempt to reach the territory of lymph node station 5. All cases were performed by experienced interventional pulmonologists at 7 tertiary care centers in the United States and Canada. We describe the patients' demographics, comorbidities, complications, and cytopathology. RESULTS A definitive diagnosis was reached in 9 of the 10 patients. One case showed atypical cells and required a confirmatory Chamberlain procedure. No complications occurred as a result of careful transpulmonary artery needle aspiration. CONCLUSIONS This multicenter case series suggests that transpulmonary artery needle aspiration guided by EBUS is possible and safe in the hands of experienced interventional pulmonologists. It is important to recognize that this is not an alternative to left VATS or Chamberlain procedure, but a last resort procedure.

Primary seminoma arising in the middle mediastinum: A case report

Abstract: Primary mediastinal seminoma often occurs in the anterior mediastinum of young males. It is unusual for the tumor to originate in the middle or posterior mediastinum, and such cases have rarely been reported in the English literature. The present study reports the case of a 52-year-old man with a 3.0-cm primary seminoma arising in the middle mediastinum. The patient presented with the symptoms of cough and chest tightness. Fluorine-18 fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) scans revealed unique abnormal FDG uptake in the middle mediastinum. A mediastinoscopy was performed and integral excision was found to be difficult. A biopsy was performed and the histological examination revealed a primary seminoma. Following 4 cycles of a standard bleomycin, etoposide and cisplatin chemotherapy regimen, and chest irradiation at a total dose of 40 Gy in 20 fractions, the tumor exhibited a partial response, decreasing in size, and FDG uptake was no longer observed on 18F-FDG-PET scan. The last follow-up date was April 2016 and the patient has remained disease-free for 20 months.

Endobronchial Ultrasound-Transbronchial Needle Aspiration of Mediastinal and Hilar Lymphadenopathy Learning Curve.

Abstract: Endobronchial ultrasound (EBUS)-transbronchial needle aspiration (TBNA) has become a widely available tool that allows sampling of mediastinal and hilar lymph nodes with comparable accuracy as compared with the gold standard procedure, mediastinoscopy. The goal of this study was to evaluate the competence accuracy of this technique in academic medical center in patients with and without malignant disease. This was a retrospective chart review of the first 150 patients who underwent EBUS-TBNA at our institution with an operator not previously trained or supervised while performing the procedure. All nondiagnostic results were confirmed with mediastinoscopy. The cumulative sum analysis is a method used to continuously monitor performance against an established standard to attain competence in the procedure performed. Learning curve was assessed using cumulative sum method. Procedures were divided into sextiles (1-25, 26-50, 51-75, 76-100, 101-125, and 126-150). The technique's diagnostic accuracy was calculated for each of the 6 categories and trend toward improved accuracy was assessed using Cochran-Armitage trend test. Operator competency was achieved between 55th and 60th procedures. The diagnostic accuracy increased from 72% to 88% (from the first to third sextile) but remained stable afterwards at 88% (C-A trend test P = 0.091). The overall diagnostic accuracy was 84%. Trainees' learning rate varies while acquiring adequate knowledge. We suggest that a learning curve for each operator be used to assess competence in EBUS-TBNA procedure before physicians perform it without supervision.

Linear endobronchial and endoesophageal ultrasound: a practice change in thoracic medicine.

Abstract: Purpose of reviewLinear endosonography, including intrathoracic lymph nodal sampling by endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) and endoesophageal ultrasound fine-needle aspiration (EUS-FNA), has an important role in the diagnosing and staging of lung cancer. Furth

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): A practical approach

Abstract: There has been wide interest in approaching, visualising and making tissue diagnosis of mediastinal and pulmonary lesions by minimal invasive techniques. In 1960s, the technique of mediastinoscopy was introduced for diagnosis and surgical management of lesions of the mediastinum as well as for lung cancer. This invasive technique required expertise, although it remained a gold standard until modern imaging modalities (CT and PET) became available. Besides, bronchoscopy started being employed widely for obtaining material for exfoliative cytology (e.g. bronchial brushing, bronchial washing, bronchoalveolar lavage) as also for aspiration cytology (e.g. transbronchial needle aspiration, i.e. TBNA). Guided transcutaneous approach for obtaining material for cytologic diagnosis of lung and mediastinal masses has also been practised with good success.

The incidence of hoarseness after mediastinoscopy and outcome of video-assisted versus conventional mediastinoscopy in lung cancer staging.

