Video-assisted mediastinoscopic lymphadenectomy (VAMLA): Mature results for staging non-small cell lung cancer with normal mediastinum.

OBJECTIVES: The aim of this study is to analyze the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and the unsuspected (u) N2/3 rates in patients with non-small cell lung cancer (NSCLC) and normal mediastinum by integrated positron emission tomography-computed tomography. METHODS: Prospective observational single-center study of 603 consecutive VAMLAs from 2010 to 2022. EXCLUSION CRITERIA: other indications (n = 32), tumors different from NSCLC (n = 91), and clinical (c) N2/3 tumors by positron emission tomography-computed tomography (n = 46). Systematic nodal dissection was the gold standard to validate negative VAMLAs. Those patients with negative VAMLA and missing reference standard test were excluded. uN2/3 rates were analyzed in the global series and in the subgroups of tumors according to their clinical nodal and tumor categories. Pathologic findings were reviewed, and staging values were calculated. RESULTS: Three hundred eighty-three patients with cN0/1 NSCLC underwent VAMLA. Staging values of VAMLA were: sensitivity, 0.98 (95% CI, 0.92-0.99); negative predictive value, 0.99 (95% CI, 0.98-1); and diagnostic accuracy, 0.99 (95% CI, 0.98-1). The uN2/3 rate for the whole series (N = 383) was 18.8%. The uN2/3 rates according to presurgical nodal and tumor categories determined by positron emission tomography computed tomography were: 3.6% (4 out of 111) in cT1N0; 16.3% (18 out of 110) in cT2N0; 10.25% (4 out of 39) in cT3N0; and 32% (7 out of 22) in cT4N0. Forty-two percent (39 out of 93) in cN1; complication rate was 7%. CONCLUSIONS: This series of NSCLC with normal mediastinum staged by VAMLA demonstrates a high accuracy of this technique and a high rate of uN2/3 disease (specially in cN1 and cT4N0). VAMLA could be considered the reference staging procedure for staging cN0/1 NSCLC.

EBUS-TBNA for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer clinically staged with PET/CT.

BACKGROUND AND OBJECTIVE: To evaluate the diagnostic accuracy and clinical usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of centrally located T1N0M0 non-small cell lung cancer (NSCLC) clinically staged with positron emission tomography/computed tomography (PET/CT). METHODS: We conducted a study that included patients with centrally located T1N0M0 NSCLC, clinically staged with PET/CT who underwent EBUS-TBNA for mediastinal staging. Patients with negative EBUS-TBNA underwent mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy (VAMLA) and/or lung resection with systematic nodal dissection, that were considered the gold standard. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), overall accuracy of EBUS-TBNA for diagnosing mediastinal metastases (N2 disease) and the number needed to treat (NNT: number of patients needed to undergo EBUS-TBNA to avoid a case of pathologic N2 disease after resection) were calculated. RESULTS: One-hundred eighteen patients were included. EBUS-TBNA proved N2 disease in four patients. In the remaining 114 patients who underwent mediastinoscopy, VAMLA and/or resection there were two cases of N2 (N2 prevalence 5.1%). The sensitivity, specificity, NPV, PPV and overall accuracy for diagnosing mediastinal metastases (N2 disease) were of 66%, 100%, 98%, 100% and 98%, respectively. The NNT was 31 (95% CI: 15-119). CONCLUSION: EBUS-TBNA in patients with central clinically staged T1N0M0 NSCLC presents a good diagnostic accuracy for mediastinal staging, even in a population with low prevalence of N2 disease. Therefore, its indication should be considered in the management of even these early lung cancers.

Impact of COVID-19 infection on cognition and its association with neurological symptoms.

