Staging Of Non-small Cell Lung Cancer Research Articles

Investigating the influence of long-axial versus short-axial field of view PET/CT on stage migration in lymphoma and non-small cell lung cancer.

The objective of this study was to evaluate the influence of a long-axial field-of-view (LAFOV) on stage migration using a large single-centre retrospective cohort in lymphoma and non-small cell lung cancer (NSCLC). A retrospective study is performed for patients undergoing PET/computed tomography (CT) on either a short-axial field-of-view (SAFOV) or LAFOV PET/CT system for the staging of known or suspected NSCLC or for therapeutic response in lymphoma. The primary endpoint was the Deauville therapy response score for patients with lymphoma for the two systems. Secondary endpoints were the American Joint Committee on Cancer stage for NSCLC, the frequency of cN3 and cM1 findings, the probability for a positive nodal staging (cN1-3) for NSCLC and the diagnostic accuracy for nodal staging in NSCLC. One thousand two hundred eighteen records were screened and 597 patients were included for analysis ( N = 367 for lymphoma and N = 291 for NSCLC). For lymphoma, no significant differences were found in the proportion of patients with complete metabolic response versus non-complete metabolic response Deauville response scores ( P = 0.66). For NSCLC no significant differences were observed between the two scanners for the frequency of cN3 and cM1 findings, for positive nodal staging, neither the sensitivity nor the specificity. In this study use of a LAFOV system was neither associated with upstaging in lymphoma nor NSCLC compared to a digital SAFOV system. Diagnostic accuracy was comparable between the two systems in NSCLC despite shorter acquisition times for LAFOV.

The Utility of EBUS-Guided Transbronchial Forceps Biopsy With or Without an Electrocautery Knife for the Diagnosis of Mediastinal and Hilar Lymphadenopathy.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to have a high diagnostic yield for mediastinal and hilar lymph node sampling, particularly in diagnosing and staging non-small cell lung cancer. However, the diagnostic yield is lower in patients with granulomatous and lymphoproliferative disorders. We prospectively compared the feasibility, safety, and diagnostic yield of EBUS-guided lymph node forceps biopsy (EBUS-TBFB) with electrocautery knife compared to EBUS-TBNA of lymph nodes in patients with suspected granulomatous and lymphoproliferative disease. Patients over 18 years of age with mediastinal/hilar lymph node >10 mm in size in short axis (on CT chest) who had suspected sarcoidosis/lymphoma radiologically/clinically were included in the study. Patients had EBUS-TBNA first with 21 or 22G needles which were followed by biopsy of the node with small forceps (EBUS-TBFB) through the same aspiration site to obtain samples. Electrocautery knife at 20W was used in patients where mucosal penetration was difficult, followed by passage of forceps through that site. A total of 30 patients were enrolled in the study, of which 25 patients underwent EBUS-TBFB. Eight patients had a history of lymphoma, one patient had history of squamous cell carcinoma, and one patient had history of chronic lymphocytic leukemia. A 22 gauge needle was used for aspiration in all the cases that were performed, and 1.5 mm or 1.8 mm forceps were used for the biopsy.The use of electrocautery knife at 20W (Olympus America Inc.) was required in 10/25 patients.The EC knife allowed all 10 of those to have successful entry of forceps into the lymph node. The cytology (aspiration from EBUS needle) and histopathology (from forceps) were concordant in 17 patients while it was discordant in eight patients. One patient developed pneumomediastinum after needle and forceps biopsy that required no intervention. EBUS-guided forceps biopsy is a safe procedure. EC knife did successfully allow forceps entry into the lymph node in all EC knife procedures. The diagnostic yield was 73% (22/30) which improved to 86% (26/30) when both techniques were combined (TBNA and TBFB).

The lung cancers: staging and response, CT, 18F-FDG PET/CT, MRI, DWI: review and new perspectives.

