The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma

Flexible bronchoscopy

Although bronchoscopy technology continues to evolve at a fairly rapid pace, basic procedures, such as bronchoalveolar lavage, transbronchial lung biopsy, and transbronchial needle aspiration, continue to play a paramount role in the diagnosis of bronchopulmonary diseases. Pulmonologists should be trained in these basic bronchoscopic procedures.

Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.

METHODS

Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

RESULTS

The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.

CONCLUSIONS

Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.

Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions < 2 or > 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.

Newer modalities in the work-up of peripheral pulmonary nodules

Technological advances in recent years have translated into the availability of newer modalities to establish the cause of peripheral pulmonary nodules (PPN). Even though the verdict is still out on the ideal diagnostic modality, there is no doubt that the bronchoscope is becoming a popular tool in the armamentarium of physicians who deal with PPN. This article focuses on newer bronchoscopic modalities being studied for the work-up of PPN. The authors also summarize the value of established diagnostic modalities to provide a balanced perspective.

Diagnostic workup of lung cancer

Lung cancer is the most frequent cause of mortality worldwide. According to recent estimates, 222,520 new cases of lung cancer (non-small cell and small cell combined) were diagnosed and 157,300 lung cancer-related deaths occurred in 2010 in the United States alone. The two major histologic types of lung cancer are small cell lung cancer and non-small cell lung cancer. The diagnosis and management of lung cancer requires a multidisciplinary approach.

Significance of the presence of lymphocytes in the cytological analysis of transbronchial needle aspiration

AIM

To evaluate the clinical relevance of the presence of lymphocytes in transbronchial needle aspiration (TBNA) samples from pathological mediastinal lymph nodes in patients with suspected lung cancer.

METHODS

Retrospective observational study evaluating the negative predictive value (NPV) of TBNA samples containing lymphocytes but not malignant cells.

RESULTS

A total of 266 TBNA were performed in 252 patients with pathological lymph nodes. One hundred and fifteen TBNA samples had evidence of malignant cells (43%), and 94 (35%) samples were considered as inadequate (absence of adequate cytological material or exclusive presence of bronchial epithelial cells). Out of the 57 TBNA samples remaining (21%), 15 could not be confirmed; in 32, TBNA samples were confirmed with alternative diagnostic techniques and in 10, they were confirmed after clinical and radiological follow-up. The NPV of the 32 samples that were confirmed with alternative diagnostic techniques was 84% decreasing down to 76% when the 10 TBNA samples confirmed after clinical and radiological follow-up were included.

CONCLUSIONS

The presence of lymphocytes in the TBNA sample does not exclude the neoplasic invasion of the specific lymph node analyzed.

Flexible bronchoscopy and its role in the staging of non-small cell lung cancer

Technologic advances in bronchoscopy continue to improve the ability to perform minimally invasive, accurate evaluations of the tracheobronchial tree and to perform an ever-increasing array of diagnostic, staging, therapeutic, and palliative interventions. The role of both old and new diagnostic bronchoscopy will continue to evolve as further improvements are made in bronchoscopes, accessory equipment, and imaging technologies. The major challenge is the adoption of the many new bronchoscopic techniques into routine clinical practice. There is a need for well-designed studies to delineate the appropriate use of these interventions and to better define their limitations and cost effectiveness.

Economic analysis of combined endoscopic and endobronchial ultrasound in the evaluation of patients with suspected non-small cell lung cancer

Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis ($18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA ($18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was <32.9%, as would occur in a patient without abnormal lymph nodes on computed tomography (CT). While EUS FNA combined with EBUS FNA was the most economical approach, if the rate of nodal metastases was higher, as would be the case in patients with abnormal lymph nodes on CT. Both of these strategies were less costly than bronchoscopy or mediastinoscopy. The pre-test probability of nodal metastases can determine the most cost-effective testing strategy for evaluation of a patient with NSCLC. Pre-procedure CT may be helpful in assessing probability of mediastinal nodal metastases.

Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

BACKGROUND

The treatment of non-small cell lung cancer (NSCLC) is determined by accurate definition of the stage. If there are no distant metastases, the status of the mediastinal lymph nodes is critical. Although imaging studies can provide some guidance, in many situations invasive staging is necessary. Many different complementary techniques are available.

METHODS

The current guidelines and medical literature that are applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee of the American College of Chest Physicians.

RESULTS

Performance characteristics of invasive staging interventions are defined. However, a direct comparison of these results is not warranted because the patients selected for these procedures have been different. It is crucial to define patient groups, and to define the need for an invasive test and selection of the best test based on this.

CONCLUSIONS

In patients with extensive mediastinal infiltration, invasive staging is not needed. In patients with discrete node enlargement, staging by CT or positron emission tomography (PET) scanning is not sufficiently accurate. The sensitivity of various techniques is similar in this setting, although the false-negative (FN) rate of needle techniques is higher than that for mediastinoscopy. In patients with a stage II or a central tumor, invasive staging of the mediastinal nodes is necessary. Mediastinoscopy is generally preferable because of the higher FN rates of needle techniques in the setting of normal-sized lymph nodes. Patients with a peripheral clinical stage I NSCLC do not usually need invasive confirmation of mediastinal nodes unless a PET scan finding is positive in the nodes. The staging of patients with left upper lobe tumors should include an assessment of the aortopulmonary window lymph nodes.

Initial Diagnosis of Lung Cancer

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph finding or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer [SCLC] or non-SCLC [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient.

OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on the initial diagnosis of lung cancer, a systematic search of MEDLINE, Healthstar, and Cochrane Library databases to July 2004, and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspiration (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the lung cancer panel prior to approval by the Thoracic Oncology Network, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physician.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer with a pooled sensitivity rate of 0.66 and specificity rate of 0.99. However, the sensitivity of sputum cytology varies by location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of flexible bronchoscopy (FB) for diagnosing lung cancer is 0.88. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions smaller or larger than 2 cm in diameter showed a sensitivity of 0.34 and 0.63, respectively. In recent years, endobronchial ultrasound (EBUS) has shown potential in increasing the diagnostic yield of FB while dealing with peripheral lesions without adding to the risk of the procedure. In appropriate situations, its use can be considered before moving on to more invasive tests. The pooled sensitivity for TTNA for the diagnosis of lung cancer is 0.90. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. The accuracy in differentiating between SCLC and NSCLC cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive rate and FN rate were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for the detection of endobronchial disease and poor for peripheral lesions < 2 cm in diameter. Detection of the latter can be aided with the use of EBUS in the appropriate clinical setting. The sensitivity of TTNA is excellent for malignant disease. The distinction between SCLC and NSCLC by cytology appears to be accurate.

Efficacy and Safety of the eXcelon Transbronchial Aspiration Needle in Mediastinal Lymph Node Enlargement: A Case-Control Study

BACKGROUND

Several different types of needles for transbronchial needle aspiration (TBNA) exist in the market. Recently, the eXcelon transbronchial needle (Boston Scientific, Boston, Mass., USA) was commercialized, and to our knowledge, no comparative studies with other types of needles have been performed up to date.

OBJECTIVES

The aim of the present study was to determine the diagnostic yield and safety of the 21-gauge eXcelon transbronchial needle in the diagnosis of mediastinal lesions and to compare it with a 22-gauge Wang cytology needle (Bard-Wang, Billerica, Mass., USA).

METHODS

A case-control prospective study was conducted. The study group included 42 TBNA of mediastinal nodes performed in 35 patients with the eXcelon 21-gauge needle from January to June 2005. A control group included 110 TBNA carried out in 99 patients that underwent mediastinal lymph node sampling using a MW-122 needle from June 2002 to December 2004.

