Towards a minimally invasive staging strategy in NSCLC: analysis of PET positive mediastinal lesions by EUS-FNA

Annema, Jouke T.; Hoekstra, Otto S.; Smit, Egbert F.; Veselic, Maud; Versteegh, Michel I.M.; Rabe, Klaus F.

doi:10.1016/j.lungcan.2003.10.013

Cited by 105 publications

(59 citation statements)

References 17 publications

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“…Several studies have assessed the use of EUS-FNA in the evaluation of mediastinal hot spots [19,20]. No study has compared EBUS-TBNA with EUS-FNA in this particular indication and these techniques in fact appear more complementary than exclusive [21].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2008

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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.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2008

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“…The current authors believe that these results are mainly due to the introduction of FDG-PET, allowing selection of positive lymph node station for EBUS localisation followed by TBNA. Prior evaluation and selection for lymph node sampling with FDG-PET has also recently been advocated for oesophageal endoscopic ultrasound with fine needle aspiration [17,18]. In order to further assess whether FDG-PET effectively contributes to the high diagnostic yield in the present study, a randomised study comparing TBNA combined with EBUS, with or without prior evaluation with FDG-PET, should be required.…”

Section: Limitations Of the Studymentioning

confidence: 99%

Endobronchial ultrasound and positron emission tomography positive mediastinal lymph nodes

Plat

Pierard²,

Haller³

et al. 2006

European Respiratory Journal

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Positron emission tomography with 18F-fluoro-2-deoxy-D-glucose (FDG-PET) is more accurate than computed tomography for staging of mediastinal (hilar) lymph nodes. In the case of positive findings, tissue sampling of lymph nodes is required. The diagnostic/staging yield of transbronchial needle aspiration (TBNA) following endobronchial ultrasound (EBUS) localisation was assessed in this particular clinical setting. The number of avoided surgical procedures was evaluated.All consecutive patients referred for staging and/or diagnosis of mediastinal FDG-PET positive lesions were included. Data were prospectively collected. TBNA sampling of lymph nodes was performed after EBUS localisation. If no diagnosis was reached, further surgical sampling or adequate follow-up was performed.From January 2003 to June 2004, 33 patients were included. The average number of TBNA samples per patient was 4.2¡1.5. Cytological or histological diagnoses were obtained in 27 (82%) of the patients, of which 78% were obtained after previous EBUS localisation. In 25 (76%) of the 33 patients, surgical staging procedures were suppressed.In conclusion, transbronchial needle aspiration after endobronchial ultrasound localisation should be considered as a primary method of evaluation of lymph nodes positive by positron emission tomography with 18F-fluoro-2-deoxy-D-glucose, and may replace the majority of surgical mediastinal staging/diagnostic procedures.

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“…Thus, there is need for less invasive procedures. Even though specialized centers reported promising results for minimally invasive mediastinal staging by endoscopic ultrasound-guided fine-needle aspiration, this method could not be established for clinical routine until now (6).…”

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confidence: 99%

18F-FDG PET for Mediastinal Staging of Lung Cancer: Which SUV Threshold Makes Sense?

Hellwig

Graeter²,

Ukena

et al. 2007

Journal of Nuclear Medicine

170

111

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18 F-FDG PET is the most accurate noninvasive modality for staging mediastinal lymph nodes in lung cancer. Besides using visual image interpretation, some institutions use standardized uptake value (SUV) measurements in lymph nodes. Mostly, an SUV of 2.5 is used as the cutoff, but this choice was never deduced from respective studies. Receiver operating characteristic (ROC) analyses demonstrated that SUV thresholds of more than 4 resulted in the highest accuracy. But these high cutoffs imply high false-negative rates (FNRs). The aim of our evaluation was to determine an optimal SUV threshold and to compare its diagnostic performance with the results of visual interpretation. Methods: This retrospective study included 95 patients with suspected lung cancer who underwent mediastinoscopy/mediastinal lymphadenectomy after 18 F-FDG PET (90-150 min after 250 MBq of 18 F-FDG). Maximum SUV was measured in 371 lymph node regions biopsied afterward and visually interpreted using a 6-level score (2 2 2 through 1 1 1). Diagnostic performance was assessed by ROC analysis. FNR and false-positive rate (FPR), the sum of both error rates (FNR 1 FPR), and diagnostic accuracy were plotted against a hypothetical SUV threshold to determine the optimum SUV threshold. Results: SUVs in metastatic lymph nodes were higher (mean 6 SD, 7.1 6 4.5; range, 1.4-26.9; n 5 70) than in tumor-free lymph node stations (2.4 6 1.7; range, 0.6-14.9; n 5 301; P , 0.01). Inflammatory lymph nodes exhibited slightly increased SUVs (2.7 6 2.0; range, 0.8-14.9; n 5 146). The plot of error rates featured a minimum of the sum FNR 1 FPR for an SUV of 2.5. With increasing SUV threshold, the FPR decreased most prominently up to that value whereas a continuous rise of FNR was noticed. Highest diagnostic accuracy was achieved with an SUV of 4.5. The areas under the ROC curves demonstrated that visual interpretation tends to be more accurate than SUV quantification (visual, 0.930 6 0.022; SUV, 0.899 6 0.025; P 5 0.241). Using an SUV of 2.5 as the threshold, the resulting sensitivity, specificity, and negative predictive value were 89%, 84%, and 96%, respectively. Conclusion: For mediastinal staging, the choice of an SUV of 2.5 as the threshold is justified because FNR 1 FPR is minimized. The resulting high negative predictive value of 96% allows the omission of mediastinoscopy in patients with negative mediastinal findings on 18 F-FDG PET images. For the experienced observer, visual analysis should be relied on primarily, with calculation of the SUV used, at most, as a secondary aid. For the less experienced observer, the SUV may be of greater value.

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Towards a minimally invasive staging strategy in NSCLC: analysis of PET positive mediastinal lesions by EUS-FNA

Cited by 105 publications

References 17 publications

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

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

Endobronchial ultrasound and positron emission tomography positive mediastinal lymph nodes

18F-FDG PET for Mediastinal Staging of Lung Cancer: Which SUV Threshold Makes Sense?

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