Staging Of Bronchogenic Carcinoma Research Articles

Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer

Background. Esophageal endoscopic ultrasonographic (EUS) guidance fo fine-needle aspiration (FNA) of mediastinal lymph nodes has been introduced only recently. The utility of EUS/FNA in diagnosing and staging bronchogenic carcinoma is unknown. Methods. After a thoracic computed tomographic scan, 27 patients with known or suspected lung cancer underwent EUS. Accessible abnormal mediastinal lymph nodes were aspirated under EUS guidance. Patients with positive cytologic studies did not undergo further testing, whereas the remaining patients underwent mediastinal exploration. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for both chest computed tomography and EUS/FNA. Results. Twenty-two of 27 patients had mediastinal adenopathy by computed tomography scan. Sixteen patients had positive findings on EUS, 15 with positive FNA (10 non-small cell lung cancer; 5 small cell lung cancer) and 1 with T4 status. Fourteen patients with positive FNA had lymph nodes samples at level 5, level 7, or both. Of 11 patients with negative EUS/FNA, 2 had positive findings at operation (sensitivity 89%). The diagnosis of lung cancer was established in 7 patients. Conclusions. The results showed that EUS/FNA improves the accuracy of computed tomographic scan in the staging of lung cancer. By accessing lymph nodes at levels 5 and 7, EUS/FNA complements mediastinoscopy and is considered the staging modality of choice in these regions. Positive EUS/FNA can obviate the need for further invasive staging.

The staging of lung cancer by bronchoscopic transbronchial needle aspiration: Harrow EM, Wang KP. 3001 South Hanover Street, Baltimore, MD 21225. Chest Surg Clin North Am 1996;6:223–225

The development of flexible transbronchial needles for hilar and mediastinal aspiration had made possible noninvasive staging at the time of the initial diagnostic bronchoscopic examination. Combining the specificity of TBNA with the sensitivity of thoracic CT scanning greatly enhances the utility of this procedure. A bronchoscopically oriented staging system that utilizes the complementary advantages of both of these techniques is outlined. The staging of bronchogenic carcinoma by TBNA is a safe and cost-effective technique that can be routinely utilized to stage lung cancer. Ultimately, its value will depend upon whether the initial encouraging reports of its use can be reproduced by bronchoscopists in practice.

Hypertrophic osteoarthropathy in staging skeletal scintigraphy for lung cancer

To assess the prognostic significance of hypertropic osteoarthropathy (HOA) discovered on routine staging bone scintigraphy in patients with lung cancer. Between 1989 and 1992 all 99mTc-MDP bone scintigrams performed for the staging of bronchogenic carcinoma were reviewed. HOA was diagnosed by the observation of cortical/periosteal increased uptake in the extremities of the long bones. Follow-up and confirmation of the diagnosis was obtained by hospital computer, histology records, operative records, patient notes and radiological data where available. 164 staging scintigrams for lung cancer were identified. Twenty-eight patients (17%) were observed to have HOA. Patients with and without HOA were well matched for age and sex. There was little difference in the distribution of cell type but the HOA groups has a greater incidence of peripheral tumours. There was no significance in survival between the two groups. Two of three long-term survivors had clinically overt HOA and one presented with arthralgia. HOA is often seen on skeletal scintigraphy for staging of lung cancer and has no prognostic significance. The data also support current teaching that a high index of suspicion for HOA, as a cause of arthralgia may lead to early diagnosis of a potentially resectable lung carcinoma.

Photodynamic therapy for early stage bronchogenic carcinoma.

Photodynamic therapy utilizing Photofrin has proved to be an effective modality that can be used in the treatment of a wide variety of solid tumors and luminal cancers. The effectiveness of photodynamic therapy (PDT) was demonstrated in our institution in 1980 for the treatment of lung cancers, and increasing attention has been focused on this new treatment technique. Over the past decade, 240 patients (283 lesions) with central type lung cancers have been treated in our hospital. Overall complete remission was obtained in 39.6% of the 112 lesions, partial remission in 59.4%, and no remission was obtained in 1.0%. However, among 95 early stage lesions, CR was obtained in 79 (83.2%) and 71 cases were disease free at 3 to 176 months. We conclude that PDT is efficacious in the treatment of superficial lung cancer where complete remission may be achieved.

