Mediastinal lymph node staging with transesophageal echography in cancer of the lung

Peripheral pulmonary diseases: evaluation with endobronchial US initial experience

Endobronchial ultrasonography (US) with 4.5-F small-caliber US probes, combined with bronchoalveolar lavage technique, was evaluated in autopsied lungs and 22 patients with various pulmonary interstitial or alveolar diseases. Several different echoic patterns were found that may reflect changes due to pathologic alteration of lung parenchyma. This technique may have potential for evaluation and diagnosis of peripheral lung diseases.

The preoperative study of mediastinal lymph nodes metastasis in lung cancer by endoscopic ultrasonography (EUS) and helical computed tomography (CT)

OBJECTIVE

Accurate staging of mediastinal lymph nodes in patients with lung cancer is fundamental for their treatment and prognosis. The aim of this study was to compare the value of EUS and CT staging in patients with non-small-cell lung cancer (NSCLC) with postsurgical stage.

METHODS

Ninety two patients with NSCLC underwent EUS and CT for preoperative detection of metastases to the mediastinal lymph nodes. EUS examinations were done with the ultrasonic linear array scanning echoendoscope (FG 32 UA, Hitachi/Pentax), CT-Toshiba Exvision GX scanner, with 24-s spiral acquisition, pitch 1:1 (7 mm collimation, 4 mm reconstruction index), during i.v. administration of non-ionic iodinated contrast media.

RESULTS

The frequency of mediastinal involvement was 22.7%. The regions most accessible by EUS evaluation were subaortic, subcarinal and paraoesophageal lymph nodes. On a per-patient basis, EUS and CT results were: sensitivity 70.0 and 60.0%, specificity 80.6 and 72.6%, accuracy 77.2 and 68.5%. On a per-sites basis, the sensitivity of EUS evaluation was 78.8%, specificity 89.9%, accuracy 87.7%, comparing with CT-63.6, 84.0, 79.9%, respectively. When the EUS and CT images were analysed in combination, the sensitivity increased to 86.4%.

CONCLUSION

We believe that EUS and CT should be used together for preoperative non-invasive staging of mediastinal lymph nodes in patients with NSCLC.

Thoraxsonography--Part II: Peripheral pulmonary consolidation

In many cases of pulmonary diseases extending up to the pleura, ultrasound (US) helps to identify the etiology of the lesion. There are several sonomorphological criteria to differentiate peripheral pulmonary consolidations. Pneumonic infiltration shows a hypoechoic inhomogeneous echo texture, with multiple air inlets and bronchoaerograms. Fluid bronchogram indicates an obstructive pneumonitis. Pulmonary infarctions are visible in different stages as triangular pleural-based lesions in most cases of pulmonary embolism. The diagnostic accuracy of chest sonography in pulmonary embolism was 85%-90%. US-guided transthoracic biopsy shows a diagnostic yield of > 90% in malignancies and 50%-83% of benign lesions. The overall complication rate is very low: 1%-2% hemoptysis, 2%-4% pneumothoraces and 1%-2% requiring chest tube drainage. Color Doppler US can demonstrate the vascular patterns and may help in the understanding of underlying pathophysiology. Sonographic examinations of the upper and central mediastinum provide good results in 90-95% of cases. Some anatomical limitations of transcutaneous US can be circumvented by endoluminal US.

Is it possible to differentiate malignant mediastinal nodes from benign nodes by size? Reevaluation by CT, transesophageal echocardiography, and nodal specimen

STUDY OBJECTIVE

To reevaluate whether it is possible to reliably differentiate malignant mediastinal lymph nodes from benign nodes by size, and to determine the frequency of metastases to normal-sized mediastinal lymph nodes that directly affects the sensitivity for detecting malignant mediastinal lymph nodes (N2 nodes) on CT.

DESIGN

Prospective study of patients with non-small cell lung cancer.

SETTING

Department of Radiology and First Department of Surgery, Yamaguchi University School of Medicine.

PATIENTS

We examined 40 patients with non-small cell lung cancer, who underwent thoracotomy because of operable stage (stage I, II, IIIA) in preoperative staging, using CT and transesophageal echocardiography (TEE).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Lymph nodes 10 mm or greater in short-axis diameter on CT and TEE were considered abnormal. Furthermore, lymph node size was measured by TEE and nodal specimens in long- and short-axis diameter in each patient. Two hundred eight mediastinal lymph nodes were dissected and N2 nodes were present in 28% of patients (11/40); in 7 of these 11 patients (64%), mediastinal lymph node metastases were misdiagnosed on CT because of normal-sized N2 nodes. Furthermore, in 73% of N2 nodes, nodal size was normal on TEE. There were no significant difference in both diameters between malignant mediastinal lymph nodes and benign nodes on TEE and nodal specimens.

CONCLUSIONS

It is not possible to reliably differentiate malignant mediastinal nodes from benign nodes by size alone, and we should be aware of high frequency of normal-sized N2 nodes in patients with operable stage of lung cancer.

