Danielle A Hylton1, Biniam Kidane2, Jonathan Spicer3, Simon Turner4, Isabella Churchill1, Kerrie Sullivan1, Christian J Finley5, Yaron Shargall5, John Agzarian5, Andrew J E Seely6, Kazuhiro Yasufuku7, Waël C Hanna8. 1. Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. 2. Section of Thoracic Surgery, Department of Surgery, University of Manitoba, Health Sciences Centre, Winnipeg, MB, Canada. 3. Division of Thoracic Surgery, Department of Surgery, McGill University, The Research Institute of the McGill University Health Centre, Montreal, QC, Canada. 4. Division of Thoracic Surgery, Department of Surgery, University of Alberta, WC Mackenzie Health Sciences Centre, Edmonton, AB, Canada. 5. Division of Thoracic Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada. 6. Division of Thoracic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada. 7. Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada. 8. Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Division of Thoracic Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada. Electronic address: hannaw@mcmaster.ca.
Abstract
BACKGROUND: Staging guidelines for lung cancer recommend endobronchial ultrasound (EBUS) and systematic biopsy of at least three mediastinal lymph node (LN) stations for accurate staging. A four-point ultrasonographic score (Canada Lymph Node Score [CLNS]) was developed to determine the probability of malignancy in each LN. A LN with a CLNS of < 2 is considered low probability for malignancy. We hypothesized that, in patients with cN0 non-small cell lung cancer, LNs with CLNS of < 2 may not require routine biopsy because they represent true node-negative disease. RESEARCH QUESTION: Do LNs considered triple normal on CT scanning, PET scanning, and CLNS evaluation require routine biopsy? STUDY DESIGN AND METHODS: LNs were evaluated for ultrasonographic features at the time of EBUS and the CLNS was applied. Triple-normal LNs were defined as cN0 on CT scanning (short axis, < 1 cm), PET scanning (no hypermetabolic activity), and EBUS (CLNS, < 2). Specificity and negative predictive value (NPV) were calculated against the gold standard pathologic diagnosis from surgically excised specimens. RESULTS: In total, 143 LNs from 57 cN0 patients were assessed. Triple-normal LNs showed a specificity and NPV of 60% (95% CI, 51.2%-68.3%) and 93.1% (95% CI, 85.6%-97.4%), respectively. After pathologic assessment, only 5.6% (n = 8/143) of triple-normal nodes were proven to be malignant. INTERPRETATION: At the time of staging for lung cancer, combining CT scanning, PET scanning, and CLNS criteria can identify triple-normal LNs that have a high NPV for malignancy. This raises the question of whether triple-normal LNs require routine sampling during EBUS and transbronchial needle aspiration. A prospective trial is required to confirm these findings.
BACKGROUND: Staging guidelines for lung cancer recommend endobronchial ultrasound (EBUS) and systematic biopsy of at least three mediastinal lymph node (LN) stations for accurate staging. A four-point ultrasonographic score (Canada Lymph Node Score [CLNS]) was developed to determine the probability of malignancy in each LN. A LN with a CLNS of < 2 is considered low probability for malignancy. We hypothesized that, in patients with cN0 non-small cell lung cancer, LNs with CLNS of < 2 may not require routine biopsy because they represent true node-negative disease. RESEARCH QUESTION: Do LNs considered triple normal on CT scanning, PET scanning, and CLNS evaluation require routine biopsy? STUDY DESIGN AND METHODS: LNs were evaluated for ultrasonographic features at the time of EBUS and the CLNS was applied. Triple-normal LNs were defined as cN0 on CT scanning (short axis, < 1 cm), PET scanning (no hypermetabolic activity), and EBUS (CLNS, < 2). Specificity and negative predictive value (NPV) were calculated against the gold standard pathologic diagnosis from surgically excised specimens. RESULTS: In total, 143 LNs from 57 cN0 patients were assessed. Triple-normal LNs showed a specificity and NPV of 60% (95% CI, 51.2%-68.3%) and 93.1% (95% CI, 85.6%-97.4%), respectively. After pathologic assessment, only 5.6% (n = 8/143) of triple-normal nodes were proven to be malignant. INTERPRETATION: At the time of staging for lung cancer, combining CT scanning, PET scanning, and CLNS criteria can identify triple-normal LNs that have a high NPV for malignancy. This raises the question of whether triple-normal LNs require routine sampling during EBUS and transbronchial needle aspiration. A prospective trial is required to confirm these findings.
Authors: Seung Hyun Yong; Sang Hoon Lee; Sang-Il Oh; Ji-Soo Keum; Kyung Nam Kim; Moo Suk Park; Yoon Soo Chang; Eun Young Kim Journal: Transl Lung Cancer Res Date: 2022-01