Diagnostic performance of endobronchial ultrasound‐guided mediastinal lymph node sampling in early stage non‐small cell lung cancer: A prospective study

Abstract

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 (AE1.63). 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 explored

Importance of oesophageal ultrasound in mediastinal staging of lung cancer

“…1 Incidentally, this is a very similar estimate to the 42% reported by Dr Naur et al 2 We strongly agree that preoperative staging in these potentially operable patients needs to be improved but believe that presently the best strategy remains unclear. The authors refer to the high number of unsuspected metastasis in station 5 found in both studies, and seem to advocate for the routine use of oesophageal ultrasound with fine needle aspiration using the bronchoscope (EUS-B-FNA) to sample this station as a strategy to increase sensitivity.…”

“…Several studies including a meta-analysis suggest that the combination of the oesophageal and tracheal approaches increases the sensitivity for detecting nodal mediastinal metastases in lung cancer patients compared with EBUS-TBNA alone. 3,4 The importance of oesophageal ultrasound with fine needle aspiration using the bronchoscope (EUS-B-FNA) is supported by both our published work and Vial et al 1,2 In approximately half of the patients in these studies, where both PET-CT and EBUS-TBNA 'overlooked' spread to the mediastinum, the metastases were ultimately found in lymph nodes that cannot be reached by the EBUS procedure, most often station 5. Vial et al highlight one patient who had a malignant lymph node in station 9, which is known to be accessible by EUS-B-FNA.…”

The importance of oesophageal ultrasound in mediastinal staging of lung cancer – Reply

“…Several studies including a meta-analysis suggest that the combination of the oesophageal and tracheal approaches increases the sensitivity for detecting nodal mediastinal metastases in lung cancer patients compared with EBUS-TBNA alone. 3,4 The importance of oesophageal ultrasound with fine needle aspiration using the bronchoscope (EUS-B-FNA) is supported by both our published work and Vial et al 1,2 In approximately half of the patients in these studies, where both PET-CT and EBUS-TBNA 'overlooked' spread to the mediastinum, the metastases were ultimately found in lymph nodes that cannot be reached by the EBUS procedure, most often station 5. Vial et al highlight one patient who had a malignant lymph node in station 9, which is known to be accessible by EUS-B-FNA.…”

“…In conclusion, the results of Vial et al 1 underline that the time has come for pulmonologists to learn and implement EUS-B-FNA in combination with EBUS-TBNA, to increase the precision of preoperative mediastinal staging of lung cancer patients. …”

Surgery for mediastinal lymph node and early stage lung cancer: individualized practice based on clinical database

“…Preoperative and intraoperative lymph node detection and modification of systemic lymph node dissection has been advocated, such as lymph node sampling, selective lymph node dissection, and sentinel lymph node resection (6)(7)(8)(9). Further clinical trial is mandatory to consolidate the indication for not performing lymph node dissection in patients with early stage lung cancer.…”