Abstract: Objectives Theoretically, video-assisted mediastinoscopy (VM) should provide a decrease in the incidence of hoarseness in comparison with conventional mediastinoscopy (CM). Methods An investigation of 448 patients with the NSCLC who underwent mediastinoscopy (n = 261 VM, n = 187 CM) between 2006 and 2010. Results With VM, the mean number of sampled LNs and of stations per case were both significantly higher (n = 7.91 ± 1.97 and n = 4.29 ± 0.81) than they were for CM (n = 6.65 ± 1.79 and n = 4.14 ± 0.84) (p < 0.001 and p = 0.06). Hoarseness was reported in 24 patients (5.4%) with VM procedures resulting in a higher incidence of hoarseness than did CM procedures (6.9% and 3.2%) (p = 0.08). The incidence of hoarseness was observed to be more frequent in patients with left-lung carcinoma who had undergone a mediastinoscopy (p = 0.03). Hoarseness developed in 6% of the patients sampled at station 4L, whereas this ratio was 0% in patients who were not sampled at 4L (p = 0.07). A multivariate analysis showed that the presence of a tumor in the left lung is the only independent risk factor indicating hoarseness (p = 0.09). The sensitivity, NPV, and accuracy of VM were calculated as to be 0.87, 0.95, and 0.96, respectively. The same staging values for CM were 0.83, 0.94, and 0.95, respectively. Conclusion VM, the presence of a tumor in the left-lung, and 4L sampling via mediastinoscopy are risk factors for subsequent hoarseness. Probably due to a wider area of dissection, VM can lead to more frequent hoarseness.

Pretreatment Biopsy for Histological Diagnosis and Induction Therapy in Thymic Tumors

Abstract: Background and objective The aim of this study is to investigate the value of pretreatment biopsy for histological diagnosis and induction therapies in the management of locally advanced thymic malignancies. Methods The clinical pathological data of patients with thymic tumors in the Chinese Alliance for Research in Thymomas (ChART) who underwent biopsy before treatment from 1994 to December 2012 were retrospectively reviewed. The application trend of preoperative histological diagnosis and its influence on treatment outcome were analyzed. Results Of 1,902 cases of thymic tumors, 336 (17.1%) had undergone biopsy for histological diagnosis before therapeutic decision was decided. In recent years, percentage of pretreatment histological diagnosis significantly increased in the later ten years than the former during the study period (P=0.008). There was also a significant increase in thoracoscopy/mediastinoscopy/endobronchial ultrasound (E-BUS) biopsy as compared to open biopsy (P=0.029). Survival in Patients with preoperative biopsy for histology had significantly higher stage lesions (P<0.001) and higher grade malignancy (P<0.001), thus a significantly lower complete resection rate (P<0.001) and therefore a significantly worse survival than those without preoperative biopsy (P=0.001). In the biopsied 336 patients, those who received upfront surgery had significantly better survival than those received surgery after induction therapy (P=0.001). In stage III and IVa diseases, the R0 resection rate after induction therapies increased significantly as compared to the surgery upfront cases (65.5% vs 46.2%, P=0.025). Tumors downstaged after induction had similar outcomes as those having upfront surgery (92.3% vs 84.2%, P=0.51). However, tumors not downstaged by induction had significantly worse prognosis than those downstaged (P=0.004), and fared even worse than those having definitive chemoradiation without surgery (37.2% vs 62.4%, P=0.216). Conclusion It is crucial to get histological diagnosis for thymoma before surgery or adjuvant treatment and minimally invasive biopsy should be undertaken. Although in our study we could not find the benefit of induction chemotherapy before surgery in survival and recurrence rate, it could increase the R0 resection rate compared with direct surgery in late stage (III and IVa). DOI: 10.3779/j.issn.1009-3419.2016.07.05

Pros: should a patient with stage IA non-small cell lung cancer undergo invasive mediastinal staging?

