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Original Research |

Using Endobronchial Ultrasound Features to Predict Lymph Node Metastasis in Patients With Lung CancerEndobronchial Ultrasound in Lung Cancer

Jessica S. Wang Memoli, MD; Ezzat El-Bayoumi, MD; Nicholas J. Pastis, MD, FCCP; Nichole T. Tanner, MD; Mario Gomez, MD; J. Terrill Huggins, MD; Georgiana Onicescu, ScM; Elizabeth Garrett-Mayer, PhD; Kent Armeson, MS; Katherine K. Taylor, MS; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

From the Section of Pulmonary, Critical Care, and Respiratory Services (Dr Wang Memoli), Washington Hospital Center, Washington, DC; Palmetto Pulmonary and Critical Care Associates (Dr El-Bayoumi), Greenville, SC; the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (Drs Pastis, Tanner, Huggins, and Silvestri and Ms Taylor), and the Department of Medicine, Division of Biostatistics and Epidemiology (Dr Garrett-Mayer; Ms Onicescu; and Mr Armeson), Medical University of South Carolina, Charleston, SC; and the Pulmonary and Sleep Center of the Valley (Dr Gomez), Weslaco, TX.

Correspondence to: Gerard A. Silvestri, MD, FCCP, 96 Jonathan Lucas St, CSB 812, Charleston, SC 29425; e-mail: silvestr@musc.edu

Data presented as No. unless otherwise noted. LLL = left lower lobe; LUL = left upper lobe; NSCLC = non-small cell lung cancer; RLL = right lower lobe; RML = right middle lobe; RUL = right upper lobe.

Sensitivity, 87%; specificity, 100%; negative predictive value, 89%; positive predictive value, 100%. EBUS = endobronchial ultrasound.

a

Four patients excluded because true stage unknown: two with metastasis found at surgery in lymph nodes not undergoing biopsy at time of EBUS, one lost to follow-up, one with radiographically larger lymph node but no tissue verification of metastasis.

See Table 3 legend for expansion of abbreviation. GEE = generalized estimating equation; Ref = referent.

a

Indicates statistical significance using α of 0.05. Estimates were calculated using a GEE logistic regression model as described in the “Statistical Analysis” section.

Adjusted models included both PET scan activity and lymph node size on CT scan of the chest. See Table 4 legend for expansion of abbreviation.

a

Indicates statistical significance using α of 0.05. Estimates were calculated using a GEE logistic regression model as described in the “Statistical Analysis” section.

Funding/Support: The research in this article was supported by National Institutes of Health K-24 Mid-Career Investigator Award in Patient-Oriented Research [Grant 5K24CA120494-02]. It was also supported in part by the Biostatistics Shared Resource as part of the Hollings Cancer Center at the Medical University of South Carolina, which is funded by a Cancer Center Support Grant [Grant P30 CA138313].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Funding/Support: The research in this article was supported by National Institutes of Health K-24 Mid-Career Investigator Award in Patient-Oriented Research [Grant 5K24CA120494-02]. It was also supported in part by the Biostatistics Shared Resource as part of the Hollings Cancer Center at the Medical University of South Carolina, which is funded by a Cancer Center Support Grant [Grant P30 CA138313].

Funding/Support: The research in this article was supported by National Institutes of Health K-24 Mid-Career Investigator Award in Patient-Oriented Research [Grant 5K24CA120494-02]. It was also supported in part by the Biostatistics Shared Resource as part of the Hollings Cancer Center at the Medical University of South Carolina, which is funded by a Cancer Center Support Grant [Grant P30 CA138313].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Chest. 2011;140(6):1550-1556. doi:10.1378/chest.11-0252
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Purpose:  Reliable staging of the mediastinum determines TNM classification and directs therapy for non-small cell lung cancer (NSCLC). Our aim was to evaluate predictors of mediastinal lymph node metastasis in patients undergoing endobronchial ultrasound (EBUS).

Methods:  Patients with known or suspected lung cancer undergoing EBUS for staging were included. Lymph node radiographic characteristics on chest CT/PET scan and ultrasound characteristics of size, shape, border, echogenicity, and number were correlated with rapid on-site evaluation (ROSE) and final pathology. Logistic regression (estimated with generalized estimating equations to account for correlation across nodes within patients) was used with cancer (vs normal pathology) as the outcome. ORs compare risks across groups, and testing was performed with two-sided α of 0.05.

Results:  Two hundred twenty-seven distinct lymph nodes (22.5% positive for malignancy) were evaluated in 100 patients. Lymph node size, by CT scan and EBUS measurements, and round and oval shape were predictive of mediastinal metastasis. Increasing size of lymph nodes on EBUS was associated with increasing malignancy risk (P = .0002). When adjusted for CT scan size, hypermetabolic lymph nodes on PET scan did not predict malignancy. Echogenicity and border contour on EBUS and site of biopsy were not significantly associated with cancer. In 94.8% of lymph nodes with a clear diagnosis, the ROSE of the first pass correlated with subsequent passes.

Conclusions:  Lymph node size on CT scan and EBUS and round or oval shape by EBUS are predictors of malignancy, but no single characteristic can exclude a visualized lymph node from biopsy. Further, increasing the number of samples taken is unlikely to significantly improve sensitivity.

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