OBJECTIVE: To characterize the cognitive profile following COVID-19 infection and its possible association to clinical symptoms, emotional disturbance, biomarkers, and disease severity. METHODS: This was a single-center cross-sectional cohort study. Subjects between 20- and 60-year old with confirmed COVID-19 infection were included. Evaluation was performed between April 2020 and July 2021. Patients with previous cognitive impairment and other neurological or severe psychiatric disorders were excluded. Demographic and laboratory data were extracted from the medical records. RESULTS: Altogether 200 patients were included, 85 subjects were female (42.3%), and mean age was 49.12 years (SD: 7.84). Patients were classified into four groups: nonhospitalized (NH, n = 21), hospitalized without intensive care unit (ICU) nor oxygen therapy (HOSP, n = 42), hospitalized without ICU but with oxygen therapy (OXY, n = 107), and ICU (ICU, n = 31) patients. NH group was younger (p = .026). No significant differences were found in any test performed attending severity of illness (p > .05). A total of 55 patients reported subjective cognitive complaints (SCC). Subjects with neurological symptoms (NS) performed worse in trail making test B (p = .013), digits backwards (p = .006), letter&numbers (p = .002), symbol digit modalities test (p = .016), and Stroop color (p = .010) tests. CONCLUSIONS: OXY patients and females referred more SCC associated with symptoms of anxiety and depression. Objective cognitive performance was unrelated to SCC. No cognitive impairment was found regarding the severity of COVID-19 infection. Results suggest that NS such as headache, anosmia, and dysgeusia during infection were a risk factor for later cognitive deficits. Tests assessing attention, processing speed, and executive function were the most sensitive in detecting cognitive changes in these patients.

Incidence and Risk Factors for Infectious Complications of EBUS-TBNA: Prospective Multicenter Study

The aim of our study was to describe the incidence of infectious complications of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) and to analyze the potential risk factors in a prospective cohort of patients. Methods: We conducted a prospective multicenter study, with all consecutive patients referred for an EBUS-TBNA with patients at risk of developing an infectious complication (considering>10 nodal samplings, known immunosuppression, bronchial colonization and cavitated or necrotic lesions) and a second group without any risk factor. Results: Three hundred seventy patients were included: 245 with risk factors and 125 without risk factors (as the control group). Overall, 15 patients (4.05%) presented an acute infectious complication: fourteen in cases (5.7%) and 1 in controls (0.8%). Of these, 4 patients presented pneumonia, 1 mediastinitis, 4 obstructive pneumonitis and 6 mild complications (respiratory tract infection that resolved with antibiotic). Also 7 (1.9%) patients had self-limited fever. One-month follow-up showed 1 mediastinitis at sixteenth day post-EBUS, which required surgical treatment, and 3 pneumonias and 3 respiratory tract infections at nineteenth day (1.9%). All patients had a good evolution and there were no deaths related with infectious complication. We observed an increased risk of complication in patients with risk factors and in patients with necrosis (p=0.018). Conclusions: The incidence of infectious complications in a subgroup of patients with risk factors was higher than in patients without risk factors. Nevertheless, it remains low, and no fatal complication occurred, which reinforces the idea that EBUS-TBNA is a safe technique for the assessment of the mediastinum. Necrotic lesions are a risk factor of post-EBUS infection, and their puncture should be avoided. (AU)

Incidence and Risk Factors for Infectious Complications of EBUS-TBNA: Prospective Multicenter Study.

The aim of our study was to describe the incidence of infectious complications of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) and to analyze the potential risk factors in a prospective cohort of patients. METHODS: We conducted a prospective multicenter study, with all consecutive patients referred for an EBUS-TBNA with patients at risk of developing an infectious complication (considering>10 nodal samplings, known immunosuppression, bronchial colonization and cavitated or necrotic lesions) and a second group without any risk factor. RESULTS: Three hundred seventy patients were included: 245 with risk factors and 125 without risk factors (as the control group). Overall, 15 patients (4.05%) presented an acute infectious complication: fourteen in cases (5.7%) and 1 in controls (0.8%). Of these, 4 patients presented pneumonia, 1 mediastinitis, 4 obstructive pneumonitis and 6 mild complications (respiratory tract infection that resolved with antibiotic). Also 7 (1.9%) patients had self-limited fever. One-month follow-up showed 1 mediastinitis at sixteenth day post-EBUS, which required surgical treatment, and 3 pneumonias and 3 respiratory tract infections at nineteenth day (1.9%). All patients had a good evolution and there were no deaths related with infectious complication. We observed an increased risk of complication in patients with risk factors and in patients with necrosis (p=0.018). CONCLUSIONS: The incidence of infectious complications in a subgroup of patients with risk factors was higher than in patients without risk factors. Nevertheless, it remains low, and no fatal complication occurred, which reinforces the idea that EBUS-TBNA is a safe technique for the assessment of the mediastinum. Necrotic lesions are a risk factor of post-EBUS infection, and their puncture should be avoided.

