Use of Imaging and Diagnostic Procedures After Low-Dose CT Screening for Lung Cancer.

BACKGROUND: Clinical trials have demonstrated a mortality benefit from lung cancer screening by low-dose CT (LDCT) in current or past tobacco smokers who meet criteria. Potential harms of screening mostly relate to downstream evaluation of abnormal screens. Few data exist on the rates outside of clinical trials of imaging and diagnostic procedures following screening LDCT. We describe rates in the community setting of follow-up imaging and diagnostic procedures after screening LDCT. METHODS: We used Clinformatics Data Mart national database to identify enrollees age 55 to 80 year who underwent screening LDCT from January 1, 2016, to December 31, 2016. We assessed rates of follow-up imaging (diagnostic chest CT scan, MRI, and PET) and follow-up procedures (bronchoscopy, percutaneous biopsy, thoracotomy, mediastinoscopy, and thoracoscopy) in the 12 months following LDCT for lung cancer screening. We also assessed these rates in an age-, sex-, and number of comorbidities-matched population that did not undergo LDCT to estimate rates unrelated to the screening LDCT. We then reported the adjusted rate of follow-up testing as the observed rate in the screening LDCT population minus the rate in the non-LDCT population. RESULTS: Among 11,520 enrollees aged 55 to 80 years who underwent LDCT in 2016, the adjusted rates of follow up 12 months after LDCT examinations were low (17.7% for imaging and 3.1% for procedures). Among procedures, the adjusted rates were 2.0% for bronchoscopy, 1.3% for percutaneous biopsy, 0.9% for thoracoscopy, 0.2% for mediastinoscopy, and 0.4% for thoracotomy. Adjusted rates of follow-up procedures were higher in enrollees undergoing an initial screening LDCT (3.3%) than in those after a second screening examination (2.2%). CONCLUSIONS: In general, imaging and rates of procedures after screening LDCT was low in this commercially insured population.

Management of Pleural Effusion After Mediastinoscopic Radical Esophagectomy.

BACKGROUND/AIM: Trans-hiatal and -cervical approach mediastinoscopic radical esophagectomy (TMrE) for esophageal cancers is a less-invasive procedure and does not require for trans-thoracic approach management. However, some patients suffer from pleural effusion after TMrE. In the present study, we investigated the clinicopathological factors of patients needing drainage of pleural effusion (DPE) after TMrE. PATIENTS AND METHODS: This study included 118 patients who underwent TMrE between 2010 and 2016. RESULTS: There were 43, 34 and 41 patients that underwent none, a single, and two or more DPEs respectively. Left-side DPE was significantly more frequent compared to right-side DPE. Change in the C-reactive protein (CRP) levels after surgery was significantly higher in patients with multiple DPEs than patients with none or a single DPE. The hospitalization days were significantly longer for patients with multiple DPEs. CONCLUSION: Pleural effusion accumulates due to continuous inflammation. Although a temporary DPE is sometimes performed, post-operative chest drainage tubes are not necessarily needed.

Computer Modeling to Evaluate the Impact of Technology Changes on Resident Procedural Volume.

BACKGROUND: As resident "index" procedures change in volume due to advances in technology or reliance on simulation, it may be difficult to ensure trainees meet case requirements. Training programs are in need of metrics to determine how many residents their institutional volume can support. OBJECTIVE: As a case study of how such metrics can be applied, we evaluated a case distribution simulation model to examine program-level mediastinoscopy and endobronchial ultrasound (EBUS) volumes needed to train thoracic surgery residents. METHODS: A computer model was created to simulate case distribution based on annual case volume, number of trainees, and rotation length. Single institutional case volume data (2011-2013) were applied, and 10 000 simulation years were run to predict the likelihood (95% confidence interval) of all residents (4 trainees) achieving board requirements for operative volume during a 2-year program. RESULTS: The mean annual mediastinoscopy volume was 43. In a simulation of pre-2012 board requirements (thoracic pathway, 25; cardiac pathway, 10), there was a 6% probability of all 4 residents meeting requirements. Under post-2012 requirements (thoracic, 15; cardiac, 10), however, the likelihood increased to 88%. When EBUS volume (mean 19 cases per year) was concurrently evaluated in the post-2012 era (thoracic, 10; cardiac, 0), the likelihood of all 4 residents meeting case requirements was only 23%. CONCLUSIONS: This model provides a metric to predict the probability of residents meeting case requirements in an era of changing volume by accounting for unpredictable and inequitable case distribution. It could be applied across operations, procedures, or disease diagnoses and may be particularly useful in developing resident curricula and schedules.