Diagnosis and staging of bronchogenic carcinoma by transtracheal and transbronchial needle aspiration

Diagnosis and staging of bronchogenic carcinoma by transtracheal and transbronchial needle aspiration

Endoscopic ultrasound with fine-needle aspiration in the Diagnosis and staging of lung cancer

Esophageal endoscopic ultrasonographic (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has been introduced only recently. The utility of EUS/FNA in diagnosing and staging bronchogenic carcinoma is unknown. After a thoracic computed tomographic scan, 27 patients with known or suspected lung cancer underwent EUS. Accessible abnormal mediastinal lymph nodes were aspirated under EUS guidance. Patients with positive cytologic studies did not undergo further testing, whereas the remaining patients underwent mediastinal exploration. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for both chest computed tomography and EUS/FNA: Twenty-two of 27 patients had mediastinal adenopathy by computed tomography scan. Sixteen patients had positive findings on EUS, 15 with positive FNA (10 non-small cell lung cancer; 5 small cell lung cancer) and 1 with T4 status. Fourteen patients with positive FNA had lymph nodes sampled at level 5, level 7, or both. Of 11 patients with negative EUS/FNA, 2 had positive findings at operation (sensitivity 89%). The diagnosis of lung cancer was established in 7 patients. The results showed that EUS/FNA improves the accuracy of computed tomographic scan in the staging of lung cancer. By accessing lymph nodes at levels 5 and 7, EUS/FNA complements mediastinoscopy and is considered the staging modality of choice in these regions. Positive EUS/FNA can obviate the need for further invasive staging.

Transbronchial Needle Aspiration in the Staging of Bronchogenic Carcinoma

To evaluate the usefulness of transbronchial needle aspiration biopsy (TBNA) for the diagnosis of mediastinal involvement, we have prospectively examined 316 patients with morphologically verified bronchogenic carcinoma. The percentage of positive aspirations (149 of 316) from the three basic lymph node groups in the mediastinum was not significantly different. Tumor cells were aspirated from the mediastinum in 75 of 112 patients with radiologically positive findings and in patients with 74 of 204 radiologically negative findings. Mediastinal involvement was verified even in 61 of 196 patients with a normal endoscopic picture. Metastases were proved in 14 of 39 patients with peripheral versus 135 of 277 patients with central carcinoma. Tumor cells were aspirated in 47 of 76 patients with undifferentiated small cell carcinoma, 92 of 227 patients with squamous cell carcinoma, and 10 of 13 patients with adenocarcinoma. Our results suggest that TBNA being a highly diagnostic and less invasive method, will prove its clinical importance.

Transbronchial fine needle aspiration in clinical practice

We review our experience of transbronchial fine needle aspiration (TBFNA) over a 3-year period. A total of 112 TBFNAs were performed on 95 patients. Four aspirates were from peripheral lung lesions, 20 from non-ulcerated submucosal infiltrative lesions, 19 from mediastinal abnormalities close to the tracheobronchial tree, and the remaining 69 were for staging of bronchogenic carcinoma with apparent mediastinal lymph node spread, evaluated by chest computed tomography (CT). In the 20 submucosal lesions TBFNA reached a sensitivity of 82.3%, providing the only evidence of a malignant process in five cases. With respect to the 19 mediastinal lesions arising in close proximity to the central airways, TBFNA permitted a diagnosis in cases that would otherwise have required more invasive procedures, although the diagnostic sensitivity of the technique in this group of patients was poor (26%). In the mediastinal staging group, the sensitivity was 76.9%, with no false positive results. Complete sensitivity of TBFNA for the detection of disease was 65.8%. We conclude that TBFNA is a reliable and low risk procedure.

Diagnosis and staging of bronchogenic carcinoma by transtracheal and transbronchial needle aspiration

Transbronchial needle aspiration (TBNA) has been used in diagnosis and staging of bronchogenic carcinoma. However, its true effectiveness seems uncertain and some models of needles are expensive. The aim of this study was to procure new experiences on this method. TBNA was performed in 194 patients with bronchogenic carcinomas. Two models of cheap, re-usable, cytological needles were used. In diagnostic application, TBNA was positive in 34 of 39 (87%) central tumors and in 31 of 45 (69%) peripheral nodules or masses. In 19 patients, TBNA was the only positive sample. In staging application, TBNA was positive in 41 of the 90 cases (46%) in which the spread of the tumor compressed the wall of the airway. When the trachea or bronchus was endoscopically normal at the site of the puncture, TBNA was only positive in 3 of 20 cases (15%). These results suggest that TBNA is effective as a diagnostic tool. However, it appears to be less effective in staging, where the attainment of a good yield with TBNA probably demands a positive computed tomography and the use of a histological needle.

