Diagnostic value of endoscopic ultrasonography-guided fine-needle aspiration cytology of mediastinal masses in patients with intrapulmonary lesions and nondiagnostic bronchoscopy

Impact of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in lymph nodal and mediastinal lesions: a multicenter experience

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established procedure in lung cancer (LC) staging and in the diagnosis of mediastinal masses. Most of the experiences reported refer to single specialized centers where dedicated teams of endoscopists and pathologists perform the procedure. We report the EUS-FNA experience of a cooperation group involving clinicians and cytopathologists from three hospitals. Fifty-seven consecutive EUS-FNA of mediastinal nodes in LC patients, eight mediastinal and two subdiaphragmatic masses were collected in 3 years. EUS-FNA was performed by two endoscopists and three experienced pathologists. On-site evaluation was performed in all cases by the three cytopathologists. Lymph node negative cases underwent surgery, which confirmed the cytological diagnoses but also detected two false negatives. Four of the 10 EUS cytological diagnoses of mediastinal and subdiaphragmatic masses were histologically confirmed. All EUS diagnoses were blindly reviewed by three pathologists to assess intra and interpersonal reproducibility. FNA-EUS diagnoses were: 10 inadequate (17%), 10 negative (17%), 4 suspicious (7%) and 33 positive (59%). Diagnoses of mediastinal and subdiaphragmatic masses were: relapse of lung carcinoma (3), mesenchimal tumor not otherwise specifiable (3), gastrointestinal stromal tumor (GIST) (1), esophageal carcinoma (2) and paraganglioma (1). The sensitivity attained was 85% and the specificity 100%; revision of the slides demonstrated a significant diagnostic reproducibility of the three cytopathologists (P < 0.5). The sensitivity and specificity attained were similar to those reported in the literature suggesting that experienced cytopathologists and endoscopists from different institutions can employ the same procedure reaching comparable results.

Implementation of endoscopic ultrasound for lung cancer staging

BACKGROUND

EUS-guided FNA is currently advocated in lung cancer staging guidelines as an alternative for surgical staging to prove mediastinal metastases. To date, training requirements for chest physicians to obtain competency in EUS for lung cancer staging are unknown.

OBJECTIVE

To test a training and implementation strategy for EUS for the diagnosis and staging of lung cancer.

DESIGN

Prospective national multicenter implementation trial. Nine (chest) physicians from 5 hospitals participated in a dedicated EUS educational program (investigation of 50 patients) for the diagnosis and staging of lung cancer. EUS outcomes of trainees were compared with those of the training center.

SETTING

Four general hospitals, the national cancer center (implementation centers), and a tertiary referral center (expert center).

PATIENTS

This study involved 551 consecutive patients with (suspected) lung cancer, all candidates for surgical staging, who underwent EUS in 1 of the 5 implementation centers (n = 346) or the single expert center (n = 205). Surgical-pathological staging was the reference standard in case no mediastinal metastases were found.

RESULTS

EUS had a sensitivity of 83% versus 82% and accuracy of 89% versus 88% for mediastinal nodal staging (implementation center vs expert center). Surgery was spared because of EUS findings in 51% versus 54% of patients. A single complication occurred in each group.

LIMITATION

Surgical-pathological verification of mediastinal nodes was not available in all patients staged negative at EUS.

CONCLUSION

Chest physicians who participate in a dedicated training and implementation program for EUS in lung cancer staging can obtain results similar to those of experts for mediastinal nodal staging.

Economic analysis of combined endoscopic and endobronchial ultrasound in the evaluation of patients with suspected non-small cell lung cancer

Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis ($18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA ($18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was <32.9%, as would occur in a patient without abnormal lymph nodes on computed tomography (CT). While EUS FNA combined with EBUS FNA was the most economical approach, if the rate of nodal metastases was higher, as would be the case in patients with abnormal lymph nodes on CT. Both of these strategies were less costly than bronchoscopy or mediastinoscopy. The pre-test probability of nodal metastases can determine the most cost-effective testing strategy for evaluation of a patient with NSCLC. Pre-procedure CT may be helpful in assessing probability of mediastinal nodal metastases.

Endoscopic ultrasound: it's accuracy in evaluating mediastinal lymphadenopathy? A meta-analysis and systematic review

AIM

To evaluate the accuracy of endoscopic ultrasound (EUS), EUS-fine needle aspiration (FNA) in evaluating mediastinal lymphadenopathy.

METHODS

Only EUS and EUS-FNA studies confirmed by surgery or with appropriate follow-up were selected. Articles were searched in Medline, Pubmed, and Cochrane control trial registry. Only studies from which a 2 multiply 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights.

RESULTS

Data was extracted from 76 studies (n = 9310) which met the inclusion criteria. Of these, 44 studies used EUS alone and 32 studies used EUS-FNA. FNA improved the sensitivity of EUS from 84.7% (95% CI: 82.9-86.4) to 88.0% (95% CI: 85.8-90.0). With FNA, the specificity of EUS improved from 84.6% (95% CI: 83.2-85.9) to 96.4% (95% CI: 95.3-97.4). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10.

CONCLUSION

EUS is highly sensitive and specific for the evaluation of mediastinal lymphadenopathy and FNA substantially improves this. EUS with FNA should be the diagnostic test of choice for evaluating mediastinal lymphadenopathy.

Endoscopic ultrasound as a first test for diagnosis and staging of lung cancer: a prospective study

RATIONALE

Multiple tests are required for the management of lung cancer.

OBJECTIVES

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was evaluated as a single test for the diagnosis and staging (thoracic and extrathoracic) of lung cancer.

