Elsevier

Lung Cancer

Volume 48, Issue 3, June 2005, Pages 357-361
Lung Cancer

EUS-guided FNA of centrally located lung tumours following a non-diagnostic bronchoscopy

https://doi.org/10.1016/j.lungcan.2004.11.017Get rights and content

Summary

Objective:

To assess the feasibility and yield of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in diagnosing centrally located lung tumours after a previously non-diagnostic bronchoscopy.

Background and hypothesis:

Bronchoscopy fails to establish a diagnosis in up to 30% of patients with suspected lung cancer. Intrapulmonary tumours located near or adjacent to the esophagus might be visualized and biopsied under real-time ultrasound guidance by EUS-FNA.

Design:

Patients with suspected lung cancer and an intrapulmonary tumour located near or adjacent to the esophagus who had undergone a non-diagnostic bronchoscopy, underwent EUS-FNA for diagnostic purposes. Surgical–pathological verification occurred when EUS-FNA was non-diagnostic and in those patients diagnosed with non-small-cell lung cancer by EUS-FNA who were surgical candidates.

Results:

EUS-FNA diagnosed lung cancer in 31 of 32 patients (97%). No complications occurred. The diagnosis obtained by EUS-FNA was confirmed in all 11 patients who were operated. In one case, in which EUS-FNA was non-diagnostic, a lymphoma was diagnosed after pneumonectomy.

Conclusions and significance:

EUS-FNA qualifies as the next diagnostic step in patients with suspected lung cancer and a non-diagnostic bronchoscopy if the intrapulmonary mass is located adjacent or near the esophagus. In these cases, EUS-FNA may replace computed tomography of the chest (CT)-guided biopsies and reduce the number of exploratory thoracotomies.

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.

Section snippets

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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