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Ann Thorac Surg 2004;77:1763-1768
© 2004 The Society of Thoracic Surgeons

Original article: general thoracic

Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography

Michael B. Wallace, MDa*, James Ravenel, MDd, Mark I. Block, MDb, Mostafa Fraig, MDe, Gerard Silvestri, MDc, Stephan Wildi, MDa, Nathan Schmulewitz, MDa, Shyam Varadarajulu, MDa, Stacey Roberts, MDa, Brenda J. Hoffman, MDa, Robert H. Hawes, MDa, Carolyn E. Reed, MDb

a Divisions of Gastroenterology and Hepatology, Medical University of South Carolina, University of South Carolina, Charleston, South Carolina, USA
b Thoracic Surgery, Medical University of South Carolina, University of South Carolina, Charleston, South Carolina, USA
c Pulmonary Medicine and Critical Care, Medical University of South Carolina, University of South Carolina, Charleston, South Carolina, USA
d Department of Radiology, Medical University of South Carolina, University of South Carolina, Charleston, South Carolina, USA
e Department of Pathology and Laboratory Medicine, Medical University of South Carolina, University of South Carolina, Charleston, South Carolina, USA

Accepted for publication October 2, 2003.

* Address reprint requests to Dr Wallace, Director of Endoscopic Research, Mayo Clinic, Jacksonville, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
e-mail: wallace.michael{at}mayo.edu

BACKGROUND: Computed tomography (CT) is the most common method of staging lung cancer. We have previously shown endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) to be highly accurate in staging patients with nonsmall cell lung cancer (NSCLC) who have enlarged mediastinal lymph nodes on CT scan. In this study we report the accuracy and yield of EUS-FNA in staging patients without enlarged mediastinal lymph nodes by CT.

METHODS: Patients with NSCLC and CT scan showing no enlarged mediastinal lymph nodes (> 1 cm for all nodes except > 1.2 cm for subcarinal) in the mediastinum underwent EUS. Fine needle aspiration was performed on at least one lymph node, if present, in the upper mediastinum, aortopulmonary window, subcarinal, and periesophagus regions. Each specimen was evaluated with on-site cytopathology and confirmed with complete cytopathologic examination.

RESULTS: Sixty-nine patients without enlarged mediastinal lymph nodes were evaluated. Endoscopic ultrasound detected malignant mediastinal lymph nodes in 14 of 69 patients as well as other advanced (American Joint Committee on Cancer [AJCC] stage III/IV) in 3 others (1 left adrenal, and 2 with mediastinal invasion of tumor) for a total of 17 of 69 (25%, 95% confidence interval: 16% to 34%) patients. Eleven additional patients were found to have advanced disease by bronchoscopy (2), mediastinoscopy (2), and thoracotomy with mediastinal lymph node dissection (7). The sensitivity of EUS for advanced mediastinal disease was 61% (49% to 75%), and the specificity was 98% (95% to 100%).

CONCLUSIONS: Endoscopic ultrasound guided fine needle aspiration can detect advanced mediastinal disease and avoid unnecessary surgical exploration in almost one of four patients who have no evidence of mediastinal disease on CT scan. In addition to previously reported results in patients with enlarged lymph nodes on CT, these data suggest that all potentially operable patients with nonmetastatic NSCLC may benefit from EUS staging.




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