METHODS

Consecutive subjects with computed tomography (CT) findings of a lung mass were enrolled for EUS and results were compared with those from CT and positron emission tomography scans.

RESULTS

Of 113 subjects with lung cancer, EUS was performed as a first test (after CT scan) for diagnosis in 93 (82%) of them. EUS-FNA established tissue diagnosis in 70% of cases. EUS-FNA, CT, and positron emission tomography detected metastases to the mediastinal lymph nodes with accuracies of 93, 81, and 83%, respectively. EUS-FNA was significantly better than CT at detecting distant metastases (accuracies of 97 and 89%, respectively; p = 0.02). Metastases to lymph nodes at the celiac axis (CLNs) were observed in 11% of cases. The diagnostic yields of EUS-FNA and CT for detection of metastases to the CLNs were 100 and 50%, respectively (p < 0.05). EUS was able to detect small metastases (less than 1 cm) often missed by CT. Metastasis to the CLNs was a predictor of poor survival of subjects with non-small cell lung cancer, irrespective of the size of the CLNs. Of 44 cases with resectable tumor on CT scan, EUS-FNA avoided thoracotomy in 14% of cases.

CONCLUSIONS

EUS-FNA as a first test (after CT) has high diagnostic yield and accuracy for detecting lung cancer metastases to the mediastinum and distant sites. Metastasis to the CLNs is associated with poor prognosis. EUS-FNA is able to detect occult metastasis to the CLNs and thus avoids thoracotomy.

EUS-guided FNA for the diagnosis of advanced lung cancer

BACKGROUND

A majority of patients with lung cancer are incurable but are symptomatic and may benefit from palliative therapy. Currently available diagnostic methods are either too risky or unsuccessful in obtaining a tissue diagnosis in up to 30% of patients.

OBJECTIVE

To evaluate the role of EUS-guided FNA in obtaining a tissue diagnosis in patients with advanced lung cancer.

DESIGN

Prospective, uncontrolled.

SETTING

Veterans Administration Medical Center.

SUBJECTS AND METHODS

Patients with suspected lung cancer who were not candidates for curative therapy were prospectively identified. CT scans were reviewed, and patients with lesions considered suitable for sampling by EUS were enrolled. Outcomes were analyzed by a final tissue diagnosis or by serial imaging.

RESULTS

Sixty-nine patients met inclusion criteria, of which 3 refused participation. The remaining 66 patients constituted the study population. EUS was technically successful in 95% of patients. A final diagnosis was based on tissue in 63 of 66 patients, serial imaging in 1 of 66 patients, and was unavailable in 2 of 66 patients. A lung mass was sampled in 21 patients, and a metastatic lesion was sampled in 45 patients. EUS made a correct diagnosis in 55 of 64 patients (86%, 95% confidence interval [CI] 77%-93%), including 24% that had undergone a failed prior attempt at diagnosis. The sensitivity of EUS was 86%, and the specificity was 100%. Sampling a metastasis was more likely to yield a correct diagnosis than sampling a lung mass (P = .02). Two self-limited complications were noted during the study.

CONCLUSIONS

EUS was an accurate and a safe method for obtaining a tissue diagnosis in patients with advanced incurable lung cancer.

Review of endoscopic ultrasound-guided fine-needle aspiration cytology

This review, based on the Hennepin County Medical Center experience and review of the literature, vastly covers the up-to-date role of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) in evaluating tumorous lesions of the gastrointestinal tract and adjacent organs. Emphasis is given to the tumoral and nodal staging of esophageal, pulmonary, and pancreatic cancer. This review also discusses technical, pathological, and gastroenterologic aspects and the role of the pathologist and endosonographer in the evaluation of these lesions, as well as the corresponding FNA cytology and differential diagnosis.

Molecular diagnostics of non-small cell lung cancer using mediastinal lymph nodes sampled by endoscopic ultrasound-guided needle aspiration

Non-small cell lung cancer is a common cancer with significant mortality. Accurate and early staging of this cancer has a significant impact on outcome. Endoscopic ultrasound-guided fine needle aspiration of involved mediastinal lymph nodes is critical for staging. Several molecular markers have been identified recently in association with non-small cell carcinoma of the lung that are promising to make early detection of metastatic disease more reliable.

EUS-guided FNA immediately after unrevealing transbronchial needle aspiration in the evaluation of mediastinal lymphadenopathy: a prospective study

BACKGROUND

Transbronchial needle aspiration (TBNA) and EUS-guided FNA (EUS-FNA) are minimally invasive diagnostic approaches to mediastinal lymphadenopathy. Rapid on-site cytopathologic evaluation (ROSE) may facilitate the decision whether to proceed to a second procedure in the same session. The aim of this study was to determine the utility of TBNA with ROSE, combined with the option for immediate EUS-FNA in a single-session approach to mediastinal lymphadenopathy.

METHODS

We prospectively recruited 20 patients (12 men; mean age 66.7 +/- 10.2 years) with mediastinal lymphadenopathy on CT who required cytopathologic evaluation. Bronchoscopy was first performed with TBNA and ROSE. If this was unrevealing, EUS-FNA was performed immediately afterward with ROSE. All procedures were performed with the patient under local anesthesia and sedation.

RESULTS

TBNA specimens were deemed adequate on-site in 13 patients, and EUS-FNA was performed in the remaining 7 patients. TBNA with ROSE was falsely negative in one patient. The diagnostic yield for TBNA and EUS-FNA alone was 65% and 86%, respectively. This single-session approach provided a yield of 90%, with no complications. The final diagnoses were 12 non-small-cell lung cancer, two small-cell lung cancer, one metastatic adenocarcinoma, two sarcoidosis, one tuberculosis, one lymphoma, and one with no definitive diagnosis.

