Bronchoscopic and Endobronchial Ultrasound Procedures in Management of Lung Cancers

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تاریخ نمایه سازی: 5 آبان 1397

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Lung cancer is the most common cause of cancer death worldwide. The clinical staging oflung identifies treatment options and guides disease prognosis. In patients with non-small-cell lungcancer with no evidence of extra-thoracic spread, the disease status of the mediastinal lymph nodescan be used to establish a patient s suitability for treatment with curative intent.Several invasive and non-invasive techniques are available to support the diagnosis and staging oflung cancer. About 50% of patients present with metastatic disease that is evident outside the thoraxand, in these patients, a biopsy sample taken from the safest most accessible location isrecommended. However, in patients with solely intrathoracic disease evident on the initial CT scan,the diagnostic and staging algorithm is more complex. A sample of the primary lesion is generallytaken by bronchoscopy or CT-guided biopsy before attention turns to mediastinal nodal staging.PET-CT is reliable if mediastinal lymph nodes that are less than 1 cm in the short axis are negative.However, invasive sampling of mediastinal lymphadenopathy is recommended when lymph nodesare avid for 18F-fluorodeoxyglucose (18F-FDG), the tumor is central, there is a PET-positive hilarlymph node, or any mediastinal node is larger than 1 cm in the short axis (irrespective of 18F-FDGuptake).The diagnosis and staging of patients with intrathoracic disease can therefore need severalinvestigative procedures, including bronchoscopy, radiology-guided biopsy sampling, PET-CT, andmediastinoscopy. This process often takes several weeks and is a time of great anxiety for patients.Further time will elapse before a treatment decision has been made which could mean that they areunfit for oncological treatments by the time a treatment decision has been reached.Previous approach to mediastinal staging of non-small-cell lung cancer (CT, PET-CT, andmediastinoscopy) can result in inaccurate nodal staging in 25% of operable patients, perhaps because the sensitivity for the detection of mediastinal metastases by CT scan is 51%, by PET-CT is74%, and by mediastinoscopy is 78%.Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is anewer technique that allows minimally invasive sampling of all intrathoracic lymph nodes adjacentto the bronchial tree. A pooled analysis of 1299 patients with known or suspected non-small-celllung cancer undergoing EBUS-TBNA showed that the procedure had a sensitivity of 90% for thedetection of mediastinal nodal metastases. Now, guidelines recommended EBUS-TBNA as analternative to mediastinoscopy for patients who needed invasive mediastinal sampling after a PETCTscan. Invasive mediastinal sampling is also recommended for staging patients with centraltumors or patients with enlarged or 18F-FDG-avid hilar lymphadenopathy.


Mostafa Tabassomi

M.D, Interventional Pulmonologist HenryMayo Newhall Memorial Hospital, Valencia, California, U.S.A