Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy

Current Opinion in Pulmonary Medicine

Volumn 15, Issue 4, 2009, Pages 334-342

  Medford, Andrew R L ^a   Bennett, Jonathan A ^a   Free, Catherine M ^a   Agrawal, Sanjay ^a  

^a GLENFIELD HOSPITAL   (United Kingdom)

Author keywords

Endobronchial ultrasound; Lung cancer; Mediastinal staging; Mediastinoscopy; Transbronchial needle aspiration

Indexed keywords

BRONCHOSCOPE; CANCER DIAGNOSIS; CANCER STAGING; CLINICAL TRIAL; COMPUTER ASSISTED TOMOGRAPHY; COST BENEFIT ANALYSIS; DIAGNOSTIC ACCURACY; ENDOBRONCHIAL ULTRASONOGRAPHY; ENDOBRONCHIAL ULTRASOUND ASPIRATION BIOPSY; HEALTH CARE COST; HUMAN; INTERMETHOD COMPARISON; LOCAL ANESTHESIA; LUNG CANCER; LUNG NON SMALL CELL CANCER; LYMPH NODE BIOPSY; MEDIASTINOSCOPY; MEDIASTINUM LYMPH NODE; MICROMETASTASIS; POSITRON EMISSION TOMOGRAPHY; REPEAT PROCEDURE; REVIEW; TRANSBRONCHIAL ASPIRATION; TUMOR BIOPSY; ULTRASOUND TRANSDUCER; VIDEORECORDING;

BIOPSY, FINE-NEEDLE; COSTS AND COST ANALYSIS; HUMANS; LUNG NEOPLASMS; MEDIASTINOSCOPY; MEDIASTINUM; NEOPLASM STAGING;

EID: 67449083872     PISSN: 10705287     EISSN: 15316971     Source Type: Journal    
DOI: 10.1097/MCP.0b013e32832b8a45     Document Type: Review

References (45)

