Browsing by Author "Stewart, John"
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Item Diagnostic performance of endobronchial ultrasound-guided mediastinal lymph node sampling in early stage non-small cell lung cancer: A prospective study(2018) Rodríguez Vial, Macarena; O’connell, Oisin J.; Grosu, Horiana B.; Hernández, Mike; Noor, Laila; Casal, Roberto F.; Stewart, John; Sarkiss, Mona; Jiménez, Carlos A.; Rice, David; Mehran, Reza; Ost, David E.; Eapen, George A.Background and objective: Standard nodal staging of lung cancer consists of positron emission tomography/ computed tomography (PET/CT), followed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) if PET/CT shows mediastinal lymphadenopathy. Sensitivity of EBUS-TBNA in patients with N0/N1 disease by PET/CT is unclear and largely based on retrospective studies. We assessed the sensitivity of EBUS-TBNA in this setting. Methods: We enrolled patients with proven or suspected lung cancer staged as N0/N1 by PET/CT and without metastatic disease (M0), who underwent staging EBUS-TBNA. Primary outcome was sensitivity of EBUS-TBNA compared with a composite reference standard of surgical stage or EBUS-TBNA stage if EBUS demonstrated N2/N3 disease. Results: Seventy-five patients were included in the analysis. Mean tumour size was 3.52 cm (1.63). Fifteen of 75 patients (20%) had N2 disease. EBUS-TBNA identified six while nine were only identified at surgery. Sensitivity of EBUS-TBNA for N2 disease was 40% (95% CI: 16.3–67.7%). Conclusion: A significant proportion of patients with N0/N1 disease by PET/CT had N2 disease (20%) and EBUS-TBNA identified a substantial fraction of these patients, thus improving diagnostic accuracy compared with PET/CT alone. Sensitivity of EBUS-TBNA however appears lower compared with historical data from patients with larger volume mediastinal disease. Therefore, strategies to improve EBUS-TBNA accuracy in this population should be further exploredItem Non-small cell lung cancer transdifferentiation into small cell lung cancer: A case series(2018) Ahmed, Tahreem; Rodríguez Vial, Macarena; Ost, David; Stewart, John; Hasan, Muhammad A.; Grosu, Horiana B.Transdifferentiation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC) has been reported mostly in adenocarcinomas and has been described as a cause of acquired tyrosine kinase inhibitor (TKI) resistance. However, transdifferentiation has also been described in patients with different histologic characteristics and patients not exposed to TKIs and with no epidermal growth factor receptor (EGFR) mutation (the target of TKIs). To this date transdifferentiation remains poorly understood. We conducted a retrospective case series of patients who had biopsy-proven SCLC within 2 years after a diagnosis of NSCLC or in the same location as the known primary NSCLC. We found that 0.2% of lung cancer patients at our institution experienced transdifferentiation. Among these, 30 had adenocarcinoma and 16 had squamous cell carcinoma. In 27 of the 30 patients with adenocarcinoma (90%), SCLC was found in the same location as the known primary. In 14 of the 30 patients (47%), SCLC occurred within 2 years after the NSCLC diagnosis. In 12 of the 16 patients with squamous cell carcinoma (75%), SCLC was found in the same location as the known primary. In 8 of these 16 patients (50%), SCLC occurred within 2 years after the NSCLC diagnosis. Few patients with adenocarcinoma and none with squamous cell carcinoma were treated with TKIs or had an EGFR mutation. In conclusion the findings in the current study suggest that the discovery of SCLC histology after treatment of NSCLC may be more common than thought suggesting that further study is warranted to evaluate the phenomenon of transdifferentiation.Item Pleural touch preparations and direct visualization of the pleura during medical thoracoscopy for the diagnosis of malignancy(American Thoracic Society, 2017) Grosu, Horiana; Vial-Rodriguez, Macarena; Vakil, Erik; Casal, Roberto; Eapen, George; Morice, Rodolfo; Stewart, John; Sarkiss, Mona; Ost, DavidRATIONALE: During diagnostic thoracoscopy, talc pleurodesis after biopsy is appropriate if the probability of malignancy is sufficiently high. Findings on direct visual assessment of the pleura during thoracoscopy, rapid onsite evaluation (ROSE) of touch preparations (touch preps) of thoracoscopic biopsy specimens, and preoperative imaging may help predict the likelihood of