Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal nodal staging of lung cancer

Background: Recently, transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS–FNA) has been evaluated for mediastinal nodal staging (N staging) of lung cancer, as this technique is less invasive than mediastinoscopy and possibly more accurate than 18F-fluorodeoxyglucose positron emission tomography with computed tomography (PET–CT). However, EUS–FNA does not provide access to pretracheal and hilar lymph nodes. More recently, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS–TBNA) has been introduced as a novel technique for accessing pretracheal and hilar lymph nodes. Although the combined endoscopic approach of EUS–FNA and EBUS–TBNA is presumably more accurate than PET–CT, only a few reports have quantitatively evaluated its diagnostic ability. Therefore, we prospectively assessed the diagnostic yield of this combined endoscopic approach for mediastinal N staging of lung cancer.

Methods: A consecutive series of 120 patients with suspected resectable lung cancer on CT findings underwent PET–CT and combined EUS–FNA/EBUS–TBNA. The accuracy and other diagnostic indices of the combined approach in mediastinal N staging were compared with those of PET–CT.

Results: Among the enrolled patients, a final pathological N stage was established in 110 patients. The accuracy of the combined approach using EUS–FNA and EBUS–TBNA was significantly higher than that of PET–CT (90.0 % vs. 73.6 %; P < 0.0001). The sensitivity, specificity, and positive and negative predictive values were respectively 71.8 %, 100 %, 100 %, and 86.6 % for the combined approach vs. 47.4 %, 87.5 %, 66.7 %, and 75.9 % for PET–CT.

Conclusions: The combined endoscopic approach using EUS–FNA and EBUS–TBNA provided excellent diagnostic performance. Therefore, this approach is strongly recommended before surgery or mediastinoscopy to avoid futile thoracotomy and surgical intervention.

• References

• 1 Marugame T, Yoshimi I. Comparison of cancer mortality (lung cancer) in five countries: France, Italy, Japan, UK and USA from the WHO Mortality Database (1960 – 2000). Jpn J Clin Oncol 2005; 35: 168-170
• 2 Detterbeck FC, Jantz MA, Wallace M et al Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132: 202-220
• 3 De Leyn P, Lardinois D, Van Schil PE et al ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer. Eur J Cardiothorac Surg 2007; 32: 1-8
• 4 Cerfolio RJ, Bryant AS, Ojha B et al Improving the inaccuracies of clinical staging of patients with NSCLC: a prospective trial. Ann Thorac Surg 2005; 80: 1207-1213 (discussion 1213-1204)
• 5 Billé A, Pelosi E, Skanjeti A et al Preoperative intrathoracic lymph node staging in patients with non-small-cell lung cancer: accuracy of integrated positron emission tomography and computed tomography. Eur J Cardiothorac Surg 2009; 36: 440-445
• 6 Wallace MB, Fritscher-Ravens A, Savides TJ. Endoscopic ultrasound for the staging of non-small-cell lung cancer. Endoscopy 2003; 35: 606-610
• 7 Fritscher-Ravens A, Bohuslavizki KH, Brandt L et al Mediastinal lymph node involvement in potentially resectable lung cancer: comparison of CT, positron emission tomography, and endoscopic ultrasonography with and without fine-needle aspiration. Chest 2003; 123: 442-451
• 8 Eloubeidi MA, Cerfolio RJ, Chen VK et al Endoscopic ultrasound-guided fine needle aspiration of mediastinal lymph node in patients with suspected lung cancer after positron emission tomography and computed tomography scans. Ann Thorac Surg 2005; 79: 263-268
• 9 Yasuda I, Kato T, Asano F et al Mediastinal lymph node staging in potentially resectable non-small cell lung cancer: a prospective comparison of CT and EUS/EUS-FNA. Respiration 2009; 78: 423-431
• 10 Yasufuku K, Chiyo M, Sekine Y et al Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004; 126: 122-128
• 11 Gu P, Zhao YZ, Jiang LY et al Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer 2009; 45: 1389-1396
• 12 Adams K, Shah PL, Edmonds L et al Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax 2009; 64: 757-762
• 13 Vilmann P, Krasnik M, Larsen SS et al Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS–FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS–TBNA) biopsy: a combined approach in the evaluation of mediastinal lesions. Endoscopy 2005; 37: 833-839
• 14 Herth FJ, Rabe KF, Gasparini S et al Transbronchial and transoesophageal (ultrasound-guided) needle aspirations for the analysis of mediastinal lesions. Eur Respir J 2006; 28: 1264-1275
• 15 Wallace MB, Pascual JM, Raimondo M et al Minimally invasive endoscopic staging of suspected lung cancer. JAMA 2008; 299: 540-546
• 16 Szlubowski A, Zielinski M, Soja J et al A combined approach of endobronchial and endoscopic ultrasound-guided needle aspiration in the radiologically normal mediastinum in non-small-cell lung cancer staging – a prospective trial. Eur J Cardiothorac Surg 2010; 37: 1175-1179
• 17 Annema JT, van Meerbeeck JP, Rintoul RC et al Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010; 304: 2245-2252
• 18 American Society of Anesthesiologists. ASA Physical Status Classification System, Retrieved from the American Society of Anesthesiologists. http://www.asahq.org/clinical/physicalstatus.htm
• 19 Rusch VW, Asamura H, Watanabe H et al The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol 2009; 4: 568-577
• 20 Bhutani MS, Hawes RH, Hoffman BJ. A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for diagnosis of malignant lymph node invasion. Gastrointest Endosc 1997; 45: 474-479
• 21 Catalano MF, Sivak Jr MV . Rice T et al. Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc 1994; 40: 442-446
• 22 Micames CG, McCrory DC, Pavey DA et al Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging: a systematic review and metaanalysis. Chest 2007; 131: 539-548
• 23 Hwangbo B, Lee GK, Lee HS et al Transbronchial and transesophageal fine-needle aspiration using an ultrasound bronchoscope in mediastinal staging of potentially operable lung cancer. Chest 2010; 138: 795-802
• 24 Herth FJ, Krasnik M, Kahn N et al Combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes through a single bronchoscope in 150 patients with suspected lung cancer. Chest 2010; 138: 790-794
• 25 Verhagen AF, Bootsma GP, Tjan-Heijnen VC et al FDG-PET in staging lung cancer: how does it change the algorithm?. Lung Cancer 2004; 44: 175-181
• 26 Meyers BF, Haddad F, Siegel BA et al Cost-effectiveness of routine mediastinoscopy in computed tomography- and positron emission tomography-screened patients with stage I lung cancer. J Thorac Cardiovasc Surg 2006; 131: 822-829
• 27 Hwangbo B, Kim SK, Lee HS et al Application of endobronchial ultrasound-guided transbronchial needle aspiration following integrated PET/CT in mediastinal staging of potentially operable non-small cell lung cancer. Chest 2009; 135: 1280-1287