Mario Gomez

Endobronchial Ultrasound for the Diagnosis and Staging of Lung Cancer

The diagnosis of indeterminate mediastinal lymph nodes, masses, and peripheral pulmonary nodules constitutes a significant challenge. Options for tissue diagnoses include computed tomography-guided percutaneous biopsy, transbronchial fine-needle aspiration, mediastinoscopy, left anterior mediastinotomy, or video-assisted thoracoscopic surgery; however, these approaches have both advantages and limitations in terms of tissue yield, safety profile, and cost. Endobronchial ultrasound (EBUS) is a new minimally invasive technique that expands the view of the bronchoscopist beyond the lumen of the airway. There are two EBUS systems currently available. The radial probe EBUS allows for evaluation of central airways, accurate definition of airway invasion, and facilitates the diagnosis of peripheral lung lesions. Linear EBUS guides transbronchial needle aspiration of hilar and mediastinal lymph nodes, improving diagnostic yield. This article will review the principles and clinical applications of EBUS, and will highlight the role of this new technology in the diagnosis and staging of lung cancer.

Using Endobronchial Ultrasound Features to Predict Lymph Node Metastasis in Patients With Lung Cancer

PURPOSES Reliable staging of the mediastinum determines TNM classification and directs therapy for non-small cell lung cancer (NSCLC). Our aim was to evaluate predictors of mediastinal lymph node metastasis in patients undergoing endobronchial ultrasound (EBUS). METHODS Patients with known or suspected lung cancer undergoing EBUS for staging were included. Lymph node radiographic characteristics on chest CT/PET scan and ultrasound characteristics of size, shape, border, echogenicity, and number were correlated with rapid on-site evaluation (ROSE) and final pathology. Logistic regression (estimated with generalized estimating equations to account for correlation across nodes within patients) was used with cancer (vs normal pathology) as the outcome. ORs compare risks across groups, and testing was performed with two-sided α of 0.05. RESULTS Two hundred twenty-seven distinct lymph nodes (22.5% positive for malignancy) were evaluated in 100 patients. Lymph node size, by CT scan and EBUS measurements, and round and oval shape were predictive of mediastinal metastasis. Increasing size of lymph nodes on EBUS was associated with increasing malignancy risk (P = .0002). When adjusted for CT scan size, hypermetabolic lymph nodes on PET scan did not predict malignancy. Echogenicity and border contour on EBUS and site of biopsy were not significantly associated with cancer. In 94.8% of lymph nodes with a clear diagnosis, the ROSE of the first pass correlated with subsequent passes. CONCLUSIONS Lymph node size on CT scan and EBUS and round or oval shape by EBUS are predictors of malignancy, but no single characteristic can exclude a visualized lymph node from biopsy. Further, increasing the number of samples taken is unlikely to significantly improve sensitivity.

The Utility of Nodule Volume in the Context of Malignancy Prediction for Small Pulmonary Nodules

BACKGROUND An estimated 150,000 pulmonary nodules are identified each year, and the number is likely to increase given the results of the National Lung Screening Trial. Decision tools are needed to help with the management of such pulmonary nodules. We examined whether adding any of three novel functions of nodule volume improves the accuracy of an existing malignancy prediction model of CT scan-detected nodules. METHODS Swensens 1997 prediction model was used to estimate the probability of malignancy in CT scan-detected nodules identified from a sample of 221 patients at the Medical University of South Carolina between 2006 and 2010. Three multivariate logistic models that included a novel function of nodule volume were used to investigate the added predictive value. Several measures were used to evaluate model classification performance. RESULTS With use of a 0.5 cutoff associated with predicted probability, the Swensen model correctly classified 67% of nodules. The three novel models suggested that the addition of nodule volume enhances the ability to correctly predict malignancy; 83%, 88%, and 88% of subjects were correctly classified as having malignant or benign nodules, with significant net improved reclassification for each (P<.0001). All three models also performed well based on Nagelkerke R2, discrimination slope, area under the receiver operating characteristic curve, and Hosmer-Lemeshow calibration test. CONCLUSIONS The findings demonstrate that the addition of nodule volume to existing malignancy prediction models increases the proportion of nodules correctly classified. This enhanced tool will help clinicians to risk stratify pulmonary nodules more effectively.