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer deaths in both sexes combined. Recent years have seen major advances in the diagnostic and treatment options for patients with non-small-cell lung cancer (NSCLC), including the routine use of 2-deoxy-2[18F]-fluoro-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) in staging and response evaluation, minimally invasive endoscopic biopsy, targeted radiotherapy, minimally invasive surgery, and molecular and immunotherapies. In this review, the central roles of CT and 18F-FDG PET/CT in staging and response in both NSCLC and malignant pleural mesothelioma (MPM) are critically assessed. The Tumour Node Metastases (TNM-8) staging systems for NSCLC and MPM are presented with critical appraisal of the strengths and pitfalls of imaging. Overviews of the Response Evaluation Criteria in Solid Tumours (RECIST 1.1) for NSCLC and the modified RECIST criteria for MPM are provided, together with discussion of the benefits and limitations of these anatomical-based tools. Metabolic response assessment (not evaluated by RECIST 1.1) will be explored. We introduce the Positron Emission Tomography Response Criteria in Solid Tumours (PERCIST 1.0) to include its advantages and challenges. The limitations of both anatomical and metabolic assessment criteria when applied to NSCLC treated with immunotherapy and the important concept of pseudoprogression are addressed with reference to immune RECIST (iRECIST). Separate consideration is given to the diagnosis and follow up of solitary pulmonary nodules with reference to the British Thoracic Society guidelines and Fleischner guidelines and use of the Brock (CT-based) and Herder (addition of 18F-FDG PET/CT) models for assessing malignant potential. We discuss how these models inform decisions by the multidisciplinary team, including referral of suspicious nodules for non-surgical management in patients unsuitable for surgery. We briefly outline current lung screening systems being used in the UK, Europe and North America. Emerging roles for MRI in lung cancer imaging are reviewed. The use of whole-body MRI in diagnosing and staging NSCLC is discussed with reference to the recent multicentre Streamline L trial. The potential use of diffusion-weighted MRI to distinguish tumour from radiotherapy-induced lung toxicity is discussed. We briefly summarise the new PET-CT radiotracers being developed to evaluate specific aspects of cancer biology, other than glucose uptake. Finally, we describe how CT, MRI and 18F-FDG PET/CT are moving from primarily diagnostic tools for lung cancer towards having utility in prognostication and personalised medicine with the agency of artificial intelligence.

Prediction Models for Mediastinal Metastasis and Its Detection by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Potentially Operable Non-Small Cell Lung Cancer: A Prospective Study

Prediction models for mediastinal metastasis and its detection by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have not been developed using a prospective cohort of potentially operable patients with non-small cell lung cancer (NSCLC). Can mediastinal metastasis and its detection by EBUS-TBNA be predicted with prediction models in NSCLC? For the prospective development cohort, 589 potentially operable patients with NSCLC were evaluated (July 2016-June 2019) from five Korean teaching hospitals. Mediastinal staging was performed using EBUS-TBNA (with or without the transesophageal approach). Surgery was performed for patients without clinical N (cN) 2-3 disease by endoscopic staging. The prediction model for lung cancer staging-mediastinal metastasis (PLUS-M) and a model for mediastinal metastasis detection by EBUS-TBNA (PLUS-E) were developed using multivariable logistic regression analyses. Validation was performed using a retrospective cohort (n= 309) from a different period (June 2019-August 2021). The prevalence of mediastinal metastasis diagnosed by EBUS-TBNA or surgery and the sensitivity of EBUS-TBNA in the development cohort were 35.3%and 87.0%, respectively. In PLUS-M, younger age (< 60 years and 60-70 years compared with≥ 70 years), nonsquamous histology (adenocarcinoma and others), central tumor location, tumor size (> 3-5cm), cN1 or cN2-3 stage by CT, and cN1 or cN2-3 stage by PET-CT were significant risk factors for N2-3 disease. Areas under the receiver operating characteristic curve (AUCs) for PLUS-M and PLUS-E were 0.876 (95%CI, 0.845-0.906) and 0.889 (95%CI, 0.859-0.918), respectively. Model fit was good (PLUS-M: Hosmer-Lemeshow P= .658, Brier score= 0.129; PLUS-E: Hosmer-Lemeshow P= .569, Brier score= 0.118). In the validation cohort, PLUS-M (AUC, 0.859 [95%CI, 0.817-0.902], Hosmer-Lemeshow P= .609, Brier score= 0.144) and PLUS-E (AUC, 0.900 [95%CI, 0.865-0.936], Hosmer-Lemeshow P= .361, Brier score= 0.112) showed good discrimination ability and calibration. PLUS-M and PLUS-E can be used effectively for decision-making for invasive mediastinal staging in NSCLC. ClinicalTrials.gov; No.: NCT02991924; URL: www. gov.

