Elsevier

Gastrointestinal Endoscopy

Volume 71, Issue 1, January 2010, Pages 64-70.e1
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Implementation of endoscopic ultrasound for lung cancer staging

Presented in part at Digestive Disease Week, May 22, 2007, Chicago Illinois, European Respiratory Society, September 16, 2007, Stockholm, Sweden, American Thoracic Society, May 20, 2008, Toronto, Ontario, Canada, and American Society of Clinical Oncology, May 20, 2008, Chicago, Illinois.
https://doi.org/10.1016/j.gie.2009.07.027Get rights and content

Background

EUS-guided FNA is currently advocated in lung cancer staging guidelines as an alternative for surgical staging to prove mediastinal metastases. To date, training requirements for chest physicians to obtain competency in EUS for lung cancer staging are unknown.

Objective

To test a training and implementation strategy for EUS for the diagnosis and staging of lung cancer.

Design

Prospective national multicenter implementation trial. Nine (chest) physicians from 5 hospitals participated in a dedicated EUS educational program (investigation of 50 patients) for the diagnosis and staging of lung cancer. EUS outcomes of trainees were compared with those of the training center.

Setting

Four general hospitals, the national cancer center (implementation centers), and a tertiary referral center (expert center).

Patients

This study involved 551 consecutive patients with (suspected) lung cancer, all candidates for surgical staging, who underwent EUS in 1 of the 5 implementation centers (n = 346) or the single expert center (n = 205). Surgical-pathological staging was the reference standard in case no mediastinal metastases were found.

Results

EUS had a sensitivity of 83% versus 82% and accuracy of 89% versus 88% for mediastinal nodal staging (implementation center vs expert center). Surgery was spared because of EUS findings in 51% versus 54% of patients. A single complication occurred in each group.

Limitation

Surgical-pathological verification of mediastinal nodes was not available in all patients staged negative at EUS.

Conclusion

Chest physicians who participate in a dedicated training and implementation program for EUS in lung cancer staging can obtain results similar to those of experts for mediastinal nodal staging.

Section snippets

Implementation strategy

Initially, several lectures regarding EUS were given at various lung cancer meetings in The Netherlands, with the aim being to disseminate information to chest physicians and lung surgeons on the indications for EUS-FNA in lung cancer staging. Subsequently, 9 physicians from 5 different hospitals were trained to perform EUS. Seven were chest physicians who had neither used US (either transthoracic or endobronchial US [EBUS]) before in clinical practice nor had been exposed to gastroscopy prior

Patient characteristics

Patient characteristics of the 551 patients with suspected lung cancer are summarized in Table 1. The study population in the implementation and expert centers were comparable with respect to age, sex, and location of the lung tumor. In the implementation centers, compared to the expert center, more patients presented with enlarged (short axis >1 cm on CT) (77% vs 60%, respectively) or PET-positive N2/N3 nodes (42% vs 27%, respectively). At inclusion, patients were intended to undergo

Discussion

This implementation trial for EUS-FNA demonstrates that chest physicians, after participating in a rather limited but dedicated EUS implementation program, can obtain results similar to those of experts regarding mediastinal staging of lung cancer. For the assessment of mediastinal metastases, sensitivity (83% vs 82%) and accuracy (89% vs 88%) did not differ between implementation centers and the expert center. Both the implementation centers and expert referral center achieved the high

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    DISCLOSURE: Supported by a grant fromThe Netherlands Organisation for Health Research and Development (Zon-Mw), provided to Dr Annema and Dr Rabe. The current study was supported within an initiative of implementation programs aiming to investigate how methods with proven accuracy and cost-effectiveness could be implemented into clinical practice. Zon-Mw had no role in the design of the study, data collection, analysis, or reporting. All authors had full access to the data. All authors disclosed no financial relationships relevant to this publication.

    If you would like to chat with an author of this article, you may contact Dr. Annema at [email protected].

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