Propensity-Matched Analysis of Clinical Relevance of the Highest Mediastinal Lymph Node Metastasis.

BACKGROUND: The clinical relevance of the highest mediastinal lymph node (HMLL) metastasis in patients with pathological N2 non-small cell lung cancer (NSCLC) is still controversial. Our study aimed to reassess the effect of HMLL metastasis on survival. METHODS: Patients with stage pT1-4N2M0 NSCLC who underwent major lung resection and systemic lymphadenectomy at Peking University People's Hospital from 2004 to 2015 were identified. Patients in the HMLL-positive group were matched to patients in the HMLL-negative group using 1:1 propensity score matching analysis. Overall survival was estimated by Kaplan-Meier method and compared using log-rank test, and multivariable Cox proportional hazard regression was constructed to identify risk factors associated with overall survival. The cumulative incidence of cancer specific mortality was evaluated through a competing risk analysis. RESULTS: A total of 266 NSCLC patients with stage pT1-4N2M0 NSCLC were enrolled. Of those, 128 cases were HMLL positive and 138 cases were HMLL negative. A higher proportion of patients in the HMLL-positive group were female (P = .034) and had a higher rate of adenocarcinoma (P = .003). Compared with the HMLL-negative, the HMLL-positive group was not associated with worse survival in unmatched cohorts (adjusted hazard ratio = 1.21; 95% confidence interval, 0.87-1.68). After propensity score matching, 109 pairs were selected. No survival difference remained in matched cohorts (adjusted hazard ratio = 1.00; 95% confidence interval, 0.70-1.42). CONCLUSIONS: Highest mediastinal lymph node metastasis does not exhibit worse survival in patients with stage pT1-4N2M0 NSCLC. The clinical relevance of HMLL metastasis needs further examination.

Survival Benefit and Genetic Profile of Pemetrexed as Initial Chemotherapy in Selected Chinese Patients With Advanced Lung Adenocarcinoma.

Objective: This study investigated survival in selected Chinese patients with advanced lung adenocarcinoma who received initial chemotherapy with pemetrexed. We also explored the relationship between genetic biomarkers and pemetrexed efficacy. Methods: We retrospectively collected patients (n = 1,047) enrolled in the Chinese Patient Assistance Program from multiple centers who received pemetrexed alone or combined with platinum as initial chemotherapy and continued pemetrexed maintenance therapy for advanced lung adenocarcinoma from November 2014 to June 2017. The outcomes were duration of treatment (DOT) and overall survival (OS). Clinical features were analyzed for their influence on the treatment effect and prognosis. Next-generation sequencing (NGS) was performed to identify genetic biomarkers associated with the efficacy of pemetrexed. Results: The median DOT was 9.1 months (95% CI: 8.5-9.8), and the median OS was 26.2 months (95% CI: 24.2-28.1). OS was positively correlated with DOT (r = 0.403, P < 0.001). Multivariable analysis showed that smoking status and Eastern Cooperative Oncology Group (ECOG) performance status (PS) were independently associated with DOT; smoking status, ECOG PS, targeted therapy, and EGFR/ALK/ROS1 status were independently associated with OS. NGS in 22 patients with available samples showed genes with high mutation rates were: TP53 (54.5%), EGFR (50.0%), MYC (18.2%), and PIK3CA (13.6%). When grouped based on progression-free survival (PFS) reported in the PARAMOUNT study, the DOT > 6.9 months set was associated with PIK3CA, ALK, BRINP3, CDKN2A, CSMD3, EPHA3, KRAS, and RB1 mutations, while ERBB2 mutation was observed only in the DOT ≤ 6.9 months set. Conclusion: This study shows that initial chemotherapy with pemetrexed is an effective regimen for advanced lung adenocarcinoma in selected Chinese patients. There is no specific genetic profile predicting the benefit of pemetrexed found by NGS. Biomarkers predicting the efficacy of pemetrexed need further exploration.

Identifying patients at higher risk of pneumonia after lung resection.

BACKGROUND: Pneumonia is considered as one of the most common and serious complications after lung resection. The purpose of this study was to identify the risk factors associated with postoperative pneumonia (POP) after lung resection and to develop a scoring system to stratify patients with increased risk of POP. METHODS: A retrospective review of a prospective database of patients between September 2014 and June 2016 was carried out. Logistic regression analysis was used to examine the risk factors for POP. Bootstrap resampling analysis was used for internal validation. Regression coefficients were used to develop weighted risk scores for POP. RESULTS: Results revealed that age ≥64 years, smoking (current or previous), high pathological stage, and extent of excision of more than one lobe as risk factors. Logistic regression analysis showed that the predictors of POP were as follows: age ≥64 years, smoking, extent of excision of more than one lobe. A weighted score based on these factors was developed which was follows: smoking (three points), age ≥64 years (four points), and extent of excision of more than one lobe (five points). POP score >5 points offered the best combination of sensitivity (64.7%) and specificity (83.3%), and an area under receiver operating characteristic (ROC) curve (AUC) of 0.830 [95% confidence interval (CI): 0.746-0.914]. CONCLUSIONS: Patients with older age, smoking and extent of excision of more than one lobe have a higher risk for pneumonia after lung cancer surgery. Also, the scoring system helps to guide decision making of POP risk reduction.

Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in intrapulmonary lesions.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered to have high value in the staging of mediastinal lymph nodes in lung cancer. The current study was conducted to investigate the diagnostic value of EBUS-TBNA in intrapulmonary lesions located near the central airway. METHODS: From September 2009 to March 2013, 66 patients with pulmonary masses located close to the central airways suspected to be lung cancer were accessed by EBUS-TBNA. Conventional bronchoscopic biopsy before EBUS-TBNA was nondiagnostic in all cases. If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy, patients were subsequently referred for a surgical procedure. RESULTS: Among the 66 cases, 59 were confirmed as pulmonary malignancies by EBUS-TBNA, of which 48 cases were non-small cell lung cancer, nine were small cell lung cancer, and two were metastatic lung tumors. No evidence of malignancy was found by biopsy and histopathological examination in the other seven cases. Thoracoscopy or thoracotomy was subsequently undergone for them. Postoperative pathological examinations confirmed three cases of squamous cell carcinoma of the lung, one case of lymphoma, two cases of sclerosing hemangioma, and one case of pulmonary tuberculoma. The definitive diagnosis rate of EBUS-TBNA for intrapulmonary lesions near the central airway was 89.4%. The sensitivity, specificity, and accuracy of EBUS-TBNA in distinguishing benign from malignant intrapulmonary lesions were 93.7%, 100.0%, and 93.9%, respectively. The positive and negative predictive values were 100.0% and 42.9%, respectively. The EBUS-TBNA procedures were well-tolerated by all patients. No associated complications were observed. CONCLUSIONS: For intrapulmonary lesions near the central airway highly suspected of cancer, EBUS-TBNA has satisfactory diagnostic value. However, the negative predictive value of this technique is low, so negative results obtained by EBUS-TBNA should be confirmed by other methods.

Diagnostic value of endobronchial ultrasound guided transbronchial needle aspiration in superior vena cava syndrome.

BACKGROUND: The pathological diagnosis is of critical importance to the subsequent treatment for the pathients with superior vena cava syndrome (SVCS). The aim of this study is to report our experience in the diagnosis of SVCS by endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). METHODS: The data of 520 patients who underwent EBUS-TBNA from September 2009 to May 2012 at our institution were reviewed. Of these, there were 14 males and 6 females (mean age of 59.1 years) with SVCS who received EBUS-TBNA that were included in the analysis. RESULTS: The mean short axis diameter of the paratracheal lesions was (3.32 ± 1.79) cm (range, 1.69 to 9.50 cm) and 6 cases also had subcarinal lymph node enlargement with a mean short axis diameter of (2.14 ± 0.49) cm (range, 1.73 to 3.01 cm). An average of 4.3 punctures was performed per lesion. Malignancy was confirmed in 16 cases (10 small cell carcinomas, 4 adenocarcinomas, 1 squamous cell carcinoma and 1 Hodgkin lymphoma). In two patients, pathological examination of tissue revealed no evidence of malignancy and for 13 to 24 months of follow-up. One patient from whom adequate tissue was not obtained refused further surgical biopsy since he had undergone endovascular stenting of the SVC. One patient in whom a diagnosis was not obtained by EBUS-TBNA underwent thoracoscopic biopsy and the final diagnosis was B cell non-Hodgkin's lymphoma. The diagnosis accuracy of EBUS-TBNA in SVCS was 18/20 patients. CONCLUSION: EBUS-TBNA is a highly effective and safe procedure for the diagnosis of SVCS.

[Application of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of isolated mediastinal lesions].

OBJECTIVE: To evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of isolated mediastinal lesions. METHODS: A retrospective study was conducted of 73 consecutive patients with isolated mediastinal lesions of unknown origin without parenchymal lung abnormalities, who underwent EBUS-TBNA from September 2009 to April 2011. The patients who were nondiagnostic with EBUS-TBNA subsequently underwent surgical biopsies and a minimum of 6 months'clinical and radiologic follow-up. RESULTS: EBUS-TBNA achieved definitive diagnoses in 60 patients of the 73 patients (82.2%, 60/73). Malignancies were diagnosed in 23 patients and benignancies in 37. The sensitivity, specificity, and accuracy of EBUS-TBNA in distinguishing malignant mediastinal lesions were 95.8%(23/24), 100%(49/49) and 98.6%(72/73), respectively. EBUS was well tolerated by all of the patients with no complications. CONCLUSION: EBUS-TBNA of isolated mediastinal lesions is a minimally invasive and safe diagnostic technique with high yield.