Confirmatory Mediastinoscopy after Negative Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for Mediastinal Staging of Lung Cancer: Systematic Review and Meta-analysis.

Rationale: Current guidelines for non-small cell lung cancer (NSCLC) mediastinal staging recommend starting invasive staging with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). However, the indication to confirm a negative result of EBUS-TBNA by means of video-assisted mediastinoscopy (VAM) before resection differs in every guideline. Objectives: Our aim was to evaluate the current evidence regarding the added value of confirmatory VAM after a negative EBUS-TBNA result for mediastinal staging in patients with NSCLC. Methods: Systematic searches of studies on EBUS-TBNA for NSCLC mediastinal staging with or without confirmatory VAM but with surgical confirmation of negative results were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement in PubMed, SCOPUS, the Cochrane Library, and guidelines from 2005 through November 2021. In the meta-analysis, the sensitivity of confirmatory VAM after a negative EBUS-TBNA result, as well as the sensitivity and negative predictive value of the combination EBUS-TBNA plus confirmatory VAM, alongside the number of confirmatory VAMs required to detect additional N2/3 disease (number needed to treat [NNT]), in patients with a previous negative EBUS-TBNA result were estimated. Results: A total of 5,412 articles were found, of which 29 studies were included. Random effects meta-analysis showed a sensitivity of 66.9% (95% confidence interval [CI], 55.8-77.1%) for confirmatory VAM, and 96.7% (95% CI, 95.1-98%) for the combination EBUS-TBNA plus confirmatory VAM. Negative predictive value in studies with confirmatory VAM increased of 79.2% (95% CI, 71.4-86.1%) for EBUS-TBNA alone to 91.8% (95% CI, 87.1-95.5%) for EBUS-TBNA plus confirmatory VAM. The NNT of confirmatory VAM in patients with a previous negative EBUS-TBNA result was 23.8 (95% CI, 19.3-31.2). Conclusions: Confirmatory VAM after negative EBUS-TBNA reduces the rate of unforeseen N2/3 disease, but with a high NNT, and it should be recommended only for certain cases yet to be defined.

How do we classify a central tumor? Results of a multidisciplinary survey from the SEPAR Thoracic Oncology area / ¿Cómo clasificamos un tumor central? Resultados de una encuesta multidisciplinaria propuesta desde el área de Oncología Torácica de SEPAR

Introduction: In patients with non-small cell lung cancer (NSCLC) and normal mediastinal imaging tests, centrally located tumors have greater occult mediastinal involvement. Clinical guidelines, therefore, recommend invasive mediastinal staging in this situation. However, definitions of centrality in the different guidelines are inconsistent. The SEPAR Thoracic Oncology area aimed to evaluate the degree of familiarity with various concepts related to tumor site among professionals who see patients with NSCLC in Spain.Methods: A questionnaire was distributed to members of Spanish medical societies involved in the management of NSCLC, structured according to the 3 aspects to be evaluated: 1) uniformity in the definition of central tumor location; 2) uniformity in the classification of lesions that extend beyond dividing lines; and 3) ability to delineate lesions in the absence of dividing lines.Results: A total of 430 participants responded. The most voted definition of centrality was «lesions in contact with hilar structures» (49.7%). The lines most often chosen to delimit the hemithorax were concentric hilar lines (89%). Most respondents (92.8%) classified tumors according to the side of the dividing line that contained most of their volume. Overall, 78.6% were able to correctly classify a central lesion in the absence of dividing lines.Conclusions: In our survey, the most widely accepted definition of centrality is not one of the proposals specified in the clinical guidelines. The results reflect wide variability in the classification of tumor lesions. (AU)

