Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Nuclear Medicine, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany.
Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Infectious Diseases and Pulmonary Medicine, Augustenburger Platz 1, 13353 Berlin, Germany.
Lung Cancer. 2021 Jul;157:66-74. doi: 10.1016/j.lungcan.2021.05.003. Epub 2021 May 7.
In patients with NSCLC, current ESTS and ESMO guidelines recommend invasive lymph node (LN) staging with EBUS-TBNA even if FDG-PET/CT is negative for mediastinal LNs if at least one of three risk factors is present (cN1, non-peripheral primary or primary >3 cm). Modified workflows to avoid unnecessary invasive procedures were evaluated.
Monocentric retrospective analysis of pretherapeutic FDG-PET/CT in 247 patients with NSCLC (62 % male; age, 68 [43-88] years) using an analog or digital PET/CT scanner. PET windowing was standardized. LNs were positive if 'LN uptake > mediastinal blood pool' or short axis >10 mm. Surgery or EBUS-TBNA served as reference for diagnostic accuracy per LN station. In all patients with negative mediastinal LNs by PET/CT, LN histology from surgery was available.
Among 700 L N stations analyzed, 180 were malignant. Sensitivity and specificity of PET/CT per LN station were 93 % and 71 %. Following current guidelines, 76 patients with mediastinal negative PET/CT required confirmatory invasive staging. Only 5/76 patients had unexpected pN2 (all had adenocarcinoma). In a modified approach, confirmatory invasive staging was confined to patients with mediastinal negative PET/CT who showed all three risk factors. Using this modification, EBUS-TBNA could have been omitted in 62 (82 %) of the 76 patients who required EBUS-TBNA based on current recommendation. Among these 62 patients, only one patient had unsuspected pN2 (single-level) while the remaining 61 of 62 omitted EBUS-TBNA were deemed unnecessary because mediastinal LNs were confirmed to be negative. No multi-level pN2 would have been missed.
In the current analysis, 82 % of EBUS-TBNA procedures in patients with mediastinal negative PET/CT could have been omitted by modifying the current guideline workflow as proposed (i.e., restricting EBUS-TBNA in patients with cN0/1 to those with all three risk factors). This was consistent with different PET/CT scanners. Prospective confirmation is required.
在非小细胞肺癌（NSCLC）患者中，目前的欧洲胸外科医师学会（ESTS）和欧洲肿瘤内科学会（ESMO）指南建议，如果至少存在三个风险因素之一（cN1、非外周原发或原发灶＞3cm），即使正电子发射断层扫描（PET）/CT 对纵隔淋巴结（LN）检查结果为阴性，也需要进行支气管内超声引导针吸活检（EBUS-TBNA）进行有创性 LN 分期。评估了避免不必要的有创性操作的改良工作流程。
对 247 例 NSCLC 患者（62%为男性；年龄 68[43-88]岁）进行了前瞻性回顾性分析，这些患者均进行了正电子发射断层扫描/CT（PET/CT）检查，使用的是模拟或数字 PET/CT 扫描仪。对 PET 窗口进行了标准化。如果 LN 的“LN 摄取量＞纵隔血池”或短轴＞10mm，则将其定义为阳性。每一个 LN 站的诊断准确性都以手术或 EBUS-TBNA 为参考。所有 PET/CT 检查结果为纵隔 LN 阴性的患者，均有手术时的 LN 组织学资料。
在分析的 700 个 LN 站中，有 180 个为恶性。PET/CT 对 LN 站的敏感性和特异性分别为 93%和 71%。按照现行指南，76 例纵隔 PET/CT 阴性的患者需要进行有创性确认性分期。只有 5/76 例有意外的 pN2（均为腺癌）。在改良的方法中，只有纵隔 PET/CT 检查结果为阴性且同时存在所有三个风险因素的患者才需要进行有创性确认性分期。使用这种改良方法，基于现行推荐，62（82%）例需要行 EBUS-TBNA 的患者可以避免行 EBUS-TBNA。在这 62 例患者中，仅有 1 例患者存在意外的 pN2（单水平），而其余 61 例因纵隔 LN 确认为阴性而被认为是不必要的。不会遗漏多水平的 pN2。
在目前的分析中，82%的纵隔 PET/CT 阴性患者的 EBUS-TBNA 操作可以通过修改现行指南工作流程来避免（即限制 cN0/1 的患者仅对有三个风险因素的患者行 EBUS-TBNA）。这与不同的 PET/CT 扫描仪一致。需要前瞻性确认。