[Establishment of a mathematical prediction model to evaluate the probability of malignancy or benign in patients with solitary pulmonary nodules].

OBJECTIVE: To evaluate the clinical factors affecting the definite pathological diagnosis of solitary pulmonary nodules (SPN) with multivariate Logistic regression analysis, and to build the clinical prediction model to estimate the probability of malignancy. METHODS: A retrospective cohort study in our institution included 371 patients (197 males and 174 females) with definite pathological diagnosis of solitary pulmonary nodules from Jan 2000 to Sep 2009 (group A). Clinical data included age, gender, course of disease, symptoms, history and quantity of smoking history, history of tumor, family history of tumor, site, diameter, calcification, speculation, border, lobulation, traction of pleural, vascular convergence sign, and cavity. The independent predictors of malignancy were estimated with multivariate analysis, then the clinical prediction model was built. Other 62 SPN patients (group B) with definite pathological diagnosis in our institute from Oct 2009 to Mar 2010, were used to validate value of this clinical prediction model. RESULTS: 53.1% of the nodules were malignant, and 46.9% were benign in goup A. Logistic regression analysis showed that seven clinical characteristics [age of patient (OR: 1.073), diameter (OR: 1.966), border (OR: 0.245), calcification (OR: 0.199), spiculation (OR: 2.088) and the family history of tumor (OR: 3.550)] were independent predictors of malignancy in patients with SPN (P<0.05). The cut-off value was 0.463. The sensitivity in group B was 92.5%, specificity 81.8%, positive predictive value 90.2%, and negative predictive value 85.7%. The area under the ROC curve for our model was 0.888±0.054. CONCLUSION: Age of patient, diameter, border, calcification, spiculation and the family history of tumor are independent predictors of malignancy in patients with SPN. Our prediction model is accurate and sufficient to estimate the malignancy of patients with SPN.

Application of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal lesions.

BACKGROUND: Mediastinal lesions are often difficult to diagnose in clinical practice because of the unique anatomical position of the mediastinum, which makes performance of biopsy difficult. The value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer and mediastinal lymph node staging has been widely accepted. However, few studies have been conducted on the value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and differential diagnosis of mediastinal lesions. The current study was conducted to investigate the value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and differential diagnosis of isolated mediastinal lesions without lung abnormalities. METHODS: We retrospectively analyzed the data of patients with isolated mediastinal lesions without lung abnormalities for whom endobronchial ultrasound-guided transbronchial needle aspiration examination was performed at the Department of Thoracic Surgery of Peking University People's Hospital, between September 2009 and December 2010. For patients who could not be diagnosed with endobronchial ultrasound-guided transbronchial needle aspiration, surgical biopsy or more than 6 months of clinical and imaging follow-up was carried out. RESULTS: Endobronchial ultrasound-guided transbronchial needle aspiration was performed for 60 patients with isolated mediastinal lesions. Correct diagnosis was made in 48 cases. Nineteen cases were malignant, and 29 were benign. The rate of correct diagnosis was 80%. The sensitivity, specificity, and accuracy of endobronchial ultrasound-guided transbronchial needle aspiration in distinguishing benign from malignant mediastinal lesions were 95%, 100%, and 98%, respectively. The examination was tolerable for all patients. No associated complications were observed. CONCLUSION: Endobronchial ultrasound-guided transbronchial needle aspiration is a safe and effective method of diagnosing mediastinal lesions.

Comparison of the autofluorescence bronchoscope and the white light bronchoscope in airway examination.

BACKGROUND AND OBJECTIVE: The sensitivity and accuracy of white light bronchoscopy (WLB) in airway examination are low. Autofluorescence bronchoscope (AFB) can determine early lesions in bronchial mucosa more sensitively, but it has seldom performed in China. To assess the clinical value of the AFB in airway examination, we compared the sensitivity and specificity of the AFB and WLB in detecting cancer of the airway mucosa. METHODS: Between September 2009 and May 2010, bronchoscope examinations using both the AFB and WLB were performed on 136 patients, 95 men and 41 women with a median age of 61.5 years (ranged from 25 to 84 years). There were 46 lesions located in the central airway, 84 in the peripheral lung parenchyma, and 6 in the mediastinal region. All patients received local and general anesthesia and were subsequently examined with the WLB and AFB in tandem. All procedures were completed safely. Abnormal visual findings were recorded, and biopsies of the affected regions were collected for pathologic examination. RESULTS: Of 241 regions sampled for biopsy, 76 sites contained malignant lesions, whereas 165 sites contained benign lesions. The AFB detected 72 of the 76 malignant lesions, but the WLB detected only 50. The sensitivities of the AFB and WLB were 94.7% and 65.8%, respectively, and the specificities were 57.0% and 83.6%, respectively. The negative predictive values of the AFB and WLB were 95.9% and 84.1%, respectively. CONCLUSIONS: The AFB is more sensitive than the WLB in detecting cancerous lesions in the mucosa, and is an effective airway examination.