Interobserver agreement in endoscopic ultrasonography staging of esophageal and cardia cancer

BACKGROUND

Endoscopic ultrasonography has been accepted as an accurate means of staging cardioesophageal cancer, but no study has focused on the variability of interobserver interpretation of images so obtained.

METHODS

We compared interpretations recorded by five independent observers in 46 cases examined by endoscopic ultrasonography. One observer then reviewed a subset of 28 examinations 6 months later.

RESULTS

Interpretations were in nearly full accord for uT0 and uT4 tumors (kappa = > or = 0.73), in good accord for uT1 and uT3 tumors (kappa = > or = 0.42), but in poor accord for uT2 tumors (kappa = 0.16). Agreement was generally good when pertaining to invasion of adjacent organs, but no agreement was noted for invasion of the pericardium. In assessment of lymph node involvement, agreement was good for intra-abdominal, subcarinal, right lower paratracheal, and paraesophageal nodes (kappa = > or = 0.49), but poor for left lower and upper paratracheal lymph nodes. Intraobserver agreement was excellent for extent of tumor infiltration (kappa = 0.91) and good for lymph nodes (kappa > or = 0.51).

CONCLUSIONS

In staging cardioesophageal cancer by endosonographic ultrasonography, improvement is needed in cases of uT2 tumors and of tumors invading the pericardium, and in assessment of lymph nodes in the upper mediastinum.

Preoperative and intraoperative ultrasonographic examination as an aid in lung cancer operations

To assess the extent of tumor invasion in lung cancer, my colleagues and I routinely use preoperative transesophageal ultrasonic endoscopy and intraoperative ultrasonography in addition to preoperative roentgenography, computed tomographic scanning, and other standard procedures. Both transesophageal ultrasonic endoscopy and intraoperative ultrasonography allow for a real-time assessment of the extent to which the lung cancer has invaded adjacent organs and are useful in determining the operability and safety margin of the involved organ or organs. We found intraoperative ultrasonography to be more accurate than transesophageal ultrasonic endoscopy, because intraoperative ultrasonography can be done at any time during the operation, as needed, and the probe can be directly applied to the desired location from a variety of angles. In contrast, when transesophageal ultrasonic endoscopy is used, the presence of air in the lung tissue can interfere with an accurate evaluation of some aspects of the tumor. Our results indicate that the sensitivity of transesophageal ultrasonic endoscopy and intraoperative ultrasonography is 68.4% and 100%, respectively, and the specificity is 81.3% for transesophageal ultrasonic endoscopy and 95.5% for intraoperative ultrasonography.

Transesophageal echocardiography in the evaluation of mediastinal masses

To assess the diagnostic impact of transesophageal echocardiography in the evaluation of mediastinal masses, 30 patients with mediastinal abnormalities detected by routine chest roentgenogram underwent transthoracic and transesophageal echocardiography. Subsequently, 29 of the patients underwent computed tomography and 16 underwent magnetic resonance imaging. The location and structure of the masses as well as their relationship to the surrounding structures were assessed. Anatomic confirmation and histopathologic diagnosis of the mediastinal masses by surgical resection and biopsy was available for all patients. Transesophageal echocardiography was more accurate than transthoracic echocardiography in detecting mediastinal masses (90% versus 73%), in identifying their structure (100% versus 90%), and in evaluating their relationship to contiguous organs (89% versus 81%). No complication was observed during the examinations. Computed tomography correctly diagnosed the location, structure, and relationships in all patients but one; magnetic resonance imaging correctly evaluated the mediastinal masses in all 16 patients. Our study suggests that transesophageal echocardiography is a valuable and safe complementary method of evaluating mediastinal masses. Moreover, this technique allows the obstruction of vessels and heart cavities, valve regurgitation, and right and left ventricular function to be easily assessed.

Panoramic transesophageal echocardiography. Clinical application of real-time, wide-angle, transesophageal two-dimensional echocardiography and color flow imaging

Panoramic transesophageal echocardiography is a new development in transesophageal echocardiography (TEE) technology, which yields a wide-angle imaging field for real-time two-dimensional and color flow imaging. We report our early experience in patients with the use of an annular-array TEE probe that provides a wide, 270 degrees angle imaging field for two-dimensional echocardiographic imaging. The field of view can, however, be narrowed to 15 degrees . The field of view for color flow imaging can be varied from 180 degrees to 10 degrees . Pulsed-Doppler recordings of flow velocity are also possible. This TEE system provides a panoramic vision of cardiac and paracardiac structures from the esophagus and stomach. Besides cardiovascular structures, other thoracic and upper abdominal organs can be visualized. The wide field of view allows a better comprehension of the cardiac anatomy and its relationship with adjacent structures. The initial experience suggests that this method, besides providing the usually required diagnostic information, may have a number of additional applications. Its clinical potential and directions for future developments are reviewed.