title: Endobronchial ultrasound-guided transbronchial needle aspiration for systematic nodal staging of lung cancer in patients with N0 disease by computed tomography and integrated positron emission tomography-computed tomography.
abstract: BACKGROUND
  Data regarding the sensitivity of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging of lung cancer in patients with radiographic N0 disease is scant and inconsistent. With increasing use of nonoperative ablative therapies, studies focusing on the performance characteristics of EBUS-TBNA in this population are important.
  
  
  OBJECTIVE
  To evaluate the sensitivity and negative predictive value (NPV) of EBUS-TBNA in patients with non-small cell lung cancer and radiographic N0 disease both by computed tomography (CT) and positron emission tomography (PET)-CT.
  
  
  METHODS
  This was a retrospective review of EBUS-TBNA performed for lung cancer staging at two major academic centers from 2009 to 2014. Patients with radiographic N0 disease (lymph nodes [LN]≤1 cm in the short axis and maximum standardized uptake value≤2.5 by PET-CT) were included. Primary outcome was sensitivity and NPV of EBUS-TBNA.
  
  
  RESULTS
  Two hundred twenty patients with radiographic N0 disease underwent EBUS-TBNA, and 734 LN were sampled (median 3, range 1-6). Median LN diameter was 0.72 cm. One hundred patients (45.5%) underwent surgery, and 120 patients (54.5%) had nonsurgical therapy. N status was up-staged in 49 patients (22.3%): 18 by EBUS-TBNA (N1=11, N2=6, N3=1), 27 by surgery (N1 intralobar=16, N1 extralobar=3, N2=8 [5 LN in stations 4 and 7, and 3 LN in stations 5-6), and 4 by imaging follow-up (N1=2, N2=2). Overall false-negative rate of EBUS was 14.1% (sensitivity, 36.7%; specificity, 100%; and NPV, 84.7%). False-negative rate was 27 and 3.3% in surgical and nonsurgical populations, respectively. Excluding patients with occult disease "outside" the reach of EBUS, the overall false-negative rate of EBUS-TBNA was 5.5% (sensitivity, 60%; specificity, 100%; and NPV, 93.4%).
  
  
  CONCLUSIONS
  This is the largest report of EBUS-TBNA in patients with N0 disease by "integrated" PET-CT. The majority of false-negative EBUS results were in LN stations outside its reach. In our study, both sensitivity and NPV of EBUS-TBNA were lower than early reports despite more extensive LN sampling. Given the high false-negative rate of imaging modalities, EBUS-TBNA may still play an important role in patients with radiographic N0 disease, particularly when nonsurgical ablative therapies are planned. Prospective studies are needed to corroborate our findings in the nonsurgical population.
authors.affiliation: 1 Section of Pulmonary and Critical Care Medicine.
authors.forename: Philip
authors.initials: P
authors.lastname: Ong
authors.forename: Horiana
authors.initials: H
authors.lastname: Grosu
authors.forename: George A
authors.initials: GA
authors.lastname: Eapen
authors.forename: Macarena
authors.initials: M
authors.lastname: Rodriguez
authors.forename: Donald
authors.initials: D
authors.lastname: Lazarus
authors.forename: David
authors.initials: D
authors.lastname: Ost
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Jimenez
authors.forename: Rodolfo
authors.initials: R
authors.lastname: Morice
authors.forename: Venkata
authors.initials: V
authors.lastname: Bandi
authors.forename: Luis
authors.initials: L
authors.lastname: Tamara
authors.forename: Lorraine
authors.initials: L
authors.lastname: Cornwell
authors.forename: Linda
authors.initials: L
authors.lastname: Green
authors.forename: Angela
authors.initials: A
authors.lastname: Zhu
authors.forename: Roberto F
authors.initials: RF
authors.lastname: Casal
mesh_terms: D000368:Aged; D044963:Biopsy, Fine-Needle / Q000379:methods; D001999:Bronchoscopy; D019160:Endosonography / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D061705:Image-Guided Biopsy / Q000379:methods*; D008175:Lung Neoplasms / Q000175:diagnosis* / Q000556:secondary; D008198:Lymph Nodes / Q000000981:diagnostic imaging / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D009367:Neoplasm Staging / Q000379:methods*; D049268:Positron-Emission Tomography / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000379:methods*
keywords: endobronchial ultrasound; lung cancer; mediastinal staging; positron emission tomography–computed tomography