Ratiometric electrochemical OR gate assay for NSCLC-derived exosomes

Non-small cell lung cancer (NSCLC) is the most common pathological type of LC and ranks as the leading cause of cancer deaths. Circulating exosomes have emerged as a valuable biomarker for the diagnosis of NSCLC, while the performance of current electrochemical assays for exosome detection is constrained by unsatisfactory sensitivity and specificity. Here we integrated a ratiometric biosensor with an OR logic gate to form an assay for surface protein profiling of exosomes from clinical serum samples. By using the specific aptamers for recognition of clinically validated biomarkers (EpCAM and CEA), the assay enabled ultrasensitive detection of trace levels of NSCLC-derived exosomes in complex serum samples (15.1 particles μL−1 within a linear range of 102–108 particles μL−1). The assay outperformed the analysis of six serum biomarkers for the accurate diagnosis, staging, and prognosis of NSCLC, displaying a diagnostic sensitivity of 93.3% even at an early stage (Stage I). The assay provides an advanced tool for exosome quantification and facilitates exosome-based liquid biopsies for cancer management in clinics.Graphical

Diagnostic Performance of Endosonography to Detect Mediastinal Lymph Node Metastasis in Patients with Radiological N1 Non-Small Cell Lung Cancer.

Guidelines recommend that non-small cell lung cancer (NSCLC) patients with suspected hilar lymph node (LN) metastases should undergo invasive mediastinal LN staging prior to surgical treatment via endosonography. We evaluated the diagnostic performance of endosonography for detecting occult mediastinal metastases (OMM) and determined the factors associated with OMM in NSCLC patients with radiological N1. Patients with confirmed primary NSCLC with radiological N1 who underwent endosonography for nodal staging assessment from January 2013 to December 2019 were retrospectively analyzed. The prevalence of OMM was found to be 83/279 (29.7%) and only 38.6% (32/83) were diagnosed via endosonography. However, five of them were confirmed as N3 by endosonography. The overall diagnostic sensitivity, negative predictive value, accuracy, and area under the curve of endosonography were 38.6%, 79.4%, 81.7%, and 0.69, respectively. In multivariable analysis, central tumor (adjusted odds ratio [aOR], 2.05; 95% confidence interval [CI], 1.15-3.68; p=0.016), solid tumor (aOR, 10.24; 95% CI, 1.32-79.49; p=0.026), and adenocarcinoma (aOR, 3.01; 95% CI, 1.63-5.55; p<0.001) were related to OMM in radiological N1 NSCLC patients. Although the sensitivity of endosonography for detecting OMM was only 40%, the prevalence of OMM was not low (30%) and some cases even turned out to be N3 diseases. Clinicians should be aware that OMM may be more likely in patients with central, solid, and adenocarcinomatous tumor when performing nodal staging in radiological N1 NSCLC via endosonography.

