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Ann Thorac Surg 1996;61:1441-1445
© 1996 The Society of Thoracic Surgeons
Departments of Surgery, Medicine, Radiology, and Pathology, Medical University of South Carolina, Charleston, South Carolina
Address correspondence to Dr Silvestri, Medical University of South Carolina, 171 Ashley Ave, Rm 812-CSB, Charleston, SC 29425.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. After a thoracic computed tomographic scan, 27 patients with known or suspected lung cancer underwent EUS. Accessible abnormal mediastinal lymph nodes were aspirated under EUS guidance. Patients with positive cytologic studies did not undergo further testing, whereas the remaining patients underwent mediastinal exploration. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for both chest computed tomography and EUS/FNA.
Results. Twenty-two of 27 patients had mediastinal adenopathy by computed tomography scan. Sixteen patients had positive findings on EUS, 15 with positive FNA (10 non-small cell lung cancer; 5 small cell lung cancer) and 1 with T4 status. Fourteen patients with positive FNA had lymph nodes sampled at level 5, level 7, or both. Of 11 patients with negative EUS/FNA, 2 had positive findings at operation (sensitivity 89%). The diagnosis of lung cancer was established in 7 patients.
Conclusions. The results showed that EUS/FNA improves the accuracy of computed tomographic scan in the staging of lung cancer. By accessing lymph nodes at levels 5 and 7, EUS/FNA complements mediastinoscopy and is considered the staging modality of choice in these regions. Positive EUS/FNA can obviate the need for further invasive staging.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Accurate determination of the extent of disease (ie, staging) is critical in patients with lung cancer, as it has implications for both prognosis and treatment. When the standard roentgenogram or computed tomographic (CT) scan of the chest reveals enlarged mediastinal lymph nodes, further diagnostic testing is warranted. Mediastinoscopy, mediastinotomy, and thoracoscopy are established invasive procedures used to evaluate enlarged mediastinal lymph nodes.
Esophageal endoscopic ultrasonography (EUS) is a new modality that can detect mediastinal lymph nodes adjacent to the esophagus. It is now possible to use EUS to visually guide a fine needle into the lymph nodes and perform aspiration. The utility of this procedure for the diagnosis and staging of bronchogenic carcinoma is unknown. We prospectively evaluated EUS with fine-needle aspiration (FNA) in patients with suspected or documented lung cancer.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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All patients underwent contrast-enhanced CT of the chest; all chest CT scans were reviewed by one chest radiologist (L.C.). The location of all enlarged lymph nodes (greater than 10 mm in short-axis diameter) was defined using American Thoracic Society criteria [1]. Tumor size and the presence or absence of metastases within the thorax or upper abdomen were also recorded. The radiologist was blinded to the results of EUS/FNA and any other diagnostic procedure performed.
Lymph nodes considered accessible by EUS were located in the aortopulmonary window (subaortic lymph nodes lateral to the ligamentum arteriosum; level 5), the subcarinal region (level 7), the right tracheobronchial angle nodes (nodes from the cephalic border of the azygos vein to the origin of the right upper lobe bronchus; 10R), the left tracheobronchial angle nodes (nodes medial to the ligamentum arteriosum; 10L), the paraesophageal nodes (level 8), and the inferior pulmonary ligament lymph nodes (level 9) (Figs 1–3
). Lymph nodes located anterior and lateral to the trachea (levels 2, 3, and 4) were considered inaccessible by this approach.
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). This instrument was placed in the lumen opposite the identified biopsy site, and the balloon was filled with water. Pulsed-wave Doppler echocardiography was performed to exclude vascular structures.
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). When the tip of the catheter was visualized endoscopically, the needle was advanced from the catheter sheath through the wall of the esophagus and guided into the target lesion using real-time ultrasound (Fig 5). The stylet was removed and suction was applied with a 10-mL syringe while manipulating the needle back and forth within the lymph node. After 1 to 2 minutes, the suction was released and the needle was retracted.
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Patients with cytologic evidence of malignancy did not undergo further testing. All other patients underwent mediastinal exploration to evaluate the lymph nodes.
Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for both chest CT and EUS/FNA.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Eleven patients had a negative EUS study or negative FNA and proceeded to operation. Two patients had malignant cells identified at exploration. One patient underwent lobectomy and mediastinal node dissection, and had a microscopic focus of tumor in a level-7 lymph node. The other had positive mediastinoscopy findings (Fig 6).
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The diagnosis of lung cancer was established by EUS in 7 patients, of whom 5 had small cell lung cancer. Ten cases of non-small cell lung cancer were properly staged by this procedure and were deemed unresectable.
