Staging Procedures For Cancer Research Articles

A novel use of endobronchial ultrasound bronchoscope to biopsy supraclavicular lymph node

Background: Accurate staging for patients with lung cancer is essential for management and prognostication. Percutaneous ultrasound-guided fine needle aspiration (US FNA) of supraclavicular lymph nodes is not always performed clinically for variety of reasons. Our study explores the utility of supraclavicular lymph node biopsy using the endobronchial ultrasound (EBUS) bronchoscope at the time of a mediastinal staging procedure as a possible alternative to US FNA. Methods: This study included 22 patients who underwent supraclavicular lymph node biopsy using the EBUS bronchoscope during lung cancer staging procedure from 2019 to 2021 at the University of Pennsylvania. Feasibility and safety of the procedure were reported. Descriptive statistics were performed for baseline demographics, imaging features, pathology results, tumor cellularity and adequacy for oncological testing. Results: The procedures were safely performed in all patients with no safety events reported. All patients were diagnosed with malignancy and EBUS-guided supraclavicular lymph node FNA showed definitive diagnosis in 19. Of the 16 patients with the final diagnosis of non-small cell lung cancer (NSCLC), 14 had tumor seen in supraclavicular lymph node sampling and 9 were upgraded to Stage IIIB disease from lower mediastinal lymph node staging. Eleven supraclavicular lymph node samples had tumor cellularity >10%. Eight samples were sent for next generation sequencing (NGS). Three of them were the only source for NGS. Conclusions: Supraclavicular lymph node biopsy using the EBUS bronchoscope is a feasible and safe procedure to perform during lung cancer staging. Sampling has significant clinical value for accurate staging and oncologic testing.

Improved Accuracy and Sensitivity in Diagnosis and Staging of Lung Cancer with Systematic and Combined Endobronchial and Endoscopic Ultrasound (EBUS-EUS): Experience from a Tertiary Center.

Combined endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided tissue acquisition (EUS-TA) are accurate procedures for the diagnosis and staging of mediastinal lymph nodes (MLNs) in lung cancer. However, the respective contribution of separate and combined procedures in diagnosis and staging has not been fully studied. The aim of this study was to assess their respective performances. Patients with suspected malignant MLNs in lung cancer or recurrence identified by PET-CT who underwent combined EBUS-TBNA and EUS-TA were retrospectively reviewed. A total of 141 patients underwent both procedures. Correct diagnosis was obtained in 82% with EBUS-TBNA, 91% with EUS-TA, and 94% with the combined procedure. The overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of EBUS-TBNA, EUS-TA, and the combined procedure for diagnosing malignancy were [75%, 100%, 100%, 58%], [87%, 100%, 100%, 75%], and [93%, 100%, 100%, 80%], respectively, with a significantly better sensitivity of the combined procedure (p < 0.0001). Staging (82/141 patients) was correctly assessed in 74% with EBUS-TBNA, 68% with EUS-TA, and 85% with the combined procedure. The overall sensitivity, specificity, PPV, and NPV of EBUS-TBNA, EUS-TA, and the combined procedure for lung cancer staging were [62%, 100%, 100%, 55%], [54%, 100%, 100%, 50%], and [79%, 100%, 100%, 68%], respectively, significantly better in terms of sensitivity for the combined procedure (p < 0.001). The combined EBUS-EUS approach in lung cancer patients showed better accuracy and sensitivity in diagnosis and staging when compared with EBUS-TBNA and EUS-TA alone.