Uniportal VATS for Diagnosis and Staging in Non-Small Cell Lung Cancer (NSCLC)

Uniportal VATS has become an accepted approach in minimally invasive thoracic surgery since its first report for lobectomy in 2011. Since the initial restrictions in indications, it has been used in almost all procedures, from conventional lobectomies to sublobar resections, bronchial and vascular sleeve procedures and even tracheal and carinal resections. In addition to its use for treatment, it provides an excellent approach for suspicious solitary undiagnosed nodules after bronchoscopic or transthoracic image-guided biopsy. Uniportal VATS is also used as a surgical staging method in NSCLC due to its low invasiveness in terms of chest tube duration, hospital stay and postoperative pain. In this article, we review the evidence of uniportal VATS accuracy for NSCLC diagnosis and staging and provide technical details and recommendations for its safe performance for that purpose.

Factors contributing to discordance between clinical and pathological staging of operable non-small cell lung cancer

Background: Clinical staging of non-small cell lung cancer (NSCLC) by CT and PET, with or without endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes (EBUS-TBNA), is essential for prognostication and to direct treatment. Our study investigated the accuracy of clinical staging compared to definitive pathological staging. Methods: Retrospective audit of clinical and pathological staging of all surgical lung cancer cases 2016–present (484 cases). Results: Discordance of clinical and pathological TNM staging (excluding sub-staging) was identified in 93 (25.9%) cases where complete data was available. This included clinical understaging in 61 (17%) and N2 disease in 20 (5.6%) cases. EBUS-TBNA was performed in 14 of the cases with N2 disease, and in five of these cases, involvement of N2 nodes detected post-surgery had been called benign at EBUS-TBNA. Factors contributing to clinical understaging may include delays between clinical staging studies and surgery [CT: median 110 days (IQR 82.5-151), PET: 81 days (59–119), EBUS-TBNA 62 days (43–95)], with significantly longer delays evident during the COVID-19 pandemic. Conclusions: Improved technical quality of lung cancer clinical staging studies and hospital management workflows will potentially increase concordance between clinical and pathological staging of operable NSCLC, improving outcomes for early stage disease. My contribution to this work has focused on the 2022 cases, analysis of which has elucidated the impact of COVID-19 on the lung cancer staging process in comparison to pre-COVID results.

Discordance between clinical and pathologic staging and the timeliness of care of non-small cell lung cancer patients diagnosed with operable tumors.

This study was performed to evaluate concordance between clinical and pathologic staging of non-small cell lung cancer (NSCLC) in our hospital network. We retrospectively reviewed records of 417 patients with NSCLC who received curative surgery and whose pathology was evaluated in our hospital between 2016 and 2021. Cytology, tissue pathology, and associated clinical, surgical, and imaging information were retrieved from hospital digital records. The cohort included 214 female and 203 male patients aged 20.6-85.8 years. Median times among staging computed tomography and surgery (105 days [interquartile range (IQR) 77.0-143.0]), positron emission tomography and surgery (78.5 days [IQR 56.0-109.0]), and endobronchial ultrasound-guided transbronchial needle aspiration and surgery (59 days [IQR 42-94]) indicated that Australian guidelines of <42 days between original referral and commencement of treatment were not being met in the majority of cases. Discordance between clinical TNM (cTNM) and pathologic TNM staging was 25.9%, including 18.4% cases that were clinically understaged and two patients with undetected stage IVA disease. cTNM understaging was significantly associated with time between the final staging investigation and surgery (p=.023), pleural (p<.05) and vessel (p<.05) invasion, and diagnosis of high-grade adenocarcinoma (p=.001). Discordance between clinical and pathologic staging of NSCLC is associated with tumor histopathologic characteristics and treatment delays. Although tumor factors that lead to discordant staging cannot be controlled, reduced time to surgery may have resulted in better outcomes for some patients in this potentially curable lung cancer cohort.

