Query: lung cancer ultrasonography

title: MEDIASTinal staging of non small cell lung cancer by endobronchial and endoscopic ultrasonography with or without additional surgical mediastinoscopy (MEDIASTrial) study protocol of a multicenter randomised controlled trial
abstract: BackgroundIn case of suspicious lymph nodes on computed tomography (CT) or fluorodeoxyglucose positron emission tomography (FDG PET) advanced tumour size or central tumour location in patients with suspected non small cell lung cancer (NSCLC) Dutch and European guidelines recommend mediastinal staging by endosonography (endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) with sampling of mediastinal lymph nodes. If biopsy results from endosonography turn out negative, additional surgical staging of the mediastinum by mediastinoscopy is advised to prevent unnecessary lung resection due to false negative endosonography findings. We hypothesize that omitting mediastinoscopy after negative endosonography in mediastinal staging of NSCLC does not result in an unacceptable percentage of unforeseen N2 disease at surgical resection. In addition, omitting mediastinoscopy comprises no extra waiting time until definite surgery, omits one extra general anaesthesia and hospital admission, and may be associated with lower morbidity and comparable survival. Therefore, this strategy may reduce health care costs and increase quality of life. The aim of this study is to compare the cost effectiveness and cost utility of mediastinal staging strategies including and excluding mediastinoscopy.designThis study is a multicenter parallel randomized non inferiority trial comparing two diagnostic strategies (with or without mediastinoscopy) for mediastinal staging in 360 patients with suspected resectable NSCLC. Patients are eligible for inclusion when they underwent systematic endosonography to evaluate mediastinal lymph nodes including tissue sampling with negative endosonography results. Patients will not be eligible for inclusion when PET/CT demonstrates 'bulky N2 N3' disease or the combination of a highly suspicious as well as irresectable mediastinal lymph node. Primary outcome measure for non inferiority is the proportion of patients with unforeseen N2 disease at surgery. Secondary outcome measures are hospitalization, morbidity, overall 2 year survival, quality of life, cost effectiveness and cost utility. Patients will be followed up 2 years after start of treatment.DiscussionResults of the MEDIASTrial will have immediate impact on national and international guidelines, which are accessible to public, possibly reducing mediastinoscopy as a commonly performed invasive procedure for NSCLC staging and diminishing variation in clinical practice.

title: A Randomized Clinical Trial of Flex 19G Needles versus 22G Needles for Endobronchial Ultrasonography in Suspected Lung Cancer
abstract: A flexible 19 gauge (Flex 19G) needle has been developed for endobronchial ultrasonography.  We aimed to evaluate quantitative and qualitative specimen characteristics of Flex 19G in a randomized controlled setting for patients with suspected lung cancer.  We undertook a single center, randomized, controlled trial. A computer generated randomization assigned all enrolled patients 1: 1 to undergo endobronchial ultrasonography using a Flex 19G or a 22 gauge (22G) needle for lymph node tissue sampling. Pathologists were blinded to the group assignment. The primary end point was histological tissue core procurement. The secondary end points were diagnostic yield, specimen bloodiness and overall quality, tissue surface area and performance for next generation sequencing (NGS) and procedure related complications.  Between June 2016 and February 2017, we randomly allocated a total of 78 patients: 39 patients to Flex 19G and 39 patients to 22G. No superiority in tissue core procurement was observed for Flex 19G compared to 22G (67 vs. 72% p 0.81) No significant difference was observed in diagnostic yield and overall specimen quality, but transbronchial needle aspiration specimens by Flex 19G were bloodier and had a larger tissue surface area. NGS was successful for clinically relevant genes in 96% and for all 26 genes tested in 81% of the samples. There was no difference in clinically relevant complications.  No superiority is observed for Flex 19G in histological tissue core procurement rate. The Flex 19G needle could be considered when a larger tissue surface is of special interest.

