Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, OH.
Department of Pulmonary and Critical Care Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX.
Chest. 2013 Dec;144(6):1776-1782. doi: 10.1378/chest.12-3046.
Evidence-based guidelines recommend mediastinal sampling as the first invasive test in patients with suspected lung cancer and mediastinal adenopathy. The goal of this study was to assess practice patterns and outcomes of diagnostic strategies in this patient population.
We conducted a retrospective analysis of all patients in 2009 who had mediastinal adenopathy without distant metastatic disease to determine whether guideline-consistent care was delivered. Guideline-consistent care was defined as mediastinal lymph node sampling being performed as part of the first invasive procedure.
One hundred thirty-seven patients were included. Guideline-consistent care was provided in 30 cases (22%). Patients receiving guideline-consistent care had fewer invasive tests than patients with guideline-inconsistent care (1.3 ± 0.5 tests/patient vs 2.3 ± 0.5 tests/patient, respectively; P < .0001) and fewer complications (0 of 30, 0% vs 18 of 108, 17%; P = .01). Most of the complications (16 of 18) were related to CT image-guided needle biopsy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was sufficient to guide treatment decisions without any other invasive tests in 88 patients (64%). Although not all the complications and costs due to CT image-guided biopsies could have been avoided, roughly two-thirds could have been eliminated by just changing the testing sequence.
Quality gaps in lung cancer staging in patients with mediastinal adenopathy are common and lead to unnecessary testing and increased complications. In patients with suspected lung cancer without distant metastatic disease with mediastinal adenopathy, EBUS-TBNA should be the first test.
循证指南建议，疑似肺癌和纵隔淋巴结肿大的患者首先进行纵隔取样作为侵入性检查。本研究旨在评估该患者人群的诊断策略的实践模式和结果。
我们对 2009 年所有纵隔淋巴结肿大且无远处转移疾病的患者进行了回顾性分析，以确定是否提供了符合指南的护理。符合指南的护理定义为纵隔淋巴结取样作为首次侵入性程序的一部分。
共纳入 137 例患者。30 例（22%）患者接受了符合指南的护理。与不符合指南护理的患者相比，接受符合指南护理的患者进行的侵入性检查较少（分别为 1.3±0.5 次/例和 2.3±0.5 次/例；P<0.0001），并发症也较少（30 例中无并发症，0%；108 例中 18 例并发症，17%；P=0.01）。大多数并发症（16 例）与 CT 引导下经皮针吸活检有关。88 例（64%）患者的经支气管超声引导下经支气管针吸活检（EBUS-TBNA）足以指导治疗决策，无需进行任何其他侵入性检查。尽管并非所有 CT 引导下活检引起的并发症和费用都可以避免，但仅通过改变测试顺序，就可以消除大约三分之二的并发症。
纵隔淋巴结肿大患者肺癌分期中的质量差距很常见，导致不必要的检查和增加并发症。对于怀疑患有肺癌且无远处转移疾病的纵隔淋巴结肿大患者，EBUS-TBNA 应作为首选检查。
