PURPOSE: In patients with suspected lung cancer, the presence of mediastinal lymph node metastases is a critical determinant of therapy and prognosis. Invasive staging with pathological confirmation is recommended. The optimal method of pathological detection of mediastinal lymph node metastases is uncertain.
METHODS: We conducted a double blind back-to-back-to-back trial comparing three methods of minimally invasive, endoscopic staging in 150 patients with suspected lung cancer: traditional transbronchial needle aspiration (TBNA), endobronchial ultrasound guided fine needle aspiration (EBUS-FNA), and transesophageal endoscopic ultrasound (EUS-FNA). The primary outcome was the sensitivity for detection of mediastinal lymph node metastases, using pathological confirmation and long term clinical follow up as the gold standard.
RESULTS: One hundred and thirty eight patients met all study criteria and 42 (30%) had malignant lymph nodes. Endobronchial ultrasound guided fine needle aspiration was significantly more sensitive than bronchoscopy (69% vs. 36%, p=0.003). The combination of EBUS and EUS results in significant gains in sensitivity (93%) as well as excellent negative predictive value (97%) when compared to either method considered alone. The superiority of EUS+EBUS was maintained for lymphadenopathy in any mediastinal location, as well as patients without lymph node enlargement.
CONCLUSION: The combination of endoscopic (via the esophagus) and endobronchial (via the airway) ultrasound guided fine needle aspiration is highly accurate for the detection of mediastinal lymph node metastases in suspected lung cancer and is superior to traditional bronchoscopy or either ultrasound guided procedure alone. This combination provide near complete medical mediastinal staging.
CLINICAL IMPLICATIONS: Based on these data, combined endoscopic and endobronchial ultrasound appears to be the preferred method for non-operative staging of lung cancer.
DISCLOSURE: Michael Wallace, No Product/Research Disclosure Information; Grant monies (from sources other than industry) National Cancer Institute R33CA97875, James and Esther King Foundation of the State of Florida, Department of Health, H06052; Grant monies (from industry related sources) Equipment for the study was provided by the Olympus Corporation