Perspectives of gynecologic oncology fellowship training and preparedness for practice

We aimed to examine the preparedness of recent gynecologic oncology fellowship graduates for independent practice.We conducted a web-based survey study using REDCap targeting Society of Gynecologic Oncology (SGO) members who graduated gynecologic oncology fellowship within the last six years. The survey included 52 items assessing fellowship training experiences, level of comfort in performing core gynecologic oncology surgical procedures and administering cancer-directed therapies. Questions also addressed factors driving participants’ selection of fellowship programs, educational experience, research and preparedness for independent practice. A total of 296 participants were invited to complete the survey. Response rate was 42% with n = 124 completed surveys included for analysis. The highest ranked factor for fellowship selection was fit with program 36% (n = 45). Upon completing fellowship, most were uncomfortable performing ureteral conduit formation 84% (n = 103), ureteroneocystostomy 77% (n = 94), exenteration 68% (n = 83), splenectomy 67% (n = 83) and lower anterior resection 41% (n = 51). Most were comfortable managing intraoperative complications 85% (n = 104) and standard cancer staging procedures (range: 61%–99%). Majority were comfortable providing cancer directed therapies with chemotherapy 99% (n = 123), immunotherapy 84% (n = 104), and poly ADP-ribose polymerase (PARP) inhibitors 97% (n = 120). Upon completing fellowship, 77% (n = 95) report having mentorship that met their expectations during fellowship and 94% (n = 116) felt they were ready for independent practice. Majority of fellowship graduates were prepared for independent practice and felt comfortable performing routine surgical procedures and cancer directed treatment. However, most are not comfortable with ultra-radical gynecologic oncology procedures. Maximizing surgical opportunities during fellowship training and acquiring early career mentorship may help.

Impact of COVID-19-related health care disruptions on pathologic cancer staging during the first pandemic year: a retrospective cohort study from March 2018 to March 2021.

The COVID-19 pandemic has created major disruptions in cancer care, with reductions in diagnostic tests and treatments. We evaluated the impact of these health care-related changes on cancer staging by comparing cancers staged before and during the pandemic. We performed a retrospective cohort study at London Health Sciences Centre and St. Joseph's Health Care London, London, Ontario, Canada. We evaluated all pathologically staged breast, colorectal, prostate, endometrial and lung cancers (the 5 most common cancers by site, excluding nonmelanoma skin cancer) over a 3-year period (Mar. 15, 2018-Mar. 14, 2021). The pre-COVID-19 group included procedures performed between Mar. 15, 2018, and Mar. 14, 2020, and the COVID-19 group included procedures performed between Mar. 15, 2020, and Mar. 14, 2021. The primary outcome was cancer stage group, based on the pathologic tumour, lymph node, metastasis system. We performed univariate analyses to compare demographic characteristics, pathologic features and cancer stage between the 2 groups. We performed multivariable ordinal regression analyses using the proportional odds model to evaluate the association between stage and timing of staging (before v. during the pandemic). There were 4055 cases across the 5 cancer sites. The average number of breast cancer staging procedures per 30 days increased during the pandemic compared to the yearly average in the pre-COVID-19 period (41.3 v. 39.6), whereas decreases were observed for endometrial cancer (15.9 v. 16.4), colorectal cancer (21.8 v. 24.3), prostate cancer (13.6 v. 18.5) and lung cancer (11.5 v. 15.9). For all cancer sites, there were no statistically significant differences in demographic characteristics, pathologic features or cancer stage between the 2 groups (p > 0.05). In multivariable regression analysis, for all cancer sites, cases staged during the pandemic were not associated with higher stage (breast: odds ratio [OR] 1.071, 95% confidence interval [CI] 0.826-1.388; colorectal: OR 1.201, 95% CI 0.869-1.661; endometrium: OR 0.792, 95% CI 0.495-1.252; prostate: OR 1.171, 95% CI 0.765-1.794; and lung: OR 0.826, 95% CI 0.535-1.262). Cancer cases staged during the first year of the COVID-19 pandemic were not associated with higher stage; this likely reflects the prioritization of cancer procedures during times of reduced capacity. The impact of the pandemic period on staging procedures varied between cancer sites, which may reflect differences in clinical presentation, detection and treatment.