Variation in Definitive Therapy for Localized Non-Small Cell Lung Cancer Among National Comprehensive Cancer Network Institutions.

PURPOSE: This study determined practice patterns in the staging and treatment of patients with stage I non-small cell lung cancer (NSCLC) among National Comprehensive Cancer Network (NCCN) member institutions. Secondary aims were to determine trends in the use of definitive therapy, predictors of treatment type, and acute adverse events associated with primary modalities of treatment. METHODS AND MATERIALS: Data from the National Comprehensive Cancer Network Oncology Outcomes Database from 2007 to 2011 for US patients with stage I NSCLC were used. Main outcome measures included patterns of care, predictors of treatment, acute morbidity, and acute mortality. RESULTS: Seventy-nine percent of patients received surgery, 16% received definitive radiation therapy (RT), and 3% were not treated. Seventy-four percent of the RT patients received stereotactic body RT (SBRT), and the remainder received nonstereotactic RT (NSRT). Among participating NCCN member institutions, the number of surgeries-to-RT course ratios varied between 1.6 and 34.7 (P<.01), and the SBRT-to-NSRT ratio varied between 0 and 13 (P=.01). Significant variations were also observed in staging practices, with brain imaging 0.33 (0.25-0.43) times as likely and mediastinoscopy 31.26 (21.84-44.76) times more likely for surgical patients than for RT patients. Toxicity rates for surgical and for SBRT patients were similar, although the rates were double for NSRT patients. CONCLUSIONS: The variations in treatment observed among NCCN institutions reflects the lack of level I evidence directing the use of surgery or SBRT for stage I NSCLC. In this setting, research of patient and physician preferences may help to guide future decision making.

The role of mediastinoscopy in the diagnosis of thoracic disease: one-year single center experience.

Our experience of using mediastinoscopy for the diagnosis of enlarged mediastinal lymph nodes or mediastinal mass is presented in this study. We reviewed 54 consecutive patients (34 men and 20 women) with mediastinal pathology of varied etiologies who underwent a standard cervical mediastinoscopy from January to December 2012. The histological results were positive in 32 cases (59.2%), and negative in 22 cases (40.8%). Transient laryngeal recurrent nerve palsy manifested as prolonged hoarseness of voice was the only minor complication in 3 cases (5.5%). The sensitivity of the procedure was 72%, and the specificity was 100%. We recommend the use of a mediastinoscopy in the staging of lung cancer and the diagnosis of mediastinal mass when other non-invasive procedures are ineffective.

Impact of EBUS-TBNA on modalities for tissue acquisition in patients with lung cancer.

BACKGROUND: The impact of the introduction of Endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) on the use of diagnostic modalities for tissue acquisition in patients with lung cancer is unknown. METHODS: A retrospective review of 328 consecutive patients diagnosed with lung cancer at a university teaching hospital, where they first presented in London in 2007, 2009 and 2011. EBUS was introduced in 2008. RESULTS: In total, 316 patients were included in the analysis. Comparing 2007 with 2011 data, there has been a significant reduction in standard bronchoscopy (P < 0.0001) and mediastinoscopy (P = 0.02). The proportion of cases diagnosed by EBUS-TBNA significantly increased from 0% in 2007 to 26.7% in 2009 and 25.4% in 2011 (P < 0.0001). In the same period there has also been an increased trend in the proportion of patients going directly to surgery without pathological confirmation with a 9.6% increase in diagnoses obtained at thoracotomy (P = 0.0526). CONCLUSION: The use of diagnostic modalities that provide information on diagnosis and staging in a single intervention are increasing. At our hospital, the use of EBUS-TBNA for providing a lung cancer diagnosis is increasing and this has led to a significant reduction in standard bronchoscopies and mediastinoscopies. These changes in practice may have implications for future service provision, training and commissioning.

Mediastinoscopy: trends and practice patterns in the United States.