Introducción: En pacientes con cáncer de pulmón de célula no pequeña (CPCNP) y mediastino normal, en pruebas de imagen, los tumores de localización central presentan mayor afectación mediastínica oculta. Por ello las guías clínicas recomiendan estadificación mediastínica invasiva en esta situación. No obstante, las definiciones de centralidad son poco uniformes entre guías. Desde el área de oncología torácica de la SEPAR se propuso evaluar el grado de familiaridad con varios conceptos relacionados con la localización tumoral entre profesionales que atienden pacientes con CPCNP en nuestro territorio.Métodos: Se envió una encuesta a miembros de sociedades médicas nacionales implicadas en el manejo del CPCNP. La encuesta se estructuró en tres aspectos a evaluar: 1) uniformidad en la definición de localización tumoral central; 2) uniformidad en la clasificación de lesiones que sobrepasan líneas divisorias y 3) capacidad para delimitar lesiones en ausencia de líneas divisorias.Resultados: 430 participantes respondieron. La definición de centralidad más votada fue «lesiones en contacto con las estructuras hiliares» (49,7%). Las líneas más escogidas para delimitar el hemitórax fueron líneas concéntricas al hilio (89%). La mayoría (92,8%) consideró los tumores según en qué lado de la línea divisoria se encontrase la mayor parte de su volumen. Un 78,6% fue capaz de catalogar correctamente una lesión central en ausencia de líneas divisorias.Conclusiones: En nuestra encuesta, la definición de centralidad más aceptada no es ninguna de las propuestas en las guías clínicas. Los resultados reflejan amplia variabilidad para clasificar lesiones tumorales. (AU)

Previously Undetected Obstructive Sleep Apnea in Patients With New-Onset Atrial Fibrillation.

Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (AF) control strategies. Continuous positive airway pressure (CPAP) may ameliorate arrhythmia control especially in early AF stages (new-onset AF). We investigated a practical screening strategy to determine the likelihood of CPAP indication in new-onset AF patients. Seventy-seven consecutive patients with new-onset (<1 month) AF were prospectively evaluated. Of them, 4 were excluded due to previously diagnosed OSA. The remaining 73 (68% persistent AF) fulfilled the Epworth, Berlin and STOP-BANG questionnaires, an ambulatory polysomnography being performed thereafter in all them in order to determine the apnea-hipopnea index (AHI). CPAP was indicated following conventional criteria. The variables associated with the diagnosis of OSA, with the AHI value and with CPAP indication were investigated by means of descriptive, univariate and multivariate analysis. The prevalence of OSA of any degree and CPAP indication was 82% and 37%, respectively. The variables associated (p < 0.05) with a higher AHI were male gender, body mass index, obesity, hypertension, and high-risk scoring at the Berlin and STOP-BANG questionnaires. In the multivariate analysis, the STOP-BANG scoring proved superior to conventional risk factors and became the only variable predicting CPAP indication (odds ratio 4.5 [1.9 to 10.6]; p = 0.01), an optimized cutoff value of ≥4 being newly established (sensitivity/specificity 76/65%). In conclusion, in patients referred with new-onset AF we documented a high risk of OSA and of need for CPAP. A STOP-BANG scoring of ≥4 in our population was a practical screening alternative to direct polysomnography in this setting.

How do we Classify a Central Tumor? Results of a Multidisciplinary Survey from the SEPAR Thoracic Oncology Area. / ¿Cómo clasificamos un tumor central? Resultados de una encuesta multidisciplinaria propuesta desde el área de Oncología Torácica de SEPAR.

