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Ann Thorac Surg 1996;61:1445-1446
© 1996 The Society of Thoracic Surgeons
DR MARK J. KRASNA (Baltimore, MD): I want to compliment Dr Reed on an excellent presentation and thank her and her coauthors for sending me their manuscript. At the University of Maryland, my pulmonary colleague, Dr Jonathan Orens, has just presented data on 80 patients in a prospective, randomized trial with endobronchial ultrasound and transbronchial needle aspiration. Basically we found that this was a very good way of minimizing the number of passes necessary to get a positive transbronchial needle aspiration, and it also allowed biopsy of lesions that were less than 1 cm in size, as opposed to the usual 1.5 cm by transbronchial needle aspiration.
As you know, we have described here and elsewhere the use of thoracoscopy in both lung and esophagus cancer for biopsy of mediastinal lymph nodes. I therefore have two questions.
First, it seems that in lung cancer, the primary areas that we are concerned with are the level 2 and 4 paratracheal lymph nodes and, as you mentioned, the subcarinal lymph nodes. These lymph nodes historically have been accessible by cervical mediastinoscopy, and I think you adequately showed that this technique, although useful for some lymph node stations, does in fact miss these paratracheal lymph nodes. I therefore wonder if you could put in perspective for us where this technique will fall in the total armamentarium of operative staging for all lung cancer patients, since you imply in your manuscript that this may be used to allocate patients to protocols.
Second, I was surprised to see how easily you were able to access level 5, the aortopulmonary window. The inferior pulmonary ligament lymph node often can be seen away from the ligament and the esophagus and actually closer to the lung. I am therefore curious as to how you are able to traverse the pleural cavity so successfully. Obviously you showed us how you were able to avoid the pulmonary artery, but I wonder if you can comment on the yield for level-5 and level-9 lymph nodes.
I do think that this is a very interesting technology, and I will look forward to new advances in this field. I guess that this is going to have more of a role in esophageal cancer staging than in lung cancer staging, where we typically are more concerned about the upper paratracheal and subcarinal lymph nodes.
DR REED: I thank Dr Krasna for his comments, and we recognize him as a leader in thoracoscopy. I will start by saying that we believe this technique complements mediastinoscopy. As you know, the paratracheal area is the easiest to access by mediastinoscopy and certainly in a variety of series has a high sensitivity. The least sensitive area for mediastinoscopy is level 7, which is easily accessed by this procedure. We have found that this technique is particularly useful for left upper lobe carcinomas, and many of these patients had left upper lobe lesions. But I hasten to reiterate that we currently believe this technique complements mediastinoscopy.
We have accessed level 5 many times with no problem. An important point in the manuscript is that when the echoendoscope is placed, especially for level 5, opposite the esophageal wall, first a pulsed-wave Doppler echocardiographic examination is performed to exclude any vascular structures.
I should add that only a few of these patients actually had the inferior mediastinum sampled, and I think it is unusual that we sample or are actually concerned about this area.
DR WILLIAM A. COOK (North Andover, MA): As a practitioner in smaller hospitals, I am sure I am not the only one who would be interested in what the costs for this procedure might be. I would also like you to reflect on the presence of positive nodes on both sides of the mediastinum and how you would approach that problem.
DR REED: We did not say anything about cost in this report because we did not examine this prospectively. However, I did go back and review some cost data, anticipating that this might be a concern. The mediastinoscopy data are for a patient who is admitted the same day and discharged that evening; as you know, a few patients may actually stay overnight, so I think this is a pretty tight cost here. At our institution, hospital and physician charges are about $4,200, whereas for EUS and FNA, it is about $1,800. So actually there is a cost savings with the EUS/FNA procedure.
As to the second question, I should note that EUS allows you to look at the contralateral hilum and mediastinum. Again, it complements the other staging procedures. It has been especially useful in those patients who present with bilateral bulky mediastinal adenopathy without a clear nodule in the lung and who have had a nondiagnostic bronchoscopy. In fact, in our hands, 5 of those patients turned out to have small cell lung cancer.
DR FRANCIS ROBICSEK (Charlotte, NC): I have difficulty appreciating how the value of different diagnostic methods are compared in this very interesting lecture. First of all, you compared EUS with CT scan for diagnostic accuracy. I believe it is more appropriate to compare EUS with CT-scan-directed needle biopsy, which has a much higher yield than CT scan alone. As presented, the data do not reflect which technique is better.
The second question concerns costs. Again, we are comparing EUS to mediastinoscopy. It is established that CT-scan-directed needle biopsy in many respects is comparable in diagnostic yield to mediastinoscopy. If we want to show the economic advantage of EUS, we should compare its cost to that of CT scan and simultaneous needle biopsy. At our institution, when we send the patient for CT scan, we ask the radiologist, in appropriate situations, to do the needle biopsy at the same time if he identifies suspicious nodes.
Therefore, my question is: How does the diagnostic yield of EUS compare with CT-scan-directed needle biopsy, and how does the cost of the procedure compare when it is done at the same sitting?
DR REED: I do not have any information on CT needle biopsy. We do that extremely infrequently at my institution. Our CT people are not anxious to perform biopsy of lymph nodes in the level 5 region, and most of the time my patients come to me with a CT scan already performed, so we cannot decide to do the needle biopsy at that time. I think you have a very good point. We are not necessarily comparing EUS as a staging tool with CT scan. I am just pointing out that the CT scan, which is used often as a staging tool, is inaccurate and that we need to have techniques that confirm positivity or negativity.
Related Article
Ann. Thorac. Surg. 1996 61: 1441-1445.
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