Mediastinal Staging Of Lung Cancer Research Articles

Presurgical invasive mediastinal staging in lung cancer, unexpected N2 and long-term survival: a registry-based study with data from the Spanish group for video-assisted thoracic surgery.

Mediastinal lymph node staging is a key element in the diagnosis of lung cancer. The combination of computed tomography (CT) and positron emission tomography (PET) has improved staging but some circumstances are known to influence their negative predictive value. The objective of this study was to assess the impact on survival of avoiding invasive mediastinal staging in surgical lung cancer patients with negative mediastinum in CT and PET and intermediate risk of unexpected pN2. Data were collected from the prospective cohort of the Spanish Group for Video-Assisted Thoracic Surgery (GEVATS), from December 2016 to March 2018. For this study, patients were selected if they had negative mediastinum in CT and PET findings but tumours >3 cm or located centrally, or with cN1 disease. Patients who did and did not undergo invasive staging [invasive group (IG) and non-invasive group (NIG)] were compared, analysing unexpected pN2 and survival with Kaplan-Meier curves and Cox regression. A total of 2,826 patients underwent surgery for primary lung cancer. We selected 1,247 patients who had tumours >3 cm, central tumours or cN1. Invasive staging was performed in 275 (22.1%) cases. The unexpected pN2 rate was 9.6% in the NIG and 13.8% in the IG, but half of them were discovered prior to surgery in the IG. Five-year overall survival (OS) was poorer in the IG (52.4% vs. 64%; P<0.001). In the Cox regression model, male sex, older age, diabetes, synchronous tumour, lower diffusing capacity for carbon monoxide, larger tumour size, higher pathological N-stage, and IG status were significant independent risk factors. Invasive staging recommended by guidelines could be reduced with an appropriate selection in mediastinal CT- and PET-negative patients with risk factors for unexpected pN2, because rates of pN2 and survival did not worsen without invasive staging.

Convex-probe Endobronchial Ultrasound: A Decade of Progress

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.

EBUS-TBNA versus mediastinoscopy for mediastinal staging of lung cancer: a cost-minimization analysis

ABSTRACTObjective:To assess cost differences between EBUS-TBNA and mediastinoscopy for mediastinal staging of non-small cell lung cancer (NSCLC). Methods:This was an economic evaluation study with a cost-minimization analysis. We used a decision analysis software program to construct a decision tree model to compare the downstream costs of mediastinoscopy, EBUS-TBNA without surgical confirmation of negative results, and EBUS-TBNA with surgical confirmation of negative results for the mediastinal staging of NSCLC. The study was conducted from the perspective of the Brazilian public health care system. Only direct medical costs were considered. Results are shown in Brazilian currency (Real; R$) and in International Dollars (I$). Results:For the base-case analysis, initial evaluation with EBUS-TBNA without surgical confirmation of negative results was found to be the least costly strategy (R$1,254/I$2,961) in comparison with mediastinoscopy (R$3,255/I$7,688) and EBUS-TBNA with surgical confirmation of negative results (R$3,688/I$8,711). The sensitivity analyses also showed that EBUS-TBNA without surgical confirmation of negative results was the least costly strategy. Mediastinoscopy would become the least costly strategy if the costs for hospital supplies for EBUS-TBNA increased by more than 300%. EBUS-TBNA with surgical confirmation of negative results, in comparison with mediastinoscopy, will be less costly if the prevalence of mediastinal lymph node metastasis is ≥ 38%. Conclusions:This study has demonstrated that EBUS-TBNA is the least costly strategy for invasive mediastinal staging of NSCLC in the Brazilian public health care system.

A Biomarker-Based Approach for the Determination of Sample Adequacy During Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Proof of Concept Study

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a highly sensitive, minimally invasive procedure1 and is universally accepted as one of the recommended first steps in mediastinal staging of lung cancer.2 To achieve optimal EBUS-TBNA lymph node assessment and staging, rapid on-site cytologic evaluation (ROSE) is beneficial in providing immediate biopsy evaluation.3,4 Unfortunately, the availability of ROSE is not widespread, which creates disparities both within and across institutions.

Confirmatory Mediastinoscopy after Negative Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for Mediastinal Staging of Lung Cancer: Systematic Review and Meta-analysis.

