EUS-guided FNA of centrally located lung tumours following a non-diagnostic bronchoscopy
Introduction
In patients with suspected lung cancer, a tissue diagnosis is obligatory in order to determine a treatment strategy. Bronchoscopy fails to establish a diagnosis in up to 30% of patients with a centrally located lung cancer [1]. This large patient group usually undergoes either computed tomography of the chest (CT)-guided biopsy or “explorative thoracotomy” in order to obtain a diagnosis. CT-guided biopsy of centrally located lesions have a false negative rate up to 30% [2] and have the risk of a pneumothoraces in 25–45% of cases from which 5–15% need a chest tube [3], [4]. Exploratory thoracotomy is a very invasive way to establish a diagnosis and is regarded futile in case of a benign disease an in patients with small-cell lung cancer.
Mediastinal lymph nodes located adjacent to the esophagus can be visualized and biopsied safely by endoscopic ultrasound guided fine needle (EUS-FNA) with a sensitivity of 88% and a specificity of 91% [5]. In addition to lymph node staging, it has recently been reported that EUS is also able to visualise intrapulmonary tumours (T) located adjacent to the esophagus and assess the presence or absence of tumour invasion in neighbouring structures (T4) [6]. We hypothesized that in analogy of mediastinal lymph node staging, EUS-FNA is a valuable technique to diagnose centrally located intrapulmonary tumours that can be visualized from the esophagus.
In this prospective study, the feasibility and yield of EUS-FNA was studied in patients with suspected lung cancer and a tumour located adjacent or near the esophagus in which bronchoscopy failed to establish a diagnosis.
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Study design
Patients with suspected lung cancer, with a tumour located near (<1 cm) or adjacent to the esophagus, in which a previous bronchoscopy was non-diagnostic were eligible for this study. Patients who met these criteria were included regardless of the tumour size or specific lobe. EUS-FNA was performed on all patients in order to establish diagnosis. Surgical–pathological verification occurred in patients with a non-diagnostic EUS-FNA procedure or in those patients in which EUS-FNA demonstrated
EUS-FNA
In all patients the intrapulmonary lesion was detected by EUS, and the diagnosis of lung cancer was established in 31 of 32 patients (97%) (squamous cell carcinoma, n = 4; adenocarcinoma, n = 7; large-cell undifferentiated carcinoma, n = 15; small-cell carcinoma, n = 4; giant-cell carcinoma n = 1). The mean number of needle passes was 2 (range 1–6). In 13 patients (39%) tumours were staged as T4 based on invasion in the mediastinum (n = 10) or in centrally located vessels (n = 3). No complications, such as
Discussion
EUS-FNA established the diagnosis lung cancer in 97% of patients with suspected lung cancer and a tumour located in near or adjacent to the esophagus after a previously non-diagnostic bronchoscopy. In addition to assessment of a tissue diagnosis, EUS provided additional staging information in 39% of patients by demonstrating tumour invasion. These data suggest that EUS-FNA might qualify as the next diagnostic step in patients with suspected lung cancer after a non-diagnostic bronchoscopy,
Acknowledgements
This study was supported by a grant from the Leiden University Medical Center (LUMC); technical support by Hitachi Ultrasound, Reeuwijk, The Netherlands.
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