Original article
General thoracic
Endobronchial Ultrasound for Lung Cancer Staging: How Many Stations Should Be Sampled?

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
https://doi.org/10.1016/j.athoracsur.2010.01.043Get rights and content

Background

No guidelines exist regarding the number of mediastinal lymph node stations that should be sampled to ensure adequate preoperative staging of lung cancer patients. In recent reports of esophageal endoscopic ultrasound and endobronchial ultrasound (EBUS), fewer than two stations/patient were sampled. An experience with systematic sampling using EBUS to determine how many stations should be sampled to adequately detect mediastinal disease was evaluated.

Methods

Records were reviewed for all patients with lung cancer who had EBUS between March 9, 2006, and January 6, 2009. For each station sampled the sequence and result (positive, negative, and nondiagnostic) were recorded. For those with a positive biopsy, the sequence number of the first positive station was determined. The affect of systematic sampling on detection of N3 disease was also evaluated.

Results

Ninety-three patients with non–small cell lung cancer had EBUS; 271 mediastinal stations were sampled (range, 0 to 6; mean, 2.9 per patient), with N3 and N2 stations sampled in 51 and 90 patients, respectively. Mediastinal disease was found in 25 patients; 15 patients had multistation N2 disease and 6 patients had N3 disease. In 15 patients (60%), mediastinal disease was detected in the first station sampled; three samples were required to detect 90% of disease, and the remaining 3 patients had their disease detected with the fourth sample.

Conclusions

Introduction of EBUS as a tool for non–small cell lung cancer staging has led to a shift from systematic nodal sampling to targeted nodal sampling. These results indicate that systematic nodal sampling is feasible with EBUS, and that routinely sampling more than two mediastinal stations may improve staging.

Section snippets

Institutional Review Board

The Institutional Review Board of the Memorial Healthcare System, Hollywood, FL, approved this retrospective chart review. The requirement for informed consent was waived.

Endoscopic Ultrasound

All endoscopic ultrasound procedures were performed as a part of routine clinical care for patients with known or suspected lung cancer. All patients had chest computed tomography (CT) scans before the procedure, and most had positron emission tomography (PET) or PET/CT studies available. The decision regarding which

Lymph Node Sampling

Between March 9, 2006, and January 6, 2009, endoscopic ultrasound was performed on 200 patients (EUS, 62; EBUS, 103; EUS and EBUS, 35). Of these, 136 (EUS, 43; EBUS, 71; EUS + EBUS, 22) had NSCLC proven either before the procedure, as a result of the procedure, or at subsequent resection. As shown in Table 2, a total of 379 mediastinal lymph node stations were sampled in these 136 patients (mean, 2.8 per patient). Ninety-three patients had EBUS with sampling of 271 mediastinal lymph node

Comment

Introduction of endoscopic ultrasound into clinical practice is transforming invasive mediastinal staging of patients with NSCLC. Increasingly gastroenterologists and pulmonologists are performing a function that historically has been performed almost exclusively by thoracic surgeons. In a recent review of practice patterns in lung cancer care, Little and colleagues [9] discovered that there was wide variability in the practice of mediastinoscopy. On the basis of a survey of data on almost

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