title: A prospective study on the diagnosis of peripheral lung cancer using endobronchial ultrasonography with a guide sheath and computed tomography guided transthoracic needle aspiration
abstract: It is difficult to collect peripheral lung cancer samples. This study analyzed the applicability of endobronchial ultrasonography with a guide sheath (EBUS GS) and computed tomography guided transthoracic needle aspiration (CT TTNA) for the diagnosis of peripheral lung cancer.  A prospective analysis of peripheral lung cancer patients was performed. The study included 150 cases in the EBUS GS group and 177 cases in the CT TTNA group. The diagnostic rate, pathological type, genetic status and complications were analyzed.  The diagnosis rates were 64.0% and 97.7% in the EBUS GS and CT TTNA groups, respectively. The EBUS GS group had undergone the most operations of the upper lobes of both lungs, while there was no significant difference in the operation distribution among the lobes in the CT TTNA group. Adenocarcinoma (64 cases versus 51 cases) was most commonly observed in both groups, followed by squamous cell carcinoma. The detection rates of patients who were given a genetic test were 96.1% and 98.9% in the EBUS GS and CT TTNA groups, respectively. The incidence of complications in the EBUS GS group was significantly less than that in the CT TTNA group.  EBUS GS and CT TTNA both had operational limitations. The diagnostic rate of EBUS GS was lower than that of CT TTNA, but there were fewer complications. CT TTNA had better tolerance. According to the specific location of the lesion, we recommend EBUS GS for lesions with a diameter 30 mm and CT TTNA for lesions with a diameter >30 mm. CT TTNA specimens were advantageous for genetic testing.

title: [Diagnostic value of endobronchial ultrasonography with guide sheath combined with virtual bronchoscopy navigation in peripheral lung cancer]
abstract: To explore the diagnostic value and safety of endobronchial ultrasonography with guide sheath (EBUS GS) combined with virtual bronchoscopy navigation (VBN) in peripheral lung cancer.  Between Dec. 2015 to Dec. 2016, patients with pulmonary solitary nodule suspected of early lung cancer on computed tomography (CT) in Department of Respiratory, Tangdu Hospital, Fourth Military Medical University were enrolled for this study. The patients underwent EBUS GS transbronchoscopic lung biopsy (TBLB) with or without VBN. The visibility rate, diagnostic yield, influencing factors, the operation time and complications were evaluated in the 2 groups. The data were compared using independent sample t test or chi squared test.  A total of 134 patients were enrolled and completed this study. Among them 74 were males and 60 were females. There were 64 cases in the group of EBUS GS with VBN (VBNA) and 70 in the group without VBN (NVBNA) The visibility rate and diagnosis rate of VBNA group were 87.5% (56/64) and 78.1% (50/64) respectively. The mean time of operation and confirming the target lesions were (25+ 5) (5.8+ 1.3) min, respectively. The visibility rate and diagnosis rate of NVBNA group were 81.4%(57/70) and 75.7%(53/70) respectively. The mean time of operation and confirming the target lesions were (27+ 6) (9.8+ 1.5)min .There was no significant difference in the visibility rate and diagnosis rate between the 2 groups (kh(2)=0.933, P=0.334; kh(2)=0.109, P=0.838) There was no significant difference in the mean operation time between the 2 groups(t=0.633, P=0.524) But the time of confirming the target lesions between the 2 groups was statistically different (t=17.41, P<0.01) EBUS GS TBLB was well tolerated. No severe complications such as pneumothorax or chest pain were observed. There were 3 patients in the VBNA group and 7 patients in the NVBNA group experiencing a small amount of biopsy site bleeding. The incidence of complications did not differ between the 2 groups(kh(2)=1.366, P=0.330)  VBN could not improve the diagnostic yield of EBUS GS. However, it could shorten the time needed to confirm the target lesions and did not increase the incidence of EBUS GS complications, indicating that EBUS GS with VBN was a safe and effective method.

title: Impact of Preoperative Ultrasonography Screening for Carotid Artery Stenosis in Lung Cancer Patients.
abstract: Stroke is a major cause of morbidity or death after lung operations. Carotid artery screening (CAS) is useful for detecting carotid artery stenosis, which is one of the causes of stroke. This study investigated the frequency of and risk factors for preoperative carotid artery stenosis to determine whether CAS with ultrasonography contributes to preventing postoperative stroke or cardiovascular comorbidities in lung cancer patients.  This retrospective study included 1,676 consecutive lung cancer patients who underwent surgical resection.  Of the 1,342 patients who underwent CAS, 173 (12.9% had carotid artery stenosis. Significant associations with carotid artery stenosis were found for older patients (p 0.0001) men (p 0.0001) smoking history (p 0.0001) history of stroke (p 0.0037) cardiovascular diseases (p 0.0001) hypertension (p 0.0353) diabetes mellitus (p 0.0037) and peripheral vascular diseases (p 0.0001) Patients with the three independent risk factors of age, male sex, and history of cardiovascular diseases had a 6.43 fold higher prevalence of carotid artery stenosis (odds ratio, 6.43; 95% confidence interval, 3.80 to 10.89) than those with none of these factors. Propensity score matched analysis showed that incidences of postoperative stroke and cardiovascular comorbidities were both lower in patients who underwent CAS and received appropriate anticoagulant therapy than in those who did not (p 0.0619 and p 0.0319, respectively) CONCLUSIONS Preoperative CAS is a simple and useful tool for detecting carotid artery stenosis. Administration of perioperative anticoagulant therapy to preoperative patients with lung cancer and carotid artery stenosis identified by CAS may prevent postoperative stroke and cardiovascular events.

