Endobronchial Ultrasound-guided Transbronchial Needle Aspiration for Systematic Nodal Staging of Lung Cancer in Patients with N0 Disease by Computed Tomography and Integrated Positron Emission Tomography–Computed Tomography

Abstract

This is the largest report of EBUS-TBNA in patients with N0 disease by "integrated" PET-CT. The majority of false-negative EBUS results were in LN stations outside its reach. In our study, both sensitivity and NPV of EBUS-TBNA were lower than early reports despite more extensive LN sampling. Given the high false-negative rate of imaging modalities, EBUS-TBNA may still play an important role in patients with radiographic N0 disease, particularly when nonsurgical ablative therapies are planned. Prospective studies are needed to corroborate our findings in the nonsurgical population.

The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer

“…Post-SBRT local failure can be as high as 15%. This may be due to undetected nodal metastasis in patients undergoing treatment under presumption that the clinical stage correlates with the pathological stage (2,(40)(41)(42)(43)(44)(45)(46)(47)(48). In addition, lung cancer screening programs have proliferated since the recent lung cancer screening recommendations of the U.S. Preventative Services Task Force (49).…”

“…EBUS-TBNA has varying performance in patients with clinical N0 disease. Some studies report sensitivity and NPV ranging between 89-92.3% and 96.3-98.9%, respectively (44,45), while others show sensitivity and NPV ranging between 35-60% and 88.4-93.4% (41,43). There may be a variety of reasons for this discrepancy aside from clinical expertise of the operator: (I) presence of multiple LNs at a station, but only selective LN sampling; (II) LNs inaccessible to EBUS-TBNA sampling (i.e., vascular structures in the needle path); (III) micrometastases in LNs not sampled (i.e., in many studies the lower limit of LN size considered for TBNA was 5 mm, with LNs smaller than that not sampled); (IV) micrometastases in small LNs which may be more challenging to sample.…”

Current advances of endobronchial ultrasonography in the diagnosis and staging of lung cancer

“…But more than 10% of patients who had no lymph node metastasis by image criteria had lymph node metastasis confirmed by thoracotomy (48)(49)(50). Because EBUS TBNA can be performed in an outpatient setting, current guidelines suggest that with patients with clinical N1 disease (51), central tumor and tumor >3 cm, and mainly adenocarcinoma with high fluorodeoxyglucose (FDG)uptake (52,53) all lymph nodes >0.5 cm found in echosonography (9,42) should be sampled, precisely because all of these conditions are associated with a high probability of mediastinal lymph node metastases.…”

Elastography in endobronchial ultrasound: Stretching the boundary of minimally invasive staging further

“…This has been described both in stage I disease, either preoperatively [8][9][10][11] or prior to stereotactic radiotherapy, 12 as well as in stage III NSCLC to direct accurate planning of radiation treatment fields.…”

“…While notable publications report preserved diagnostic performance in CT/PET-normal LN, 8 most studies report a lower sensitivity of EBUS-TBNA for detection of N2 disease in this clinical setting. [9][10][11] Hence, as revolutionary as EBUS-TBNA has been, there is still potential for novel tools to further improve minimally invasive mediastinal assessment of patients with NSCLC. In the present issue of Respirology, Korrungruang and Boonsarngsuk report findings regarding the ability of elastography to differentiate between benign and malignant LNs in patients undergoing EBUS for investigation of intrathoracic LNs.…”