INTRODUCTION: In patients with non-small cell lung cancer (NSCLC) and normal mediastinal imaging tests, centrally located tumors have greater occult mediastinal involvement. Clinical guidelines, therefore, recommend invasive mediastinal staging in this situation. However, definitions of centrality in the different guidelines are inconsistent. The SEPAR Thoracic Oncology area aimed to evaluate the degree of familiarity with various concepts related to tumor site among professionals who see patients with NSCLC in Spain. METHODS: A questionnaire was distributed to members of Spanish medical societies involved in the management of NSCLC, structured according to the 3 aspects to be evaluated: 1) uniformity in the definition of central tumor location; 2) uniformity in the classification of lesions that extend beyond dividing lines; and 3) ability to delineate lesions in the absence of dividing lines. RESULTS: A total of 430 participants responded. The most voted definition of centrality was «lesions in contact with hilar structures¼ (49.7%). The lines most often chosen to delimit the hemitorax were concentric hilar lines (89%). Most participants (92.8%) classified tumors according to the side of the dividing line that contained most of their volume. Overall, 78.6% were able to correctly classify a central lesion in the absence of dividing lines. CONCLUSIONS: In our survey, the most widely accepted definition of centrality is not one of the proposals specified in the clinical guidelines. The results reflect wide variability in the classification of tumor lesions.

Geometrical Measurement of Central Tumor Location in cT1N0M0 NSCLC Predicts N1 but Not N2 Upstaging.

BACKGROUND: In patients with non-small cell lung cancer (NSCLC) and normal mediastinum, the central tumor location predicts occult nodal disease (both N1 and N2). We evaluated a novel definition of central location based on a geometrical measurement of the tumor location within the lung that could predict N2, N1, or both. METHODS: This retrospective study included patients with confirmed NSCLC, radiologically and metabolically staged T1 N0 M0, who underwent invasive mediastinal staging and/or lung resection. The central tumor location was measured considering 2 ratios. The inner margin ratio (IMR) and outer margin ratio (OMR) were both calculated as the distance from the inner margin of the lung to both margins of the tumor (inner [IMR], outer [OMR]) divided by the lung width. Optimal cutoffs for IMR and OMR were calculated. Tumors with values lower than the cutoffs were considered central. Prevalences of N1 and N2 upstaging were estimated and bivariate logistic regression analysis was performed to predict the odds of N1 and N2 upstaging using IMR and OMR cutoffs. RESULTS: A total of 209 patients were included. The prevalence of N1 and N2 upstaging was 11% and 5.3%, respectively. Cutoffs of 0.5 for IMR and 0.64 for OMR were estimated. Both ratios predicted N1 upstaging (adjusted odds ratio [95% confidence interval]: 4.2 [1.5-12]; P < .007; area under the curve, 0.65) but did not predict N2 upstaging. CONCLUSIONS: Central tumor location can be assessed by means of IMR and OMR and predicts N1 upstaging in patients with radiologically and metabolically T1 N0 M0 tumors. This is important for the selection of patients for therapies that require N0 tumors.

Risk factors for later hospitalization of patients discharged from an emergency department with nonsevere COVID-19 symptoms. / Factores de riesgo de rehospitalización en pacientes con COVID-19 leve tras el alta desde el servicio de urgencias.

OBJECTIVES: To describe the clinical course of patients discharged from the emergency department (ED) with nonsevere coronavirus disease 2019 (COVID-19) and explore possible risk factors for later hospitalization. MATERIAL AND METHODS: Patients with nonsevere COVID-19 who were discharged from the ED were included prospectively. We explored risk factors for hospitalization after discharge. RESULTS: Seventy-four patients were included; 17 (23%) were hospitalized after discharge. Three (4%) of the 17 patients died. Age, lymphopenia, a high Charlson Comorbidity Index, and a shorter delay between the onset of symptoms and the first visit to the ED were associated with hospitalization afterwards, although on multivariate analysis only time less than 6 days between symptom onset and the first ED visit was associated with later hospitalization (odds ratio, 4.62; 95% CI, 1.08-19.7). CONCLUSION: More than 20% of ED patients with nonsevere COVID-19 require hospitalization later.