Borderline ovarian tumor frozen section diagnoses with features suspicious of invasive cancer: a retrospective study

BackgroundA frozen section diagnosis of a borderline ovarian tumor with suspicious features of invasive carcinoma (“at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full ovarian cancer staging procedure. Quantification of this dilemma may help us with the issue of this clinical decision. The present study assessed and compared both the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses and the proportion of these women with a final histopathological diagnosis of invasive carcinoma, with a special interest in histologic subtypes.MethodsA retrospective cohort study was performed in three hospitals in The Netherlands. All women that underwent ovarian surgery with perioperative frozen section evaluation in one of these hospitals between January 2007 and July 2018 were identified and included in case of a borderline or “at least borderline” frozen section diagnosis and a borderline ovarian tumor or invasive carcinoma as a final diagnosis.ResultsA total of 223 women were included, of which 41 women (18.4%) were diagnosed with “at least borderline” at frozen section. Thirteen of forty-one women (31.7%) following “at least borderline” frozen section diagnosis and 14 of 182 women (7.7%) following a straightforward borderline frozen section diagnosis were diagnosed with invasive carcinoma at paraffin section evaluation (p < 0.001). When compared to straightforward borderline frozen section diagnoses, the proportion of women diagnosed with invasive carcinoma increased from 3.1 to 35.7% for serous tumors (p = 0.001), 10.0 to 21.7% for mucinous tumors (p = 0.129) and 50.0 to 75.0% (p = 0.452) in case of other histologic subtypes following an “at least borderline” frozen section diagnosis.ConclusionsOverall, when compared to women with a decisive borderline frozen section diagnosis, women diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis (7.7% vs 31.7%). Especially in the serous subtype, full staging during initial surgery might be considered after preoperative consent to prevent a second surgical procedure or chemotherapy in unstaged women. Further studies are needed to evaluate whether additional sampling in case of an “at least borderline” diagnosis may decrease the risk of surgical over-treatment.

Retrograde bladder filling after robotic-assisted endometrial cancer staging

Objectives: To assess the utility of bladder backfill voiding trials in reducing the time to void after robotic-assisted endometrial cancer staging procedures Methods: All patients undergoing robotic staging for endometrial cancer from April 1, 2017 to April 1, 2019 at a tertiary referral center were identified and included in the cohort for analysis. Patients prior to April 1, 2018 were managed by Foley catheter removal in the OR at the conclusion of surgery. All patients after April 1, 2018 underwent a retrograde bladder filling with 300 mL of 0.9% NaCl (NS) with immediate Foley removal and subsequent voiding trial. A successful voiding trial entails voiding ≥200 mL with Results: During the study period, 96 patients from a single provider underwent robotic-assisted endometrial cancer staging. Forty-four patients underwent standard Foley removal in the OR at the conclusion of the surgery from April 1, 2017 to March 30, 2018. Beginning April 1, 2018 until April 1, 2019, 52 patients had retrograde bladder filling with 300 mL of NS with immediate Foley removal and subsequent voiding trial. The median time to void was 166 minutes following standard Foley removal protocol compared to 32 minutes in the retrograde backfill cohort (p Download : Download high-res image (161KB) Download : Download full-size image Conclusions: Bladder backfill voiding trial is associated with reduced time to void following robotic-assisted staging for endometrial cancer. The lack of difference in time to discharge is likely due to other criterion required for same-day discharge. This serves an impetus to address other means to expedite same-day discharge.

A Prediction Model to Optimize Invasive Mediastinal Staging Procedures for Non-small Cell Lung Cancer in Patients With a Radiologically Normal Mediastinum: The Quebec Prediction Model

