Endobronchial ultrasound-transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: variability of results and perspectives

Abstract

The remarkable value of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging of non-small cell lung cancer (NSCLC) is recognized worldwide.Reports from different centers however show considerable variation of EBUS-TBNA performance in terms of diagnostic yield, sensitivity and negative predictive value (NPV). Interpretation of EBUS-TBNA diagnostic efficacy requires clarifying whether the technique is used for purely diagnostic purpose or mediastinal staging, recognizing that different study groups may be inherently heterogeneous and that numerous factors may impact on the procedure outcomes. Review of these factors indicates that the prevalence of N2/N3 disease, the thoroughness of mediastinal sampling and >3 needle passes per target lymph node (LN) [in the absence of rapid on-site evaluation (ROSE)] influence the procedure outcomes, while many details in the sample preparation technique are unlikely to impact on the results and should be left to the proceduralists' preference. Generalized use of a standardized database for prospective collection of relevant EBUS-TBNA data would allow reporting institutional results by subgroups of N2/N3 disease prevalence and thoroughness of staging, and would help establishing quality standards for the procedure.

Optimising rapid on‐site evaluation‐assisted endobronchial ultrasound‐guided transbronchial needle aspiration of mediastinal lymph nodes: The real‐time cytopathology intervention process

“…These variables include prevalence of lung cancer, number of cases, experience of the proceduralist and CP, patient's likelihood for cancer or advance tumour stage, size and number of lymph nodes sampled, characteristics of medical facility, and use of anaesthesia or sedation 6,10‐12 …”

“…Several investigators indicate that prevalence of lung cancer, volume of cases and skill of the physician performing the EBUS‐TBNA influence sample adequacy 11 . The prevalence of lung cancer patients in high‐volume EBUS‐TBNA hospitals (eg, cancer centres or university hospitals) that serve as referral centres is higher than that of private clinics or public hospitals.…”

“…Current guidelines for mediastinal staging by EBUS‐TBNA recommend aiming to target at least three LN stations, including those LN with computed tomography/positron‐emission tomography features suggestive of malignancy 11 . Despite these recommendations, during many EBUS‐TBNAs, fewer than three LN stations are sampled because of bleeding, restless patient, difficult to puncture, longer procedures and evidence of metastatic disease early in the procedure 11 …”

Preoperative mediastinal staging in patients with cT1‐3NxM0 non‐small cell lung cancer

“…The outcome of mediastinal lymph node staging is dependent on the interpretation of the FDG PET-CT scan and thoroughness and performance of the procedure according to current guidelines. 7 Sampling from at least three lymph node stations is recommended for both mediastinoscopy and endosonography. 6,8 The aim of this study was to assess the performance and outcome in daily practice of the mediastinal staging process in patients with suspected cT1-3NxM0 NSCLC in a general teaching hospital according to current ESTS guidelines.…”

“…The outcome of mediastinal lymph node staging is dependent on the interpretation of the FDG PET‐CT scan and thoroughness and performance of the procedure according to current guidelines 7 . Sampling from at least three lymph node stations is recommended for both mediastinoscopy and endosonography 6, 8 …”