Different Liquid Biopsies for the Management of Non-Small Cell Lung Cancer in the Mutational Oncology Era

In the last ten years, liquid biopsy has been slowly joining the traditional invasive techniques for the diagnosis and monitoring of tumors. Liquid biopsies allow easy repeated sampling of blood, reflect the tumor scenario, and make personalized therapy real for the patient. Liquid biopsies isolate and utilize different substrates present in patients' body fluids such as circulating tumor cells, circulating tumor DNA, tumor extracellular vesicles, etc. One of the most-used solid cancers in the development of the non-invasive liquid biopsy approach that has benefited from scientific advances is non-small cell lung cancer (NSCLC). Using liquid biopsy, it is possible to have more details on NSCLC staging, progression, heterogeneity, gene mutations and clonal evolution, etc., basing the treatment on precision medicine as well as on the screening of markers for therapeutic resistance. With this review, the authors propose a complete and current overview of all different liquid biopsies available to date, to understand how much has been carried out and how much remains to be completed for a better characterization of NSCLC.

Impact of Type 2 Diabetes Mellitus on the Prognosis of Non-Small Cell Lung Cancer

Type 2 diabetes mellitus (T2DM) is the most common metabolic disease and is characterized by sustained hyperglycemia. The impact of T2DM on the survival of lung cancer patients remains controversial. The aim of this study was to investigate the associations of type 2 diabetes with lung cancer mortality. From January 2019 to January 2020, 228 patients with non-small cell lung cancer (NSCLC) staging earlier than IIIA were included. In our study, we found that the overall survival (OS) and progression-free survival (PFS) of lung cancer patients with diabetes was longer than non-diabetes group. Diagnosed T2DM was associated with the prognosis of lung cancer after adjusting for age and covariates. The association between T2DM and OS was influenced by age, stage of cancer and cancer treatment, as well as whether taking metformin was associated with the OS of lung cancer. However, with the adjustment for age and covariates, the relation trended to lose statistical significance. T2DM is an independent prognostic factor for patients with NSCLC staging before IIIA. The patients with both NSCLC and T2DM trended to having a longer OS, possibly due to metformin.

Assessment of Tissue Adequacy by EBUS in Conjunction with PET Scan and Operator's Experience.

Mediastinal lymph node assessment is a crucial step in non-small cell lung cancer staging. Positron emission tomography (PET) has been the gold standard for the assessment of mediastinal lymphadenopathy, though it has limited specificity. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is quick, accurate, and a less invasive method for obtaining a diagnostic sample in contrast to mediastinoscopy. We performed a retrospective chart analysis of 171 patients to assess the adequacy of tissue obtained by EBUS for diagnosis and molecular profiling as well as the assessment of staging and lymph node (LN) stations diagnostic yield, in correlation to PET scan and the operator's level of experience. A significantly increased tissue adequacy was observed based on the operators' experience, with the highest adequacy noted in trained Interventional Pulmonologist (IP) (100%), followed by &gt;5 years of experience (93.33%), and 88.89% adequacy with &lt;5 years of experience (p = 0.0019). PET-CT scan 18F-fluorodeoxyglucose (FDG) uptake in levels 1, 2, and 3 LN had a tissue adequacy of 76.67%, 54.64%, and 35.56%, respectively (p = 0.0009). EBUS bronchoscopy method could be used to achieve an accurate diagnosis, with IP-trained operators yielding the best results. There is no correlation with PET scan positivity, indicating that both PET and EBUS are complementary methods needed for staging.

