title: A combined approach of endobronchial and endoscopic ultrasound-guided needle aspiration in the radiologically normal mediastinum in non-small-cell lung cancer staging--a prospective trial.
abstract: OBJECTIVE
  This prospective study aimed to assess the diagnostic yield of the combined approach - endobronchial (EBUS) and endoscopic (EUS) ultrasound-guided needle aspiration (combined ultrasound-needle aspiration (CUS-NA)) in the radiologically normal mediastinum in non-small-cell lung cancer (NSCLC) staging.
  
  
  METHODS
  CUS-NA was performed simultaneously under local anaesthesia and sedation in consecutive NSCLC patients with mediastinal nodes that were not enlarged on CT (stage IA-IIB). All patients with negative CUS-NA subsequently underwent the transcervical extended bilateral mediastinal lymphadenectomy (TEMLA) as a confirmatory test.
  
  
  RESULTS
  A total of 120 NSCLC patients underwent CUS-NA between 1 January 2008 and 31 December 2008. There were 318 mediastinal nodes biopsied (158 EBUS-NA - stations: 2R - 2, 2L - 1, 4R - 34, 4L - 33 and 7 - 88 and 160 EUS-NA - stations: 4L - 57, 7 - 101 and 9 - 2). CUS-NA revealed metastatic lymph node involvement in 19 of 120 patients (16%) and in 31 of 318 biopsies (10%). The prevalence was 22%. In 99 patients with negative CUS-NA, who underwent subsequent TEMLA, metastatic nodes were diagnosed in nine patients (8%) in 11 stations: 2R - 2, 4R - 4, 4L - 1, 5 - 3 and 7 - 1. In all but one patient there were 'minimal N2' only. Diagnostic sensitivity, specificity, total accuracy, positive predictive value (PPV) and negative predictive value (NPV) of CUS-NA for normal mediastinum was 68% (95% confidence interval (CI): 48-84), 98% (95% CI: 92-100), 91% (95% CI: 86-96), 91% (95% CI: 70-99) and 91% (95% CI: 83-96), respectively. The sensitivity of CUS-NA was significantly higher than with EBUS-NA alone (p=0.04) and higher, close to the level of significance than with EUS-NA alone (p=0.07). The NPV of all techniques was high and that of CUS-NA was significantly higher than EBUS-NA alone and EUS-NA alone (p=0.01, p=0.03). No complications of CUS-NA were observed.
  
  
  CONCLUSIONS
  In the radiologically normal mediastinum, CUS-NA is a highly effective and safe technique in NSCLC staging and, if negative, a surgical diagnostic exploration of the mediastinum may be omitted.
authors.affiliation: Endoscopy Unit, Pulmonary Hospital, Zakopane, Poland. artondo@mp.pl
authors.forename: Artur
authors.initials: A
authors.lastname: Szlubowski
authors.forename: Marcin
authors.initials: M
authors.lastname: Zieliński
authors.forename: Jerzy
authors.initials: J
authors.lastname: Soja
authors.forename: Jouke T
authors.initials: JT
authors.lastname: Annema
authors.forename: Witold
authors.initials: W
authors.lastname: Sośnicki
authors.forename: Magdalena
authors.initials: M
authors.lastname: Jakubiak
authors.forename: Juliusz
authors.initials: J
authors.lastname: Pankowski
authors.forename: Adam
authors.initials: A
authors.lastname: Cmiel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle / Q000379:methods; D001999:Bronchoscopy / Q000379:methods; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000473:pathology / Q000556:secondary*; D019160:Endosonography / Q000379:methods; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology*; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008482:Mediastinum; D008875:Middle Aged; D009367:Neoplasm Staging; D014057:Tomography, X-Ray Computed; D018084:Ultrasonography, Interventional / Q000379:methods