OBJECTIVES: Historically, mediastinoscopy has been the gold standard for the staging of lung cancer. A practice gap exists as the result of a variation in knowledge concerning current trends and practice patterns of mediastinoscopy usage. In addition, there are regional variations in practice-based learning and patient care. Lessons learned during surgeries performed on patients with lung cancer and other advances such as positron emission tomography and endobronchial ultrasound could be universally applied to improve surgeons' management of patient care. The purpose of this study was to assess contemporary practices in the staging of lung cancer. METHODS: We queried the Society of Thoracic Surgeons National Database for data regarding mediastinoscopy usage, yield, and variation, both by year and region. RESULTS: Cases with mediastinoscopy, as a percentage of all cases performed in the database, have significantly decreased from 14.6% in 2006 to 11.4% in 2010 (P < 0.001). The 5-year median rate of mediastinoscopy in lung cancer patients at 163 centers was 15.3% (interquartile range 5.2%-31.7%), indicating significant variation among centers. The overall median center rate also decreased over time from 21.4% (2006) to 10.0% (2010). CONCLUSIONS: With advances in minimally invasive procedures and imaging, mediastinoscopy usage has declined significantly. Our findings are likely to be relevant to both clinical practice and practice guidelines.

Thoroughness of mediastinal staging in stage IIIA non-small cell lung cancer.

INTRODUCTION: Guidelines recommend that patients with clinical stage IIIA non-small cell lung cancer (NSCLC) undergo histologic confirmation of pathologic lymph nodes. Studies have suggested that invasive mediastinal staging is underutilized, although practice patterns have not been rigorously evaluated. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients with stage IIIA NSCLC diagnosed from 1998 through 2005. Invasive staging and use of positron emission tomography (PET) scanning were assessed using Medicare claims. Multivariable logistic regression was used to identify patient characteristics associated with use of invasive staging. RESULTS: Of 7583 stage IIIA NSCLC patients, 1678 (22%) underwent invasive staging. Patients who received curative intent cancer treatment were more likely to undergo invasive staging than patients who did not receive cancer-specific therapy (30% versus 9.8%, adjusted odds ratio, 3.31; 95% confidence interval, 2.78-3.95). The oldest patients (age, 85-94 years) were less likely to receive invasive staging than the youngest (age, 67-69 years; 27.6% versus 11.9%; odds ratio, 0.46; 95% confidence interval, 0.34-0.61). Sex, marital status, income, and race were not associated with the use of the invasive staging. The use of invasive staging was stable throughout the study period, despite an increase in the use of PET scanning from less than 10% of patients before 2000 to almost 70% in 2005. CONCLUSION: Nearly 80% of Medicare beneficiaries with stage IIIA NSCLC do not receive guideline adherent mediastinal staging; this failure cannot be entirely explained by patient factors or a reliance on PET imaging. Incentives to encourage use of invasive staging may improve care.

Overview of lung cancer surgery in Ontario.

BACKGROUND: Surgery is the primary curative treatment for lung cancer and thus appropriate surgical resource allocation is critical. This study describes the distribution of lung cancer incidence and surgical care in Ontario, a Canadian province with universal health care, for the fiscal year of 2004. METHODS: All new lung cancer cases in Ontario between April 1, 2003 and March 31, 2004 were identified in the Ontario Cancer Registry. Incidence rates and surgical procedures were compared by age, health region, neighborhood income, and community size. RESULTS: Lung cancer incidence was highest in lower income neighborhoods (90.2 cases of 100,000 vs 55.6 in the highest quintile, p < 0.001) and smaller communities (87.1 of 100,000 in communities less than 100,000 vs 56.3 of 100,000 in cities greater than 1.25 million, p < 0.001). Surgical interventions were most common in younger patients (47.4% aged 20 to 54 years versus 30.5% greater than 75 years, p < 0.001), and those in wealthier neighborhoods (43.4% in highest quintile versus 35.8% in the lowest, p < 0.001). Surgical procedures overall and specifically formal resections (20% in cities >1.25 million versus 18% in communities <100,000, p < 0.03) were more common in larger communities (43.4% versus 37.7%, p < 0.001). Pneumonectomy was more common in smaller communities (14.5% vs 9.9%, p = 0.048, whereas more lobar (53.8 vs 45.2%, p = 0.01) and sublobar resections (44.9% vs 31.7%, p < 0.0001) were more common in larger communities. Thoracic surgeons provided the majority of formal resections (51% to 57%) compared with general surgeons (17% to 21%). CONCLUSIONS: Lung cancer incidence and surgical care vary significantly by health region, income level, and community size. These disparities require further evaluation to meet the needs of patients with lung cancer.

Characteristics associated with complete surgical resection of primary malignant mediastinal tumors.

