Thoracic Surgeons (ESTS) (original) (raw)
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Endobronchial ultrasound in the diagnosis and staging of lung cancer and other thoracic tumors
Seminars in thoracic and cardiovascular surgery, 2007
Bronchoscopy has been in clinical use for a long time with an excellent safety record. Unfortunately, the yield of bronchoscopic procedures for staging mediastinal lymph nodes as well as for the biopsy of peripheral lesions with conventional techniques has been disappointing. Transbronchial biopsy as well as transbronchial needle aspiration are generally performed without direct visualization, which partially explains this problem. The advent of endobronchial ultrasound has dramatically changed the environment, and, if used for guidance of transbronchial biopsy, lymph nodes can be reliable samples challenging the notion that mediastinoscopy should be the mediastinal staging procedure of choice. This article reviews technological background, application, and results of endobronchial ultrasound added to diagnostic bronchoscopy in the diagnosis and staging of patients with lung cancer.
Minimally Invasive Endoscopic Staging of Suspected Lung Cancer
JAMA, 2008
UNG CANCER IS THE MOST COMmon cancer-related cause of death in the United States. 1 Stage of disease dictates the choice of therapy. Surgery is most appropriate for patients in whom disease is confined to the lung and hilar lymph nodes. For patients with ipsilateral mediastinal lymph node metastases, the benefit of surgery as primary therapy is questionable. For patients with contralateral mediastinal lymph node metastases, surgery is generally not indicated, and chemotherapy, radiotherapy, or both are considered the standard of care. 2 Noninvasive staging with chest computed tomography (CT) or positron emission tomography (PET) is associated with high rates of false-positive and false-negative results, respectively. 3 The American College of Chest Physicians recommends invasive staging with tissue confirmation of suspected metastatic mediastinal lymph nodes. 4 Mediastinoscopy or thoracoscopy has been the diagnostic standard, but less invasive methods have emerged as potential alternatives. Such methods include blind transbronchial needle aspiration (TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), and, most recently, endobronchial ultrasound-guided fineneedle aspiration (EBUS-FNA). 5 We hypothesized that EBUS-FNA would be more accurate than TBNA and that the combination of EUS-FNA and EBUS
Endoscopic Ultrasound As a First Test for Diagnosis and Staging of Lung Cancer
American Journal of Respiratory and Critical Care Medicine, 2007
Rationale: Multiple tests are required for the management of lung cancer. Objectives: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was evaluated as a single test for the diagnosis and staging (thoracic and extrathoracic) of lung cancer. Methods: Consecutive subjects with computed tomography (CT) findings of a lung mass were enrolled for EUS and results were compared with those from CT and positron emission tomography scans. Results: Of 113 subjects with lung cancer, EUS was performed as a first test (after CT scan) for diagnosis in 93 (82%) of them. EUS-FNA established tissue diagnosis in 70% of cases. EUS-FNA, CT, and positron emission tomography detected metastases to the mediastinal lymph nodes with accuracies of 93, 81, and 83%, respectively. EUS-FNA was significantly better than CT at detecting distant metastases (accuracies of 97 and 89%, respectively; p ϭ 0.02). Metastases to lymph nodes at the celiac axis (CLNs) were observed in 11% of cases. The diagnostic yields of EUS-FNA and CT for detection of metastases to the CLNs were 100 and 50%, respectively (p Ͻ 0.05). EUS was able to detect small metastases (less than 1 cm) often missed by CT. Metastasis to the CLNs was a predictor of poor survival of subjects with non-small cell lung cancer, irrespective of the size of the CLNs. Of 44 cases with resectable tumor on CT scan, EUS-FNA avoided thoracotomy in 14% of cases. Conclusions: EUS-FNA as a first test (after CT) has high diagnostic yield and accuracy for detecting lung cancer metastases to the mediastinum and distant sites. Metastasis to the CLNs is associated with poor prognosis. EUS-FNA is able to detect occult metastasis to the CLNs and thus avoids thoracotomy.