Rationale: Current guidelines for non-small cell lung cancer (NSCLC) mediastinal staging recommend starting invasive staging with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). However, the indication to confirm a negative result of EBUS-TBNA by means of video-assisted mediastinoscopy (VAM) before resection differs in every guideline. Objectives: Our aim was to evaluate the current evidence regarding the added value of confirmatory VAM after a negative EBUS-TBNA result for mediastinal staging in patients with NSCLC. Methods: Systematic searches of studies on EBUS-TBNA for NSCLC mediastinal staging with or without confirmatory VAM but with surgical confirmation of negative results were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement in PubMed, SCOPUS, the Cochrane Library, and guidelines from 2005 through November 2021. In the meta-analysis, the sensitivity of confirmatory VAM after a negative EBUS-TBNA result, as well as the sensitivity and negative predictive value of the combination EBUS-TBNA plus confirmatory VAM, alongside the number of confirmatory VAMs required to detect additional N2/3 disease (number needed to treat [NNT]), in patients with a previous negative EBUS-TBNA result were estimated. Results: A total of 5,412 articles were found, of which 29 studies were included. Random effects meta-analysis showed a sensitivity of 66.9% (95% confidence interval [CI], 55.8-77.1%) for confirmatory VAM, and 96.7% (95% CI, 95.1-98%) for the combination EBUS-TBNA plus confirmatory VAM. Negative predictive value in studies with confirmatory VAM increased of 79.2% (95% CI, 71.4-86.1%) for EBUS-TBNA alone to 91.8% (95% CI, 87.1-95.5%) for EBUS-TBNA plus confirmatory VAM. The NNT of confirmatory VAM in patients with a previous negative EBUS-TBNA result was 23.8 (95% CI, 19.3-31.2). Conclusions: Confirmatory VAM after negative EBUS-TBNA reduces the rate of unforeseen N2/3 disease, but with a high NNT, and it should be recommended only for certain cases yet to be defined.

Endosonography in mediastinal staging of lung cancer: a concise literature review

Fausto Leoncini, Daniele Magnini, Vanina Livi, Maria Chiara Flore, Lucia Maria Porro, Daniela Paioli, Rocco Trisolini

Clinical Validation of the Canada Lymph Node Score for Endobronchial Ultrasound

BackgroundThe Canada Lymph Node Score (CLNS) uses 4 sonographic criteria to predict the risk of malignancy in lymph nodes during endobronchial ultrasound. The CLNS may play a role in identifying targets for biopsy or rebiopsy during invasive mediastinal staging for lung cancer. However the CLNS has not yet been prospectively validated in routine clinical practice. MethodsCLNSs for each lymph node biopsied during endobronchial ultrasound were prospectively captured for 1 year (2019). The CLNS and the presence of malignancy in each node were compared. Univariate binary logistic regression was completed for each ultrasonographic feature and multivariate logistic regression model. ResultsCLNSs and diagnostic pathology results were available for 367 lymph nodes. Incidence of malignancy increased with higher scores. Scores ≥ 3 were significantly associated with malignancy (specificity, 84.4%; positive likelihood ratio, 4.0). Area under the curve was 0.76, indicating a good ability of the model to predict presence or absence of malignancy. Nodes scoring < 2 and negative on computed tomography and positron emission tomography were malignant in 10.1%. ConclusionsThe CLNS correlates with the presence or absence of malignancy in thoracic lymph nodes and may serve as an adjunct to currently available methods of invasive and noninvasive mediastinal staging. The CLNS may be most helpful in selecting which nondiagnostic lymph nodes require rebiopsy. There is a significant risk of a false-negative result even with a score of 0, and using a combination of low CLNSs and negative conventional radiology to obviate the need for any initial biopsy remains to be studied in prospective trials.

Diagnosis and staging of lung cancer using transesophageal ultrasound: Training and assessment.

Diagnosis and staging of lung cancer using transesophageal ultrasound: Training and assessment.

Magnetic resonance imaging for the study of mediastinal adenopathies in lung cancer: Comparison with standard tests.