Current guideline-recommended criteria for invasive mediastinal staging in patients with a radiologically normal mediastinum fail to identify a significant proportion of patients with occult mediastinal disease (OMD), despite it leading to a large number of invasive staging procedures. Which variables available before surgery predict the probability of OMD in patients with a radiologically normal mediastinum? We identified all cTxN0/N1M0 non-small cell lung cancer tumors staged by CT imaging and PET with CT imaging in our institution between 2014 and 2018 who underwent gold standard surgical lymph node dissection or were demonstrated to have OMD before surgery by invasive mediastinal staging techniques and divided them into a derivation and an independent validation cohort to create the Quebec Prediction Model (QPM), which allows calculation of the probability of OMD. Eight hundred three patients were identified (development set, n= 502; validation set, n= 301) with a prevalence of OMD of 9.1%. The developed prediction model included largest mediastinal lymph node size (P< .001), tumor centrality (P= .23), presence of cN1 disease (P= .29), and lesion standardized uptake value (P= .09). Using a calculated probability of more than 10%as a threshold to identify OMD, this model had a sensitivity, specificity, positive predictive value, and negative predictive value in the derivation cohort of 73.9%(95%CI, 58.9%-85.7%), 81.1%(95%CI, 77.2%-84.6%), 28.3%(95%CI, 23.4%-33.8%), and 96.8%(95%CI, 95.0%-98.1%), respectively. It performed similarly in the validation cohort (P = .77, Hosmer-Lemeshow test; P= .5163, Pearson χ2 and unweighted sum-of-squares statistics; and P= .0750, Stukel score test) and outperformed current guideline-recommended criteria in identifying patients with OMD (area under the receiver operating characteristic curve [AUC] for American College of Chest Physicians guidelines criteria, 0.65 [95%CI, 0.59-0.71]; AUC for European Society of Thoracic Surgeons guidelines criteria, 0.60 [95%CI, 0.54-0.67]; and AUC for the QPM, 0.85 [95%CI, 0.80-0.90]). The QPM allows the clinician to integrate available information from CT and PET imaging to minimize invasive staging procedures that will not modify management, while also minimizing the risk of unforeseen mediastinal disease found at surgery.

Performance monitoring of EBUS for the staging and diagnosis of lung cancer: auditing the Greater Manchester EBUS service against new national standards

IntroductionEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a pivotal test in lung cancer staging and diagnosis, mandating robust audit and performance monitoring of EBUS services. We present the first regional...

Updates and Controversies of Robotic-Assisted Surgery in Gynecologic Surgery.

minimally invasive surgery (MIS) is the standard approach to performance of several gynecologic procedures, including hysterectomy, gynecologic cancer staging procedures, myomectomy, pelvic organ prolapse repair, and select adnexal procedures. Robotic-assisted surgery, a computer-based MIS approach, has been adopted widely in the United States and several other countries. Robotics may offer technological and ergonomic benefits that overcome limitations associated with conventional laparoscopy; however, it is not clear that reported claims of superiority translate into improved gynecologic patient outcomes compared with other MIS approaches. This review critically appraises the evolving role, benefits, limitations, and controversies of robotic-assisted surgery utilization in benign and oncologic gynecology settings.

Impact of retroperitoneal lymph node dissection in ovarian cancer - time for paradigm shift?

Ovarian cancer is the second most common malignant neoplasm of the genital tract. Staging procedures for ovarian cancer include longitudinal laparotomy, hysterectomy, bilateral salpingo-oophorectomy and infragastric omentectomy as well as systematic pelvic and para-aortic lymphadenectomy. In general, the goal of this primary procedure is to achieve the maximum cytoreduction of all abdominal diseases; a residual disease <1 cm defines optimal cytoreduction, however, a maximal effort should be made to remove all gross disease as this offers superior survival outcomes. The role of lymphadenectomy in ovarian cancer has been the focus of gynecological oncologists during recent years. The core issue of the controversy is whether the removal of lymph nodes should be performed only to stage the disease or if the removal itself improves survival. To further comprehend the issue, one must take into account that several studies have shown that systematic lymphadenectomy is associated with a risk of vascular injury, lymph cyst formation, pulmonary embolism and increased post-operative mortality even when performed by surgeons with extensive experience. We present an extensive review of the available literature on the matter, hoping to provide some insight into the true need for such a procedure.

Ultrasonographic characterization of cervical lymph nodes in healthy dogs.

