BackgroundEndobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) diagnoses and stages mediastinal lymph node pathology. This retrospective study determined the relationship between EBUS‐TBNA utility and non‐small cell lung cancer (NSCLC) stage, lymph node size, and positron emission tomography (PET) standard uptake values (SUV), and the utility of neck ultrasound in bulky mediastinal disease.MethodsData of 284 consecutive patients who had undergone EBUS‐TBNA was collected. Two hundred patients had suspected NSCLC, with 148 confirmed NSCLC cases. The diagnostic utility of EBUS‐TBNA was determined according to NSCLC stage, EBUS lymph node size, PET SUV, use in distal metastases, and mutation testing. The utility of neck ultrasound for N3 disease was calculated in patients with bulky mediastinal disease.Results EBUS‐TBNA was well tolerated with 97% sensitivity in distant metastatic disease, avoiding the need for distal metastases biopsy in 81% of cases. It had equivalent diagnostic accuracy in all NSCLC stages and in lymph nodes <10 mm, <20 mm or >20 mm (sensitivity >92% in all cases), with no mutation testing failures. EBUS‐TBNA had 33% sensitivity in PET indolent (SUV < 4) nodes and 79% sensitivity in PET active nodes (SUV > 4). EBUS‐TBNA diagnosed 12 cases of lymphoma without flow cytometry.ConclusionsThe use of EBUS‐TBNA meant that distant metastatic biopsy was avoided in 81% of cases, performing well irrespective of cancer stage, node size, and facilitating mutation testing. Neck ultrasound failed to detect N3 disease in patients with bulky mediastinal disease. EBUS‐TBNA had a sensitivity of 33% for metastases in PET negative nodes, highlighting PET limitations.
pathways: 2WW 37, inpatients 15, angiograms 6, PE service 5, respiratory OPD 17, other MDT 4, OPD 11, GP 3. Only 4/107 patients (3.7%) had high suspicion for lung cancer at outset, -2 confirmed at surgery, 1 received radiotherapy (age 91yrs), 1 declined treatment. No further pathology was detected from surveillance. So far, a total of 246 CTs have been performed with 72 awaited (table 1). Fifteen patients had PET-CT (all low SUV). Fourteen underwent bronchoscopy (normal). Two had CT biopsy (benign), 2 declined biopsy, 2 were smaller at biopsy. One benign lesion was resected (patient choice). Only 28 patients have been discharged from surveillance; 10/28 resolved on 3month CT, 3/28 resolved on 6month CT, 15/28 stable on 12month CT. Fleischner guidance was accurately followed in 67%, most deviance due to delayed timing of 6month CT. Twenty-nine (27%) were discussed without documented nodule size. Conclusion Nodule surveillance has put a significant burden on local Thoracic-Oncology services. No unexpected pathology was encountered during this surveillance period. Until clear clinical and/or radiological identifying factors for high risk patients are understood and rationalised, nodule surveillance will have to continue. There are cost implications not only for Radiology and Respiratory services, but also to patients' emotional and physical well-being. This highlights the continued need for clear surveillance protocols supported by service development. A retrospective study to analyse the outcomes and costs of follow-up of incidental nodules (solitary and multiple) referred to our Department from 2010-2011. Method Consecutive nodule cases were identified by reviewing CT reports of 619 patients discussed at our Lung Cancer MDT from 2010-2011. Only clinically incidental nodules were included. Information was gathered using PACS and hospital records. In our department incidental nodules are seen once in clinic and then largely managed 'remotely' via correspondence. All nodules are managed to Fleischner guidelines.Costs for investigations/procedures/appointments were calculated using local 2012-13 reference costs. Manpower costs for MDTs and correspondence were calculated using a 'bottom-up' costing approach. Results 62 patients were referred with a new incidental nodule (s). Mean age was 66(34-92) with a 1:1 male:female ratio. 56% (35/62) had PS 0-1 and 56%(35/62) were current/ex-smokers. 66%(41/62) had a SPN. Mean size of largest nodule was 9mm. 11%(7/62) were diagnosed with malignancy, 6%(4/62) of pulmonary origin. The 3 non-pulmonary malignancies were renal, breast and metastatic squamous cell. New clinically important diagnoses were made in a further 11%(7/62) including TB/amyloid/ILD, whilst 78%(48/62) were benign.In the malignancy group, 71% (5/7) were current/ex-smokers, 86% (6/7) had a SPN with mean size 7.7mm and there was a higher likelihood of nodules enlarging on follow-up CTs (40% versus 2% at 2nd CT). 75%(3/4) of patients with lung malignancy underwent curative treatment. In the benign group (48), the me...
histological and surgical details were extracted from clinical records. Analysis was conducted on MedCalc software v13.3.1 and reviewed by an independent statistician. Results 42 patients who underwent EBUS+/-EUS for mediastinal staging were found to have no evidence of N2/3 disease. In 3 cases subsequent mediastinoscopy was performed as a high degree of suspicion for mediastinal disease persisted. However, in all cases surgical staging correlated with endosonographic staging. At thoracotomy, 3 (other) patients were upstaged to N2 disease. In two cases, micrometastatic disease was present in a station 7 node and one case had positive station 5/6 not accessible at EBUS/EUS. Overall the NPV of EBUS+/-EUS was 93% (95% CI, 80%-98%). In 22 of 42 patients, the same nodal stations sampled on EBUS/EUS were removed at surgery. In this subset, EBUS/EUS had a NPV of 91% (95% CI, 71% to 99%). Conclusion We have shown that in an experienced centre, mediastinal staging by EBUS+/-EUS can have a high NPV. In these circumstances, surgical staging following negative endosonography is probably not warranted unless a high degree of clinical suspicion remains following MDT discussion. Regular audit of NPV is recommended to ensure performance standards are maintained.
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