OBJETIVO: Describir la evolución clínica de pacientes con COVID-19 leve tras el alta de urgencias y analizar los posibles factores de riesgo para una posterior hospitalización. METODO: Pacientes con COVID-19 leve dados de alta desde urgencias fueron prospectivamente incluidos. Los factores de riesgo de hospitalización fueron evaluados. RESULTADOS: Se incluyeron 74 pacientes y 17 (23%) requirieron hospitalización, de los cuales 3 (4%) fallecieron. La edad, la linfopenia, un mayor índice Charlson y un menor tiempo desde el inicio de los síntomas hasta la primera consulta a urgencias se asociaron a hospitalización, aunque en el análisis multivariado únicamente un tiempo desde el inicio de síntomas a la consulta a urgencias - 6 días se asoció a hospitalización (OR: 4,62: IC 95%: 1,08-19,7). CONCLUSIONES: Más del 20% de pacientes con COVID-19 leve dados de alta desde urgencias requiere hospitalización.

Factores de riesgo de rehospitalización en pacientes con COVID-19 leve tras el alta desde el servicio de urgencias / Risk factors for later hospitalization of patients discharged from an emergency department with non severe COVID-19 symptoms

OBJETIVO: Describir la evolución clínica de pacientes con COVID-19 leve tras el alta de urgencias y analizar los posibles factores de riesgo para una posterior hospitalización. MÉTODO: Pacientes con COVID-19 leve dados de alta desde urgencias fueron prospectivamente incluidos. Los factores de riesgo de hospitalización fueron evaluados. RESULTADOS: Se incluyeron 74 pacientes y 17 (23%) requirieron hospitalización, de los cuales 3 (4%) fallecieron. La edad, la linfopenia, un mayor índice Charlson y un menor tiempo desde el inicio de los síntomas hasta la primera consulta a urgencias se asociaron a hospitalización, aunque en el análisis multivariado únicamente un tiempo desde el inicio de síntomas a la consulta a urgencias < 6 días se asoció a hospitalización (OR: 4,62: IC 95%: 1,08-19,7). CONCLUSIONES: Más del 20% de pacientes con COVID-19 leve dados de alta desde urgencias requiere hospitalización

OBJETIVES: To describe the clinical course of patients discharged from the emergency department (ED) with non severe coronavirus disease 2019 (COVID-19) and explore possible risk factors for later hospitalization. METHODS: Patients with nonsevere COVID-19 who were discharged from the ED were included prospectively. We explored risk factors for hospitalization after discharge. RESULTS: Seventy-four patients were included; 17 (23%) were hospitalized after discharge. Three (4%) of the 17 patients died. Age, lymphopenia, a high Charlson Comorbidity Index, and a shorter delay between the onset of symptoms and the first visit to the ED were associated with hospitalization afterwards, although on multivariate analysis only time less than 6 days between symptom onset and the first ED visit was associated with later hospitalization (odds ratio, 4.62; 95% CI, 1.08-19.7). CONCLUSION: More than 20% of ED patients with nonsevere COVID-19 require hospitalization later

Preoperative staging of the mediastinum is an essential and multidisciplinary task.

Mediastinal staging is a crucial step in the management of patients with NSCLC. With the recent development of novel techniques, mediastinal staging has evolved from an activity of interest mainly for thoracic surgeons to a joint effort carried out by many specialists. In this regard, the debate of cases in MDT sessions is crucial for optimal management of patients. Current evidence-based clinical guidelines for preoperative NSCLC staging recommend that mediastinal staging should be performed with increasing invasiveness. Image-based techniques are the first approach, although they have limited accuracy and findings must be confirmed by pathology in almost all cases. In this setting, the advent of radiomics is promising. Invasive staging depends on procedural factors rather than diagnostic performance. The choice between endoscopy-based or surgical procedures should depend on the local expertise of each centre. As the extension of mediastinal disease in terms of number of involved lymph nodes and nodal stations affects prognosis and the choice of treatment, systematic samplings are preferred over random targeted samplings. Following this approach, a diagnosis of single mediastinal nodal involvement can be unreliable if all reachable mediastinal nodal stations have not been assessed. The performance of confirmatory mediastinoscopy after a negative endoscopy-based procedure is controversial but currently recommended. Current indications of invasive staging in patients with radiologically normal mediastinum have to be re-evaluated, especially for central tumour location.