Lung Cancer Screening

Lung cancer is the leading cause of cancer-related death worldwide. Most patients present symptomatically when the disease is often at an advanced stage and prognosis is poor. In contrast, outcomes are significantly better in patients diagnosed at earlier stages, with a 5-year survival for stage I approaching 75%. Screening for lung cancer may detect potentially fatal cases earlier in their disease course, at a stage when a curative surgical intervention is feasible. The objective of this review is to examine the current evidence for lung cancer screening and the clinical effectiveness of screening for lung cancer by using computed tomography.

Physician Preferences for Management of Patients with Stage IIIA NSCLC: Impact of Bulk of Nodal Disease on Therapy Selection

Introduction: Stage IIIA non-small cell lung cancer (NSCLC) constitutes a heterogeneous group of patients with predominant ipsilateral mediastinal (N2) disease. The spectrum of lymph node presentation has lead to a host of trials involving various therapeutic combinations, and optimal management has been unclear. Methods: In 2007 and 2008, 10 live research events surveyed the practice preferences of American medical oncologists using two hypothetical scenarios. The first scenario was of a stage IIIA NSCLC in the right upper lobe with a single enlarged (>1 cm) 4R lymph node found to be malignant by mediastinoscopy. The second was of a bulky stage IIIA NSCLC with multistation N2 pathologically positive nodes. Results: In the first scenario, 373 (92%) of the oncologists incorporated surgery into their treatment plan. Only 34 (8%) offered chemoradiotherapy alone. Neoadjuvant chemotherapy, followed by surgery and then additional chemoradiotherapy (32%), was the most commonly offered treatment strategy. In the second scenario, 209 (52%) medical oncologists chose definitive chemoradiation. A total of 193 (48%) included surgery as part of the treatment plan. Conclusions: The current standard of care for IIIA N2 NSCLC recognized before treatment is concurrent chemoradiotherapy. This study demonstrated that a significant proportion of oncologists treating locally advanced lung cancer include surgery as part of the treatment plan more so in single versus multinodal station disease. Since node positive locally advanced disease is such a common presentation for patients with lung cancer, well-designed clinical trials are needed to define the most advantageous treatment strategy for individual subsets of patients with stage IIIA disease.

Tuberculous mediastinal lymphadenitis that evolved into pulmonary tuberculosis following transbronchial needle aspiration

This case report describes a patient with multi‐drug‐resistant mediastinal lymph node tuberculosis that evolved to smear‐positive pulmonary tuberculosis following transbronchial needle aspiration. This is the first report of this complication, and bronchoscopists should be vigilant for its occurrence.

Denture misadventure: an unusual cause of hemoptysis.

We report a case of a foreign body aspirated 9 years before presentation with hemoptysis. Chest radiographs failed to show 2 radiolucent denture palate fragments that ultimately were identified on computed tomography of the chest. After an unsuccessful flexible bronchoscopy, the foreign bodies were extracted using rigid bronchoscopy. Although rare, foreign body aspiration can be overlooked. Thus, it is important to maintain this diagnosis in the differential for patients with unexplained pulmonary symptoms.

Preoperative Evaluation for Lung Cancer Resection

Lung resection is the most effective available treatment for patients with early stage non-small cell lung cancer. However, surgical resection can lead to a decrease in lung function. Patients with lung cancer may have concomitant lung disease secondary to tobacco smoking and a low tolerance to further loss in lung function. The objective of the preoperative evaluation for lung cancer resection is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if lung resection were to occur. Pulmonary function measures including the forced expiratory volume in 1 s and the diffusing capacity for carbon monoxide are useful predictors of postoperative outcome. In patients with abnormal lung function, the assessment of exercise capacity can further clarify surgical risks. Those patients deemed high risk should be evaluated in a multidisciplinary setting with thoracic oncologic input prior to eliminating the option of surgery for cure. This chapter discusses the factors considered in the preoperative evaluation for lung resection and summarizes the available guidelines.

Invasive Staging of Non-small Cell Lung Cancer

In the absence of distant metastases, the prognosis and treatment of non-small cell lung cancer are determined by accurate mediastinal lymph node staging. Several noninvasive and invasive techniques exist for mediastinal staging. Invasive techniques include mediastinoscopy, left anterior mediastinotomy, video-assisted thoracoscopic surgery, transbronchial needle aspiration, transthoracic needle aspiration, esophageal endoscopic ultrasound-guided fine-needle aspiration, and endobronchial ultrasound-guided transbronchial needle aspiration. Each technique has its own strengths, limitations, and risks and requires differing skills sets. This chapter discusses the performance characteristics of the invasive staging tests of the mediastinum in patients with lung cancer.