Ultrasonography provides a minimally invasive method to evaluate the cervical lymph nodes in dogs as part of staging head and neck cancer; however, standardized cohesive reports of the normal lymph node size and appearance are lacking. The purpose of this prospective, descriptive, reference interval study was to characterize the ultrasonographic appearance of cervical lymph nodes in 27 clinically healthy dogs. The size, shape, echogenicity, and margination of the mandibular, medial retropharyngeal, and superficial cervical lymph nodes were evaluated and correlated with age, breed, sex, body weight, and stage of dental disease. The appearance of the lymph nodes was variable among the population. The majority were cigar or ovoid in shape with smooth margins. The echogenicity of the mandibular lymph nodes was predominantly hypoechoic whereas the medial retropharyngeal lymph nodes were predominantly isoechoic compared to the salivary glands. The superficial cervical lymph nodes were predominantly hyperechoic to the surrounding muscle bellies. Higher body weight and younger age were associated with increased size in the medial retropharyngeal and superficial cervical lymph nodes (P-values<.05). Sex and breed were not found to correlate with lymph node characteristics, and there was no trend noted in lymph node appearance associated with dental disease. These data establish normal parameters for the ultrasonographic size and appearance of cervical lymph nodes in dogs and can provide a reference of comparison for future canine cervical ultrasounds, which can be considered for routine staging procedures for head and neck cancer.

Lymph node resection induces the activation of tumor cells in the lungs.

Lymph node (LN) dissection is a crucial procedure for cancer staging, diagnosis and treatment, and for predicting patient survival. Activation of lung metastatic lesions after LN dissection has been described for head and neck cancer and breast cancer. Preclinical studies have reported that dissection of a tumor‐bearing LN is involved in the activation and rapid growth of latent tumor metastases in distant organs, but it is also important to understand how normal (non‐tumor‐bearing) LN resection influences secondary cancer formation. Here, we describe how the resection of tumor‐bearing and non‐tumor‐bearing LN affects distant metastases in MXH10/Mo‐lpr/lpr mice. Tumor cells were administered intravenously and/or intranodally into the right subiliac lymph node (SiLN) to create a mouse model of lung metastasis. Luciferase imaging revealed that tumor cells in the lung were activated after resection of the SiLN, irrespective of whether it contained tumor cells. No luciferase activity was detected in the lungs of mice that did not undergo LN resection (excluding the intravenous inoculation group). Our results indicate that resection of an LN can activate distant metastases regardless of whether the LN contains tumor cells. Hence, lung metastatic lesions are suppressed while metastatic LN are present but activated after LN resection. If this phenomenon occurs in patients with cancer, it is likely that lung metastatic lesions may be activated by elective LN dissection in clinical N0 cases. The development of minimally invasive cancer therapy without surgery would help to minimize the risk of activation of distant metastatic lesions by LN resection.

Investigating cancer patient acceptance of Whole Body MRI

BackgroundWhole Body magnetic resonance imaging (WB-MRI) enables early cancer detection, without exposing the patient to ionizing radiation. Our aim was to investigate patients' acceptance of WB-MRI as a procedure for cancer staging and follow up. Materials and methods135 oncologic subjects participated to the study. An ad hoc questionnaire was administered before and after WB-MRI, to assess patient's confidence and concerns about WB-MRI, psychological reactions, experience and perceived utility of the procedure. ResultsBefore undergoing WB-MRI, about 58% of the patients were concerned for cancer progression outcome. 80.4% felt that they were given good information about the exam and the most informed group also perceived and higher level of utility of WB-MRI and no risk. Among people reporting discomfort with the exam (51.9%) the main reasons were noise and exam duration. Despite this, 80% of patients expressed high levels of satisfaction, and the majority (69%) judged WB-MRI more acceptable than other diagnostic exams. Patients who believed to have received more information before the exam rated their global satisfaction higher. ConclusionOur results show that WB-MRI examinations were well-accepted and perceived with high levels of satisfaction by most patients. WB-MRI appears to be equally or more tolerable than other total body imaging modalities (e.g. PET, CT), especially if they receive enough information from the radiologist.