malignancy; however, data on the performance of these methods are limited. OBJECTIVES: To assess the performance of ROSE of touch preps, direct visual assessment of the pleura during thoracoscopy, and preoperative imaging in diagnosing malignancy. METHODS: Patients who underwent ROSE of touch preps during thoracoscopy for suspected malignancy were retrospectively reviewed. Malignancy was diagnosed on the basis of final pathologic examination of pleural biopsy specimens. ROSE results were categorized as malignant, benign, or atypical cells. Visual assessment results were categorized as tumor studding present or absent. Positron emission tomography (PET) and computed tomography (CT) findings were categorized as abnormal or normal pleura. Likelihood ratios were calculated for each category of test result. RESULTS: The study included 44 patients, 26 (59%) with a final pathologic diagnosis of malignancy. Likelihood ratios were as follows: for ROSE of touch preps: malignant, 1.97 (95% confidence interval [CI], 0.90-4.34); atypical cells, 0.69 (95% CI, 0.21-2.27); benign, 0.11 (95% CI, 0.01-0.93); for direct visual assessment: tumor studding present, 3.63 (95% CI, 1.32-9.99); tumor studding absent, 0.24 (95% CI, 0.09-0.64); for PET: abnormal pleura, 9.39 (95% CI, 1.42-62); normal pleura, 0.24 (95% CI, 0.11-0.52); and for CT: abnormal pleura, 13.15 (95% CI, 1.93-89.63); normal pleura, 0.28 (95% CI, 0.15-0.54). CONCLUSIONS: A finding of no malignant cells on ROSE of touch preps during thoracoscopy lowers the likelihood of malignancy significantly, whereas finding of tumor studding on direct visual assessment during thoracoscopy only moderately increases the likelihood of malignancy. A positive finding on PET and/or CT increases the likelihood of malignancy significantly in a moderate-risk patient group and can be used as an adjunct to predict malignancy before pleurodesis.Item Pleural Touch Preparations and Direct Visualization of the Pleura during Medical Thoracoscopy for the Diagnosis of Malignancy(2017) Grosu, Horiana B.; Vial-Rodriguez, Macarena; Vakil, Erik; Casal, Roberto F.; Eapen, George A.; Morice, Rodolfo; Stewart, John; Sarkiss, Mona G.; Ost, David E.Rationale: During diagnostic thoracoscopy, talc pleurodesis after biopsy is appropriate if the probability of malignancy is sufficiently high. Findings on direct visual assessment of the pleura during thoracoscopy, rapid onsite evaluation (ROSE) of touch preparations (touch preps) of thoracoscopic biopsy specimens, and preoperative imaging may help predict the likelihood of malignancy; however, data on the performance of these methods are limited. Objectives: To assess the performance of ROSE of touch preps, direct visual assessment of the pleura during thoracoscopy, and preoperative imaging in diagnosing malignancy. Methods: Patients who underwent ROSE of touch preps during thoracoscopy for suspected malignancy were retrospectively reviewed. Malignancy was diagnosed on the basis of final pathologic examination of pleural biopsy specimens. ROSE results were categorized as malignant, benign, or atypical cells. Visual assessment results were categorized as tumor studding present or absent. Positron emission tomography (PET) and computed tomography (CT) findings were categorized as abnormal or normal pleura. Likelihood ratios were calculated for each category of test result. Results: The study included 44 patients, 26 (59%) with a final pathologic diagnosis of malignancy. Likelihood ratios were as follows: for ROSE of touch preps: malignant, 1.97 (95% confidence interval [CI], 0.90–4.34); atypical cells, 0.69 (95% CI, 0.21–2.27); benign, 0.11 (95% CI, 0.01–0.93); for direct visual assessment: tumor studding present, 3.63 (95% CI, 1.32–9.99); tumor studding absent, 0.24 (95% CI, 0.09–0.64); for PET: abnormal pleura, 9.39 (95% CI, 1.42–62); normal pleura, 0.24 (95% CI, 0.11–0.52); and for CT: abnormal pleura, 13.15 (95% CI, 1.93–89.63); normal pleura, 0.28 (95% CI, 0.15–0.54). Conclusions: A finding of no malignant cells on ROSE of touch preps during thoracoscopy lowers the likelihood of malignancy significantly, whereas finding of tumor studding on direct visual assessment during thoracoscopy only moderately increases the likelihood of malignancy. A positive finding on PET and/or CT increases the likelihood of malignancy significantly in a moderate-risk patient group and can be used as an adjunct to predict malignancy before pleurodesis.