Advances in lung cancer diagnosis and staging: endobronchial ultrasound
Internal Medicine Journal, 2007
Background: Endobronchial ultrasound (EBUS) is an accurate and relatively less invasive procedure for the diagnosis of lung lesions and mediastinal lymph node staging for lung cancer. We aimed to evaluate the clinical utility and safety of this new EBUS service established in our hospital. Methods: Consecutive patients who underwent EBUS-transbronchial lung biopsy (EBUS-TBLB) for biopsy of peripheral pulmonary lesions or for transbronchial needle aspiration (TBNA) of mediastinal lymph node enlargement were included in this audit. Demographic and clinical data were obtained prospectively. Diagnostic yield from the results of EBUS was compared to other clinical information obtained. Results: Thirty-eight patients underwent EBUS over a 10-month period. The yield from EBUS-TBLB was 62%. The average size of the lung lesions biopsied was 3.5 cm and 62% were located in the upper lobes. Malignancy was diagnosed in 14 cases and a benign aetiology in four. The yield from EBUS-TBNA was 88% and the average size of the lymph nodes was 2.3 cm. The lymph nodes were all located in the subcarinal station except for two that were in the lower paratracheal station. Malignancy was diagnosed in 10 cases on TBNA and 4 cases had benign pathology. There was one complication seen (small pneumothorax). Conclusion: EBUS is safe and an effective method for both, diagnosis of peripheral pulmonary lesions and staging for lung cancer.
Endoscopic ultrasound
The learning of transesophageal ultrasound guided fine needle aspiration (FNA) (endoscopic ultrasound-FNA), and endobronchial ultrasound guided transbronchial needle aspiration (endosonography) should be based on the following steps: Acquiring theoretical knowledge, training on simulators, and supervised performance on patients. Each step should be completed by passing a validated exam before proceeding to the next step. This approach will assure basic competency on all levels, and testing also facilitates learning and improves retention. Competence in endosonography can be based on a systematic an easy principle consisting of 2 times six anatomical landmarks.
Endobronchial ultrasound for the diagnosis and staging of lung cancer
Proceedings of the American Thoracic Society, 2009
The diagnosis of indeterminate mediastinal lymph nodes, masses, and peripheral pulmonary nodules constitutes a significant challenge. Options for tissue diagnoses include computed tomography-guided percutaneous biopsy, transbronchial fine-needle aspiration, mediastinoscopy, left anterior mediastinotomy, or video-assisted thoracoscopic surgery; however, these approaches have both advantages and limitations in terms of tissue yield, safety profile, and cost. Endobronchial ultrasound (EBUS) is a new minimally invasive technique that expands the view of the bronchoscopist beyond the lumen of the airway. There are two EBUS systems currently available. The radial probe EBUS allows for evaluation of central airways, accurate definition of airway invasion, and facilitates the diagnosis of peripheral lung lesions. Linear EBUS guides transbronchial needle aspiration of hilar and mediastinal lymph nodes, improving diagnostic yield. This article will review the principles and clinical applicati...
Thorax, 2004
Background: Positron emission tomography (PET) is accurate for mediastinal staging of lung cancer but has a moderate positive predictive value, necessitating pathological verification. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) is a technique for tissue verification of mediastinal and upper retroperitoneal abnormalities. The use of EUS-FNA may decrease the number of surgical procedures and thereby staging costs. Methods: EUS-FNA was used prospectively for the cytological assessment of mediastinal and/or upper retroperitoneal PET hot spots in patients with suspected lung cancer. Only if EUS-FNA was positive for malignancy was subsequent mediastinoscopy or exploratory thoracotomy cancelled. The cost effectiveness of EUS-FNA was determined. Results: Of 488 consecutive patients with suspected lung cancer, 81 were enrolled with mediastinal and/ or upper retroperitoneal PET hot spots. EUS-FNA was positive in 50 (62%) patients, negative in six, and inconclusive in 25. Of the 31 negative or inconclusive patients, 26 underwent surgical staging (resulting in 14 patients with and 12 without mediastinal malignancy), while five patients had mediastinal metastases during follow up. No EUS-FNA related morbidity or mortality was encountered. The accuracy of the decision to proceed to surgery (or not) on the basis of EUS-FNA was 77% (95% CI 68 to 86). EUS-FNA detected more mediastinal abnormalities than PET except for the upper mediastinal region. Addition of EUS-FNA to conventional lung cancer staging reduced staging costs by 40% per patient, mainly due to a decrease in surgical staging procedures. Conclusion: EUS-FNA can replace more than half of the surgical staging procedures in lung cancer patients with mediastinal and/or upper retroperitoneal PET hot spots, thereby saving 40% of staging costs.