Endobronchial ultrasound-guided transbronchial needle aspiration

In the last years, several techniques have been developed to obtain a prompt diagnosis or rule out lung cancer. Endobronchial ultrasound- guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for mediastinal and central pulmonary lesions. This procedure is especially useful for lung cancer diagnosis and mediastinal staging. Two different types of EBUS are currently available: Radial EBUS and lineal EBUS. Each one has technical differences together with a range of clinical indications. The aim of this review is to discuss about EBUS-TBNA and its current clinical indications, evidence about the accuracy of the procedure for lung cancer diagnosis and staging, and evaluation of the pathological and molecular studies (EGFR, ALK, and ROS1) obtained through EBUS-TBNA and rapid on-site evaluation (ROSE).

Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery

Study ObjectiveTo evaluate the ability of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator to predict discharge to postacute care and perioperative complications in gynecologic oncology patients undergoing minimally invasive surgery (MIS). DesignA retrospective chart review (Canadian Task Force classification II-1). SettingA university hospital. PatientsAll patients undergoing MIS on the gynecologic oncology service from January 1, 2009, to December 30, 2013. InterventionsSurgical procedures were reviewed, and appropriate Common Procedural Terminology codes were assigned. Twenty-one preoperative risk factors were abstracted from the chart and entered into the ACS NSQIP surgical risk calculator. The predicted risk of discharge to postacute care and 8 additional postoperative complications were calculated and recorded. Actual postoperative complications were abstracted from the medical record. The association between the calculated risk and the actual outcome was determined using logistic regression. The ability of the calculator to accurately predict a particular event was assessed using the c-statistic and Brier score. Measurements and Main ResultsOf the 876 patients reviewed, a majority underwent hysterectomy (71.6%), with almost half of those patients undergoing additional cancer staging procedures (34.8%). Although the calculator was a poor predictor of postoperative complications, it was a strong predictor for discharge to postacute care (c-statistic = 0.91, Brier score = 0.02) with an odds ratio of 2.31 (95% confidence interval, 1.65–3.25; p < .0001). ConclusionThe ACS NSQIP surgical risk calculator does not accurately predict postoperative complications or length of stay in gynecologic oncology patients undergoing MIS. Although it was a strong predictor of need for discharge to postacute care, it vastly overestimated the number of patients requiring this service. Therefore, the calculator's risk score for discharge to postacute care may be considered during preoperative counseling but should not be a predictor of whether or not the patient should proceed with surgery.

Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy as part of staging operation for early ovarian cancer and high grade endometrial cancer.

ObjectiveThe aim of this paper was to demonstrate the techiniqes of single-port laparoscopic transperitoneal infrarenal paraaortic lymphadenectomy as part of surgical staging procedure in case of early ovarian cancer and high grade endometrial cancer.MethodsAfter left upper traction of rectosigmoid, a peritoneal incision was made caudad to inferior mesenteric artery. Rectosigmoid was mobilized, and then the avascular space of the lateral rectal portion was found by using upward traction of rectosigmoid mesentery. Inframesenteric nodes were removed without injury to the ureter and the left common iliac nodes were easily removed due to the upward traction of the rectosigmoid. The superior hypogastric plexus was found overlying the aorta and sacral promontory, and presacral nodes were removed at subaortic area. Peritoneal traction suture to right abdomen was needed for right para-aortic lymphadenectomy. After right lower para-aortic node dissection, operator was situated between the patient’s legs. After upper traction of the small bowel, left upper para-aortic nodes were removed. To prevent chylous ascites, we used hemolock or Ligasure application (ValleyLab Inc.) to upper part of infrarenal and aortocaval nodes.ResultsSingle-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy was performed without serious perioperative complications.ConclusionEven though the technique of single-port surgery is still a difficult operation, the quality of single-port laparoscopic transperitoneal infrarenal para-aortic node dissection is excellent, especially mean number of para-aortic nodes. In cases of staging procedures for ovary and endometrial cancer, single-port transperitoneal para-aortic lymphadenectomy is acceptable as an oncologic procedure.