Pleural Contact in Clinical Early-Stage NSCLC: Recurrence Patterns and Survival

<h3>Purpose/Objective(s)</h3> Visceral pleural invasion is a pathologic finding utilized for non-small cell lung cancer (NSCLC) staging that portends worse outcomes. There have been efforts to evaluate the utility of radiographic pleural contact as a surrogate for pleural invasion for the purposes of clinical staging. These efforts have produced conflicting results. We sought to contribute to this growing body of data and hypothesized that our cohort would validate previous findings that pleural contact carries prognostic value in early-stage NSCLC treated with stereotactic radiotherapy (SBRT). <h3>Materials/Methods</h3> Following IRB approval, we retrospectively reviewed patients treated with SBRT between 2007 and 2019 at a single institution and identified those treated for early-stage (T1-3N0M0) NSCLC. We stratified this group into tumor with or without evidence of pleural contact on pre-treatment imaging, defined as visible direct abutment of the visceral pleura on computed tomography. We then analyzed the impact of the presence or absence of pleural invasion on treatment outcomes including in-field control (IFC), lobar control (LC), locoregional control (ipsilateral lung + regional nodes) (LRC), distant control (DC), and overall survival (OS). Outcomes were analyzed using the Kaplan Meier method and the influence of pleural contact was assessed with the log-rank method. <h3>Results</h3> We identified 217 courses of SBRT performed for early-stage NSCLC. Pre-treatment imaging was unavailable for review for 29, leaving 188 evaluable courses. The cohort included 149 T1, 29 T2, and 10 T3 tumors, of which 101 had radiographic evidence of pleural contact. Tumors were treated to a median of 50 Gy (range: 48-60) in a median of 4 fractions (range: 3-8). Median follow up was 39.4 months (range: 2.1-137 months). We evaluated cancer outcomes between those with pleural contact and those without and found statistically significant differences in 3-year IFC (85.2% vs 94.6%, p=0.0018), LC (83.0% vs 93.2%, p=0.017), LRC (74.6% vs 89.2%, p=0.03), and DC (76.9% vs 93.5%, p=0.004). Most notably, we found that pleural contact was associated with a significant decrease in 3-year OS (56.1% vs 77.1%, p<0.001). Tumors with pleural contact were larger (median 21 versus 15 mm; p<0.0001) as compared to those without. However, in the subgroup of T1 tumors, pleural contact remained predictive of IFC (p=0.015), DC (p=0.02) and OS (p=0.0004). <h3>Conclusion</h3> Radiographic pleural contact in clinical early-stage NSCLC treated with SBRT is associated with significantly higher locoregional and distant recurrence rates and decreased overall survival. There is growing evidence to suggest pleural contact is of prognostic significance and future studies should focus on ongoing validation in larger patient cohorts. If confirmed, patients with radiographic pleural contact could be considered for treatment intensification strategies.

Relationship between PLR and Clinicopathological Characteristics of Patients with Advanced NSCLC and Its Predictive Value for the Efficacy of Chemotherapy and Prognosis.

Objective To investigate the relationship between blood platelet-to-lymphocyte ratio (PLR) and clinicopathological characteristics of patients with advanced non-small cell lung cancer (NSCLC) and evaluate the value of PLR for predicting the efficacy of chemotherapy and prognosis. Methods The clinical data of 175 patients with advanced NSCLC diagnosed from March 2017 to December 2018 in our hospital were retrospectively analyzed, and the data of 175 healthy subjects from our hospital physical examinations were included. The platelet was detected by using a blood cell analyzer to calculate PLR. According to the average PLR value (197) before chemotherapy, 175 patients were divided into the low PLR group (=78) and the high PLR group (=97). The relationship between the expression levels of PLR and clinicopathologic features was analyzed, and the Kaplan–Meier survival curve was used to analyze the relationship between the expression levels of PLR and prognosis. Results The results showed that prechemotherapy PLR levels were significantly higher in NSCLC compared with the healthy subjects (P < 0.05). After 4 cycles of chemotherapy, the PLR levels were significantly lower than those during prechemotherapy (P < 0.05). The proportion of TNM (IV) stage cases in the low PLR group was lower than that in the high PLR group (P < 0.05). The total effective rate of the first-line chemotherapy was 46.9% (82/175). The effective rate of IIIb staging was higher than that in IV staging (P < 0.05), and the effective rate of the low PLR group was higher than that in the high PLR group (P < 0.05). Multivariate logistic analysis showed that TNM stage 4 and high PLR level were the independent risk factors for the efficacy of the first-line chemotherapy in patients with advanced NSCLC (P < 0.05), and the high PLR level was an independent risk factor affecting the prognosis of patients with advanced NSCLC. The median overall survival (OS) of patients with the low PLR group was 20.8 months, higher than the 12.0 months of patients with the high PLR group (P < 0.05). Conclusion PLR might have a certain clinical significance for predicting the TNM staging of NSCLC and can provide important diagnostic and prognostic results for patients.