Staging of Bronchogenic Carcinoma by Bronchoscopy

1994;106;588-593 Chest Ko-Pen Wang Bronchoscopy Staging of Bronchogenic Carcinoma by http://chestjournal.chestpubs.org/content/106/2/588.citation services can be found online on the World Wide Web at: The online version of this article, along with updated information and ISSN:0012-3692 ) http://chestjournal.chestpubs.org/site/misc/reprints.xhtml ( prior written permission of the copyright holder. this article or PDF may be reproduced or distributed without the Dundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright1994by the American College of Chest Physicians, 3300 Physicians. It has been published monthly since 1935. is the official journal of the American College of Chest Chest

POSITRON EMISSION TOMOGRAPHY IMAGING OF THE THORAX

Positron emission tomography (PET) is just beginning to emerge as a clinically useful tool in the thorax. Imaging with FDG is used primarily to differentiate benign from malignant abnormalities, including solitary pulmonary nodules, staging bronchogenic carcinoma, and differentiating recurrent tumor from fibrosis following treatment. This article discusses the fundamental properties of PET images, techniques, and current clinical indications in the thorax.

Positron emission tomography for improved staging of bronchogenic carcinoma : Knopp M.V., Bischoff H. b, Mangeold C. b, Delorme S., Lorenz W.J., Vogt-Moykopf I. b, Drings P. b, van Kaick G. German Cancer Research Center (dkfz), bThoraxklinik Heidelberg-Rohrbach, Heidelberg, Germany

Positron emission tomography for improved staging of bronchogenic carcinoma : Knopp M.V., Bischoff H. b, Mangeold C. b, Delorme S., Lorenz W.J., Vogt-Moykopf I. b, Drings P. b, van Kaick G. German Cancer Research Center (dkfz), bThoraxklinik Heidelberg-Rohrbach, Heidelberg, Germany

Extended cervical mediastinoscopy: Prospective study of fifty cases

To assess the usefulness of extended cervical mediastinoscopy (ECM) in the staging of bronchogenic carcinoma, an ECM was performed prospectively in 50 patients with bronchogenic carcinoma of the left lung. The ECM was used after evaluation of disease operability and computed tomographic findings, and was performed simultaneously with standard cervical mediastinoscopy. In ECM, using the same cervical incision as in a standard cervical mediastinoscopy, dissection is performed behind the anterior face of the sternum. The aortic arch is reached at the level of the origin of the innominate artery. The mediastinoscope is then passed by sliding it along the left anterolateral face of the aortic arch until it reaches the aortopulmonary window. Extended cervical mediastinoscopy was considered positive when a nodal biopsy result consistent with a neofomative process or direct invasion of the mediastinal structures was found. Four patients with positive standard cervical mediastinoscopy and negative ECM were excluded. A false negative ECM was defined as the presence of infiltrated adenopathies at the paraaortic level detected on postoperative histologic study. The ECM was positive in 5 patients in whom operation was contraindicated. Resectability in the remaining 41 patients was 97.6%. Postoperative pathologic study showed infiltrated adenopathy in 3 patients (2 subcarinal, 1 subaortic) accounting for 40 true negatives (the subtarinal group is inaccessible by ECM). This study suggests that ECM has outstanding specificity (100%), sensitivity of 83.3%, and a diagnostic accuracy of 97.8%. A positive predictive value of 100% and a negative predictive value of 97.5% were also identified by this study. We conclude that ECM is a useful technique to assess involvement of the aortopulmonary window in the preoperative staging of bronchogenic carcinoma of the left lung.

