Focused Neck Ultrasound and Lymph Node Sampling by Respiratory Physicians in Suspected Lung Cancer

Abstract

<b><i>Background:</i></b> Malignant cervical lymphadenopathy in the setting of lung cancer represents N3 disease, and neck ultrasound (NUS) with sampling is described in the Royal College of Radiologists ultrasound training curriculum for the non-radiologists. This study reviews the incorporation of NUS +/− biopsy in the routine practice of a lung cancer fast-track clinic in the UK. <b><i>Methods:</i></b> We retrospectively assessed 29 months of activity of a lung cancer fast-track clinic. Systematic focused NUS was conducted in suspected thoracic malignancy, sampling nodes with a ≥5-mm short axis, under real-time US using a linear probe (5–12 Mhz). Fine-needle aspirations (FNAs) with or without 18 Ga core biopsies were taken. <b><i>Results:</i></b> Between August 2017 and December 2019, of 152 peripheral lymph nodes (LNs)/deposits sampled, 98 (64.5%) were supraclavicular fossa LNs with median [IQR] size 12 [8–18] mm. Core biopsies were performed in 54/98 (55%) patients, while all patients had FNAs. No complications occurred. The representative yield was 90/95 (94.7%) in cases with suspected cancer. No difference was seen between FNA versus core biopsy (<i>p</i> = 0.44). Of the 5 non-diagnostic samples, one was FNA only. The commonest diagnosis was lung cancer in 66/98 (67.3%). PDL-1 was sufficient in 35/36 tested (97.2%). ALK-FISH was successful in 24/25 (96%) cases. EGFR mutation analysis was successful in 28/31 (90.3%) cases. Median time from clinic to initial diagnosis was 7 [5–10] days. Computed tomography (CT) scans reported no significant lymphadenopathy in 18/96 (18.7%) cases, yet 10/18 (55.5%) cases were positive for malignancy. <b><i>Conclusion:</i></b> Neck nodal sampling by respiratory physicians was safe, timely, with a high diagnostic yield and suitability for molecular testing. Neck US can provide a timely diagnosis in cases that may be missed by CT alone.

Additional Up-Front Thoracic Ultrasound in the Workup of Patients with Unilateral Pleural Effusion: A Prospective Observational Pilot Study

“…Additional TUS in the Workup of Patients with Unilateral Pleural Effusion suspected lung cancer [14] and a high diagnostic yield of instant ultrasound-guided biopsies [15]. In our study, a minority were diagnosed with lung cancer, while several patients had mesothelioma where spread to cervical lymph nodes is rare [16].…”

“…We did not find any cases of enlarged infraclavicular, supraclavicular, or cervical lymph nodes. Previous studies have found a high prevalence of ultrasound-verified enlarged cervical lymph nodes in patients with suspected lung cancer [ 14 ] and a high diagnostic yield of instant ultrasound-guided biopsies [ 15 ]. In our study, a minority were diagnosed with lung cancer, while several patients had mesothelioma where spread to cervical lymph nodes is rare [ 16 ].…”

Endobronchial Ultrasound-guided Sampling of Centrally Located Intrapulmonary Tumors Provides Suitable Material for Diagnostic and Molecular Testing

“…The main limitations of our evaluation were that the retrospective design incorporates operator selection bias in the decision-making to both select the patient for EBUS and proceed to sampling intraprocedurally. In addition, suspected lung cancer patients are increasingly screened for the percutaneous US-guided sampling from accessible lymph nodes, lung, chest wall, and anterior mediastinum, if an alternative target is present 24,25. This may have contributed to the small proportion of intrapulmonary tumor sampling we observed at our center as this is undertaken routinely at our center.…”

“…In addition, suspected lung cancer patients are increasingly screened for the percutaneous US-guided sampling from accessible lymph nodes, lung, chest wall, and anterior mediastinum, if an alternative target is present. 24,25 This may have contributed to the small proportion of intrapulmonary tumor sampling we observed at our center as this is undertaken routinely at our center. Finally, we identified complications retrospectively which may have underestimated rates.…”

The diagnostic value and safety of modified needle aspiration biopsy for superficial lymphadenectasis

“…Hassan et al ( 20 ) reported a CNB positive diagnostic rate of 82.6% in cases with suspected cervical lymph node metastasis of lung cancer. Elsewhere, Oh et al ( 21 ) studied the sensitivity and specificity of CNB in the diagnosis of cervical lymph node metastasis and found them to be 91.6% and 100%, respectively.…”