Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Leuven, Belgium.
Eur J Cardiothorac Surg. 2018 Jul 1;54(1):134-140. doi: 10.1093/ejcts/ezy018.
Current guidelines recommend preoperative invasive mediastinal staging in centrally located tumours with negative mediastinum on positron emission tomography-computed tomography, based on a 20-30% prevalence of occult mediastinal disease (pN2-3). However, a uniform definition of central tumour location is lacking. Our objective was to determine the best definition in predicting occult pN2-3.
A single-institution database was queried for patients with (suspected) non-small-cell lung cancer staged cN0 after positron emission tomography-computed tomography and referred to invasive staging and/or primary surgery. We evaluated 5 definitions: inner 1/3, inner 2/3, contact with bronchovascular structures, ≤2 cm from bronchus or endobronchial visualization.
Between 2005 and 2015, 813 patients were eligible (cT1: 42%, cT2: 28%, cT3: 17% and cT4: 11%). Invasive mediastinal staging and resection were performed in 30% and 97% of patients, respectively. Any nodal upstaging (pN+) was found in 21% of patients, of whom pN2-3 was found in 8%. Central tumour location demonstrated 4 times higher odds for any pN+ [for inner 1/3 vs outer 2/3, odds ratio 3.90 (95% confidence interval 2.24-6.77), P < 0.001], whereas no significantly different odds was observed for pN2-3. The discriminative ability for pN+ was not significantly different between the several definitions.
The prevalence of occult pN2-3 was only 8% when modern fusion positron emission tomography-computed tomography imaging pointed at clinical N0 non-small-cell lung cancer. None of the 5 verified definitions of centrality was predictive for occult pN2-3. However, each definition of centrality was related to any pN+ at a prevalence of 21%, without significant differences in discriminative ability between definitions. These data question whether indication for preoperative invasive mediastinal staging should be based on centrality alone.
目前的指南建议对正电子发射断层扫描-计算机断层扫描（PET-CT）检查提示纵隔阴性的中央型肿瘤进行术前有创纵隔分期，如果存在 20-30%的隐匿性纵隔疾病（pN2-3）的患病率。然而，对于中央型肿瘤的统一定义却有所缺失。我们的目标是确定预测隐匿性 pN2-3 的最佳定义。
通过查询单机构数据库，找出经过 PET-CT 检查后分期为 cN0（疑似）非小细胞肺癌且需进行有创纵隔分期和/或原发性手术的患者。我们评估了 5 种定义：内 1/3、内 2/3、与支气管血管结构接触、距支气管或支气管内可视化≤2cm。
2005 年至 2015 年，共有 813 名患者符合条件（cT1：42%，cT2：28%，cT3：17%和 cT4：11%）。分别有 30%和 97%的患者进行了有创纵隔分期和切除术。21%的患者存在任何淋巴结分期上调（pN+），其中 8%为 pN2-3。中央型肿瘤位置使任何 pN+的几率增加了 4 倍[内 1/3 与外 2/3 相比，比值比 3.90（95%置信区间 2.24-6.77），P<0.001]，而 pN2-3 的几率则无明显差异。对于 pN+，几种定义之间的判别能力无显著差异。
当现代融合 PET-CT 成像提示临床 N0 非小细胞肺癌时，隐匿性 pN2-3 的患病率仅为 8%。验证的 5 种中央性定义均不能预测隐匿性 pN2-3。然而，每种中央性定义都与任何 pN+相关，患病率为 21%，定义之间的判别能力无显著差异。这些数据质疑术前有创纵隔分期的指征是否应仅基于中央性。
