Elsevier

Lung Cancer

Volume 69, Issue 1, July 2010, Pages 60-65
Lung Cancer

EUS-FNA in the preoperative staging of non-small cell lung cancer

https://doi.org/10.1016/j.lungcan.2009.08.016Get rights and content

Abstract

Background

According to current guidelines, transesophageal ultrasound-guided fine needle aspiration (EUS-FNA) can be performed as an alternative for surgical staging to confirm mediastinal metastases in patients with non-small cell lung cancer (NSCLC). To date however, data regarding the routine use of EUS-FNA in the preoperative staging of unselected patients with NSCLC are limited.

Aims and objectives

  • (1)

    To evaluate the diagnostic value of EUS-FNA in consecutive, patients with NSCLC regardless of nodal size at CT.

  • (2)

    To determine the impact of EUS-FNA on the prevention of surgical staging procedures.

  • (3)

    To assess the accuracy of mediastinal staging by combining EUS-FNA and mediastinoscopy.

  • (4)

    To investigate whether a subgroup of patients exists that can be accurately staged by EUS-FNA alone.

Methods

152 consecutive operable patients with proven or suspected NSCLC who underwent EUS-FNA were retrospectively analyzed. In the absence of mediastinal metastases, mediastinoscopy and/or thoracotomy with lymph node dissection was performed.

Results

The prevalence of mediastinal metastases was 49%. Sensitivity, negative predictive value (NPV) and accuracy of EUS-FNA for N2/N3 disease were 74%, 73% and 85% respectively, whereas these values for the combined staging of EUS-FNA and mediastinoscopy were 92%, 85% and 95%. Additional surgical staging in patients staged N0 at EUS-FNA reduces the false negative EUS-findings by 55%. The NPV of EUS-FNA for left-sided tumors was 68%. EUS-FNA prevented surgical staging procedures in 60 of 152 patients (39%). No major complications occurred during EUS-FNA.

Conclusion

Routine use of EUS-FNA in unselected patients with NSCLC reduces the need for surgical staging procedures in nearly half of patients. Additional surgical staging in patients without nodal metastases at EUS-FNA reduces the false negative EUS-FNA findings considerably regardless of the location of the primary lung tumor.

Introduction

Preoperative staging of non-small cell lung cancer (NSCLC) defines the anatomic extent of the disease at the time of the diagnosis and will determine treatment recommendations and prognosis. The basis for NSCLC staging is the TNM system [1]. In the absence of distant metastases, regional lymph node status is critical for determining treatment options. Contrast enhanced computed tomography (CT) scanning of the chest is useful in providing anatomic detail, but the accuracy of chest CT scanning in differentiating benign from malignant lymph nodes in the mediastinum is limited [2]. Therefore, tissue verification of mediastinal lymph nodes is indicated to ensure accurate nodal staging.

Mediastinoscopy is considered the reference standard for invasive staging of patients with potentially operable NSCLC. Though invasive, mediastinoscopy is an accurate staging method, but it has limited access to posterior subcarinal lymph nodes and the lower mediastinum [3]. Transesophageal ultrasound-guided fine needle aspiration (EUS-FNA) is a safe and minimally invasive staging procedure with a diagnostic reach complementary to mediastinoscopy. EUS-FNA added to mediastinoscopy in the preoperative staging of lung cancer has been shown to result in improved nodal staging and to prevent futile thoracotomies [4], [5]. EUS-FNA is useful for confirming mediastinal metastases, but has its limitations regarding its negative predictive value (73–83%) [6], [7]. EUS-FNA has been shown to prevent surgical staging procedures in 50–70% of patients by demonstrating the presence of lymph node metastases [8], [9]. Therefore, EUS-FNA has been advocated in recent guidelines as the first mediastinal staging test to provide tissue confirmation (but not exclusion) of nodal metastases [3], [6]. The impact and accuracy of EUS-FNA have mostly been investigated in cohorts of selected patients with nodal enlargement on CT or with positron emission tomography (PET) positive lymph nodes [7]. To date, however, its merits in the routine preoperative staging of unselected patients with NSCLC are as yet unclear.

Therefore, we evaluated a lung cancer staging strategy involving consecutive patients with potentially operable lung cancer who were initially staged by EUS-FNA. Sensitivity, NPV and accuracy of EUS-FNA in the preoperative nodal staging of NSCLC were assessed. We also investigated whether a subgroup of lung cancer patients exists that can be accurately staged by EUS-FNA alone without subsequent surgical staging. Finally, we determined the impact of EUS-FNA on the prevention of surgical staging procedures.

Section snippets

Design and patients

We retrospectively evaluated a lung cancer staging strategy over a 3.5-year period (between August 2003 and February 2007) in which patients with operable lung cancer were initially staged by EUS-FNA. Consecutive patients with (suspected) NSCLC who were medically fit to undergo surgical resection of the lung tumor were discussed at the weekly Lung Oncology Board meeting of the Leiden University Medical Center. All patients had previously undergone a contrast enhanced chest computed tomography

Results

A total of 152 patients were included in this study. There were 101 males and 51 females with a median age of 66 years (range 38–82). Contrast enhanced CT scans of the chest showed the primary lung tumor to be located in the LUL (n = 44), LLL (n = 30), lingula (n = 1), central left lung (n = 6), RUL (n = 31), ML (n = 8), RLL (n = 28) and central right lung (n = 3). There was 1 patient with a double tumor on CT. 103 of 152 patients were shown to have nodal enlargement (short axis >10 mm) on CT. Based on CT, 32%

Discussion

In this cohort of 152 consecutive operable patients with (suspected) NSCLC who were unselected by PET or CT, EUS-FNA had a sensitivity, NPV and accuracy of 74%, 73% and 85% for detecting malignant mediastinal lymph nodes. For the subgroup of 40 patients who were staged by both EUS-FNA and mediastinoscopy, these test results were 92%, 85% and 95%. Based on EUS-FNA findings, surgical staging procedures were prevented in 60 of 152 patients (39%) with lung cancer due to tissue proof of locally

Conflict of interest

None declared.

Acknowledgments

Funding source and writing assistance: not applicable.

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