CONCLUSIONS

Combining TBNA with the option for EUS-FNA immediately after unrevealing TBNA gave a yield approaching that of mediastinoscopy and, therefore, may reduce the need for invasive mediastinal sampling. This single-session endoscopic approach was safe, required only local anesthesia and sedation, was convenient, and obviated the need for patients to return for a second procedure.

Endoscopic ultrasound-guided fine needle aspiration of mediastinal lymph node in patients with suspected lung cancer after positron emission tomography and computed tomography scans

BACKGROUND

The treatment of patients with non-small cell lung cancer (NSCLC) depends on the stage. Positron emission and computed tomography (CT) scans can identify suspicious lymph nodes that require biopsy. We prospectively evaluated the yield and accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in sampling mediastinal lymph nodes and compared its accuracy to that of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and CT in staging NSCLC.

METHODS

A consecutive series of patients with suspicious nodes on PET or CT scan in the posterior mediastinal lymph node stations (#5, 7, 8, or 9) were prospectively evaluated by EUS-FNA. The reference standard included thoracotomy with complete lymphadenectomy in patients with lung cancer or if EUS-FNA was benign, repeat clinical imaging, or long-term follow-up.

RESULTS

There were 104 patients (63 men) with 125 lesions (117 lymph nodes, 8 left adrenal glands) who underwent EUS-FNA. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 92.5%, 100%, 100%, 94%, and 97%, respectively. EUS-FNA was more accurate and had a higher positive predictive value than the PET or CT (p < 0.001) scan in confirming cancer in the posterior mediastinal lymph nodes. EUS-FNA documented metastatic cancer to the left adrenal in all 4 patients with advanced disease. No deaths resulted from EUS-FNA. One patient experienced self-limited stridor.

CONCLUSIONS

EUS-FNA is a safe, accurate, and minimally invasive technique that improves the staging of patients with NSCLC. It is more accurate and has a higher predictive value than either the PET scan or CT scan for posterior mediastinal lymph nodes.

Endoscopic Ultrasound for Thoracic Malignancy: A Review

Accurate cancer staging is critical in providing the most appropriate therapy for patients with lung cancer. The decision to attempt a curative surgery or avoid an unnecessary surgery is dependent on accurate staging. In the case of non-small-cell lung cancer (NSCLC), the most important parameters for optimal treatment and prognosis are the presence of cancer spread to the lymph nodes within the mediastinum and to distant organs. Endoscopic ultrasound (EUS) has become an important tool for the assessment of mediastinal lymph nodes and in some cases, distant organ metastases, because of its minimally invasive access to these sites through a transesophageal, transgastric, or transduodenal approach. The capability of performing fine needle aspiration (FNA) has greatly improved the accuracy and acceptability of EUS for lung cancer staging. This review will outline the basic principals of EUS-guided lung cancer staging and EUS-FNA techniques and outline the indications and contraindications to EUS staging of thoracic malignancy.

The utility of EUS-guided FNA in the diagnosis of metastatic breast cancer to the esophagus and the mediastinum

BACKGROUND

Breast cancer can metastasize to the esophagus and the mediastinum. EUS-guided FNA (EUS-FNA) is being used increasingly as a less invasive alternative to mediastinoscopy for procuring a tissue diagnosis of mediastinal disease and may be useful for the diagnosis of breast cancer metastatic to the esophagus and the mediastinum.

METHODS

Twelve women (age range 54-82 years) with a history of breast cancer presented with dysphagia or other symptoms between 1 and 15 years after initial diagnosis and treatment. CT and endoscopy with biopsies suggested a mediastinal mass or lymphadenopathy with extrinsic esophageal compression but failed to provide a tissue diagnosis. EUS-FNA was performed for diagnosis.

RESULTS

Cytologic evaluation of specimens obtained by EUS-FNA confirmed breast cancer metastases in 11 of 12 patients (91%). Recurrent disease was found in intramural masses and periesophageal lymph nodes. No complication resulted from any EUS-FNA procedure.

CONCLUSIONS

EUS-FNA is safe and effective for the diagnosis of breast cancer metastases to the esophagus and the mediastinum. EUS-FNA may be useful as a first-line method of evaluation when breast cancer metastasis to the esophagus and the mediastinum is suspected.

Accurate Molecular Detection of Non-small Cell Lung Cancer Metastases in Mediastinal Lymph Nodes Sampled by Endoscopic Ultrasound-Guided Needle Aspiration

OBJECTIVES

The recurrence of disease after the complete resection of early stage non-small cell lung cancer (NSCLC) indicates that undetected metastases were present at the time of surgery. Quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) is a highly sensitive technique for detecting rare gene transcripts that may indicate the presence of cancer cells, and endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a minimally invasive technique for the nonoperative sampling of mediastinal lymph nodes. The aim of this study was to determine whether these two techniques could enhance the preoperative detection of occult metastases.

METHODS

Patients with NSCLC were evaluated with chest CT and positron emission tomography scans. Those patients without evidence of metastases (87 patients) underwent EUS-guided FNA. Lymph nodes from levels 2, 4, 5, 7, 8, and 9 were sampled and evaluated by standard cytopathology and real-time RT-PCR. Normal control FNA specimens were obtained from patients without cancer who were undergoing EUS for benign disease (17 control specimens). For each sample, messenger RNA was extracted and real-time RT-PCR was used to quantitate the expression of six lung cancer-associated genes (ie, CEA, CK19, KS1/4, lunx, muc1, and PDEF) relative to the expression of an internal control gene (beta(2)-microglobulin).

