The critical role of EBUS‐TBNA cytology in the staging of mediastinal lymph nodes in lung cancer patients: A correlation study with positron emission tomography findings

Abstract

BACKGROUND:The sensitivity and specificity of positron emission tomography (PET) have been significantly improved for the identification of malignancies in recent years; however, it is still necessary to confirm PET findings in a lymph node (LN) by direct tissue sampling. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the most commonly used approach for diagnosing and staging mediastinal LNs, particularly in lung cancer patients with locally advanced disease. Despite this fact, evidence-based studies of EBUS-TBNA cytology and PET findings are still suboptimal. METHODS:The electronic database at the Johns Hopkins Medical Institutions and the pathology archives were searched to identify patients with mediastinal lymphadenopathy who had both EBUS-TBNA mediastinal LN sampling and a PET scan over a 14-month period. Patients suspected of having lung cancer and patients with a history of lung cancer were included in this study. Cytological diagnoses and follow-up surgical LN diagnoses were reviewed and correlated with PET scan findings. RESULTS: A total of 140 LNs from 79 patients, including 86 PET-positive LNs and 54 PET-negative LNs, were included. The most frequently sampled LNs were 4R and 7. The average size of PET-positive and PET-negative LNs was 1.2 and 1.6 cm, respectively. Among PET-positive LNs, 41.9% were malignant, 41.9% showed reactive changes or granulomatous inflammation, and 9.3% were nondiagnostic by EBUS-TBNA. However, among PET-negative LNs, 74.1% showed reactive changes or granulomatous inflammation, 7.4% were malignant, and 18.5% were nondiagnostic by EBUS-TBNA. CONCLUSIONS:The data demonstrate that EBUS-TBNA cytology improves the diagnostic accuracy of mediastinal LNs and clinical staging. Furthermore, EBUS-TBNA may identify additional malignant LNs (7.4%), and this highlights the risk for false-negative findings with PET scanning in isolation. Cancer Cytopathol 2017;125:717-25. V C 2017 American Cancer Society.KEY WORDS: endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA); fine-needle aspiration (FNA) cytology; lung cancer staging; mediastinal lymphadenopathy; positron emission tomography (PET) scan.

Endobronchial ultrasound-transbronchial needle aspiration (EBUS/TBNA): a diagnostic challenge for mediastinal lesions

“…In view o f t h e l o w i n v a s i v e n e s s , E B U S -T B N A m a y b e recommended as a complementary examination to the imaging study. Lilo et al (35) reported the results of EBUS-TBNA on 70 patients previously subjected to 18 F-FDG-PET/CT for the study of lymph nodes. Of 140 lymph nodes considered, 54 were negative to 18 F-FDG-PET/CT while the subsequent use of EBUS-TBNA allowed identifying 4 (7%) lymph nodes that possessed signs of malignancy.…”

Cytologic Evaluation of Positron Emission Tomography-Computed Tomography–Positive Lymph Nodes Sampled by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Experience at a Large Cancer Center

“…Only 65 of 314 lymph nodes (21%; Figure 5, B) in the PET-CTþ/CytoÀ group had significant cytologic findings of infection, acute inflammation, necrosis, or granulomatous inflammation, including 3 patients with fungal organisms identified on smears. Similarly, Lilo et al 14 reported that 36 of 86 PETþ lymph nodes (41.8%) were negative for malignancy and 25% of benign lymph nodes had granulomas. Other small case series have described increased FDG uptake in benign conditions, most of which are granulomatous inflammation including sarcoidosis, infection, pneumonitis, previous pulmonary tuberculosis, and silicosis.…”

“…PET-CT is a noninvasive imaging modality commonly used as the initial step in clinical staging for cancer patients as well as for restaging cancer patients after treatment. 13,14 However, the overlap in SUV/FDG-avidity between benign and malignant conditions, 15,16 as well as high prevalence of inflammation/infection within mediastinal lesions with increased uptake of FDG [17][18][19] in thoracic lesions, has encouraged cytologic sampling by a minimally invasive modality, EBUS-TBNA for PET-CTþ lymph nodes. 20,21 In this study, we retrospectively compared the PET-CTþ/Cytoþ versus PET-CTþ/CytoÀ mediastinal lymph nodes sampled by EBUS-TBNA in patients with primary lung cancer, nonlung cancer, and patients with no known malignancy.…”

Risk Prediction for Locoregional Recurrence in Epidermal Growth Factor Receptor-Mutant Stage III-pN2 Lung Adenocarcinoma after Complete Resection: A Multi-center Retrospective Study

“…Although positive capsule is regarded as a potential indicator of PORT, further validation would be essential, because paradoxical results from another study suggested that PORT could only benefit those without extracapsular invasion. 30 In recent studies, EBUS-TBNA showed an increased capacity in detecting the eventual presence of extracapsular extension, 31 , 32 making it possible to investigate neoadjuvant radiotherapy in pre-surgically diagnosed extracapsular disease.…”