Eus Guided Fna for Mediastinal Tumors (Lung Cancer and Lymph Nodes)

Abstract

Trans-esophageal endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) has proven to be a safe and minimally invasive tissue-sampling method which can be used to obtain a cytological diagnosis from mediastinal lesions. The aims of EUS-FNA in the mediastinum are either to diagnose a lesion of unknown origin, to stage mediastinal lymph nodes in lung cancer patients or to diagnose other diseases involving lymph nodes of the mediastinum. In patients with non-small cell lung cancer (NSCLC), surgery may be regarded as futile in up to 45% of patients operated, apparently because the stage of the disease is more advanced than expected preoperatively. This, combined with a stage-dependent multimodality treatment, underlines the importance of exact staging of the disease. Conventional imaging and tissue sampling methods all have variable sensitivities.Twenty-two studies concerning EUS-FNA and mediastinal staging of lung cancer have been published with a total number of 1245 patients. The reported sensitivity for mediastinal malignancy range from 0.61-1.00 (median 0.90), and with specificities of 0.71-1.00 (median 1.00). The majority of the studies are retrospective and present the results of EUS-FNA performed in lung cancer patients selected by computer tomography (CT). Recent data suggests that EUS-FNA in addition can diagnose advanced mediastinal disease in 22-42% of NSCLC patients with normal sized lymph nodes ( < 1 cm) on chest CT. EUS-FNA may also be used as a re-staging procedure after induction chemotherapy and it seems that EUS-FNA is more accurate for mediastinal staging of NSCLC compared to positron emission tomography (PET). However, further studies are necessary before final conclusions can be made. At present, mediastinoscopy is still considered complementary to EUS-FNA because EUS-FNA cannot visualize structures anterior to the air-filled trachea and main bronchi. Endoscopic trans -bronchial real-time ultrasound guided biopsy (EBUS-TBNA) performed via the trachea and main bronchi seems to be an obvious solution. Preliminary experience with a prototype EBUS-TBNA bronchoscope (Olympus, XBF-UC40P, Tokyo, Japan) in 214 patients has shown promising results. Hopefully the combination of EUS-FNA and EBUS-TBNA will be able to replace more invasive and risky staging methods and improve the N-staging accuracy of the mediastinum and lung hilar regions in the near future.Key words: endoscopic ultrasound guided biopsy from lymph nodes in the mediastinum, endosonography guided biopsy of the mediastinum, EUS-FNA, lung cancer staging, staging of NSCLC.

Endoscopic ultrasound-guided biopsy in the chest: little to lose, much to gain

“…The reported complication rate of EUS-FNA is ,0.5%, most of these were minor [2]. This is in contrast with the more invasive method of mediastinoscopy, with a reported complication rate of 2-5% and with the potential of fairly serious complications.…”

“…In expert hands the sensitivity of endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) for these lesions reaches 90-98%. The number of patients included in the publications is currently .1,500 patients [2]. In this issue of European Respiratory Journal, CADDY et al [3] further underline the benefit of EUS-FNA in mediastinal staging of selected patients with NSCLC and for diagnosis of unexplained mediastinal lymph nodes.…”

Recent developments in advanced diagnostic bronchoscopy

“…EBUS-TBNA has reported pooled sensitivity of roughly 90% for the staging of lung cancer [6,13]. These statistics are comparable to a pooled sensitivity of 89% for video mediastinoscopy, which is considered superior to that of conventional cervical mediastinoscopy [7,10].…”

“…Many of the concerns regarding the use and adoption of C-TBNA were allayed with the introduction of EBUS-TBNA. The first report on the clinical application of linear probe EBUS was published in 2004 [6]. The literature from the ASTER trial in 2013 integrated the era of EBUS-TBNA in the staging and diagnostic algorithm of cancer in the lung and mediastinum [7].…”

Agreement of Mediastinal Lymph Node Size Between Computed Tomography and Endobronchial Ultrasonography: A Study of 617 Patients

“…T he initial step in the evaluation of suspected intrathoracic (mediastinal and hilar) lymph node enlargement is contrast-enhanced computed tomography (CT) of the thorax [1]. Subsequently, a cytologic or histologic specimen from the intrathoracic lymph nodes can be obtained with various techniques such as CT-guided fine needle aspiration (FNA), conventional transbronchial needle aspiration (TBNA), endobronchial ultrasound (EBUS)-guided TBNA, endoscopic ultrasound (EUS)-guided FNA, EUS with an echobronchoscope, and mediastinoscopy [2][3][4][5][6][7][8][9]. EBUS-TBNA is the preferred minimally invasive technique for mediastinal lymph node sampling and cytologic diagnosis [9][10][11][12].…”