RESULTS

Clinical thresholds of marker positivity were set at 100% specificity, as determined by the receiver operating characteristic curve analysis. Of the cytology-positive lymph nodes (27 lymph nodes), the expression of the KS1/4 gene was above its respective clinical threshold in 25 of 27 samples (93%), making this the most sensitive marker for the detection of metastatic NSCLC. At least one of the six lung cancer-associated genes was overexpressed in 18 of 61 cytology-negative patients (30%), of which KS1/4 was overexpressed in 15 of 61 patients (25%).

CONCLUSIONS

Based on the high accuracy of EUS-guided FNA/RT-PCR, we predict that some of the patients in the cytology-negative/marker-positive category will have high NSCLC recurrence rates. Among the genes used in our marker panel, KS1/4 appears particularly useful for the detection of overt or occult metastatic disease.

Endoscopic Ultrasound in Non–Small Cell Lung Cancer and Negative Mediastinum on Computed Tomography

Despite technical advances in staging non-small cell lung cancer (NSCLC), accurate staging remains a challenge. Endoscopic ultrasound is useful in staging NSCLC when lymphadenopathy is present on a computed tomography (CT), but its role in the absence of lymphadenopathy on CT has not been well defined. Therefore, we sought to determine the clinical impact of endoscopic ultrasound (EUS) in staging NSCLC in absence of mediastinal lymphadenopathy on CT. Seventy-six patients with NSCLC with absence of mediastinal lymphadenopathy on CT were enrolled and followed prospectively. EUS-guided fine-needle aspiration was performed on sites that were suspicious for metastases. Surgical pathology after thoracotomy was used as the reference standard for assessing accuracy. Sixty-two (86%) patients underwent surgery, and 10 (13%) did not. EUS precluded surgery in 9 patients (12%) and influenced management in 18 (25%) of all patients in this study. EUS detected malignant mediastinal lymphadenopathy more frequently in patients with lower lobe and hilar cancers combined compared with upper lobe cancers (p = 0.004). EUS played a significant role in identifying patients with unresectable (N3) NSCLC when adenopathy was not present on CT imaging and appears to be more sensitive in detecting lymph node metastases in lower lobe and hilar NSCLC compared with upper lobe NSCLC.

Endoscopic ultrasound and staging of non-small cell lung cancer

This article outlines the basic principals of lung cancer staging and EUS-FNA techniques and suggests appropriate and inappropriate indications of EUS-FNA for lung cancer.

Endoscopic ultrasound in the diagnosis, staging, and management of gastrointestinal and adjacent malignancies

Endoscopic ultrasound (EUS) is a superior modality for local staging of gastrointestinal cancer. In interventional endosonography linear array echoendoscopes permit real-time EUS-guided puncture of target lesions for cytologic evaluation of such lesions. This article describes the basic principles of EUS, established indications pertaining to gastrointestinal cancer and other malignancies, and emerging indications for this minimally invasive technology.

Impact of EUS-guided FNA of enlarged mediastinal lymph nodes on subsequent thoracic surgery rates

BACKGROUND

A histopathologic diagnosis of metastasis in enlarged mediastinal lymph nodes usually results in non-surgical management. Cytologic specimens obtained by EUS-guided FNA can be used to detect malignancy in posterior mediastinal lymph nodes. The purpose of this study was to determine the rate of thoracic surgery after EUS-guided FNA of enlarged mediastinal lymph nodes.

METHODS

A prospective observational study of patients with enlarged posterior mediastinal lymphadenopathy who were referred for EUS-guided FNA. All patients were candidates for mediastinoscopy. Patients were followed for 12 months to determine the subsequent rate of mediastinoscopy or thoracotomy and the diagnostic accuracy of EUS-guided FNA.

RESULTS

Evaluation of cytologic specimens obtained by EUS-guided FNA revealed malignancy in 23 of 59 (39%) patients. The overall rate of surgery was 22% (13/59): 95% CI[0.12, 0.35]. The surgery rate for patients with a positive cytologic result was 4% (1/23) compared with 33% (12/36) for those with a negative result (p=0.009). Of patients with CT findings of a peripheral lung mass plus mediastinal lymphadenopathy, 22 of 26 (42%) underwent surgery after EUS-guided FNA, compared with two of 33 (6%) of those with mediastinal lymphadenopathy alone (p=0.0009). For cytologic evaluation of specimens obtained by EUS-guided FNA, the overall sensitivity, specificity, and accuracy for the diagnosis of malignant lymphadenopathy were 96%, 100%, and 98%, respectively.

CONCLUSIONS

Few patients who undergo EUS-guided FNA of enlarged posterior mediastinal lymph nodes require subsequent thoracic surgery.

Current concepts in the mediastinal lymph node staging of nonsmall cell lung cancer

OBJECTIVE

To review the current concepts in the mediastinal staging of nonsmall cell lung cancer (NSCLC), evaluating traditional and modern staging modalities.

SUMMARY BACKGROUND DATA

Staging of NSCLC includes the assessment of mediastinal lymph nodes. Traditionally, computed tomography (CT) and mediastinoscopy are used. Modern staging modalities include magnetic resonance imaging (MRI), positron emission tomography (PET), and endoscopic ultrasound with fine-needle aspiration (EUS-FNA) METHODS: Literature was searched with PubMed and SUMSearch for original, peer-reviewed, full-length articles. Studies were evaluated on inclusion criteria, sample size, and operating characteristics. Endpoints were accuracy, safety, and applicability of the staging methods.

