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Combination approach to mediastinal staging effective
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For patients with suspected lung cancer, combined endobronchial and transesophageal endoscopic ultrasound-guided fine-needle aspiration may be an alternative method for mediastinal staging.
Researchers from the Mayo Clinic in Jacksonville, Fla. and Rochester, Minn. conducted invasive mediastinal staging in 138 patients with suspected lung cancer to compare the diagnostic accuracy of three minimally invasive endoscopic staging methods.
The researchers found that the combined method provided near-complete staging of the mediastinum. In the detection of 42 (30%) malignant lymph nodes, endobronchial ultrasound-guided fine-needle aspiration was more sensitive and detected 29 (69%) malignant lymph nodes, compared with 15 (36%) detected by transbronchial needle aspiration (P=.003).
Compared with either method alone, the combination of transesophageal endoscopic and endobronchial ultrasound-guided fine-needle aspiration had a higher negative predictive value (97% [96/99]; 95% CI, 91%-99%) and higher estimated sensitivity (93% [39/42]; 95% CI, 81%-99%) for detecting lymph nodes, the researchers wrote. The combination also had higher sensitivity and higher negative predictive value for detecing lymph nodes in any mediastinal location, and for patients without lymph node enlargement on chest CT. – by Stacey L. Adams
JAMA. 2008;299:540-546.
This is a good set of techniques and a good group of people analyzing them. Certainly we need to be very careful about staging, and we do not always do that as diligently as we should, so I very much agree with all of those points. This study highlights that there is a broader awareness about the importance of appropriate preoperative staging of patients. It emphasizes the fact that there are a number of new tools available to help us stage better and these tools work pretty well.
One of the unique aspects of this study is that they were able to use several tools simultaneously and that is a neat combination; however, logistically it is a bit difficult. They had a pulmonologist do the two interventions—the transbronchial needle and the endobronchial ultrasound-guided fine-needle aspiration—and then immediately after that they had a gastroenterologist do the transesophageal endoscopic ultrasound-guided fine-needle aspiration. For this to work you would need a pulmonologist to be right there and right after that a gastroenterologist, which requires some logistical coordination. While the combination is great, the logistical issues are a bit difficult. And I think that is going to be one of the limitations to this combination. We need to figure out how we can combine this better—perhaps we will need to have people that are trained in both techniques so that two people are not required to be in the same place at the same time. Whatever the answer may be, we need to find a way to improve the combination.
– Frank C. Detterbeck, MD, FACS
Surgical Director of thoracic oncology at Yale Cancer Center