OBJECTIVE: To identify preoperative characteristics associated with complete surgical resection of primary malignant mediastinal tumors. METHODS: Between 1996 and 2006, 42 patients with primary malignant mediastinal tumors were submitted to surgery with curative intent at a single facility. Patient charts were reviewed in order to collect data related to demographics, clinical manifestation, characteristics of mediastinal tumors and imaging aspects of invasiveness. RESULTS: The surgical resection was considered complete in 69.1% of the patients. Cases of incomplete resection were attributed to invasion of the following structures: large blood vessels (4 cases); the superior vena cava (3 cases); the heart (2 cases); the lung and chest wall (3 cases); and the trachea (1 case). Overall survival was significantly better among the patients submitted to complete surgical resection than among those submitted to incomplete resection. The frequency of incomplete resection was significantly higher in cases in which the tumor had invaded organs other than the lung (as identified through imaging studies) than in those in which it was restricted to the lung (47.6% vs. 14.3%; p = 0.04). None of the other preoperative characteristics analyzed were found to be associated with complete resection. CONCLUSIONS: Preoperative radiological evidence of invasion of organs other than the lung is associated with the incomplete surgical resection of primary malignant mediastinal tumors.

Long-term effects of infrasternal mediastinoscopic thymectomy in myasthenia gravis.

BACKGROUND: Endoscopic thymectomy is commonly used for treatment of myasthenia gravis (MG) patients due to its relatively low invasiveness. However, the long-term effects of endoscopic thymectomy have not been fully evaluated. OBJECTIVE: To assess the long-term effects of extended infrasternal mediastinoscopic thymectomy (IMT) in MG patients and compare them with those of extended transsternal thymectomy (TT). METHODS: Among 24 MG patients without thymoma who underwent thymectomy in our Institute between January 1997 and December 2000, 14 patients who received IMT and 10 who received TT were enrolled in the present study. Quantitative myasthenia gravis (QMG) score and anti-acetylcholine receptor antibody (anti-AChR) titers were evaluated before and at five years after surgery. RESULTS: After five years, QMG scores were reduced from 6.6 to 1.8 (p<0.01) in the IMT group, and from 7.6 to 2.7 (p<0.01) in the TT group. The anti-AChR titers were reduced from 75.2 to 40.1 (p=0.027) in the IMT group, and from 224 to 61.3 (p=0.020) in the TT group. CONCLUSION: These data suggest that the long-term therapeutic effect of IMT is equivalent to TT, and is thus suitable for the treatment of MG patients.

Characteristics associated with complete surgical resection of primary malignant mediastinal tumors / Características associadas à ressecção cirúrgica completa de tumores malignos primários do mediastino

OBJECTIVE: To identify preoperative characteristics associated with complete surgical resection of primary malignant mediastinal tumors. METHODS: Between 1996 and 2006, 42 patients with primary malignant mediastinal tumors were submitted to surgery with curative intent at a single facility. Patient charts were reviewed in order to collect data related to demographics, clinical manifestation, characteristics of mediastinal tumors and imaging aspects of invasiveness. RESULTS: The surgical resection was considered complete in 69.1 percent of the patients. Cases of incomplete resection were attributed to invasion of the following structures: large blood vessels (4 cases); the superior vena cava (3 cases); the heart (2 cases); the lung and chest wall (3cases); and the trachea (1 case). Overall survival was significantly better among the patients submitted to complete surgical resection than among those submitted to incomplete resection. The frequency of incomplete resection was significantly higher in cases in which the tumor had invaded organs other than the lung (as identified through imaging studies) than in those in which it was restricted to the lung (47.6 percent vs. 14.3 percent; p = 0.04). None of the other preoperative characteristics analyzed were found to be associated with complete resection. CONCLUSIONS: Preoperative radiological evidence of invasion of organs other than the lung is associated with the incomplete surgical resection of primary malignant mediastinal tumors.