RESULTS

CT had moderate sensitivities and specificities. With few exceptions magnetic resonance imaging (MRI) offered no advantages when compared with CT, against higher costs. PET was significantly more accurate than CT. Mediastinoscopy and its variants were widely used as gold standard, although meta-analyses were absent. Percutaneous transthoracic needle biopsy (PTNB) and transbronchial needle biopsy (TBNA) were moderately sensitive and specific. EUS-FNA had high sensitivity and specificity, is a safe and fast procedure, and is cost-effective. EUS-FNA evaluates largely a nonoverlapping mediastinal area compared with mediastinoscopy.

CONCLUSIONS

PET has the highest accuracy in the mediastinal staging of NSCLC, but is not generally used yet. EUS-FNA has the potential to perform mediastinal tissue sampling more accurate than TBNA, PTNB, and mediastinoscopy, with fewer complications and costs. Although promising, EUS-FNA is still experimental. Mediastinoscopy is still considered as gold standard for mediastinal staging of NSCLC.

Non-small cell lung cancer staging techniques and endoscopic ultrasound: tissue is still the issue

Non-small cell lung cancer (NSCLC) in the United States will continue to be a major public health issue, particularly as our elderly population grows. As surgery offers the best hope of cure for NSCLC, staging of NSCLC is critical because it directly impacts on the management of lung cancer. Cost, quality of life, safety, and accuracy of various staging methods all influence the clinical outcome. Staging of NSCLC is evolving due to the emergence of new and improved technologies. The objective of this article is to review the current methods used in staging of NSCLC. Currently, positron emission tomography and endoscopic ultrasound (EUS) show promise in identifying patients that may benefit from surgery. Histologic confirmation via EUS-guided fine-needle aspiration, however, may still be necessary to accurately stage the mediastinum.

Endoscopic transesophageal and endoscopic transbronchial real-time ultrasound-guided biopsy

The goal of preoperative staging of non-small-cell lung cancer is to identify patients who will benefit from surgical resection. Various imaging and less invasive modalities are now available to improve therapy decision-making, and with the introduction of multimodality treatment of lung cancer, proper staging of this disease is becoming more and more important. This staging process is therefore not only a question of determining the prognosis, but it is also necessary information for institution of the right treatment. Proper staging and restaging of lung cancer should also be a must in the evaluation of the different treatments of lung cancer in controlled clinical trials. In lung cancer, endoscopic ultrasound scanning (EUS) is emerging as an accurate, nonsurgical alternative to staging the mediastinum through EUS-fine-needle aspiration (EUS-FNA). The author presents publications on evaluating EUS in diagnosing lymph node involvement in lung cancer and tumor ingrowths in the mediastinum. With EUS it is possible to guide FNA with direct visualization of the needle path into the lymph nodes in real time. Although this method is only able to visualize the posterior path and the inferior parts of the mediastinum, it makes it possible to visualize the aortopulmonary window. The limitation of EUS is a sensitivity of about 90%; nonetheless, this method is more precise than other staging procedures except for mediastinoscopy, which is limited to only the anterior parts of the mediastinum.

Mediastinal lymph node involvement in potentially resectable lung cancer: comparison of CT, positron emission tomography, and endoscopic ultrasonography with and without fine-needle aspiration

PURPOSE

A prospective comparison of three imaging techniques: thoracic CT, positron emission tomography (PET), and endoscopic ultrasonography (EUS) with fine needle aspiration (FNA), each performed under routine conditions, for the detection of metastatic lymph nodes metastases in patients with lung cancer considered for operative resection.

PATIENTS AND METHODS

Following bronchoscopic evaluation, CT, PET, and EUS were performed to evaluate potential mediastinal involvement in 33 consecutive patients with bronchoscopic biopsy/cytology proven (n = 25) or radiologically suspected (n = 8) lung cancer prior to surgery. Surgical histology was used as "gold standard" to confirm the diagnosis of the primary tumor and the mediastinal status in all patients. Histology proved non-small cell lung cancer in 30 patients, neuroendocrine tumor in 1 patient, and benign disease in 2 patients.

RESULTS

The mean age of the study group was 61.5 years (range, 41 to 80 years; 23 male patients). CT, PET, and EUS detected mediastinal lymph nodes (size, 0.4 to 1.6 cm) in 15, 14, and 27 patients (21 of which were suspected to be malignant on EUS), respectively. With respect to the correct prediction of mediastinal lymph node stage, the sensitivities of CT, PET, and EUS were 57%, 73%, and 94%. Specificities were 74%, 83%, and 71%. Accuracies were 67%, 79%, and 82%. Results of PET could be improved when combined with CT (sensitivity, 81%; specificity, 94%; accuracy, 88%). The specificity of EUS (71%) was improved to 100% by FNA cytology (EUS-guided FNA), which gave a tissue diagnosis including tumor type, without complications.

CONCLUSIONS

No single imaging method alone was conclusive in evaluating potential mediastinal involvement in apparently operable lung cancer and routine clinical conditions. A tissue diagnosis is extremely helpful. Because FNA can be performed at the same time as EUS, this combination emerged as the most useful technique in the evaluation of even very small mediastinal metastases of lung cancer. CT seems necessary additionally to evaluate the pretracheal region as well as the rest of the thorax, and PET may be valuable to detect distant metastases.

Critical care transesophageal endosonography and guided fine-needle aspiration for diagnosis and management of posterior mediastinitis

BACKGROUND

Acute mediastinitis is a serious complication; it occurs after esophageal perforation and thoracic surgery and is rarely due to infections. Clinical and computed tomographic scan signs may be nonspecific, especially in postoperative patients.

DESIGN

We prospectively evaluated the value of transesophageal endosonography with guided fine-needle aspiration in the diagnosis and identification of etiologic agents in critically ill patients with suspected posterior mediastinitis.

