Elsevier

Lung Cancer

Volume 48, Issue 1, April 2005, Pages 85-92
Lung Cancer

Endoscopic ultrasound guided biopsy versus mediastinoscopy for analysis of paratracheal and subcarinal lymph nodes in lung cancer staging

https://doi.org/10.1016/j.lungcan.2004.10.002Get rights and content

Summary

Background:

Exact mediastinal evaluation of patients with non-small-cell lung cancer (NSCLC) is mandatory to improve selection of resectable and curable patients for surgery. Mediastinoscopy (MS) and endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) are considered complementary, MS covering the anterior- and EUS-FNA the posterior mediastinum. Both methods can reach the paratracheal- and subcarinal-regions, but little is known about which method is most accurate, when compared in patients having both procedures performed. The aim of this study was to assess and compare the diagnostic value of MS and EUS-FNA with regard to mediastinal malignancy in the paratracheal- and subcarinal-regions.

Methods:

Sixty patients considered to be potential candidates for resection of verified or suspected NSCLC underwent MS and EUS-FNA. The EUS-FNA diagnoses were confirmed either by open thoracotomy, MS or clinical follow-up.

Results:

MS and EUS-FNA were conclusive for paratracheal or subcarinal mediastinal disease in 6 and 24 patients, respectively. Two patients with N2 disease diagnosed by EUS-FNA were upstaged to N3 by MS. The sensitivity for lymph node metastases in the right paratracheal region (2/4R) was 67% for EUS-FNA versus 33% for MS (p = 0.69). In the left paratracheal region (2/4L) the sensitivity of EUS-FNA was 80% versus 33% for MS (p = 0.06). In the subcarinal region (7) the sensitivity of EUS-FNA was 100% versus 7% for MS (p < 0.01). The sensitivity for lymph node metastases in region 2/4L and/or 2/4R and/or 7 was 96% for EUS-FNA versus 24% for MS (p < 0.01).

Conclusion:

In our hands EUS-FNA was superior to MS in the examination of paratracheal- and subcarinal-regions of patients considered for resection of lung cancer.

Introduction

Exact staging of patients with non-small-cell lung cancer (NSCLC) is important to improve selection of resectable and curable patients for surgery. Non-invasive methods, such as chest computer tomography (CT) and positron emission tomography (PET) are not recognised as proof of N2–N3 disease, because of inadequate accuracy of these examinations [1]. Therefore a pathological diagnosis of mediastinal tumour spread, obtained by an invasive staging method, is necessary to avoid unjustified rejection of patients from curative surgery.

Mediastinoscopy (MS) is considered as the gold standard method for invasive mediastinal staging, and recent guidelines recommend MS before all lung cancer resections with curative intent [2]. MS is performed in the operating room under general anaesthesia with a complication rate of 2–3% [3], [2]. The accessible area of MS is limited to the anterior part of the mediastinum, and in 10–15% of patients undergoing thoracotomy after a negative MS, N2–N3 disease is found [3], [4], [5].

During the past decade endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) has been introduced as a method for obtaining biopsy specimens from mediastinal structures. A number of studies have been published [6], [7], [8], [9], [10], [11], [12], [13], [14], the majority presenting retrospective results of EUS-FNA performed in patients selected by CT. The diagnostic values for such patients are relatively uniform with a high sensitivity of around 90% for mediastinal malignancy. Very few complications have been reported.

MS and EUS-FNA are often considered as complementary methods, MS covering the anterior- and EUS-FNA the posterior mediastinum [8], [15], [2]. However, no published studies have actually compared the two methods in patients, who had both procedures performed. Whether one of the methods may obviate the need for the other is unknown. Both methods can reach the paratracheal- and subcarinal-regions, but little is known about which method is the most accurate, when compared in patients undergoing both procedures.

The aim of this study was to assess and compare diagnostic values of MS and EUS-FNA for mediastinal malignancy in the paratracheal- and subcarinal-regions among patients, who had both procedures performed.

Section snippets

Patients

The patients were selected from a randomised controlled trial as those who had both MS and EUS-FNA performed. The purpose of the randomised trial was to compare routine EUS-FNA in lung cancer staging with a conventional staging strategy (including routine MS, but EUS-FNA only for selected patients). Between November 2001 and February 2004, 60 patients admitted to the Department of Respiratory Diseases, Gentofte University Hospital, Copenhagen, had both MS and EUS-FNA performed. All patients had

Results

Forty-eight patients had MS and EUS-FNA performed in the same session (EUS-FNA first), five had a MS date before EUS-FNA-date and seven had EUS-FNA-date before MS date.

Discussion

In this study the sensitivity of EUS-FNA was superior to that of MS for mediastinal malignancy in regions accessible by both methods. This trend was especially pronounced in the subcarinal region, where EUS-FNA diagnosed all of the 15 patients with subcarinal malignancy, whereas MS diagnosed only one. The yield of EUS-FNA was comparable to that of other studies [6], [7], [8], [9], [10], [11], [12], [13], [14], while the yield of MS was lower [5], [17], [18].

According to the literature

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