title: Differentiating metastatic lymph nodes in lung cancer patients based on endobronchial ultrasonography features.
abstract: The aim of this study was to identify easy and relatively effective ultrasound criteria for metastatic mediastinal lymph node prediction.  A retrospective chart review of patients who underwent endobronchial ultrasound guided transbronchial needle aspiration (EBUS TBNA) from March 2014 to September 2016 was performed. We used the following EBUS sonographic features for metastatic lymph node prediction: 1) length of the short axis, 2) shape, 3) margin, 4) echogenicity, 5) central hilar structure, and 6) coagulation necrosis sign. These sonographic findings were compared with the final pathology results or clinical follow up.  A total of 227 lymph nodes were retrospectively evaluated in 133 lung cancer patients; 72% of the lymph nodes had been proven to be malignant metastasis. Logistic regression analysis revealed that the length of the short axis, shape, margin, and echogenicity were independent predictive factors for metastasis. We developed a sum score based on these four sonographic features. A larger sum score trended toward a greater possibility of malignancy. If all four predictive factors were preserved, the diagnostic accuracy, the value of the specificity and the positive predictive value of the sonographic feature would be higher than 90%  The sonographic features of EBUS are valuable tools in predicting metastatic lymph nodes in lung cancer patients.

title: Diagnostic yield of N3 hilar staging by endobronchial ultrasonography (EBUS) in lung cancer.
abstract: Systematic lung cancer staging with EBUS has proven to be equivalent to cervical mediastinoscopy. Nevertheless, in the daily practice it is common to explore and sample negative PET CT hilar N3 lymph nodes (LN) This study aims to explore if there is enough evidence to support this clinical practice.  Retrospective study from our database including 1,013 explorations over the last 5 years. Including criteria were patients with lung cancer staged by PET CT and EBUS TBNA. Mediastinal and hilar N3 LN with a short axis 5 mm were sampled assessed by rapid on site evaluation. A single nuclear medicine expert reviewed blindly all PET CT scans and determined the SUVmax of every LN. Those that were 5 SUVmax by PET CT and/or 10mm in short axis by EBUS were considered abnormal.  87 patients were included. The final histopathology diagnoses were adenocarcinoma (46% squamous cell carcinoma (39% and other histology (14% None of the 61 normal hilar and normal mediastinum N3 LN, and none of the 7 normal N3 hilar LN with abnormal mediastinal LN (3 by PET CT, 3 by EBUS and 1 for both) resulted positive for lung cancer. Of the 19 patients with abnormal N3 hilar LN (6 by PET CT, 8 by EBUS and 6 for both) malignancy was found in 16.7% 25% and 60% for both techniques, respectively.  In absence of abnormal N3 hilar LN (PET: SUVmax<5; EBUS<10mm in short axis) it seems there is not enough evidence to sample them, regardless of N3 mediastinal status.

title: Outcomes of research biopsies in clinical trials of EGFR mutation positive non small cell lung cancer patients pretreated with EGFR tyrosine kinase inhibitors.
abstract: Research biopsies (RBs) are crucial for developing novel molecular targeted agents. However, the safety and diagnostic yields of RBs have not been investigated in EGFR mutation positive non small cell lung cancer (NSCLC) patients pretreated with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) METHODS We searched the medical records of NSCLC patients who participated in lung cancer clinical trials and underwent mandatory RBs between 2012 and 2014 at our institution. Only patients with EGFR mutation positive NSCLC pretreated with at least 1 EGFR TKI were enrolled.  Of 140 enrolled patients, 73 (52.1% and 59 (42.1% had exon 19 deletions and exon 21 L858R mutation, respectively. Before RBs, 108 (77.1% 83 (59.3% and 36 (25.7% patients had been treated with gefitinib, erlotinib, and afatinib, respectively. Computed tomography guided percutaneous core needle biopsy was the most frequently used modality among 181 RBs performed (50.8% followed by ultrasonography guided (32.0% and endoscopic RBs (16.0% The most common RB sites were the lung (69.6% pleura (8.8% and liver (6.1% Pathologic examinations revealed malignant cells in most RB specimens (72.9% Complications due to RBs included pneumothorax (11.6% bleeding (6.1% and infection (1.1% Only 1 patient required chest tube placement for pneumothorax, and 2 patients underwent endotracheal intubation because of bleeding.  RBs in this patient population were generally safe. Pneumothorax was the most frequent complication; bleeding, while infrequent, increased the risk of severe events. The diagnostic yields and complications of any particular modality should therefore be discussed with prospective clinical trial participants.