SETTING

University hospital.

PATIENTS AND METHODS

Transesophageal endosonography/fine-needle aspiration was performed at the bedside in the intensive care unit with a Pentax 34UX echo-endoscope and a portable Hitachi console (EUB 525). Eighteen patients with clinically suspected mediastinitis were examined with intensive care team support.

RESULTS

Computed tomography was performed before transesophageal endosonography in all 18 patients and was inconclusive in 9. Transesophageal endosonography detected mediastinal lesions in 16 (89%) of 18 patients and was more accurately diagnostic than computed tomography (p =.0082). Fifteen patients had undergone surgery (11 esophagectomy, 1 other esophageal surgery, 1 head/neck cancer surgery, 1 complication after dilatational tracheostomy, and 1 with intervention after polytrauma). Three patients were suspected to have nonpostoperative mediastinitis. In 16 patients, infectious organisms were detected (bacterial, n = 14; fungal, n = 1; tuberculosis, n = 1). Culture and sensitivity of transesophageal endosonography/fine-needle aspiration specimens led to appropriate drug therapy. In two patients, methicillin-resistant Staphylococcus aureus was detected, leading to isolation care. Twelve patients improved; six died. Of the two patients in whom transesophageal endosonography did not detect a mediastinitis, one was false negative on autopsy. There were no complications.

CONCLUSION

Bedside transesophageal endosonography/fine-needle aspiration of posterior mediastinal lesions in critically ill patients was an effective and relatively noninvasive way to detect mediastinitis and provide material to identify the etiologic agent. It was particularly useful in postesophagectomy patients.

Real-time chest ultrasonography: a comprehensive review for the pulmonologist

This review discusses real-time pulmonary ultrasonography (US) for the practicing pulmonologist. US supplements chest radiography and chest CT scanning. Major advantages include bedside availability, absence of radiation, and guided aspiration of fluid-filled areas and solid tumors. Pulmonary vessels and vascular supply of consolidations may be visualized without contrast. US may help to diagnose conditions such as pneumothorax, hemothorax, pleural or pericardial effusion, pneumonia, and pulmonary embolism in the critically ill patient who is in need of bedside diagnostic testing. The technique of US, which is cost-effective compared to CT scanning and MRI, may be learned relatively easily by the pulmonologist.

Gastrointestinal endoscopic ultrasonography

Although conventional endoscopy provides excellent visualization of gastrointestinal mucosa, it provides little information about intramural or nearby extramural lesions. The imaging of intraabdominal structures by conventional transabdominal ultrasound is degraded by ultrasound energy attenuation with distance. The provision of an ultrasound probe on a flexible gastrointestinal endoscope, to form an echoendoscope, provides excellent imaging of the gastrointestinal wall and of adjacent extramural structures. During the last two decades, endoscopic ultrasound, using an echoendoscope, has revolutionized the diagnosis and treatment of gastrointestinal diseases that affect the submucosa, deep bowel wall, and adjacent extramural structures. This article reviews the role of endoscopic ultrasound in the diagnosis and treatment of gastrointestinal disease, including standard and promising new applications, as well as standard and emerging new technology.

Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy

BACKGROUND

Mediastinal masses represent a diagnostic challenge because of their proximity to numerous critical structures, difficulty of access for tissue sampling, and myriad potential pathologic etiologies. A large, single-center experience with EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of non-lung cancer-related mediastinal masses is presented.

METHODS

An EUS database was reviewed and all cases of mediastinal mass or lymphadenopathy encountered between 1994 and 1999 were included. Final diagnoses were determined by EUS-FNA cytology and clinical follow-up.

RESULTS

Forty-nine patients were identified (27 women, 22 men; mean age 58.1 years, range 30-89 years). A malignant process was diagnosed in 22 cases (45%) and a benign process in 24 (49%). The EUS-FNA specimen was nondiagnostic in 3 cases (6%). An accurate diagnosis was made in 46 of the 49 patients (94%). No complication was noted.

CONCLUSIONS

EUS-FNA is a minimally invasive technique that facilitates detection and tissue sampling of mediastinal masses. It is a safe procedure that can be performed with the patient under conscious sedation in an outpatient setting.

Peripheral pulmonary diseases: evaluation with endobronchial US initial experience

Endobronchial ultrasonography (US) with 4.5-F small-caliber US probes, combined with bronchoalveolar lavage technique, was evaluated in autopsied lungs and 22 patients with various pulmonary interstitial or alveolar diseases. Several different echoic patterns were found that may reflect changes due to pathologic alteration of lung parenchyma. This technique may have potential for evaluation and diagnosis of peripheral lung diseases.

Lung cancer staging

Accurate staging of lung cancer is essential for proper treatment and management of the disease, and allows predictions for patient survival. Several different invasive and noninvasive modalities exist for staging, and the determination of the best approach of one or a combination of those methods depends on the clinical situation and the clinician's assessment of the most appropriate means of staging evaluation. This review discusses the elements and framework of lung cancer staging, with particular emphasis on those newer modalities, especially positron emission tomography and endoscopic ultrasound needle biopsy, which will be expected to be used increasingly more common in clinical practice.

Endobronchial ultrasonography for mediastinal and hilar lymph node metastases of lung cancer

STUDY OBJECTIVES

Conventional radiologic procedures are frequently unreliable in the diagnosis of mediastinal and hilar lymph node metastases of lung cancer. In order to improve diagnostic accuracy, we performed endobronchial ultrasonography (EBUS) during bronchofiberscopic examinations of patients with lung cancer.

