PURPOSE: Endobronchial Ultrasound (EBUS) and videomediastinoscopy (VM) have important roles in the diagnosis of mediastinal adenopathy, particularly in the staging of patients with lung cancer. Our goal to use the least invasive modality possible and obtain definitive results while minimizing delay, led us to develop a hybrid operating room mediastinal staging technique (ORMST). ORMST begins with EBUS, utilizing rapid on-site cytologic analysis, either establishing a diagnosis, thereby terminating the case, or confirming the need to progress to the more invasive VM.
METHODS: A Retrospective chart review of twenty patients who underwent the ORMST between January 2009 and April 2011 was conducted.
RESULTS: Twelve men and 8 women underwent ORMST; the mean age was 68 years (range 28-89). Clinical indications included lung cancer 15(75%), or mediastinal adenopathy of unknown etiology 5(25%). Four (20%) patients had positive cytology from EBUS and did not proceed to VM. Four (20%) patients with negative EBUS had positive results on VM, including 2 with sarcoid, 1 with lymphoma, and 1 with lung cancer in a node not biopsied with EBUS (high paratracheal). There was 1 false negative ORMST where adenocarcinoma was identified at surgical resection within the subcarinal node, which had been previously biopsied using both techniques. Operating room (OR) times average 139 minutes, while procedural times average 106 minutes. This is about an hour longer than our standard VM where OR times average 93 minutes, and procedural times average 49 minutes. Total outpatient EBUS in room times average 90 minutes with 44 minutes of procedure time.
CONCLUSIONS: The ORMST procedure led to a diagnosis or accurate staging in 95% of patients and avoided VM in 20% of patients. No intraoperative or postoperative complications were identified. The hybrid procedure added an hour to standard VM. Whether this increase in cost is offset by the increased efficiency and convenience is the subject of ongoing investigation.
CLINICAL IMPLICATIONS: This single setting hybrid ORMST appears to be ideally suited for patients with lung cancer whose nodes are not grossly involved on Computed Tomography or Positron Emission Tomography, but where invasive staging is indicated.
DISCLOSURE: The following authors have nothing to disclose: Richard Koehler, Steve Kirtland
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