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Radiation Oncology • Thoracic Malignancies • Medical Oncology • Thoracic Surgery • NCI-CCC Tumor Board Question • Yale • COVID-19 • NCI-CCC Thoracic Tumor Board Question • Pulmonology
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
Should staging and treatment decisions be made based on imaging alone?
Question Created by Frederick H. Wilson
It certainly has pushed me more to using EBUS than mediastinoscopy and having to give patients the benefit of the doubt even when the EBUS retrieves only a small sample.
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I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between procedures to allow complete air exchange between patients, reducing daily procedure capacity by 50%. Thus EBUS turn around time has gone from 3-4 days from ordering to 10-12 days.
Because of this, our thoracic radiation oncology section has discussed omitting mediastinal staging for certain early stage patients being considered for SBRT: Patients with a negative PET CT scan in the mediastinum who have peripheral or peripheral and small lesion (e.g. < 2 cm).
In addition, I anticipate that with fewer resources, as more patients are COVID +, we would omit EBUS for some (many?) locally advanced unresectable patients receiving definitive chemoradiotherapy. In these incidences, I think it makes sense to be more generous in covering borderline enlarged, or borderline FDG avid LNs in the mediastinum without tissue confirmation of involvement.
I completely agree with @Percy Lee's comments above. At our institution, we will be much more sparing in our use of bronchoscopy and EBUS for diagnosis and staging of lung cancer during the COVID-19 epidemic for all of the reasons stated above by Dr. Lee.
One might alternatively be more careful at this time and avoid liberal expansions of target volumes. Contouring only PET+ nodes is probably best, given lung damage by RT + lung damage by SARS-CoV-2 could = catastrophic. The mortality of lung cancer patients undergoing Tx who got infected in Italy was ~20%.
Indeed @Drew Moghanaki, we are in agreement. One has to use clinical judgement when including nodal stations without the aid of pathological confirmation. That is why judicious vs. liberal inclusion of suspicious mediastinal nodes based on imaging is what I have recommended.