OBJETIVO: Identificar características pré-operatórias associadas à ressecção cirúrgica completa de tumores malignos primários do mediastino. MÉTODOS: Entre os anos de 1996 e 2006, 42 pacientes com tumores malignos primários do mediastino foram submetidos a tratamento cirúrgico com intenção curativa em uma única instituição. Dados demográficos, manifestações clínicas, características do tumor mediastinal e aspectos de invasão por métodos de imagem foram identificados através da análise de prontuários. RESULTADOS: A ressecção cirúrgica foi considerada completa em 69,1 por cento dos pacientes. As causas de ressecção incompleta foram atribuídas à invasão das seguintes estruturas: grandes vasos (4 casos); veia cava superior (3 casos); coração (2 casos); pulmão e parede torácica (3 casos); e traqueia (1 caso). Os pacientes que foram submetidos à ressecção cirúrgica completa tiveram sobrevida global significativamente melhor que os pacientes submetidos à ressecção incompleta. A frequência de ressecção incompleta foi significativamente maior nos casos nos quais foram identificadas características radiológicas de invasão de outros órgãos além do pulmão do que nos casos cujas características eram restritas ao pulmão (47,6 por cento vs. 14,3 por cento; p = 0,04). Nenhuma das outras características pré-operatórias analisadas foi associada com a ressecção cirúrgica completa. CONCLUSÕES: Evidências radiológicas de invasão de órgãos além do pulmão no pré-operatório estão associadas à ressecção cirúrgica incompleta de tumores primários malignos do mediastino.

Endoscopic ultrasound reduces surgical mediastinal staging in lung cancer: a randomized trial.

RATIONALE: Assessment of mediastinal lymph nodes is recommended in patients with non-small cell lung cancer without distant metastases. Linear transesophageal endoscopic ultrasound with real-time guided fine-needle aspiration (EUS-FNA) is a promising, nonsurgical tool for mediastinal staging. OBJECTIVES: We conducted a randomized controlled trial comparing surgical staging with EUS-FNA. METHODS: Patients with proven or suspected non-small cell lung cancer in whom mediastinal exploration was required were randomly assigned to undergo EUS-FNA or the appropriate surgical staging procedure. When EUS-FNA did not show malignant lymph node invasion, a confirmatory surgical staging procedure was done. A negative surgical staging procedure was followed by thoracotomy with systematic lymph node sampling. The primary endpoint was the rate of surgical staging interventions. The secondary endpoints were test performance of EUS-FNA and surgical staging, morbidity, and length of hospital stay, considering surgical staging was performed as an in-patient procedure. MEASUREMENTS AND MAIN RESULTS: A total of 40 patients were randomized: 19 to EUS-FNA, and 21 to surgical mediastinal staging. Patient and tumor characteristics were well balanced between both groups. For patients allocated to EUS-FNA, surgical staging was needed in 32% (P < 0.001). The sensitivity to detect malignant lymph node invasion was 93% (95% confidence interval, 66-99%) for EUS-FNA and 73% (95% confidence interval, 39-93%) for surgical staging (P = 0.29). Complication rate was 0% for EUS-FNA and 5% for surgical staging (P = 1.0). The median hospital stay was significantly shorter for EUS-FNA than for surgical staging (0 vs. 2 nights; P < 0.001). CONCLUSIONS: EUS-FNA reduces the need for surgical staging procedures in patients with (suspected) lung cancer in whom a mediastinal exploration is needed.

The effect of race on invasive staging and surgery in non-small-cell lung cancer.

PURPOSE: Black patients with early-stage non-small-cell lung cancer (NSCLC) have worse overall survival than white patients. Decreased likelihood of resection has been implicated. To isolate the effect of decision making from access to care, we used receipt of surgical staging as a proxy for access and willingness to undergo invasive procedures, and examined treatments and outcomes by race. PATIENTS AND METHODS: We examined registry and claims data of Medicare-eligible patients with nonmetastatic NSCLC in areas monitored by the Surveillance, Epidemiology, and End Results program from 1991 to 2001. Patients who obtained invasive staging, defined as bronchoscopy, mediastinoscopy, or thoracoscopy, were included. Logistic regression and Cox modeling calculated the odds of having staging and surgery, and survival outcomes. RESULTS: A total of 14,224 patients underwent staging, and 6,972 had surgery for lung cancer. Black patients were less likely to undergo staging (odds ratio [OR] = 0.75; 95% CI, 0.67 to 0.83), and once staged, were still less likely to have surgery than whites (OR = 0.55; 95% CI, 0.47 to 0.64). Survival for blacks and whites was equivalent after resection (hazard ratio = 1.02; P = .06). Staged black patients were less likely to receive a recommendation for surgery when it was not clearly contraindicated (67.0% v 71.4%; P < .05), and were more likely to decline surgery (3.4% v 2.0%; P < .05). CONCLUSION: Black patients obtain surgery for lung cancer less often than whites, even after access to care has been demonstrated. They are more likely not to have surgery recommended, and more likely to refuse surgery. Additional research should focus on the physician-patient encounter as a potential source of racial disparities.