1. Lennon AM, Penman ID. Endoscopic ultrasound in cancer staging. Br Med Bull 2007; 84:81-98.
2. Toloza EM, Harpole L, Detterbeck F, McCrory DC. Invasive staging of nonsmall cell lung cancer: a review of the current evidence. Chest 2003; 123 (1 Suppl):157S-166S.
3. Detterbeck FC, Jantz MA, Wallace M, et al. Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132 (3 Suppl):202S-220S.
4. Cybulsky IJ, Bennett WF. Mediastinoscopy as a routine outpatient procedure. Ann Thorac Surg 1994; 58:176-178.
5. Leschber G, Sperling D, Klemm W, Merk J. Does video-mediastinoscopy improve the results of conventional mediastinoscopy? Eur J Cardiothorac Surg 2008; 33:289-293. A recent retrospective analysis of cervical mediastinoscopy and video mediastinoscopy techniques from 2003 to 2005. Video mediastinoscopy obtained more lymph nodes with a slightly higher accuracy and negative predictive value with less recurrent laryngeal nerve palsies and bleeding.
6. Lardinois D, Schallberger A, Betticher D, Ris HB. Postinduction video-mediastinoscopy is as accurate and safe as video-mediastinoscopy in patients without pretreatment for potentially operable nonsmall cell lung cancer. Ann Thorac Surg 2003; 75:1102-1106.
7. Venissac N, Alifano M, Mouroux J. Video-assisted mediastinoscopy: experience from 240 consecutive cases. Ann Thorac Surg 2003; 76:208-212.
8. Karfis EA, Roustanis E, Beis J, Kakadellis J. Video-assisted cervical mediastinoscopy: our seven-year experience. Interact Cardiovasc Thorac Surg 2008; 7:1015-1018.
9. De Leyn P, Stroobants S, De Wever W, et al. Prospective comparative study of integrated positron emission tomography-computed tomography scan compared with remediastinoscopy in the assessment of residual mediastinal lymph node disease after induction chemotherapy for mediastinoscopy-proven stage IIIA-N2 Nonsmall-cell lung cancer: a Leuven Lung Cancer Group Study. J Clin Oncol 2006; 24:3333-3339.
10. Van Schil P, van der Schoot J, Poniewierski J, et al. Remediastinoscopy after neoadjuvant therapy for nonsmall cell lung cancer. Lung Cancer 2002; 37:281-285.
11. Mateu-Navarro M, Rami-Porta R, Bastus-Piulats R, et al. Remediastinoscopy after induction chemotherapy in nonsmall cell lung cancer. Ann Thorac Surg 2000; 70:391-395.
12. Schenk DA, Bower JH, Bryan CL, et al. Transbronchial needle aspiration staging of bronchogenic carcinoma. Am Rev Respir Dis 1986; 134:146-148.
13. Shure D, Fedullo PF. The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma. Chest 1984; 86:693-696.
14. Ratto GB, Mereu C, Motta G. The prognostic significance of preoperative assessment of mediastinal lymph nodes in patients with lung cancer. Chest 1988; 93:807-813.
15. Roth K, Hardie JA, Andreassen AH, et al. Predictors of diagnostic yield in bronchoscopy: a retrospective cohort study comparing different combinations of sampling techniques. BMC Pulm Med 2008; 8:2.
16. Stratakos G, Porfyridis I, Papas V, et al. Exclusive diagnostic contribution of the histology specimens obtained by 19-gauge transbronchial aspiration needle in suspected malignant intrathoracic lymphadenopathy. Chest 2008; 133:131-136. A cohort study using 19-gauge needles in TBNA to obtain histology samples demonstrating their safety, a 35% increase in diagnostic yield for TBNA over cytology alone and a higher sensitivity and for TBNA than in systematic reviews.
17. Goldberg R, Colt HG, Davoudi M, Cherrison L. Realistic and affordable lo-fidelity model for learning bronchoscopic transbronchial needle aspiration. Surg Endosc 2008 [Epub ahead of print].
18. Hermens FH, Limonard GJ, Termeer R, et al. Learning curve of conventional transbronchial needle aspiration in pulmonologists experienced in bronchoscopy. Respiration 2008; 75:189-192. A recent retrospective study performed by operators experienced in normal bronchoscopy confirming no significant learning curve for TBNA and that diagnostic yield was related to the size of the lymph node but not location.
19. Sheski FD, Mathur PN. Endobronchial ultrasound. Chest 2008; 133:264-270. A recent review including studies up to 2006 of all aspects pertaining to EBUS including technical aspects, cost analysis, performance, indications, training and service development.
20. Ernst A, Anantham D, Eberhardt R, et al. Diagnosis of mediastinal adenopathy-real-time endobronchial ultrasound guided needle aspiration versus mediastinoscopy. J Thorac Oncol 2008; 3:577-582. The only published completed comparative trial for EBUS and cervical mediastinoscopy to date. Prospective cross-over trial in patients with suspected NSCLC and enlarged mediastinal nodes showing superior diagnostic yield, sensitivity and negative predictive value for EBUS but no significant difference in N status in a cohort of high disease prevalence. There was significant disagreement between EBUS and cervical mediastinoscopy at station 7. Two other trials are in progress due for publication in 2009 and 2012. The combined results of all these will be important in assessing how well EBUS can replace cervical mediastinoscopy.
21. Yasufuku K, Quadri M, dePerrot M, et al. A prospective controlled trial of endobronchial ultrasound guided transbronchial needle aspiration compared to mediastinoscopy for mediastinal lymph node staging of lung cancer. Western Thoracic Surgical Association 33rd Annual Meeting (abstract). Canada; 2007.
22. http://www.ncchta.org/project/1603.asp. Assessment of Surgical sTaging versus Endobronchial and endoscopic ultrasound in lung cancer: a Randomised controlled trial (ASTER) 2008-12.
23. Herth FJ, Eberhardt R, Vilmann P, et al. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax 2006; 61:795-798.
24. Yasufuku K, Chiyo M, Koh E, et al. Endobronchial ultrasound guided transbronchial needle aspiration for staging of lung cancer. Lung Cancer 2005; 50:347-354.
25. Yasufuku K, Chiyo M, Sekine Y, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004; 126:122-128.
26. Szlubowski A, Kuzdzal J, Kolodziej M, et al. Endobronchial ultrasound-guided needle aspiration in the nonsmall cell lung cancer staging. Eur J Cardiothorac Surg 2009; 35:332-335. A recent prospective cohort study using extended surgical lymphadenectomy to rigorously confirm negative EBUS results. The negative predictive value for EBUS here was superior to systematic reviews but still inferior to cervical mediastinoscopy, reinforcing the need for surgical staging if EBUS results are negative for malignancy.
