title: Performance of EUS-FNA for mediastinal lymphadenopathy: impact on patient management and costs in low-volume EUS centers.
abstract: BACKGROUND
  Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mediastinal lymphadenopathy has been shown to be a valuable diagnostic tool in high-volume EUS centers (≥ 50 mediastinal EUS-FNA/endoscopist/year). Our goal was to assess the diagnostic accuracy of EUS-FNA and its impact on clinical management and costs in low-volume EUS centers (<50 mediastinal EUS-FNA/endoscopist/year).
  
  
  METHODS
  Consecutive patients referred to two Dutch endoscopy centers in the period 2002-2008 for EUS-FNA of mediastinal lymphadenopathy were reviewed. The gold standard for a cytological diagnosis was histological confirmation or clinical follow-up of more than 6 months with repeat imaging. The impact of EUS-FNA on clinical management was subdivided into a positive impact by providing (1) adequate cytology that influenced the decision to perform surgery or (2) a diagnosis of a benign inflammatory disorder, and a negative impact which was subdivided into (1) false-negative or inconclusive cytology or (2) an adequate cytological diagnosis that did not influence patient management. Costs of an alternative diagnostic work-up without EUS-FNA, as established by an expert panel, were compared to costs of the actual work-up.
  
  
  RESULTS
  In total, 213 patients (71% male, median age= 61 years, range = 23-88 years) underwent EUS-FNA. Sensitivity, specificity, and negative and positive predictive values were 89%, 100%, 80%, and 100%, respectively. EUS-FNA had a positive impact on clinical management in 84% of cases by either influencing the decision to perform surgery (49%) or excluding malignant lymphadenopathy (35%), and a negative impact in 7% of cases because of inadequate (3%) or false-negative (4%) cytology. In 9% of cases, EUS-FNA was performed without an established indication. Two nonfatal perforations occurred (0.9%). Total cost reduction was €100,593, with a mean cost reduction of €472 (SD = €607) per patient.
  
  
  CONCLUSIONS
  Mediastinal EUS-FNA can be performed in low-volume EUS centers without compromising diagnostic accuracy. Moreover, EUS-FNA plays an important role in the management of patients with mediastinal lymphadenopathy and reduces total diagnostic costs.
authors.affiliation: Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. m.m.c.hirdes@umcutrecht.nl
authors.forename: Meike M C
authors.initials: MM
authors.lastname: Hirdes
authors.forename: Matthijs P
authors.initials: MP
authors.lastname: Schwartz
authors.forename: Kristien M A J
authors.initials: KM
authors.lastname: Tytgat
authors.forename: Noël J
authors.initials: NJ
authors.lastname: Schlösser
authors.forename: Daisy M D S
authors.initials: DM
authors.lastname: Sie-Go
authors.forename: Menno A
authors.initials: MA
authors.lastname: Brink
authors.forename: Bas
authors.initials: B
authors.lastname: Oldenburg
authors.forename: Peter D
authors.initials: PD
authors.lastname: Siersema
authors.forename: Frank P
authors.initials: FP
authors.lastname: Vleggaar
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044963:Biopsy, Fine-Needle / Q000191:economics / Q000379:methods*; D016009:Chi-Square Distribution; D019160:Endosonography / Q000191:economics; D005260:Female; D006801:Humans; D008206:Lymphatic Diseases / Q000000981:diagnostic imaging / Q000473:pathology*; D008297:Male; D008477:Mediastinal Diseases / Q000000981:diagnostic imaging / Q000473:pathology*; D008875:Middle Aged; D009426:Netherlands; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D018084:Ultrasonography, Interventional / Q000191:economics