title: Peroral cholangioscopy of nivolumab related (induced) ulcerative cholangitis in a patient with non small cell lung cancer.
abstract: Approximately 10% 15% of patients treated with nivolumab may develop grade 3/4 immuno related adverse events (irAEs)  Rash and diarrhea are the common irAEs, whereas there have been few reports of nivolumabrelated cholangitis and its clinical features  A 69 year old male patient with advanced lung adenocarcinoma had been treated with nivolumab as third line chemotherapy. After the third course of nivolumab, he complained of pruritic rash. His laboratory data showed increased liver and biliary tract enzymes. He was treated with oral prednisolone at a dose of 60mg a day. As his medical condition was not improved by steroid therapy, he was referred to our department. Computed tomography showed diffuse hypertrophy of extrahepatic bile ducts without any obstruction, such as stones or malignancies >Fig. 1) Endoscopic ultrasonography showed slight dilation of the extrahepatic bile ducts without obstruction >Fig. 2) Endoscopic retrograde cholangiopancreatography showed that the epithelium of the bile duct was irregular and coarse >Fig. 3) After endoscopic sphincterotomy had been performed, peroral cholangioscopy revealed that the epithelium of the extrahepatic bile duct was erosive and bled easily, with many black spots and inflammation, giving a "burnedout" appearance >Fig. 4, >Video1) A biopsy of the lesions of the extrahepatic bile duct showed infiltrating inflammatory cells in the bile duct epithelium >Fig. 5) As the patient's liver toxicity worsened despite the treatment with oral prednisolone, intravenous methyl prednisolone treatment (500mg/day) was started, but this also failed to improve his condition. He died from nivolumabrelated cholangitis 3 months after the start of treatment. In this case, peroral cholangioscopy showed ulcerative lesions with the "burned out" epithelium of the extrahepatic bile duct, which was erosive and bled easily. The pathology revealed infiltrating inflammatory cells in the bile duct epithelium, suggesting that the lymphocytes affected by nivolumab might attack the epithelial cells and/or microvessels of the bile duct.

title: Surgery for advanced non small cell lung cancer patient after epidermal growth factor receptor tyrosine kinase inhibitor neoadjuvant therapy.
abstract: This study aimed to evaluate the survival of the advanced non small cell lung cancer (NSCLC) patients underwent salvage surgeries after EGFR TKI neoadjuvant therapies.  From 2014 to 2016, 10 patients diagnosed as advanced stage NSCLC (N2 metastasis or great vessels invasion) who responded to EGFR TKI neoadjuvant therapy were recruited in this study. All patients underwent surgeries and consented the follow up study.  All patients received successful radical surgeries (complete resection of the tumor with systematic lymphadenectomy) Among them, one patient passed away 7 days post operatively due to respiratory failure. The pathology of the lesions and the lymph nodes suggested the replacement of tumors by fibrotic tissue, and concentration of focal residual tumors limited in areas of fibrous stroma and lymphocyte infiltration. Adjuvant therapy of EGFR inhibitor gefitinib for at least 6 months was applied to each patient. Each of the patients was followed up with contrasted CT scan, ultrasonography, bronchoscope and tumor markers for at least 8 months (8 30 months, median time: 24 months) The progression free survival of these patients was 14 months since neoadjuvant therapy.  EGFR TKI neoadjuvant therapy is feasible and effective, along with surgery may improve the surgical rate and survival of advanced NSCLC patients.  Non small cell lung cancer (NSCLC) epidermal growth factor receptor tyrosine kinase inhibitor neoadjuvant therapy (EGFR TKI neoadjuvant therapy) salvage surgery.