Identifying lung cancer type better with less invasive method

Identifying lung cancer type better with less invasive method

A less invasive method of determining the stage of suspected NSCLC (non-small cell lung cancer) leads to fewer unnecessary surgical interventions and the side effects that go with them, and appears to be more efficient too, researchers from the Leiden University Medical Center, the Netherlands, report in JAMA (Journal of the American Medical Association) this week.

Approximately 1.35 million people worldwide are diagnosed with lung cancer annually, and 1.2 million die from it. The authors write that it is the most commonly diagnosed cancer, as well as being the most frequent cause of death.

To know what type of therapy to administer to a lung cancer patient, it is necessary to stage the cancer - identify how advanced it is. Doctors also need staging in order to make a prognosis; estimate the outlook for the patient.

Using surgery to stage a lung cancer is a cause of too many unnecessary incisions into the chest cavity (thoracotomies). These thoracotomies can cause serious health problems for the patient, and even death.

Currently, guidelines acknowledge the use of endosonography for the detection of nodal disease. Endosonography uses internal ultrasound with a fiberoptic endoscope. Endosonography is accepted as a minimally invasive alternative to surgery.

Only if the endosonography finds no nodal metastases, does surgical staging follow.

A surgical diagnostic procedure performed by mediastinoscopy is generally carried out to stage samples from the mediastinal tissue - an area in the thoracic cavity close to the lungs.

The authors wrote:

    "At present it is not known whether initial mediastinal tissue staging of lung cancer by endosonography improves the detection of nodal metastases and reduces the rate of unnecessary thoracotomies."
Jouke T. Annema, M.D., Ph.D., performed a randomized, controlled, multicenter trial to compare just surgical staging with endosonography (transesophageal combined with endobronchial ultrasound) followed by surgical staging if nothing was detected. The trial consisted of 241 participants, they had suspected (resectable) NSCLC; mediastinal staging was indicated for all of them according to computed or imaging techniques (positron tomography).

All the patients received either surgical staging or endosonography (which was followed by surgery if no nodal metastases were detected). When there was no evidence of mediastinal tumor spread a thoracotomies with lymph node dissection was performed.

The 241 patients were selected randomly for the following:

  • Surgical staging - 118 participants
  • Enosonography - 123 participants, of whom 65 subsequently underwent surgical staging.
The authors wrote:
    "Nodal metastases were found in 41 patients (35%) by surgical staging vs. 56 patients (46%) by endosonography and in 62 patients (50%) by endosonography followed by surgical staging. This corresponded to sensitivities of 79% (41/52) vs. 85% (56/66) and 94% (62/66)."
Below is data on the number of unnecessary thoracotomies:
  • 21 (18%) in the surgical staging group
  • 9 (7%) in the endosonography group
6% of the surgical patients had complications, compared to 5% in the endosonography group - the authors wrote there was no statistically significant difference.

The authors wrote:

    "We have shown that commencing mediastinal nodal staging with endosonography significantly improves the detection of nodal metastases and reduces the rate of unnecessary thoracotomies by more than half compared with surgical staging alone, in patients with resectable NSCLC. Furthermore, endosonography does not require general anesthesia, is preferred by patients, and is considered cost-effective compared with surgical staging."
The authors believe endosonography should be the first step for mediastinal nodal staging for the following reasons:
  • Endosonography has an 85% sensitivity rate.
  • Mediastinoscopy has a 79% sensitivity rate.
  • Endosonography has a complication rate of 1%.
  • Mediastinoscopy has a complication rate of 6%.

Accompanying Editorial

Mark D. Iannettoni, M.D., M.B.A., University of Iowa, wrote:
    "Even though this emerging technology of endoscopic study can result in excellent results for predicting both positive and now improved negative results, highly skilled interventionalists are required to provide these exceptional outcomes.... Until this modality can be reproduced at all centers where thoracic surgery is commonly performed, or until all of these patients are cared for at specialized centers, surgical staging must remain the gold standard for adequate preoperative evaluation."
"Mediastinoscopy vs Endosonography for Mediastinal Nodal Staging of Lung Cancer - A Randomized Trial"

Jouke T. Annema, MD, PhD; Jan P. van Meerbeeck, MD, PhD; Robert C. Rintoul, FRCP, PhD; Christophe Dooms, MD, PhD; Ellen Deschepper, PhD; Olaf M. Dekkers, MA, MD, PhD; Paul De Leyn, MD, PhD; Jerry Braun, MD; Nicholas R. Carroll, FRCP, FRCR; Marleen Praet, MD, PhD; Frederick de Ryck, MD; Johan Vansteenkiste, MD, PhD; Frank Vermassen, MD, PhD; Michel I. Versteegh, MD; Maud Veseliç, MD; Andrew G. Nicholson, FRCPath, DM; Klaus F. Rabe, MD, PhD; Kurt G. Tournoy, MD, PhD

JAMA. 2010;304(20):2245-2252. doi:10.1001/jama.2010.1705

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