Lung cancer is the second most common cancer in both men and women. Mediastinal lymph node involvement in these patients, determined by imaging tests, indicates prognosis and modifies therapeutic attitude. The aim of this study was to analyze the diagnostic capacity of magnetic resonance imaging (MRI) in the study of the mediastinum in comparison with conventional tests (computed tomography [CT] and positron-emission tomography [PET] or PET/CT scans), taking histology as the gold standard. An observational study was conducted on 16 patients with suspicion of primary lung cancer (June 2016 through December 2018). We studied their demographic characteristics and used CT, PET, or PET/CT scans and MRI (diffusion-weighted imaging-MRI sequence) to examine mediastinal disease and compare MRIs diagnostic yield and percentage agreement to that of conventional tests. As compared to CT and PET scanning, MRI displayed a very low sensitivity and a specificity of 90 and 88%, respectively; positive predictive value was 0.67 (both) and negative predictive value (NPV) was 0.28 and 0.22, respectively. MRI showed a high degree of agreement in lymph node diagnosis when compared with histology (91.2%; P = 0.001): specificity in this case was high (E = 0.94), as was the NPV (NPV = 0.97). The results of this study would appear to indicate that MRI could play a relevant role in mediastinal staging of lung cancer. More prospective, multicenter studies are, however, needed to be able to draw up firm recommendations about the role of MRI and its place in lung cancer staging.

Preoperative mediastinal staging in patients with cT1‐3NxM0 non‐small cell lung cancer

BackgroundEndosonography is accepted as the initial procedure for mediastinal staging in patients with suspected non‐small cell lung cancer (NSCLC). However, the diagnostic value of different staging methods in specific subgroups is unclear. The purpose of this study was to assess the performance and outcome of mediastinal staging in lung cancer in a general teaching hospital.MethodsThe records of 870 consecutive patients with potentially resectable NSCLC (cT1‐3NxM0) were analyzed in a retrospective cohort study between January 2010 and December 2016. Patients were divided into four different groups according to ESTS guidelines. The primary endpoint was the rate of unforeseen mediastinal metastasis in these groups and the sensitivity of different staging methods.ResultsMediastinal staging was performed in 336 patients of whom 112 (33%) underwent lobectomy. Unforeseen mediastinal metastasis was seen in 10 (9%) patients after negative mediastinal staging. Sensitivity after combined mediastinal staging (endosonography with mediastinoscopy) in the overall group was 94%. In patients without suspected mediastinal lymph nodes but with suspected hilar lymph nodes (N1), or a peripheral tumor >3 cm, sensitivity of endosonography was 33% and mediastinoscopy 75%. Biopsy of at least level 4L, 4R and 7 was taken in 18% of the endosonographies and 58% of the mediastinoscopies.DiscussionCombined mediastinal staging (endosonography with mediastinoscopy) is reliable with a sensitivity of 94%. However, the diagnostic value of endosonography in patients with suspected hilar lymph nodes or a peripheral tumor >3 cm is questionable, and in these patients, performing direct mediastinoscopy should be considered.Key pointsSignificant findings of this studyThe diagnostic value of endosonography in patients without suspected mediastinal lymph nodes but with potential risk factors (suspected N1 disease or peripheral tumor >3 cm) is questionable. Therefore, mediastinoscopy as the first choice should be considered in these patients.What this study adds?Accurate mediastinal nodal staging is essential in patients with suspected NSCLC to avoid unnecessary lobectomy. Detailed knowledge about sensitivity and specificity of mediastinal staging techniques in different patient groups can make a difference.

Endobronchial ultrasound-guided transbronchial needle aspiration versus mediastinoscopy for mediastinal staging of lung cancer: A systematic review of economic evaluation studies.

The emergence of endobronchial ultrasound (EBUS) changed the approach to staging lung cancer. As a new method being incorporated, the use of EBUS may lead to a shift in clinical and costs outcomes. The aim of this systematic review is to gather information to better understand the economic impact of implementing EBUS. This review is reported according to the PRISMA statement and registered on PROSPERO (CRD42019107901). Search keywords were elaborated considering descriptors of terms related to the disease (lung cancer / mediastinal staging of lung cancer) and the technologies of interest (EBUS and mediastinoscopy) combined with a specific economic filter. The literature search was performed in MEDLINE, EMBASE, LILACS, Cochrane Library of Trials, Web of Science, Scopus and National Health System Economic Evaluation Database (NHS EED) of the Center for Reviews and Dissemination (CRD). Screening, selection of articles, data extraction and quality assessment were carried out by two reviewers. Seven hundred and seventy publications were identified through the database searches. Eight articles were included in this review. All publications are full economic evaluation studies, one cost-effectiveness, three cost-utility, and four cost-minimization analyses. The costs of strategies using EBUS-TBNA were lower than the ones using mediastinoscopy in all studies analyzed. Two of the best quality scored studies demonstrate that the mediastinoscopy strategy is dominated by the EBUS-TBNA strategy. Information gathered in the eight studies of this systematic review suggest that EBUS is cost-effective compared to mediastinoscopy for mediastinal staging of lung cancer.