Abstract: Mediastinal lymph node involvement is an important prognostic factor in patients with non-small cell lung cancer (NSCLC). The American and European guidelines for preoperative mediastinal lymph node staging agree in which situations a pre-surgical exploration of the mediastinum is required in order to avoid futile pulmonary resections (1,2). Invasive mediastinal staging with cyto-histological confirmation is indicated when computed tomography (CT) shows enlarged mediastinal or hilar lymph nodes, when positron emission tomography (PET) shows an increase uptake in the mediastinum or hilum, when the tumour is centrally located and when the tumour size is more than 3 cm, especially in adenocarcinoma with high 18F-Fluorodeoxyglucose (FDG) uptake. In general, a minimally invasive technique (endobronchial or endoesophageal ultrasound fine needle aspiration) is indicated of first choice, but when negative, a surgical exploration of the mediastinum (mainly a video mediastinoscopy) is required. In some particular situation, like clinical (c) staged N1 tumours, with normal mediastinum on imaging techniques, it was suggested to proceed directly to surgical resection when preoperative endosonography was negative. However, this issue has been analyzed, concluding that in cN1 NSCLC, endosonography alone has an unsatisfactory sensitivity to detect mediastinal involvement and, therefore, a confirmatory video mediastinoscopy is mandatory when endoscopic techniques show a negative result (3). Although stage cIA NSCLC is the main situation in which invasive mediastinal staging might be omitted, this paper will analyze the established indications and other particular situations in which performing a pre-surgical mediastinal staging in this group of patients can add a benefit in terms of accurate staging.

A new needle on the block: EchoTip ProCore endobronchial ultrasound needle

Abstract: Endobronchial ultrasound has become the first choice standard of care procedure to diagnose benign or malignant lesions involving mediastinum and lung parenchyma adjacent to the airways owing to its characteristics of being real-time and minimally invasive. Although the incidence of lung cancer has been decreasing, it is and will be the leading cause of cancer-related mortality in the next few decades. When compared to other cancers, lung cancer kills more females than breast and colon cancers combined and more males than colon and prostate cancers combined. The type of lung cancer has changed in recent decades and adenocarcinoma has become the most frequent cell type. Prognosis of lung cancer depends upon the cell type and the staging at the time of diagnosis. The cell type and molecular characteristics of adenocarcinoma may allow individualized targeted treatment. Other malignant conditions in the mediastinum and lung (eg, metastatic lung cancers and lymphoma) can be biopsied using endobronchial ultrasound needles. Endobronchial ultrasound needle biopsies provides mostly cytology specimens due to its small sizes of needles (22 gauge or larger) which may not give enough tissue to make a definitive diagnosis in malignant (eg, lymphoma) or benign conditions (eg, sarcoidosis). EchoTip ProCore endobronchial needle released in early 2014 provides histologic biopsy material. Larger tissue biopsies may potentially provide a higher diagnostic yield and it eliminates mediastinoscopy or other surgical interventions. Here we aim to review bronchoscopic approach in the diagnosis of mediastinal lesions with emphasis of EchoTip ProCore needles.

A critical reappraisal of sentinel lymph node biopsy for non-small cell lung cancer

Abstract: Because of unsatisfactory accuracy of preoperative imaging and/or of mediastinoscopy, current guidelines recommend routine dissection of mediastinal lymph nodes for patients with operable non-small cell lung cancer (NSCLC). However, at final histopathology this surgical procedure, which is performed mostly for staging purposes and implies a non-negligible rate of severe complications, turns out to be unnecessary in a quite large proportion of patients with early NSCLC. These considerations explain the interest in exploring the potential of sentinel lymph node biopsy (SLNB) in patients with NSCLC, an approach based on the same rationale that has led to establish SLNB as the standard of care in patients with cutaneous melanoma or breast cancer (especially if performed with intraoperative gamma probe guidance after injection at the tumor site of a radiolabeled agent for lymphatic mapping). However, in the case of NSCLC objective anatomic difficulties prevent the possibility to access the primary tumor for injection of the lymphatic mapping agent through an easy and minimally invasive administration route and with adequate timing so to allow for adequate preoperative imaging. Although different methodological approaches have been explored to overcome these difficulties, the clinical evidence so far acquired does not justify the use of SLNB as a routine clinical procedure to stage the tumor status of mediastinal lymph nodes in patients with NSCLC. Nonetheless, the search is continuing for the optimal combination of techniques to optimize and validate the SLNB approach for NSCLC; promising perspectives in this regard include a combination of multimodal techniques, for instance intraoperative gamma probe guidance combined with detection of either an optical and/or a magnetic signal.

Mediastinoscopy-assisted Transhiatal Esophagectomy for Esophageal Cancer: A Single-Institutional Cohort Study.

