title: Minimally invasive endoscopic staging of suspected lung cancer.
abstract: BACKGROUND
  In patients with suspected lung cancer, the presence of mediastinal lymph node metastasis is a critical determinant of therapy and prognosis. Invasive staging with pathologic confirmation is recommended. Many methods for staging exist; mediastinoscopy, an invasive procedure requiring general anesthesia, is currently regarded as the diagnostic standard.
  
  
  OBJECTIVE
  To compare the diagnostic accuracy of 3 methods of minimally invasive endoscopic staging (and their combinations): traditional transbronchial needle aspiration (TBNA), endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA), and transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). In particular, we aimed to compare EBUS-FNA with TBNA.
  
  
  METHODS
  Invasive staging of the mediastinum among consecutive patients with suspected lung cancer at a US academic medical center from November 2004 through October 2006.
  
  
  METHODS
  TBNA, EBUS-FNA, and EUS-FNA performed sequentially as a single combined procedure.
  
  
  METHODS
  Sensitivity for detecting mediastinal lymph node metastases, using pathologic confirmation and 6- to 12-month clinical follow-up as the criterion standard.
  
  
  RESULTS
  Among 138 patients who met all study criteria, 42 (30%) had malignant lymph nodes. EBUS-FNA was more sensitive than TBNA, detecting 29 (69%) vs 15 (36%) malignant lymph nodes (P = .003). The combination of EUS-FNA and EBUS-FNA (EUS plus EBUS) had higher estimated sensitivity (93% [39/42]; 95% confidence interval, 81%-99%) and negative predictive value (97% [96/99]; 95% confidence interval, 91%-99%) compared with either method alone. EUS plus EBUS also had higher sensitivity and higher negative predictive value for detecting lymph nodes in any mediastinal location and for patients without lymph node enlargement on chest computed tomography.
  
  
  CONCLUSIONS
  These findings suggest that EBUS-FNA has higher sensitivity than TBNA and that EUS plus EBUS may allow near-complete minimally invasive mediastinal staging in patients with suspected lung cancer. These results require confirmation in other studies but suggest that EUS plus EBUS may be an alternative approach for mediastinal staging in patients with suspected lung cancer.
authors.affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida 32224, USA. wallace.michael@mayo.edu
authors.forename: Michael B
authors.initials: MB
authors.lastname: Wallace
authors.forename: Jorge M S
authors.initials: JM
authors.lastname: Pascual
authors.forename: Massimo
authors.initials: M
authors.lastname: Raimondo
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Woodward
authors.forename: Barbara L
authors.initials: BL
authors.lastname: McComb
authors.forename: Julia E
authors.initials: JE
authors.lastname: Crook
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Johnson
authors.forename: Mohammad A
authors.initials: MA
authors.lastname: Al-Haddad
authors.forename: Seth A
authors.initials: SA
authors.lastname: Gross
authors.forename: Surakit
authors.initials: S
authors.lastname: Pungpapong
authors.forename: Joy N
authors.initials: JN
authors.lastname: Hardee
authors.forename: John A
authors.initials: JA
authors.lastname: Odell
mesh_terms: D000368:Aged; D001707:Biopsy, Needle / Q000379:methods*; D001980:Bronchi / Q000000981:diagnostic imaging; D001999:Bronchoscopy; D019160:Endosonography / Q000379:methods*; D004945:Esophagoscopy; D004947:Esophagus / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology*; D008207:Lymphatic Metastasis / Q000473:pathology*; D008297:Male; D008482:Mediastinum; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009367:Neoplasm Staging; D049268:Positron-Emission Tomography; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed