Poorer Outcomes Associated with Failure to Use Pre-Surgical Sampling to Stage Lung Cancer

Providers should perform mediastinal biopsy in order to properly stage lung cancer, after diagnosis, and before surgery.

Providers should perform mediastinal biopsy in order to properly stage lung cancer, after diagnosis, and before surgery, according to a presentation Tuesday at CHEST 2013, the annual meeting of the American College of Chest Physicians, in Chicago, IL.

Current guidelines from the American College of Chest Physicians, published this year in the journal CHEST, recommend needle technique over surgical staging as the first test, but another CHEST article found that only 21% of procedures that are performed were consistent with the guidelines, and 44% of non-small cell lung cancer cases were done without any mediastinal sampling, according to David E. Ost, MD, associate professor of medicine at The University of Texas MD Anderson Cancer Center in Houston, an author on the latter article.

“Failure to sample the mediastinum first, or at all, is a problem,” said Ost, who on Tuesday delivered the Pasquale Ciaglia Memorial Lecture in Interventional Medicine, titled, “Advanced Diagnostic Bronchoscopy: From Expert-Based to Evidence-Based Practice.”

The discussion reflected a difference between two strategies: diagnose, then stage, then treat, or stage and diagnose, then treat, explained Ost. While staging lung cancer is sometimes associated with complications such as pneumothorax or intubation of the patient, failing to stage the disease is associated with poorer outcomes, Ost explained in another CHEST article from 2013.

In small cell carcinoma, whether the surgeon sampled the mediastinum first or second also made a statistically significant difference in survival outcomes, he added.

For example, in the AQuIRE Registry, a study of 1,317 patients conducted at six hospitals, the complication rate among patient receiving endobronchial ultrasound (EBUS) with transbronchial biopsy was 3.2%, with pneumothorax occurring in 0.5% of cases (p value 0.001), according to the slide.

“If you never sample the mediastinum, you never have to pay that price, but there’s a different price you have to pay,” explained Ost.

The decision is made easier by advances in technologies, suggested Ost, noting that while conventional EBUS had problems with sensitivity, more recent techniques such as convex EBUS have been shown in a meta-analysis of clinical trials to have sensitivity rates between 88 and 93%, low complication rates, and may be superior to mediastinoscopic surgery, he said.

Which sampling procedure surgeons should use depends on the site of the lesions, Ost explained. If the lymph nodes are affected, the procedures to compare are EBUS versus transbronchial needle aspiration versus mediastinoscopy, whereas if the surgeon is looking for peripheral lesions, they need to compare CT-guided fine needle aspiration versus radial EBUS versus electromagnetic Navigation (EMN), according to Ost.

“There is a quality gap regarding mediastinal lymph node staging,” Ost summarized, noting that physicians may also achieve better results based on what lymph nodes they choose to stage. For example, stage seven lymph nodes are considered very easy to sample with a bronchoscopy. “But it’s different with a mediastinoscopy, especially if it’s posterior,” he added.