Endobronchial ultrasound and value of PET for prediction of pathological results of mediastinal hot spots in lung cancer patients

Abstract

SummaryIn the staging of lung cancer with positron emission tomography (PET) positive mediastinal lymph nodes, tissue sampling is required. The performance of transbronchial needle aspiration (TBNA) using linear endobronchial ultrasound (real-time EBUS-TBNA) under local anaesthesia and the value of PET for prediction of pathological results were assessed in that setting. The number of eluded surgical procedures was evaluated. All consecutive patients with suspected/proven lung cancers and FDG-PET positive mediastinal adenopathy were included. If no diagnosis was reached, further surgical sampling was required. Lymph node SUVmax (maximum standardized uptake value) was assessed in patients whose PET was performed in the leading centre. One hundred and six patients were included. The average number of TBNA samples per patient was 4.9 ±1.1. The prevalence of lymph node metastasis was 58%. Sensitivity, accuracy and negative predictive value of EBUS-TBNA in the staging of mediastinal hot spots were 95, 97 and 91%. Patients without malignant lymph node involvement showed lower SUVmax (respective median values of 3.7 and 10.0; p < 0.0001 ). Surgical procedures were eluded in 56% of the patients. Real-time EBUS-TBNA should be preferred over mediastinoscopy as the first step procedure in the staging of PET mediastinal hot spots in lung cancer patients. In case of negative EBUS, surgical staging procedure should be undertaken. The addition of SUVmax cut-off may allow further refinement but needs validation.

Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review

“…The majority of studies do not differentiate between these subgroups and this is an important drawback. Even though the current authors could find no observable differences in studies that exclusively enrolled patients with NSCLC [12,13,15,17] or that primarily analyse mediastinal and hilar metastasis [9,13,17,20] in comparison to those that include only patients with mediastinal metastases [12,18,24], additional studies are required to clarify the effectiveness of this test in different clinical situations.…”

“…In three of the studies reviewed [13,19,20], imaging techniques, fundamentally CT and FDG-PET, which are frequently used as initial staging methods, displayed a lower sensitivity and specificity than that observed for EBUS-TBNA. The findings of a recent meta-analysis [32] are also in line with the inferiority of imaging techniques in detecting mediastinal involvement: the estimated sensitivity and specificity of FDG-PET and CT were 83% and 92%, and 59% and 78%, respectively.…”

“…EUS-FNA is a complementary technique that enables visualisation of posterior nodes not visualised by EBUS-TBNA but does not allow the visualisation of the anterior mediastinum [13,19]. Two studies [19,24] support the theory that the combination of EBUS-TBNA and EUS-FNA could dispense with surgical techniques in the great majority of cases, but one of these studies includes only 20 patients [20] and the validity of both is diminished due to the lack of confirmation of all negative results using reference techniques such as mediastinoscopy and/or thoracoscopy. Additionally, WALLACE et al [19] used lymph nodes, instead of patients, as the unit of analysis, so the possibility that study results are inflated cannot be dismissed [34].…”

“…Recently, BAUWENS et al [20] investigated the value of EBUS-TBNA in 106 patients with suspected or proven lung cancer and fluorodeoxyglucose (FDG)-PET-positive mediastinal adenopathy. In this subset of patients, the sensitivity and NPV for staging mediastinal N1, N2 or N3 lesions were 95% and 91%, …”

“…Only three studies reported having observed agitation [31], cough [20,31], and presence of blood [9] at the puncture site.…”