Mediastinoscopy

There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative. EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses. Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requi...

BACKGROUND:
The diagnostic yield and accuracy of new approaches to diagnose cancer should focus on comparison with established surgical techniques.  Our objective was to evaluate the diagnostic performance of EBUS to detect cancer in patients with radiographically abnormal mediastinal lymph nodes.

METHODS:
The medical records of patients who underwent EBUS and had abnormal mediastinal lymph nodes (short-axis >1 cm and/or PET-positive) over a 25 month period at the University of Pittsburgh were reviewed.  Demographic and clinical data, cytology and pathology results were entered in a database and analyzed.

RESULTS:
A total of 172 patients (male:female = 1.8:1; median age = 67 (range = 20-90)) were included.  The diagnostic yield of EBUS cytology was 79.7% (137/172).  Pathologic testing was available in 68% (117/172) and 82% (96/117) had a diagnostic EBUS.  The diagnostic accuracy of EBUS was 91.7%.  The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were 88.1% (95% CI = 77.3-94.3), 100% (95% CI = 85.9-100), 100% (95% CI = 92.4-100), and 80.6% (95% CI = 63.4-91.2), respectively.  In 67 patients who had a suspected or biopsy-proven, primary lung cancer, diagnostic yield was 86.6% and accuracy was 94.8%.  In this subgroup, the sensitivity, specificity, PPV and NPV were 93% (95% CI = 76.5-98.9), 100% (95% CI = 69.9-100), 100% (95% CI = 85-100) and 83.3% (95% CI = 56.2-97.5). 

CONCLUSION:
Diagnostic performance data support the clinical usefulness of EBUS in the evaluation of patients with a radiographically abnormal mediastinum.  It should be considered complementary to mediastinoscopy rather than substitutive.

Long-term survival after minimally invasive major lung resections for lung carcinoma has been repeatedly shown to be equal or better than after open surgery [1], [2], [3] and [4], despite mediastinal dissection with VATS lobectomy being poorly documented and not always performed ...

Lung cancer is the most frequent malignant disease and the leading cause of death from malignant diseases in the world and its incidence is increasing. At the time when diagnosis is established most patients have advanced disease and are not candidates for radical surgical treatment. Patients without distant metastases are subjected to various diagnostic methods to detect metastases in mediastinal lymph nodes that make up the path of lymph drainage from the lungs. The most reliable invasive diagnostic procedures for detecting metastases in mediastinal lymph nodes are videomediastinoscopy and endobronchial ultrasound with transtracheal puncture. In the absence of mediastinal lymph node metastases surgery is the treatment of choice. If mediastinal lymph nodes are positive for metastases multimodal treatment is implemented. At the Department of Thoracic Surgery, Zadar General Hospital, videomediastinoscopy for the staging of primary non-small cell lung cancer has been performed routine...

The role of surgery in the multimodality treatment is still a matter of discussion. Until recently, neoadjuvant chemotherapy with subsequent pulmonary resection was regarded the standard of treatment for patients with N2 metastatic nodes discovered preoperatively [1], [2] and ...

Diagnosis of indeterminate mediastinal masses and staging of lung cancer poses a significant challenge. Options for tissue diagnoses include computed tomography (CT)-guided percutaneous biopsy, transbronchial fine-needle aspiration, mediastinoscopy/mediastinotomy or thoracoscopy, but these investigations have limitations in terms of tissue yield, safety profile and cost. Trans-esophageal endoscopic ultrasound scanning (EUS) is a new minimal invasive method that provides high resolution imaging of the mediastinum using high frequency ultrasound probes attached to the tip of a flexible endoscope and offers in addition the facility of fine needle aspiration (EUS-FNA) or tru-cut biopsy (TCB) under real-time ultrasound guidance. EUS-FNA allows access to the posterior mediastinum and tissue acquisition under real-time ultrasound guidance through the oesophageal wall. Indications of EUS-FNA in the mediastinum is to obtain a diagnosis from an unknown primary lesion or to sample tissue from ...