[Endobronchial ultrasound]

Ultrasound techniques in the evaluation of the mediastinum, part I: endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS) and transcutaneous mediastinal ultrasound (TMUS), introduction into ultrasound techniques

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography (EUS and EBUS) should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [EBUS combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [EUS fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all mediastinal lymph nodes can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review, in two integrative parts, is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part I is dealing with an introduction into ultrasound techniques, mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques and part II with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

Surgical intervention for pulmonary metastases

INTRODUCTION

Autopsy studies of persons who died of cancer have shown the lungs to be the sole site of metastasis in about 20% of cases. The resection of pulmonary metastases is indicated for palliative purposes if they contain a large volume of necrotic tumor, infiltrate the thoracic wall to produce pain, or cause hemoptysis or retention pneumonia. Metastasectomy with curative intent may be indicated for carefully selected patients.

METHODS

This review is based on a selective search of the PubMed database for articles that were published from 2006 to 2011 and contained the keywords "pulmonary metastasectomy," "lung resection of metastasis," and "lung metastasectomy."

RESULTS

No prospective comparative trials have been performed to date that might provide evidence for prolongation of survival by pulmonary metastasectomy; nor have there been any randiomized, controlled trials yielding evidence that would assist in the decision whether to treat pulmonary metastases with surgery, radiotherapy, or chemotherapy (or some combination of these). The indication for surgery is a function of the histology of the primary tumor, the number and location of metastases, the lung capacity that is expected to remain after surgery, and the opportunity for an R0 resection. Favorable prognostic factors include a long disease-free interval between the treatment of the primary tumor and the discovery of pulmonary metastases, the absence of thoracic lymph node metastases, and a small number of pulmonary metastases. The reported 5-year survival rates after pulmonary metastasectomy, depending on the primary tumor, are 35.5% to 47% for renal-cell carcinoma, 39.1% to 67.8% for colorectal cancer, 29% to 52% for soft-tissue sarcoma, 38% to 49.7% for osteosarcoma, and 79% to 94% for non-seminomatous germ-cell tumors. For the latter two types of tumor, chemotherapy is the most beneficial form of treatment for long-term survival.

CONCLUSION

When there is no good clinical alternative, the resection of pulmonary metastases can give some patients long-lasting freedom from malignant disease. Patients should be carefully selected on the basis of clinical staging with defined prognostic indicators.

[Lung cancer staging]

Lung cancer is the third most frequent new cancer diagnosis in Germany. An elaborate clinical diagnosis is essential for successful therapy planning. The necessary examinations are defined in the current S3 guideline on lung cancer diagnosis and therapy. A compilation of diagnostic reports has led to the current 7th edition of the TNM system. According to this update staging is carried out in terms of tumor extent, lymph node status and distant metastases. The resultant tumor stage forms the basis for individual therapy planning. Current guidelines as well as the current TNM system are presented. The usefulness of modern cross-sectional imaging and the possible modalities in this system is reported.