CT-guided biopsy of adrenal masses in preoperative management of bronchogenic carcinoma

Discovery of an adrenal mass in a patient with a bronchogenic carcinoma requires assessment of the histological type in order to choose the best treatment. Over the past 6 years unilateral (n -23) or bilateral (n-6) adrenal masses were discovered using computed tomography (CT) in 29 patients during staging of bronchogenic carcinoma. CT-guided biopsy was performed in all eases and diagnosed metastases in 14 patients and benign adenomas in 12, as well as 3 false-negative results (89 % accucaracy). Minor complications occurred in 3 cases. Metastases were more frequent from adenocarcinoma (10 of 11) than from squamous-cell carcinoma (4 of 12) and undifferentiated carcinoma (3 of 6). CT-guided biopsy is a fairly reliable method to distinguish metastases from benign adenomas.

Staging of bronchogenic carcinoma.

Both computed tomography (CT) and magnetic resonance imaging (MRI) can provide important information not obtainable by chest radiography regarding staging of patients with bronchogenic carcinoma. However, while CT and MRI can both detect enlarged mediastinal nodes, this only approximately indicates tumor involvement. For example, enlarged nodes do not necessarily contain tumor, so biopsy is necessary before declaring the patient inoperable. As well, normal-sized nodes may contain tumor, and whether mediastinoscopy is required in such situations is controversial. Similarly, neither MRI nor CT is highly accurate in detecting mediastinal or chest-wall involvement, although certain specific features can occasionally be highly predictive of invasion.

The Role of Transcarinal Needle Aspiration in the Staging of Bronchogenic Carcinoma

Metastatic spread to subcarinal lymph nodes in patients with bronchogenic carcinoma generally indicates unresectability. Transcarinal needle aspiration of the main carina (TCNA) has been used to obviate the need for more invasive procedures, particularly thoracic surgery. Of 510 transbronchial needle aspirations performed at our institution from 1983 to 1991, 88 (17 percent) were from the main carina in patients with bronchogenic carcinoma. We reviewed these 88 TCNA procedures to assess our experience with TCNA in the staging of lung cancer. The TCNA results were positive in 32 of 88 (36 percent) patients (20 non-small-cell cancers, 12 small-cell lung cancers). Following bronchoscopy, TCNA was the only evidence of unresectability in all 20 patients with non-small-cell lung cancer and was the only mode of diagnosis in 5 of 12 (42 percent) patients with small-cell lung cancer. Thirteen patients with non-small-cell lung cancer and positive TCNA also had positive bronchial secretion cytologic studies. Five of these patients had further subcarinal sampling and in all cases metastatic involvement was confirmed. TCNA was positive in 29 of 67 (43 percent) patients with radiographic evidence of mediastinal adenopathy. Of the remaining 38 patients with radiographic evidence of mediastinal adenopathy and negative TCNA results, 23 patients had further mediastinal sampling with mediastinoscopy or thoracotomy and in all cases mediastinal spread of cancer was established. Nineteen of 58 (33 percent) patients with an endoscopically normal-appearing main carina had a positive TCNA, while 13 of 30 (43 percent) patients with broadening or widening of the main carina had positive TCNA results. There were no complications. We conclude that TCNA is often a safe and useful staging modality in patients with bronchogenic carcinoma.

Thoracoscopic mediastinal lymph node sampling: Useful for mediastinal lymph node stations inaccessible by cervical mediastinoscopy

Cervical mediastinoscopy is useful for the diagnosis of paratracheal lymph node metastasis from bronchogenic carcinoma. Access to adenopathy in the aorticopulmonary window, anterior mediastinal, periazygos, and subcarinal lymph nodes is difficult with this technique. Operative visibility in these locations through anterior mediastinotomy, the Chamberlain procedure, is limited. We have used thoracoscopic mediastinal exploration in 40 patients with computed tomographic scan evidence of enlarged aorticopulmonary window (n = 30) or enlarged right periazygos or subcarinal lymph nodes (n = 10). This procedure was used primarily as an adjunct to cervical mediastinoscopy in the staging of bronchogenic carcinoma. Adjunctive thoracoscopic nodal sampling was 100% sensitive and 100% specific in diagnosing the mediastinal adenopathy. It did not significantly delay thoracotomy in cases of benign adenopathy. Visibility of the ipsilateral pleural space and mediastinum was excellent. Thoracoscopic exploration with mediastinal nodal sampling is a valuable diagnostic adjunct for assessment of adenopathy inaccessible to cervical mediastinoscopy and can overcome many of the limitations of anterior mediastinotomy.