27. Bauwens O, Dusart M, Pierard P, et al. Endobronchial ultrasound and value of PET for prediction of pathological results of mediastinal hot spots in lung cancer patients. Lung Cancer 2008; 61:356-361. A recent prospective study of EBUS assessment of relatively small nodes with high SUV on PET demonstrating a sensitivity and negative predictive value of EBUS far superior to systematic reviews and comparing favourably with cervical mediastinoscopy. This study also suggests the utility of EBUS may be better refined in combination with PET, as the SUV for positive and negative nodes differed significantly.
28. Herth FJ, Eberhardt R, Krasnik M, Ernst A. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer. Chest 2008; 133:887-891. A recent landmark study demonstrating the ability of EBUS to sample subcentimetre nodes which are radiologically normal (on CT and PET) with a sensitivity and negative predictive value superior to conventional surgical staging. This suggests that EBUS could have a role in presurgical staging but further studies are needed to corroborate these findings. The low prevalence of nodal metastases may have contributed to the high negative predictive value.
29. Koh MS, Tee A, Wong P, et al. Advances in lung cancer diagnosis and staging: endobronchial ultrasound. Int Med J 2008; 38:85-89. A recent observational study evaluating the experience of setting up a recent EBUS service and its clinical utility using CT and PET but without rapid on-site cytopathology. The reported sensitivity compares favourably with surgical staging techniques (although the negative predictive value was inferior). These data in a real world setting and nonexperienced centre demonstrate the short learning curve of EBUS and potential to be developed in other centres.
30. Rintoul RC, Skwarski KM, Murchison JT, et al. Endobronchial and endoscopic ultrasound-guided real-time fine-needle aspiration for mediastinal staging. Eur Respir J 2005; 25:416-421.
31. Lee HS, Lee GK, Lee HS, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal staging of nonsmall cell lung cancer: how many aspirations per target lymph node station? Chest 2008; 134:368-374. An important recent cohort study assessing the number of passes necessary at EBUS for clinical utility. A minimum of three passes are needed unless a tissue core is obtained, in which case two passes per node gives acceptable sensitivity and negative predictive value. The drop off in sensitivity below three passes (in the absence of tissue core) is marked.
32. Klapman JB, Logrono R, Dye CE, Waxman I. Clinical impact of on-site cytopathology interpretation on endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol 2003; 98:1289-1294.
33. Alsharif M, Andrade RS, Groth SS, et al. Endobronchial ultrasound-guided transbronchial fine-needle aspiration: the University of Minnesota experience, with emphasis on usefulness, adequacy assessment, and diagnostic difficulties. Am J Clin Pathol 2008; 130:434-443. An excellent cytopathological review of experience with EBUS cytology samples at a centre between 2006 and 2008 using an on-site cytopathologist. The presence of abundant lymphocytes and tingible macrophages predicts an adequate sample but this service has resource implications. With such a cytological service, EBUS achieved an excellent negative predictive value and comparable sensitivity to surgical staging.
34. Asano F, Matsuno Y, Tsuzuku A, et al. Diagnosis of peripheral pulmonary lesions using a bronchoscope insertion guidance system combined with endobronchial ultrasonography with a guide sheath. Lung Cancer 2008; 60:366-373.
35. Nakajima T, Yasufuku K, Iyoda A, et al. The evaluation of lymph node metastasis by endobronchial ultrasound-guided transbronchial needle aspiration: crucial for selection of surgical candidates with metastatic lung tumours. J Thorac Cardiovasc Surg 2007; 134:1485-1490.
36. Wong MK, Wong MP, Lam DC, et al. Endobronchial ultrasound for diagnosis of synchronous primary lung cancers. Lung Cancer 2009; 63:154-157.
37. Herth FJ, Annema JT, Eberhardt R, et al. Endobronchial ultrasound with transbronohial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol 2008; 26:3346-3350. The first study to demonstrate the potential utility of EBUS in re-staging the mediastinum. This retrospective cohort study did not use CT-PET and achieved a sensitivity superior to that of surgical re-staging, although the negative predictive value was poor probably relating to sampling error. This study requires validation but suggests that EBUS might be a feasible re-staging tool in place of surgical restaging.
38. Mohamed S, Yasufuku K, Nakajima T, et al. Analysis of cell cycle-related proteins in mediastinal lymph nodes of patients with N2-NSCLC obtained by EBUS-TBNA: relevance to chemotherapy response. Thorax 2008; 63:642-647. A recent retrospective study demonstrating for the first time that EBUS can obtain nodal tissue that can be used for prognostic cell cycle protein studies. p53 overexpression predicted poorer response to chemotherapy. This study suggests EBUS may facilitate molecular marking to further refine treatment planning for lung cancer in addition to staging.
39. Kennedy MP, Jimenez CA, Bruzzi JF, et al. Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lymphoma. Thorax 2008; 63:360-365.
40. Nakajima T, Yasufuku K, Fujiwara T, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrapulmonary lesions. J Thorac Oncol 2008; 3:985-988.
41. Kramer H, van Putten JW, Post WJ, et al. Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer. Thorax 2004; 59:596-601.
42. Wallace MB, Pascual JM, Raimondo M, et al. Minimally invasive endoscopic staging of suspected lung cancer. J Am Med Assoc 2008; 299:540-546. This recent study demonstrates the ability of EBUS to avoid surgical staging in a significant proportion of patients despite being done in a centre only recently trained in EBUS and without rapid on-site cytopathology. This study also performed EUS but similar avoidance of surgical staging has been reported in other studies using EBUS alone.
43. Vincent BD, El-Bayoumi E, Hoffman B, et al. Real-time endobronchial ultrasound-guided transbronchial lymph node aspiration. Ann Thorac Surg 2008; 85:224-230.
44. Tournoy KG, Rintoul RC, van Meerbeeck JP, et al. EBUS-TBNA for the diagnosis of central parenchymal lung lesions not visible at routine bronchoscopy. Lung Cancer 2009; 63:45-49.
45. Hsu LH, Ko JS, You DL, et al. Transbronchial needle aspiration accurately diagnoses subcentimetre mediastinal and hilar lymph nodes detected by integrated positron emission tomography and computed tomography. Respirology 2007; 12:848-855.