An International Survey of Mediastinal Staging Practices amongst Interventional Bronchoscopists

Introduction: In potentially curable non-small-cell lung cancer, different practice guidelines recommend invasive me­diastinal staging in tumors larger than 3 cm, central, or hy­permetabolic N1 lymph nodes. There is no consensus concerning the use of an endosonographic procedure or a mediastinoscopy in the first line in patients with a radiologically normal mediastinum, while in case of a mediastinal involvement, the latest European guidelines recommend the combination of endobronchial ultrasound (EBUS) and endoscopic ultrasound/endoscopic ultrasound with EBUS endoscope (EUS/EUS-B), using a systematic endosonographic procedure. This international survey was conducted to describe current medical practices in endoscopic mediastinal staging amongst interventional bronchoscopists. Methods: A survey was developed and sent to all members of different interventional pulmonology societies, with the purpose to describe who, when and how an endoscopic mediastinal staging was performed. Results: One hundred and fifty-three bronchoscopists responded to the survey. Most of them practiced in Europe (n = 84, 55%) and North America (n = 52, 34%). In the first line, EBUS alone was the most widely used endoscopic procedure for mediastinal staging. Half of the responders performed a systematic endoscopic staging procedure, including a systematic examination of all accessible nodal stations and a sampling of all lymph nodes >5 mm in the short axis at each station. A higher proportion of bronchoscopists who have completed a dedicated fellowship program performed systematic endoscopic mediastinal staging. Few endoscopists routinely perform combined EBUS/EUS(-B) for mediastinal staging and use the combination only in selected cases. Conclusion: There are several areas of divergence between published guidelines and current practices reported by interventional bronchoscopists. EBUS alone is the most widely used endoscopic procedure for mediastinal staging in lung cancer, and a combined endoscopic approach is frequently omitted by the responders. A fellowship program appears to be associated with a higher rate of systematic endoscopic staging procedures.

Next-generation sequencing for genetic analysis of endobronchial ultrasound transbronchial needle aspiration samples in advanced lung cancer.

e15586 Background: Next-generation sequencing (NGS) typically requires greater quantities of DNA than traditional molecular testing. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) is a minimally invasive technique with high sensitivity in the mediastinal staging of lung cancer. This study aimed to evaluate the adequacy of EBUS-TBNA in providing adequate size specimens for genetic mutations and immunotherapy biomarkers analysis in patients with lung cancer. Methods: Tissue samples from patients with advanced lung cancer were collected by EBUS-TBNA and were formalin-fixed paraffin-embedded. NGS assay was carried on with acornmed panel including 808 genes. PD-L1 expression through immunohistochemistry was assessed. Results: A total of 98 patients was enrolled, of which 74 (76%) were adenocarcinoma and 20 (20%) were squamous cell carcinomas. Among the patients, 108 samples (including multipoint puncture of different location and retest of the same patient) were obtained. NGS assay was completed successfully on 106 of the 108 samples (98.14%), and 97.96% of patients had successful testing, identifying an average of 11.3 mutations. With a multi-gene panel comprising up to 808 tumor related genes, actionable variations were found in 93 (86%) samples. Of these, the positive rates of actionable alterations in lung adenocarcinoma samples and lung squamous cell carcinoma samples were 90% and 79%, respectively. The tumor mutation burden (TMB), Microsatellite instability (MSI) and PD-L1 expression were found High in 20 (41%), 1 (2%), and 37 (72%) patients respectively. Conclusions: NGS assay can be successfully conducted with tissue samples obtained from EBUS-TBNA. NGS assay provides more comprehensive information on genetic mutations in tumors, which greatly assists therapeutic decision making for advanced lung cancer.

