title: Negative EBUS-TBNA Predicts Very Low Prevalence of Mediastinal Disease in Staging of Non-Small Cell Lung Cancer.
abstract: BACKGROUND
  Confirmation of mediastinal disease (N2/3) in non-small cell lung cancer (NSCLC) generally precludes curative surgical management. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a routine first test in mediastinal staging of NSCLC; however, it remains unclear whether a negative EBUS-TBNA should be followed by mediastinoscopy before proceeding to surgery. Understanding the prevalence of metastases in lymph nodes with benign findings on EBUS-TBNA will inform decision making following negative EBUS-TBNA.
  
  
  METHODS
  We examined a retrospective cohort of patients who underwent EBUS-TBNA before resection with mediastinal lymph node sampling for NSCLC between December 2009 and June 2014 in 3 hospitals in Melbourne, Australia. All patients had integrated positron emission tomography/computed tomography (PET/CT) before EBUS-TBNA.
  
  
  RESULTS
  Eighty-two matched mediastinal lymph node stations were sampled in 57 patients by both EBUS-TBNA and surgical resection, 47 nodes in patients staged cN0/1 by PET/CT and 35 nodes in patients staged cN2/3. All patients had a negative EBUS-TBNA. Four malignant nodes were identified surgically (4.9% of lymph nodes). The mean size of malignant deposits was 5.5 mm. Per-node negative predictive value was 78/82=0.95. All malignant nodes were located in patients with moderate-high risk disease (cN2/3), giving a disease prevalence in cN2/3 patients of 11%, and 0% in cN0/1. In patients staged cN2, per-node NVP was 0.89.
  
  
  CONCLUSIONS
  The prevalence of mediastinal nodal disease following negative EBUS-TBNA is very low, at 4.9%. The per-node NVP of EBUS-TBNA is 0.95, decreasing to 0.89 in moderate-high risk patients. We suggest that a negative EBUS-TBNA of mediastinal nodes does not need to be confirmed by mediastinoscopy of those nodal stations, regardless of PET/CT findings.
authors.affiliation: Departments of *Respiratory Medicine †Cardiothoracic Surgery, Royal Melbourne Hospital ‡Department of Medicine, University of Melbourne, Parkville, Vic., Australia.
authors.forename: John
authors.initials: J
authors.lastname: Taverner
authors.forename: Mun-Yoong
authors.initials: MY
authors.lastname: Cheang
authors.forename: Phillip
authors.initials: P
authors.lastname: Antippa
authors.forename: Katharine
authors.initials: K
authors.lastname: See
authors.forename: Louis B
authors.initials: LB
authors.lastname: Irving
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Steinfort
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology*; D015331:Cohort Studies; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration / Q000379:methods*; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D008479:Mediastinal Neoplasms / Q000473:pathology*; D008481:Mediastinoscopy; D008875:Middle Aged; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D015995:Prevalence; D012189:Retrospective Studies