Introducing PET/CT in Cervical Cancer Staging Procedures Leads to Stage Migration and Selection Bias

Introducing PET/CT in Cervical Cancer Staging Procedures Leads to Stage Migration and Selection Bias

Electromagnetic Navigational Bronchoscopy and Robotic-Assisted Thoracic Surgery

With the use of electromagnetic navigational bronchoscopy and robotics, lung lesions can be diagnosed and resected during one surgical procedure. Global positioning system technology allows surgeons to identify and mark a thoracic tumor, and then robotics technology allows them to perform minimally invasive resection and cancer staging procedures. Nurses on the perioperative robotics team must consider the logistics of providing safe and competent care when performing combined procedures during one surgical encounter. Instrumentation, OR organization and room setup, and patient positioning are important factors to consider to complete the procedure systematically and efficiently. This revolutionary concept of combining navigational bronchoscopy with robotics requires a team of dedicated nurses to facilitate the sequence of events essential for providing optimal patient outcomes in highly advanced surgical procedures.

Exhaled breath temperature in NSCLC: could be a new non-invasive marker?

The exhaled breath temperature (EBT) has been proven to be the expression of airways inflammation as well as of the increased vascularity. Although both these conditions characterize lung cancer pathogenesis, this is the first study where the EBT has been analysed in patients affected by non-small-cell lung cancer. The aim of this study was to verify whether and how the lung cancer being examined influences the EBT for possible future clinical implications. Eighty-two consecutive subjects with a radiological suspicion of lung cancer were enrolled and underwent standard diagnostic and staging procedures for cancer. EBT was measured in all the subjects at the enrolment with the X-Halo device. Forty patients resulted as affected by lung cancer while 42 as false-positive (controls). We found a higher EBT in NSCLC patients compared to healthy subjects. The EBT was correlated with number of packs/year and associated with the stage of lung cancer. We identified a cut-off value for the EBT that is able to screen patients with lung cancer with a high sensitivity and specificity. Our results suggest that lung cancer causes an increase in the EBT, which, whether confirmed and validated, could become a new non-invasive clinical tool in the screening and monitoring of this disease.

MRNA and miRNA analyses in cytologically positive endobronchial ultrasound‐guided transbronchial needle aspiration: Implications for molecular staging in lung cancer patients

Lung cancer is highly aggressive and tends to metastasize early. Therefore, accurate mediastinal staging is important for therapeutic decision making. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a minimally invasive procedure for mediastinal lymph node sampling and cancer staging. Classical EBUS-TBNA cytology has been combined with molecular staging techniques to improve sensitivity and specificity. This study aimed to assess mRNA integrity in samples acquired by EBUS-TBNA in the clinics. As proof-of-principle experiments, we also investigated whether stable miRNA could be detected in these samples. Integrity of mRNA isolated from tumor-positive EBUS-TBNA samples was assessed by calculating the RNA integrity number (RIN). In addition, 4 microRNAs were investigated (miRNA 21, miRNA 155, miRNA 200c, and miRNA 34a) because their relation to lung cancer has been documented recently. A group of patients with benign mediastinal lymphadenopathy served as a control. mRNA isolated from EBUS-TBNA samples was nearly completely degraded if handled under clinical conditions (RIN <5). Intact miRNA was detected in all samples, with no nonspecific amplification in negative control samples. miRNA 21 and miRNA 200c levels were significantly higher in tumor-positive than in control samples (miRNA 21: median, 325,678 [range, 34,822-583,502] vs. 801,430 (range, 17,013-5,362,145]; P < .05; miRNA 200c: median, 9,198 [range, 610-211,121] vs. 42,870 [range, 0-926,252]; P < .05). Under clinical conditions, mRNA detection is likely unsuitable for improving sensitivity of EBUS-TBNA-facilitated cancer staging. In contrast, detection of miRNA combined with EBUS-TBNA cytology may improve staging sensitivity.