The Relationship of Clinical Findings to CT Scan Evidence of Adrenal Gland Metastases in the Staging of Bronchogenic Carcinoma

To determine whether, during the staging of newly diagnosed bronchogenic carcinoma, clinical indicators predict the presence or absence of adrenal metastases detected by computerized tomographic (CT) scans. Retrospective review of charts and roentgenograms. Academic medical center. Two hundred five consecutive patients diagnosed with bronchogenic carcinoma, of whom 173 had sufficient data available for analysis. Charts were reviewed for abnormalities in three clinical categories (signs, symptoms, and routine laboratory tests) and the presence of extrapulmonary tumor spread. The CT scans were reviewed for evidence of adrenal involvement by radiologists blinded to clinical findings. Thirty patients had abnormal adrenal glands on CT scan. In 26 the abnormality was believed to represent adrenal metastasis, whereas in four the CT findings were consistent with adrenal adenomas. The frequency of adrenal metastases varied with the number of positive, clinical findings (chi 2 = 105.4; p < 0.001). All 26 patients with adrenal metastases had at least one clinical abnormality, and 21 (81 percent had abnormalities in either two or all three clinical categories. In 40 patients without any clinical indicators of widespread disease, none had CT evidence of adrenal metastases. The presence of adrenal metastases also varied with the extent of coexistent disease (chi 2 = 111.82; p < 0.001). Eighty-one percent (21) of the patients with and 18 percent of those without adrenal metastases had both intrathoracic and extrathoracic involvement. Our findings indicate that adrenal metastases are found in patients with a large tumor burden who have clinical indicators of widespread disease. We found no evidence of adrenal metastases by CT in any patient with a normal clinical evaluation. We conclude that CT scans through the adrenal glands are unnecessary when staging newly diagnosed bronchogenic carcinoma if the findings from the initial clinical evaluation are normal.

Thoracoscopic resection of 85 pulmonary lesions

Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (<3 cm) in the outer third of the lung. Patients with preoperative, histologic evidence of bronchogenic carcinoma were excluded unless there was impairment of cardiopulmonary function, advanced age, or concomitant extrathoracic malignancy. These thoracoscopic pulmonary resections were accomplished with the neodymium:yttriumaluminum garnet laser (31), endoscopic stapler (29), or both (25). The mean diameter of the lesions was 1.3 cm (range, 0.4 to 2.7 cm). There has been one late death (38th postoperative day) unrelated to the operation. Morbidity consisted of postoperative atelectasis (2), pneumonia (2), bleeding requiring transfusion (1), and bronchopleural fistula of greater than 7 days duration (3). There were no wound problems. The mean period of chest tube drainage was 3.3 ± 3.0 days. Mean postoperative stay was 5.7 ± 4.9 days. The pathologic diagnosis was benign disease in 28 patients (interstitial fibrosis/pneumonitis, 15; radiation fibrosis, 1; sclerosing hemangioma, 1; rheumatoid nodules, 1; granuloma, 2; nocardia, 1; infarct, 1; hamartoma, 4; scar, 1; cytomegalovirus pneumonia, 1), metastatic malignancy in 20 patients, and bronchogenic carcinoma in 13 patients. Five patients found at thoracoscopic pulmonary resection to have bronchogenic cancer had adequate pulmonary function and therefore underwent formal segmentectomy (3) or lobectomy (2). Thoracoscopic pulmonary resection was the only operation performed on patients with benign disease, patients with metastatic lesions, and selected patients with limited stage bronchogenic carcinoma at increased risk for thoracotomy. Continued success with thoracoscopic resection may have a significant impact on the operative management of carefully selected patients with peripheral pulmonary lesions.

Contrast-enhanced MRI for the staging of bronchogenic carcinoma: Comparison with CT and histopathologic staging— preliminary results : Stiglbauer R, Schurawitzki H, Klepetko W, et al. (Universitäts Klinik fur Radiodiagnostik, Universität Wien-AKH, Alserstrasse 4, A-1997 Vienna, Austria). Clin Radiol 1991;44:293–298

Contrast-enhanced MRI for the staging of bronchogenic carcinoma: Comparison with CT and histopathologic staging— preliminary results : Stiglbauer R, Schurawitzki H, Klepetko W, et al. (Universitäts Klinik fur Radiodiagnostik, Universität Wien-AKH, Alserstrasse 4, A-1997 Vienna, Austria). Clin Radiol 1991;44:293–298