Systematic and combined endosonographic staging of lung cancer (SCORE study)

Abstract

Guidelines recommend endosonography for mediastinal nodal staging in patients with resectable nonsmall cell lung cancer (NSCLC). We hypothesise that a systematic endobronchial ultrasound (EBUS) evaluation combined with an oesophageal investigation using the same EBUS bronchoscope (EUS-B) improves mediastinal nodal stagingversusthe current practice of targeted positron emission tomography (PET)-computed tomography (CT)-guided EBUS staging alone.A prospective, multicentre, international study (NCT02014324) was conducted in consecutive patients with (suspected) resectable NSCLC. After PET-CT, patients underwent systematic EBUS and EUS-B. Node(s) suspicious on CT, PET, EBUS and/or EUS-B imaging and station 4R, 4L and 7 (short axis ≥8 mm) were sampled. For patients without N2/N3 disease determined on endosonography, surgical-pathological staging was the reference standard.229 patients were included in this study. The prevalence of N2/N3 disease was 103 out of 229 patients (45%). A PET-CT-guided targeted approach by EBUS identified 75 patients with N2/N3 disease (sensitivity 73%, 95% CI 63–81%; negative predictive value (NPV) 81%, 95% CI 74–87%). Four additional patients with N2/N3 disease were found by systematic EBUS (sensitivity 77%, 95% CI 67–84%; NPV 84%, 95% CI 76–89%) and five more by EUS-B (84 patients total; sensitivity 82%, 95% CI 72–88%; NPV 87%, 95% CI 80–91%). Additional clinical relevant staging information was obtained in 23 out of 229 patients (10%).Systematic EBUS followed by EUS-B increased sensitivity for the detection of N2/N3 disease by 9% compared to PET-CT-targeted EBUS alone.

Predictive Value of Endobronchial Ultrasound Strain Elastography in Mediastinal Lymph Node Staging: The E-Predict Multicenter Study Results

“…However, it should be considered that good overall accuracy does not necessarily correlate to high sensitivity. Earlier studies have used cut-off values varying from 5 to 10 mm with success [3][4][5][6][7][8]. Based on our results, we propose to at least routinely include nodes of ≥8 mm for aspiration when no additional predictive variables are used.…”

“…However, there is no consensus on the lower limit in ultrasound size for aspiration. While the 10-mm short axis size, as equal to CT, is often used, cutoffs ranging from 5 to 10 mm are found across studies [3][4][5][6][7][8]. Studies assessing B-mode criteria such as node heterogeneity, shape, and a central hilar structure have also been found to be contradictory in their results [9].…”

The utility of endosonography for mediastinal staging of non-small cell lung cancer in patients with radiological N0 disease

“…It is likely that physicians did not consider adding EUS-B-FNA after systematic EBUS-TBNA to be useful in radiological N0 patients. A recent prospective study revealed that the addition of EUS-B-FNA was more valuable in terms of upstaging from single-level to multilevel N2/N3 disease, rather than upstaging from N0-1 to N2 disease [10]. We compared the diagnostic performance of endosonography based on tumor centrality and diameter; these two parameters were associated with the prevalence of occult mediastinal metastases [9,26,[30][31][32].…”

“…After systematic inspection of mediastinal, hilar, and interlobar lymph nodes (2R, 4R, 10R, 11R, 7, 11 L, 10 L, 4 L, 2 L, etc), nodal sampling was performed from N3 to N2, then to N1 when the short diameter of lymph node was 5 mm or more in sonography [10,11]. LN stations were determined based on the International Association for the Study of Lung Cancer LN map [12].…”

Endobronchial and endoscopic ultrasound: it only takes an echobronchoscope to tango

“…A combination of EUS‐B and EBUS improves in‐depth staging of lung cancer with better patient tolerance and access to evaluate upper paratracheal stations (2R and 2L), the left lower paratracheal station (4L) and possibly the left adrenal gland by a single operator during one session . A recent study demonstrated that combined endosonography showed an increased sensitivity of 9% for N2/N3 disease in lung cancer staging compared to conventional PET‐CT‐targeted EBUS . An extension to the assessment of structures located on both sides of the diaphragm has also been described previously .…”