Systematic endoscopic staging of mediastinum to determine impact on radiotherapy for locally advanced lung cancer (SEISMIC): protocol for a prospective single arm multicentre interventional study

BackgroundEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is established as the preferred method of mediastinal lymph node (LN) staging in non-small cell lung cancer (NSCLC). Selective (targeted) LN sampling is most commonly performed however studies in early stage NSCLC and locally advanced NSCLC confirm systematic EBUS-TBNA evaluation improves accuracy of mediastinal staging. This study aims to establish the rate of detection of positron emission tomography (PET)-occult LN metastases following systematic LN staging by EBUS-TBNA, and to determine the utility of systematic mediastinal staging for accurate delineation of radiation treatment fields in patients with locally advanced NSCLC.MethodsConsecutive patients undergoing EBUS-TBNA for diagnosis/staging of locally advanced NSCLC will be enrolled in this international multi-centre single arm study. Systematic mediastinal LN evaluation will be performed, with all LN exceeding 6 mm to be sampled by TBNA. Where feasible, endoscopic ultrasound staging (EUS-B) may also be performed. Results of minimally invasive staging will be compared to FDG-PET. The primary end-point is proportion of patients in whom systematic LN staging identified PET-occult NSCLC metastases. Secondary outcome measures include (i) rate of nodal upstaging, (ii) false positive rate of PET for mediastinal LN assessment, (iii) analysis of clinicoradiologic risk factors for presence of PET-occult LN metastases, (iv) impact of systematic LN staging in patients with discrepant findings on PET and EBUS-TBNA on target coverage and dose to organs at risk (OAR) in patients undergoing radiotherapy.DiscussionWith specificity of PET of 90%, guidelines recommend tissue confirmation of positive mediastinal LN to ensure potentially early stage patients are not erroneously denied potentially curative resection. However, while confirmation of pathologic LN is routinely sought, the exact extent of mediastinal LN involvement in NSCLC in patient with Stage III NSCLC is rarely established. Studies examining systematic LN staging in early stage NSCLC report a significant discordance between PET and EBUS-TBNA. In patients with locally advanced disease this has significant implications for radiation field planning, with risk of geographic miss in the event of PET-occult mediastinal LN metastases. The SEISMIC study will examine both diagnostic outcomes following systematic LN staging with EBUS-TBNA, and impact on radiation treatment planning.Trial registrationACTRN12617000333314, ANZCTR, Registered on 3 March 2017.

Radiotherapy improves the outcomes of immunotherapy with Sintilimab in non-small-cell lung cancer: A real-world analysis.