Impact of an Onsite Endobronchial Ultrasound Program on the Time to Treatment of Cancer in Veterans

Endobronchial ultrasound (EBUS) is commonly employed in the diagnostic evaluation of pulmonary nodules and for mediastinal staging of lung cancer. We hypothesized that the establishment of an onsite EBUS program would decrease the time to the diagnosis and treatment of detected malignancy in veterans seen in a dedicated pulmonary nodule clinic.

Endobronchial ultrasound elastography for diagnosing mediastinal and hilar lymph nodes

BackgroundThe main objective was to analyze the technical variability of EBUS-elastography in the differentiation of benign and malignant hilar and mediastinal lymph nodes. As a secondary objective, the results of the EBUS-elastography in said differentiation were analyzed, comparing them with the anatomopathological results. MethodsProspective and analytical study of lymph nodes in which EBUS-elastography was performed. Elastographic variables and their variability were analyzed. Results24 patients and 38 lymph nodes were evaluated. Of these, 60.5 % had a history of neoplasia, 71 % of them were EBUS-elastography with diagnostic intention, 53 % were mediastinal staging of lung cancer. Both procedures were performed in 25 % of the patients. Lymph nodes were classified into elastographic colour patterns, red being characteristic of elastic tissues and blue of rigid tissues. The lymphadenopathies with apredominantly blue pattern were associated with an anatomopathological result of malignancy (86 % vs 14 %, OR 20.4 (3.1–245.1) p-value = .00015). Malignant lymph nodes presented less colour dispersion in the frequency histograms and a higher ratio of blue pixels and higher strain ratio. These variables showed a variability of 8.7 %, 9.9 % and 31.6 % respectively in repetitions in the same adenopathy. Finally, a 66 % of consistency was obtained in the event of colour pattern variability (p 0.0000). ConclusionEBUS-elastography is feasible during EBUS and may be helpful in predicting malignant lymph node infiltration. The quantitative elastographic data show low variability in repetitions in the same adenopathy. The strain ratio is the most variable elastographic parameter.

Mediastinal staging: when and how?

Mediastinal staging for lung cancer includes both the assessment of mediastinal lymph nodes status before treatment and the postoperative pathological staging obtained by lymph-node removal performed during surgery. In patients with early stage NSCLC, the aim is to exclude with the highest certainty and the lowest morbidity the presence of mediastinal node involvement. Before treatment, mediastinal staging is based on imaging techniques, endoscopic techniques, and surgical procedures. Final pathological staging is based on lymph-node removal performed with lung resection according with different modalities (sampling, systematic dissection, etc.) and various approaches (thoracotomy, VATS, robotic). Data and indications from literature evidences are reported and discussed.

Endobronchial ultrasound-guided transbronchial needle aspiration versus mediastinoscopy for mediastinal staging of lung cancer: A protocol for a systematic review of economic evaluation studies.

Background:Lung cancer is a major health problem, with estimates of 1.6 million tumor-related deaths annually worldwide. The emergence of endobronchial ultrasound (EBUS), a minimally invasive procedure capable of providing valuable information for primary tumor diagnosis and mediastinal staging, significantly changed the approach of pulmonary cancer, becoming part of the routine mediastinal evaluation of lung cancer in developed countries. Some economic evaluation studies published in the last 10 years have already analyzed the incorporation of the EBUS technique in different health systems. The aim of this systematic review is to synthesize the relevant information brought by these studies to better understand the economic effect of the implementation of this staging tool.Methods:The systematic review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Eletronic databases (Medline, Lilacs, Embase, Cochrane Library of Trials, Web of Science, Scopus, National Health System Economic Evaluation Database) will be searched for full economic analyses regarding the use of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) compared to the surgical technique of mediastinoscopy for the mediastinal staging of lung cancer. Two authors will perform the selection of studies, data extraction, and the assessment of risk of bias. Occasionally, a senior reviewer will participate, if necessary, on study selection or data extraction.Results:Results will be published in a peer-reviewed journal.Conclusion:This review may influence a more cost-effective mediastinal staging approach for patients with lung cancer around the world and help health decision makers decide whether the EBUS-TBNA technique should be incorporated into their health systems and how to do it efficiently.Protocol Registry:PROSPERO 42019107901.

