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Endoscopic Ultrasonography, Fine-Needle Aspiration Biopsy Guided by Endoscopic Ultrasonography, and Computed Tomography in the Preoperative Staging of Non-Small-Cell Lung Cancer: A Comparison Study

Frank G. Gress, MD; Thomas J. Savides, MD; Alan Sandler, MD; Kenneth Kesler, MD; Dewey Conces, MD; Oscar Cummings, MD; Praveen Mathur, MD; Steven Ikenberry, MD; Sandy Bilderback, RN; and Robert Hawes, MD
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From Indiana University School of Medicine, Indianapolis, Indiana. Acknowledgments: The authors thank Marilyn Datzman, MD, and Syed Zaidi, MD, for technical support and recruitment of patients; Chris Lambert, Nancy Ruiz, and Stephen Melson for editorial and typing assistance; and Mark Hanna, MS, and Rene Gonin, PhD, for statistical advice. Grant Support: In part by a research grant from the American College of Gastroenterology. Requests for Reprints: Frank G. Gress, MD, Division of Gastroenterology and Hepatology, Winthrop-University Hospital, State University of New York at Stony Brook, School of Medicine and Health Science Center, 222 Station Plaza North, Suite 429, Long Island, NY 11501. Current Author Addresses: Dr. Gress: Division of Gastroenterology and Hepatology, Winthrop-University Hospital, State University of New York at Stony Brook, School of Medicine and Health Science Center, 222 Station Plaza North, Suite 429, Long Island, NY 11501. Dr. Savides: University of California at San Diego, 200 West Arbor Drive, San Diego, CA 92103. Drs. Sandler, Kesler, Conces, Cummings, and Mathur and Ms. Bilderback: 550 North University Boulevard, Indiana University Medical Center, Indianapolis, IN 46202. Dr. Ikenberry: 200 East Pennsylvania, Peoria, IL 45050. Dr. Hawes: Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;127(8_Part_1):604-612. doi:10.7326/0003-4819-127-8_Part_1-199710150-00004
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Background: Current methods for detecting mediastinal lymph node involvement with non-small-cell lung cancer can be inaccurate and are often invasive and expensive.

Objective: To assess the utility of endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography for the detection of metastases to the posterior mediastinal lymph nodes in non-small-cell lung cancer.

Design: Prospective preoperative evaluation of the diagnostic operating characteristics of these procedures.

Setting: Referral-based academic medical center.

Patients: 130 consecutive patients with non-small-cell lung cancer who were otherwise good surgical candidates.

Interventions: All patients had initial computed tomography of the chest; those with enlarged nodes were referred for endoscopic ultrasonography. Endoscopic ultrasonography-guided fine-needle aspiration biopsy was done on suspicious contralateral posterior mediastinal or subcarinal lymph nodes identified by ultrasonography. At surgery, lymph nodes were dissected and categorized by location and underwent histopathologic evaluation.

Results: 52 patients were ultimately enrolled in the study: Thirty-one had thoracotomy with mediastinal dissection, and 21 had tumors considered unresectable on the basis of preoperative evaluation. Ultrasonography without aspiration biopsy had an overall accuracy of 84% for predicting metastasis to lymph nodes; computed tomography had an accuracy of 49% (P < 0.025). Twenty-four patients had ultrasonography-guided aspiration biopsy; 14 of the 24 were ineligible for surgery because cytology showed malignancy. Results of surgical pathology correlated with negative aspiration cytology results in 9 of 10 patients; the one node with false-negative results contained a 2-mm focus of cancer. The accuracy of ultrasonography-guided aspiration biopsy in diagnosing metastasis to lymph nodes was 96%; the results of this test prompted a change in management in 95% of the patients who had the procedure.

Conclusions: Endoscopic ultrasonography alone or with fine-needle aspiration biopsy adds useful diagnostic information in determining metastasis to posterior mediastinal or subcarinal lymph nodes in patients with non-small-cell lung cancer. These procedures are especially helpful in the preoperative evaluation of patients with suspicious contralateral mediastinal or “bulky” subcarinal nodes.


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Figure 1.
American Thoracic Society scheme for mapping mediastinal lymphadenopathy by anatomic location, as seen from behind with endoscopic ultrasonography.VC

Ao = aorta; D = diaphragm; E = esophagus; inf VC = inferior vena cava; L = left; I.PA = left pulmonary artery; PV = pulmonary vein; R = right; r.PA = right pulmonary artery; = superior vena cava. Numbers refer to specific mediastinal zones.

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Figure 2.
A mediastinal lymph node as imaged with the linear-array endoscopic ultrasonography system.arrow

The needle is exiting the scope; the tip of the needle is in the center of the lymph node ( ). Just inferior to the lymph node is the pulmonary artery. One advantage of the linear-array instrument is its Doppler capability, which allows precise imaging of regional blood vessels and safe positioning of the needle relative to the target lymph node.

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Figure 3.
Endoscopic ultrasonographic image obtained from the radial scanning instrument showing a large hypoechoic, oval subcarinal lymph node (LN) suspicious for metastatic involvement.

The lymph node is adjacent to the aorta (Ao).

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Figure 4.
Flow diagram showing how patients were studied on the basis of the study protocol.

* = 8 subcarinal and 2 contralateral mediastinal lymph nodes; † = 2 subcarinal and 12 contralateral mediastinal lymph nodes.

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