Accurate and safe mediastinal restaging by combined endobronchial and endoscopic ultrasound-guided needle aspiration performed by single ultrasound bronchoscope

• Published in: European journal of cardio-thoracic surgery Vol. 46; no. 2; pp. 262 - 266
• Main Authors: Szlubowski, Artur, Zieliński, Marcin, Soja, Jerzy, Filarecka, Anna, Orzechowski, Stanisław, Pankowski, Juliusz, Obrochta, Anna, Jakubiak, Magdalena, Węgrzyn, Joanna, Ćmiel, Adam
• Format: Journal Article
• Language: English
• Published: Germany Oxford University Press 01.08.2014
• Subjects: Aged; Aged, 80 and over; Biopsy, Needle - instrumentation; Biopsy, Needle - methods; Bronchoscopy - instrumentation; Bronchoscopy - methods; Carcinoma, Non-Small-Cell Lung - diagnostic imaging; Carcinoma, Non-Small-Cell Lung - epidemiology; Carcinoma, Non-Small-Cell Lung - pathology; Carcinoma, Non-Small-Cell Lung - surgery; Endosonography - instrumentation; Endosonography - methods; Female; Humans; Lung Neoplasms - diagnostic imaging; Lung Neoplasms - epidemiology; Lung Neoplasms - pathology; Lung Neoplasms - surgery; Male; Mediastinum - pathology; Mediastinum - surgery; Middle Aged; Neoplasm Staging - methods; Predictive Value of Tests; Restaging; Combined ultrasound-needle aspiration; Non-small-cell lung cancer; Mediastinum
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1093/ejcts/ezt570

OBJECTIVES The aim of this prospective trial was to assess the diagnostic utility of combined endobronchial (EBUS) and endoscopic (EUS) ultrasound-guided needle aspiration by use of a single ultrasound bronchoscope (CUSb-NA) in non-small-cell lung cancer (NSCLC) restaging in patients after induction therapy. METHODS In a consecutive group of NSCLC patients with pathologically confirmed N2 disease (clinical stage IIIa and IIIb) who underwent induction chemotherapy, CUSb-NA was performed. All of the patients with negative or suspected for metastases (uncertain) diagnosed by endoscopy underwent subsequently transcervical extended mediastinal lymphadenectomy (TEMLA) as a confirmatory test. RESULTS From January 2009 to December 2012, 106 patients met the inclusion criteria and underwent restaging CUSb-NA under mild sedation, in whom 286 (mean 2.7, range 2–5) lymph node stations were biopsied, 127 (mean 1.2, range 1–3) by EBUS-transbronchial needle aspiration (TBNA) and 159 (mean 1.5, range 1–4) by EUS-fine needle aspiration (FNA). The CUSb-NA revealed metastatic lymph node involvement in 37/106 patients (34.9%). In 69 (65.1%) patients with negative and uncertain CUSb-NA in 4 (3.8%) out of them, who underwent subsequent TEMLA metastatic nodes were found in 18 patients (17.0%) and there were single lymph nodes found only in one mediastinal station (minimal N2) in 10 (9.4%) out of them. False-positive results were found in 2 (1.9%) patients. In 9 (8.5%) patients CUSb-NA occurred to be false negative in Stations 2R and 4R (only accessible for EBUS), exclusively in small nodes and in 4 (3.8%) patients in Station 5—not accessible for CUSb-NA. The prevalence of mediastinal lymph node metastases in the present study was 51.9%. Diagnostic sensitivity, specificity, total accuracy, positive predictive value and negative predictive value (NPV) of the restaging CUSb-NA were 67.3% (95% CI [confidence interval]—53–79), 96.0% (95% CI—86–99), 81.0% (95% CI—73–87), 95.0% (95% CI—83–99) and 73.0% (95% CI—61–83), respectively. The sensitivity, accuracy and NPV of CUSb-NA were higher compared with EBUS-TBNA and EUS-FNA alone. No complications of CUSb-NA were observed. CONCLUSIONS The CUSb-NA is a reasonable and safe technique in mediastinal restaging in NSCLC patients after induction therapy. Following our data, in patients with negative result of CUSb-NA, a surgical restaging of the mediastinum should be considered.