Abstract: We compared the therapeutic outcomes of mediastinoscopy-assisted transhiatal esophagectomy (MATHE) with transthoracic esophagectomy (TTE), and with video-assisted thoracoscopic esophagectomy (VATS-E) for the treatment of esophageal cancer. Twenty patients underwent MATHE in our institute from 2001 to 2005 were enrolled. We evaluated the therapeutic outcomes, including perioperative complications and long-term prognosis after surgery, and compared these with 15 patients who underwent TTE during the same time period and 15 who underwent VATS-E at a later date. MATHE was performed safely and the long-term prognosis were satisfactory compared with TTE. However, the number of dissected mediastinal lymph nodes, total blood loss, and sophistication of the procedure were inferior to VATS-E. MATHE represents a less invasive surgical procedure. However, in light of the risk of leaving lymph node metastasis around the tracheal bifurcation in patients with tumor invasion beyond the muscularis mucosa, MATHE should only be adopted in a minority of patients.

Pretreatment biopsy for histological diagnosis and induction therapy in thymic tumors.

Abstract: Background: This study was to investigate the value of pretreatment biopsy for histological diagnosis and induction therapies in the mnagement of locally advanced thymic malignancies. Methods: The clinical pathological data of patients with thymic tumors in the Chinese Alliance for Research in Thymomas (ChART) who underwent biopsy before treatment from 1994 to December 2012 were retrospectively reviewed. The application trend of preoperative histological diagnosis and its influence on treatment outcome were analyzed. Results: Of 1,902 cases of thymic tumors, 336 (17.1%) had undergone biopsy for histological diagnosis before therapeutic decision was decided. In recent years, percentage of pretreatment histological diagnosis significantly increased in the later ten years than the former during the study period (P=0.008). There was also a significant increase in thoracoscopy/mediastinoscopy/E-BUS biopsy as compared to open biopsy (P=0.029). Survival in Patients with preoperative biopsy for histology had significantly higher stage lesions (P=0.000) and higher grade malignancy (P=0.000), thus a significantly lower complete resection rate (P=0.000) and therefore a significantly worse survival than those without preoperative biopsy (P=0.000). In the biopsied 336 patients, those who received upfront surgery had significantly better survival than those received surgery after induction therapy (P=0.000). In stage III and IVa diseases, the R0 resection rate after induction therapies increased significantly as compared to the surgery upfront cases (65.5% vs . 46.2%, P=0.025). Tumors downstaged after induction had similar outcomes as those having upfront surgery (92.3% vs . 84.2%, P=0.51). However, tumors not downstaged by induction had significantly worse prognosis than those downstaged (P=0.004), and fared even worse than those having definitive chemoradiation without surgery (37.2% vs . 62.4%, P=0.216). Conclusions: It is crucial to get histological diagnosis for thymoma before surgery or adjuvant treatment and minimally invasive biopsy should be undertaken. Although in our study we could not find the benefit of induction chemotherapy before surgery in survival and recurrence rate, it could increase the R0 resection rate compared with direct surgery in late stage (III and IVa).

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Mediastinal Staging in a Community Medical Center.

Abstract: Rationale: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and positron emission tomography (PET)–computed tomography (CT) are valuable tools for lung cancer staging. Data from tertiary referral centers suggest that these modalities are superior to mediastinoscopy in mediastinal staging.Objectives: To validate EBUS-TBNA for lung cancer staging in a community center with operators with various levels of experience.Methods: At an 800-bed community hospital, we reviewed all cases where EBUS-TBNA and PET-CT were performed for mediastinal staging by one of seven private practice pulmonologists. Cases were reviewed with lymph node dissection by mediastinoscopy after negative EBUS-TBNA.Measurements and Main Results: Of the 333 cases that were reviewed, 44 underwent mediastinoscopy after negative EBUS-TBNA. Four patients were positive for malignancy at stations 4R and 7 lymph nodes. In none of these cases did EBUS-TBNA reveal lymphoid tissue confirming the sample location. PET-CT show...

Thoracic Extramedullary Hematopoiesis Mimicking Metastatic Cancer.

Abstract: Thoracic extramedullary hematopoiesis (EMH) is a rare manifestation in patients with myeloproliferative neoplasm. A 76-year-old woman with a long-standing history of polycythemia vera presented with a 2-month history of worsening dyspnea and left-sided wheezing. A chest computed tomography showed an ill-defined soft tissue mass encasing the left mainstem bronchus causing airway obstruction, associated with paratracheal and paraesophageal lymphadenopathy. Endobronchial ultrasound-guided fine needle aspiration of the soft tissue mass and mediastinoscopy with excisional biopsy of a paratracheal lymph node demonstrated EMH with increased myeloid blasts. A bone marrow biopsy confirmed postpolycythemic myelofibrosis consistent with progression of polycythemia vera to myelofibrosis. We describe the bronchoscopic management of a case of EMH presenting as a mediastinal mass, mimicking malignancy.