Elastografía asociada a la ecografía endobronquial en el estudio de adenopatías hiliares y mediastínicas

IntroductionThe main objective was to analyze the technical variability of EBUS-elastography in the differentiation of benign and malignant hilar and mediastinal lymph nodes. As a secondary objective, the results of the EBUS-elastography in said differentiation were analyzed, comparing them with the anatomopathological results. Material and MethodsProspective and analytical study of lymph nodes in which EBUS-elastography was performed. Elastographic variables and their variability were analyzed. Results24 patients and 38 lymph nodes were evaluated. Of these, 60.5% had a history of neoplasia, 71% of them were EBUS-elastography with diagnostic intention, 53% were mediastinal staging of lung cancer. Both procedures were performed in 25% of the patients. Lymph nodes were classified into elastographic colour patterns, red being characteristic of elastic tissues and blue of rigid tissues. The lymphadenopathies with apredominantly blue pattern were associated with an anatomopathological result of malignancy (86% vs. 14%, OR 20.4 (3.1 -245.1) p-value = .00015). Malignant lymph nodes presented less colour dispersion in the frequency histograms and a higher ratio of blue pixels and higher strain ratio. These variables showed a variability of 8.7, 9.9 and 31.6% respectively in repetitions in the same adenopathy. Finally, a 66% of consistency was obtained in the event of colour pattern variability (p .0000). ConclusionsEBUS-elastography is feasible during EBUS and may be helpful in predicting malignant lymph node infiltration. The quantitative elastographic data show low variability in repetitions in the same adenopathy. The strain ratio is the most variable elastographic parameter.

Impact of an Onsite Endobronchial Ultrasound Program on the Time to Treatment of Cancer in Veterans

Endobronchial ultrasound (EBUS) is commonly employed in the diagnostic evaluation of pulmonary nodules and for mediastinal staging of lung cancer. We hypothesized that the establishment of an onsite EBUS program would decrease the time to the diagnosis and treatment of detected malignancy in veterans seen in a dedicated pulmonary nodule clinic. We conducted a retrospective chart review of patients seen at the Baltimore Veterans Affairs Medical Center (BVAMC) pulmonary nodule clinic and required diagnostic evaluation. One hundred and fifty consecutive patients before and after implementation of an onsite EBUS program were screened. Forty-nine patients from the pre-intervention group and 41 patients from the post-intervention group underwent diagnostic evaluation and were included in study analyses. There was no significant difference in the median number of days between CT chest and initial visit to the BVAMC Lung Mass Clinic (22 vs. 14 days, P = 0.06), CT chest to diagnostic procedure (47.5 vs. 37 days, P = 0.33), and CT chest to initial treatment of detected malignancy (103 vs. 88 days, P = 0.15). There was no significant difference in the lung cancer stages or 1-year mortality between groups. A total of 76 barriers to care were identified among the 90 patients. There was a trend towards improving the time from the initial CT chest to the treatment of cancer with onsite availability of EBUS. More efforts need to be done to decrease the modifiable barriers to treatment to improve the overall lung cancer care for veterans.

The value of mediastinoscopy in N staging of clinical N2 lung cancer.

BackgroundTo determine the value of mediastinoscopy in N staging of lung cancer with clinical N2 disease.MethodsWe retrospectively reviewed 87 patients who received mediastinoscopy for known or suspected lung cancer, including 83 cervical mediastinoscopies and 4 parasternal mediastinoscopies. All patients were clinically staged N2 for enlarged ipsilateral mediastinal and/or subcarinal lymph nodes (short axis >1.0 cm) on computed tomography scan.ResultsOf the 87 patients, 61 cases proved to be N2 disease by mediastinoscopy; the other 26 mediastinoscopy-negative patients underwent thoracotomy for lung resection and mediastinal lymph node dissection in the same operation. Final pathologic N staging was consistent with mediastinoscopic sampling and surgical dissection in 24 patients, and N2 disease was found in 2 patients (false-negative by mediastinoscopy). The sensitivity, specificity, and accuracy of mediastinoscopy were 96.8%, 100%, and 97.7%, respectively. Among all 87 mediastinoscopic procedures, there was no mortality and only 1 complication (1.1%).ConclusionsMediastinoscopy is a highly effective and safe procedure for the mediastinal staging of lung cancer with clinical N2 disease.