METHODS AND PATIENTS

To evaluate mediastinal and hilar lymph node metastases, EBUS was performed prospectively using a radial scanning probe of 20 MHz through a bronchofiberscope.

RESULTS

We observed hilar lymph nodes (10R, 11R superior, 11R inferior, 12R, 10L, 11L, 12L) in 20 of 37 patients who underwent EBUS, and we could clearly identify whether direct invasion of the pulmonary artery by a lymph node had occurred. Of the 27 patients who showed no hilar lymph nodes on chest CT scan, lymph node swellings < 10 mm or > or = 10 mm in diameter were identified by EBUS in 9 patients and 2 patients, respectively. Interestingly, EBUS also revealed that the pulmonary artery was directly invaded by an interlobar lymph node < 10 mm in diameter in one patient. In most patients, lymph node 7 was easily identified and was clearly differentiated from the surrounding esophagus, vessels, and mediastinal fat tissue by EBUS. However, fused lymph nodes or lymph nodes with low central density when visualized by chest CT scan were occasionally observed as independent lymph nodes by EBUS. When compared with the pathologic diagnosis of lymph node metastasis in 16 patients who underwent surgery, the most specific and sensitive method for identifying lymph node metastases were EBUS alone (92%) and EBUS in combination with CT scan (100%), respectively. The overall accuracy of EBUS was 94% for the diagnosis of direct invasion of the pulmonary arteries by a hilar lymph node.

CONCLUSIONS

EBUS in combination with conventional radiologic tools may contribute to improved staging, especially in surgical cases with hilar lymph node metastases.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy

OBJECTIVE

To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC).

METHODS

A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT).

RESULTS

The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not.

CONCLUSIONS

Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.

Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management

BACKGROUND

A study was undertaken to evaluate the clinical impact of endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) in patients with mediastinal masses suspected of malignancy.

METHODS

From April 1993 to December 1999, 84 patients were referred for EUS-FNA. In all patients CT scanning had shown a lesion of the mediastinum suspected of malignancy located adjacent to the oesophagus. In order to evaluate the clinical impact of EUS-FNA, the history of each patient up to referral for EUS-FNA was reviewed. A board of thoracic specialists was asked to decide the further course of the patient if EUS-FNA had not been available, and this diagnostic strategy was compared with the actual clinical course after EUS-FNA.

RESULTS

For the 79 patients in whom sufficient verification was obtained, EUS-FNA had a sensitivity of 92%, specificity of 100%, PPV of 100%, NPV of 80%, and an accuracy of 94% for cancer of the mediastinum. In 18 of 37 patients (49%) a thoracotomy/thoracoscopy was avoided as a result of EUS-FNA, and in 28 of 41 patients (68%) a mediastinoscopy was avoided. The direct result of the cytological diagnosis obtained by EUS-FNA was that a final diagnosis of small cell lung cancer was made in eight patients resulting in referral for chemotherapy, and in another three patients with benign disease specific treatment could be initiated (sarcoidosis, mediastinal abscess, and leiomyoma of the oesophagus).

CONCLUSIONS

EUS-FNA is a safe and sensitive minimally invasive method for evaluating patients with a solid lesion of the mediastinum suspected by CT scanning. EUS-FNA has a significant impact on patient management and should be considered for diagnosing the spread of cancer to the mediastinum in patients with lung cancer considered for surgery, as well as for the primary diagnosis of solid lesions located in the mediastinum adjacent to the oesophagus.

Evaluation of mediastinal masses by endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration

OBJECTIVE

Interest has been growing in using endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration in the evaluation of mediastinal masses. The purpose of this study was to review the spectrum of mediastinal masses encountered using endoscopic ultrasound.

METHODS

We reviewed all cases of mediastinal masses examined by endoscopic ultrasound, with or without endoscopic ultrasound-guided fine needle aspiration, prospectively gathered from our electronic database from April 1995 to July 2000.

RESULTS

Of 1447 upper endoscopic ultrasound examinations, 33 (2.3%) involved a mediastinal mass. Sixty-one percent of the patients were male and the average age was 65 yr. Fifty-five percent of patients had dysphagia, 48 percent experienced weight loss, and only 12 percent were totally asymptomatic. Seventy-three percent had masses by chest CT. Sixty-seven percent were ultimately found to be malignant, 21 percent were solid benign lesions, and four were cystic. Only two lesions were resected. Endoscopic ultrasound-guided fine needle aspiration was used in 76 percent of all patients. The median survival of patients with malignant lesions was only 87 days.

CONCLUSIONS

Lesions of the deep mediastinum are often difficult to conclusively diagnose with nonendoscopic studies. Endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration can easily access this region to aid in the diagnosis and management of these lesions.

Diagnosing sarcoidosis using endosonography-guided fine-needle aspiration

STUDY OBJECTIVES

The ability to diagnose sarcoidosis cytologically has been reported previously, but the method is rarely used. Endoscopic ultrasonography (EUS) is a sensitive technique for detecting mediastinal lymph nodes, which in addition provides an opportunity to carry out guided fine-needle aspiration (FNA) cytology. We report herein on the use of EUS-FNA in the diagnosis of sarcoidosis.

PATIENTS AND METHODS

Nineteen patients with suspected sarcoidosis were investigated using EUS-FNA with a linear echoendoscope and a 22-gauge Hancke-Vilman needle.