IntroductionRadiotherapy may augment systemic antitumor responses to immunotherapy. We did a retrospective study to infer whether radiotherapy improves outcomes to immunotherapy in patients with stage III and IV non-small-cell lung cancer (NSCLC).MethodsThis retrospective study conducted at Enze Medical Center enrolled 259 patients with histopathology confirmed NSCLC from December 2018 to December 31, 2021. All were treated with Sintilimab, some patients received radiotherapy at an appropriate time point. Radiation type includes conventional radiotherapy and stereotactic body radiotherapy. The progression-free survival (PFS), and overall survival (OS) were the primary endpoint.ResultsA retrospective analysis was performed on 259 patients, of whom 140 had been treated with immunotherapy lonely and 119 had been remedied with immunotherapy plus radiotherapy. Baseline variables were well balanced between the two groups, including gender, age, smoking status, TNM staging, number of metastases, ECOG score, pathological type and lines of previous systemic therapy. The median PFS in the immunotherapy alone group was 5.00 months (95%CI 4.38-5.62) versus immunotherapy plus radiotherapy was 9.00 months (5.95-12.05; p<0.001). The median OS in the immunotherapy alone group was 16.00 months (12.59-19.42) versus immunotherapy plus radiotherapy was 30.00 months (20.75-39.25; p=0.027). PFS was finer in the radiotherapy plus immunotherapy group than the immunotherapy group alone in both stage III(P=0.0069) and Stage IV(P=0.006) patients. In the univariate analysis, radiotherapy, male, ECOG=0 and <2 lines of previous systemic therapy were connected with an observably better PFS (P<0.001; P=0.03; P=0.002;P=0.021). In a multivariate analysis, radiotherapy, ECOG=0 and <2 lines of previous systemic therapy were independent prognostic factors with a markedly better PFS (P<0.001; P=0.006;P=0.009). An univariate analysis, radiotherapy, male, stage III, non-metastasis, ECOG=0 and squamous carcinoma were associated with a significantly better OS (P=0.032, P=0.036,P=0.002,P<0.001,P=0.002,P=0.025). A multivariate analysis, non-metastasis was a standalone prognostic indicator with a significantly better OS (P=0.006). However, radiotherapy was a tendency indicator with a better OS (HR0.70 95% CI 0.47-1.06). There were also no obvious increases in adverse events in the combination group.ConclusionsRadiotherapy with addition of immunotherapy was observably linked to a better outcome in patients with III and IV staging NSCLC.

EP16.03-022 Endobronchial Ultrasound Guided Transbronchial Needle Aspiration Sampling Is Sufficient for Lung Cancer Molecular Profiling

Molecular testing of non-small cell lung cancer (NSCLC) specimens for somatic gene alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies that are unlikely to provide clinical benefit. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique that is effective for diagnosis and staging NSCLC. Although several studies have shown two to six needle passes are sufficient for adequate molecular profiling, concern remains that EBUS-TBNA samples do not provide enough material.

MA04.07 A Controlled Study of Pathological T- staging and Imaging T-staging of NSCLC Based on Artificial Intelligence

The incidence of non-small cell lung cancer (NSCLC) currently ranks first in lung cancer, and accurate staging is the key to its prognosis. Multi-slice computed tomography (MSCT) is the preferred method for evaluating lung cancer staging, prognosis and efficacy. By measuring the maximum diameter of the tumor, more accurate preoperative imaging and clinical T staging can be made. In recent years, the rapid development of artificial intelligence (AI) has brought a lot of convenience to physicians in the automatic detection, measurement and risk assessment of pulmonary nodules.

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.

Mediastinal Staging with Endobronchial Ultrasound in Early-Stage Non—Small Cell Lung Cancer: Is It Necessary?

Herein we examine the need for minimally invasive mediastinal staging for patients with early-stage non-small cell lung cancer (NSCLC) using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Early NSCLC, stages 1 and 2, has a 5-year survival rate between 53 and 92%, whereas stages 3 and 4 have a 5-year survival of 36% and below. With more favorable outcomes in earlier stages, greater emphasis has been placed on identifying lung cancer earlier in its disease process. Accurate staging is crucial as it dictates both prognosis and therapy. Inaccurate staging can adversely impact surgical candidacy (if falsely "over-staged") or lead to inadequate treatment (if "under-staged"). Clinical staging utilizes noninvasive methods to evaluate the anatomic extent of disease; however, it remains controversial whether mediastinal staging of early NSCLC with radiological exams alone is sufficient. EBUS-TBNA has altered the landscape of invasive mediastinal staging and is a crucial component to improving confidence in lung cancer staging, specifically in early NSCLC. Radiographic occult lymph node metastasis identified upon review of surgical resection specimens of early NSCLC may support the argument to perform EBUS-TBNA in all cases of early-stage disease. Other data suggest that EBUS-TBNA could be spared in cases of peripheral cT1aN0 and cT1bN0 for which surgical resection with lymph node dissection is planned. By reviewing reported EBUS-TBNA outcomes in patients with early NSCLC, we aim to emphasize the necessity of staging with EBUS in this population.