The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of EUS/FNA and chest CT were as follows: 89%, 100%, 100%, 89%, and 82%, and 89%, 38%, 74%, 76%, and 60%, respectively.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Esophageal endoscopic ultrasonography-guided aspiration of various lesions within or outside the gastrointestinal wall became feasible with the development of the linear-array echoendoscope. This instrument is a 60-degree oblique-forward-viewing fiberoptic endoscope with a curved-array ultrasonic transducer mounted in front of the optic lens. A biopsy channel ends close to the optic lens (see Fig 4). A needle can be introduced into the sector-shaped sound field and be visualized both through the optics and on the ultrasonographic image.
This study demonstrates that EUS offers a modality to identify and biopsy lymph nodes in regions not easily accessible by cervical mediastinoscopy (ie, levels 5, 7, 8, and 9). It allows examination of the contralateral mediastinum and hilum. The results of our study confirm that EUS/FNA is feasible and safe. It can be performed in the outpatient setting, with the patient discharged the same day.
We evaluated the utility of EUS/FNA in the diagnosis and staging of presumed or known lung cancer. We showed that EUS/FNA is useful in the diagnosis of lung cancer, particularly in patients who have bulky mediastinal adenopathy and a nondiagnostic bronchoscopy study. Five patients in this category had small cell lung cancer. In all, EUS/FNA provided the diagnosis in 7 of the 27 patients (26%). In addition, 10 patients (45%) with non-small cell lung cancer were deemed to have unresectable disease or to be candidates for a neoadjuvant protocol based on EUS/FNA. This compares favorably with a report by Gress and associates [4], which showed that operation was precluded in 59% of patients by EUS/FNA.
We compared this modality to chest CT, the primary noninvasive test for evaluation of mediastinal adenopathy in bronchogenic carcinoma. The accuracy of CT in the identification of mediastinal lymph node metastases is variable, with a sensitivity that ranges from 57% to 95% [5–15]. Accuracy varies by nodal station, with the highest sensitivity in the right paratracheal region (4R) and the lowest in level 7 [2]. Eight percent to 15% of patients without mediastinal lymph node enlargement on CT have mediastinal lymph node metastases found at operative exploration [9, 11, 12]. Greater than 30% of patients with enlarged mediastinal lymph nodes detected by CT do not have metastatic disease when explored [16]. Because decisions regarding operative resectability are based upon the presence or absence of tumor in the mediastinum, CT alone cannot be used to stage the mediastinum, and histologic confirmation of enlarged mediastinal lymph nodes is imperative.
The 89% accuracy of EUS/FNA in our study is comparable to that in other reports. Giovannini and colleagues [17] performed 50 lymph node aspirations (24 mediastinal and 26 celiac) with an accuracy of 82%. Gress and associates [4] compared EUS alone versus CT scan versus EUS/FNA in predicting mediastinal lymph node involvement. In 22 patients, EUS/FNA had a 95% accuracy, compared with a 43% accuracy of the CT scan. Our study also demonstrated an unacceptably low accuracy of CT, which supports the need for histologic confirmation of enlarged mediastinal lymph nodes detected by CT.
The sensitivity of EUS/FNA was limited by microscopic foci of metastatic disease in normal-appearing lymph nodes. This accounted for one of our false-negative results; probable sampling error accounted for the other. Despite these two false-negative results, the sensitivity of EUS/FNA is similar to that of mediastinoscopy [18].
The utility of EUS/FNA must be compared with that of mediastinoscopy, which is the most frequently used invasive staging tool to evaluate the peritracheal and anterior subcarinal lymph nodes. The accuracy of mediastinoscopy ranges from 89% to 95% [18], with the subcarinal region (level 7) the most commonly missed. The aortopulmonary region (level 5) is not accessible unless extended cervical mediastinoscopy is used [19], and the inferior mediastinum cannot be sampled. Anterior mediastinotomy (Chamberlain procedure) has been used on the left to evaluate lymph nodes in the subaortic and lateral aortic regions. More recently, thoracoscopy has been used to access nodes in the posterior mediastinum as well as the paratracheal, subazygos, and aortopulmonary nodal regions. Subcarinal lymph nodes can be sampled, most easily by a right thoracoscopic approach [20]. Transcarinal needle aspiration (Wang needle) performed through a bronchoscope can also access the subcarinal lymph nodes [21]. Unfortunately, the yield of this procedure is highly variable depending on the technician, and is generally lower than that of either mediastinoscopy or EUS/FNA [22]. An important finding in this study was the accessibility of lymph node stations 5 and 7, which are currently difficult to evaluate by mediastinoscopy.
In summary, EUS/FNA is useful in the diagnosis and staging of bronchogenic cancer. This modality improves the accuracy of CT and complements mediastinoscopy by readily accessing lymph nodes at levels 5 and 7 and the inferior mediastinum. We consider EUS/FNA the modality of choice for obtaining cytologic confirmation of malignancy in the aortopulmonary window and the subcarinal region. The technique of EUS/FNA in the mediastinal lymph nodes is feasible and safe and can be performed in the outpatient setting. Lung cancer can be diagnosed by EUS/FNA. Documentation of positive mediastinal lymph nodes by EUS/FNA may obviate further operative staging.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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