MEASUREMENTS AND RESULTS

In all 19 patients, EUS revealed enlarged mediastinal lymph nodes (mean size, 2.4 cm), located subcarinally (n = 15), in the aortopulmonary window (n = 12), or in the lower posterior mediastinum (n = 5). The nodes had an isoechoic or hypoechoic appearance, with atypical vessels in five cases. The amount of aspirate obtained using EUS-FNA was adequate in all patients, and contained blood in excess of normal in some, indicating a high degree of vascularity. Cytology demonstrated epithelioid cell granuloma formation, suggesting sarcoidosis. Mycobacterial cultures were negative in all of the patients except one, in whom the final diagnosis was tuberculosis. The specificity and sensitivity of EUS-FNA in the diagnosis of sarcoidosis were 94% and 100%, respectively.

CONCLUSIONS

EUS of mediastinal lymph nodes in sarcoidosis reveals certain characteristic features. However, it is not capable of differentiating the lesions from tuberculosis or malignancy. EUS-FNA is a safe and sensitive method of aspirating material for cytology and mycobacterial cultures. We believe it will provide a useful alternative in the diagnosis of sarcoidosis.

Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNA-based differential cytodiagnosis in 153 patients

OBJECTIVE

Mediastinal lymphadenopathy (ML) is a cause for concern, especially in patients with previous malignancy. The investigation of choice is thoracic CT with a variable sensitivity and specificity requiring tissue diagnosis. We used endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for cytodiagnosis of ML in patients with and without previous malignancy. The cause, distribution of lesions, and incidence of second cancers were investigated.

METHODS

Linear echoendoscopes and 22-gauge needles for cytology were used for EUS-FNA. A cytological diagnosis of malignancy was accepted, and histology or consistent follow-up of at least 9 months confirmed benign results.

RESULTS

One hundred fifty-three patients underwent EUS-FNA between November 1997 and November 1999 (mean age, 60 yr; range, 13-82 yr; 105 men). Cytology was adequate in 150 patients. Final diagnosis was malignancy in 84 and benign in 66 patients (sensitivity, specificity, and diagnostic accuracy: 92%, 100%, 95%, respectively). In 101 patients without previous cancer cytology identified 48 malignant (lung, 41; extrathoracic, 7) and 51 benign lesions (inflammation, 35; various, 9; sarcoidosis, 7) (sensitivity, specificity, accuracy: 88%, 100%, 94%). Fifty-two patients had prior malignancy, mostly in extrathoracic sites. Cytology revealed recurrences in 21 patients, second cancer in 9 and benign lesions in 21 patients (inflammatory, 11; sarcoidosis, 8; tuberculosis, 1; abscess, 1) (sensitivity, specificity, accuracy: 97%, 100%, 98%).

CONCLUSIONS

In patients without previous cancer malignant ML originates from the lung >80%. In those with previous malignancy recurrence of extrathoracic sites is the major cause. Benign lesions and treatable second cancers occur in a significant frequency, emphasizing the need for tissue diagnosis. EUS-FNA is a safe and minimally invasive alternative for cytodiagnosis in the mediastinum.

Diagnosis and staging of lung cancer

Lung cancer is the biggest cancer killer among men and women in the United States. Lung cancer can present in a myriad of ways and the goal of prompt diagnosis and staging requires that the clinician be able to knowledgeably choose from a variety of tools available for such purpose. Review of some of these tools and general strategies with regard to staging is provided. Many new technologies are becoming available and much evaluation needs to be done before their proper roles become well defined. Little has changed with regard to staging of small cell lung cancer in recent years. The International System for Staging Non-Small-Cell Lung Cancer was revised for a second time in 1997. Although the revisions have largely corrected the shortcomings of the 1985 version, some controversies persist. Whenever possible, a multidisciplinary approach to diagnosis, staging, and therapy should be utilized. This should include incorporating the services of the pulmonologist, the thoracic surgeon, the medical oncologist, the radiologist, the radiation therapist, the pathologist, the respiratory therapist, and the social worker.

Role of transesophageal endosonography-guided fine-needle aspiration in the diagnosis of lung cancer

STUDY OBJECTIVE

Bronchoscopic methods fail to diagnose lung cancer in up to 30% of patients. We studied the role of transesophageal endosonography (EUS)-guided fine-needle aspiration (FNA; EUS-FNA) in such patients.

DESIGN

Prospective study. The final diagnosis was confirmed by cytology, histology, or clinical follow-up.

SETTING

University hospital.

PATIENTS

Thirty-five patients (30 male and 5 female; mean age, 60.9 years; range, 34 to 88 years) with suspected lung cancer in whom bronchoscopic methods failed. Patients with a known diagnosis, recurrence of lung cancer, or mediastinal metastasis from an extrathoracic primary were excluded.

INTERVENTIONS

EUS and guided FNA of mediastinal lymph nodes.

RESULTS

The procedure was uneventful, and material was adequate in all. The final diagnosis by EUS-FNA was malignancy in 25 patients (11 adenocarcinoma, 10 small cell, 3 squamous cell, and 1 lymphoma) and benign disease in 9 patients (5 inflammatory, 2 sarcoidosis, and 2 anthracosis). Another patient with a benign result had signet-ring cell carcinoma diagnosed on pleural fluid cytology (probably false-negative in EUS-FNA). The sensitivity, specificity, accuracy, and positive and negative predictive values were 96, 100, 97, 100, and 90%, respectively. There were no complications. Reviewing the EUS morphology, the nodes were predominantly located in levels 7 and 8 of American Thoracic Society mediastinal lymph node mapping (subcarinal and paraesophageal region). In seven patients, the punctured nodes were < 1 cm (four malignant and three benign), which are difficult to sample by other methods. The malignant nodes had a hypoechoic, homogenous echotexture.

CONCLUSIONS

EUS-FNA is a safe, reliable, and accurate method to establish the diagnosis of suspected lung cancer when bronchoscopic methods fail, especially in the presence of small nodes.