Lucena Carmen M, Martin-Deleon Roberto, Boada Marc, Marrades Ramon M, Sánchez David, Sánchez Marcelo, Vollmer Ivan, Martínez Daniel, Fontana Ainhoa, Reguart Noemi, Molins Laureano, Agustí Carlos
Pulmonary Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain.
Thoracic Surgery Service, Thoracic Oncology Unit, Hospital Clínic, Barcelona, Spain.
Respir Med. 2023 Mar;208:107132. doi: 10.1016/j.rmed.2023.107132. Epub 2023 Jan 30.
In patients with non-small cell lung cancer (NSCLC), the presence of abnormal hiliar lymph nodes (clinical N1; cN1), central tumor location and/or tumor size (diameter >3 cm) increases the risk of occult mediastinal metastasis (OMM). This study investigates prospectively the diagnostic value of an integral mediastinal staging (IMS) strategy that combines EndoBronchial Ultrasound-TransBronchial Needle Aspiration (EBUS-TBNA) and Video-Assisted Mediastinoscopy (VAM) in patients with NSCLC at risk of OMM.
Patients with NSCLC and radiologically normal mediastinum assessed non-invasively by positron emission tomography and computed tomography of the chest (PET-CT), and OMM risk factors (cN1, central tumor and/or >3 cm) underwent EBUS-TBNA followed by VAM if the former was negative. Those with negative IMS underwent resection surgery of the tumor.
EBUS-TBNA identified OMM in 2 out of the 49 patients evaluated (4%) and VAM in 1 of the 47 patients with negative EBUS (2%). Two patients with a negative IMS had OMM at surgery. Overall, the prevalence of OMM was 10%. EBUS-TBNA has a sensitivity of 40%, a negative predictive value (NPV) of 93.6%, and negative likelihood ratio of 0.60 (95%CI:0.30-1.16). The risk of not diagnosing OMM after EBUS was 6% and after IMS was 4.4%.
Integral mediastinal staging in patients with NSCLC and clinical risk factors for OMM, does not seem to provide added diagnostic value to that of EBUS-TBNA, except perhaps in patients with cN1 disease who deserve further research.
在非小细胞肺癌（NSCLC）患者中，肺门淋巴结异常（临床N1；cN1）、肿瘤位于中央和/或肿瘤大小（直径>3 cm）会增加隐匿性纵隔转移（OMM）的风险。本研究前瞻性地调查了一种综合纵隔分期（IMS）策略的诊断价值，该策略将支气管内超声引导下经支气管针吸活检（EBUS-TBNA）和电视辅助纵隔镜检查（VAM）相结合，用于有OMM风险的NSCLC患者。
通过胸部正电子发射断层扫描和计算机断层扫描（PET-CT）进行无创评估且纵隔影像学正常、具有OMM风险因素（cN1、中央型肿瘤和/或>3 cm）的NSCLC患者，先接受EBUS-TBNA检查，若结果为阴性则再接受VAM检查。IMS结果为阴性的患者接受肿瘤切除手术。
在49例接受评估的患者中，EBUS-TBNA发现2例OMM（4%）；在47例EBUS结果为阴性的患者中，VAM发现1例OMM（2%）。两名IMS结果为阴性的患者在手术时发现有OMM。总体而言，OMM的患病率为10%。EBUS-TBNA的敏感性为40%，阴性预测值（NPV）为93.6%，阴性似然比为0.60（95%CI：0.30-1.16）。EBUS检查后未诊断出OMM的风险为6%，IMS检查后为4.4%。
对于有OMM临床风险因素的NSCLC患者，综合纵隔分期似乎并未比EBUS-TBNA提供更多的诊断价值，可能cN1疾病患者除外，这部分患者值得进一步研究。