RESULTS

There was no statistical differentiation in the characteristics of the disease, mediastinal lymph nodes or number of passes between cases and controls. Adequate samples were obtained in 30 (71.4%) cases and 81 (73.6%) controls (p = 0.8). Technical complications occurred in 7 (16.6%) cases and 14 (12.7%) controls (p = 0.7). The only clinical complication was bleeding presented in 2 (4.8%) cases and 3 (2.7%) controls (p = 0.3).

CONCLUSION

The eXcelon 21-gauge transbronchial needle is as effective and safe as the MW-122 needle in the diagnosis of mediastinal lymph node enlargement.

Transbronchial Needle Aspiration of Diseased Mediastinal Lymph Nodes: Predictors of Positive Findings

OBJECTIVE

To assess the factors that may determine the effectiveness of transbronchial needle aspiration through a flexible bronchoscope in the diagnosis of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors.

METHODS

Prospective study carried out at 2 hospitals between 1998 and 2004 that included all transbronchial needle aspirations performed on patients who had diseased mediastinal lymph nodes larger than 10 mm and nonlymphoid neoplasms. Univariate and multivariate analysis of the diagnostic results of transbronchial needle aspiration were performed according to the type and location of the primary neoplasm and the lymph node station biopsied, the diameter of the affected node, endoscopic findings, and the results of other bronchoscopic techniques.

RESULTS

The study evaluated the transbronchial needle aspiration of 230 lymph node stations in 207 patients. Histologic examination revealed 151 cases (72.9%) of non-small cell lung cancer, 42 cases (20.3%) of small cell lung cancer, and 14 cases (6.8%) of extrapulmonary cancer. The best predictors of obtaining a diagnostic sample were a diameter of the diseased node greater than 20 mm in diameter (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.2-4.7; P=.01) and a histologic diagnosis of small cell lung cancer (OR, 2.7; 95% CI, 0.9-8.2; P=.07).

CONCLUSIONS

The size of the diseased node and the tumor type are the best predictors of obtaining a diagnostic sample with transbronchial needle aspiration of diseased mediastinal lymph nodes in patients with lung or extrapulmonary tumors.

Analysis of Subcarinal Lymph Nodes in (Suspected) Non-Small-Cell Lung Cancer after a Negative Transbronchial Needle Aspiration – What’s Next?

BACKGROUND

Transbronchial needle aspiration (TBNA) of subcarinal lymph nodes (LN) has a variable yield. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has demonstrated a high accuracy in the analysis of enlarged subcarinal LN.

OBJECTIVE

To assess the diagnostic accuracy of EUS-FNA in the analysis of enlarged subcarinal LN previously staged tumor negative by TBNA.

METHODS AND PATIENTS

In this retrospective study, we included all patients with (suspected) lung cancer and enlarged (>1 cm on CT) subcarinal LNs staged tumor negative by TBNA, who were subsequently staged by EUS-FNA. In addition, surgical-pathological information had to be available in those cases in which EUS-FNA was tumor negative.

RESULTS

Subcarinal LN metastases were assessed by EUS-FNA in 10 of 14 patients (71%). In 1 patient granulomas without necrosis were found. The remaining 3 patients staged tumor negative by both TBNA and EUS-FNA had reactive LN tissue, which was confirmed by surgical-pathological staging. Sensitivity, specificity and diagnostic accuracy of EUS in analyzing TBNA-negative LNs was 100% in all.

CONCLUSIONS

In patients with (suspected) lung cancer and enlarged subcarinal LNs staged tumor negative by TBNA, additional staging by EUS-FNA confirmed subcarinal LN metastasis in 71% of the patients. These data suggest that for the analysis of the subcarinal LNs the real-time controlled technique of EUS-FNA is superior to the 'blind' technique of TBNA.

Invasive staging of non-small cell lung cancer: a review of the current evidence

STUDY OBJECTIVES

To determine the test performance characteristics of transbronchial needle aspiration (TBNA), transthoracic needle aspiration (TTNA), endoscopic ultrasound-guided needle aspiration (EUS-NA), and mediastinoscopy in staging non-small cell lung cancer (NSCLC).

DESIGN, SETTING, AND PARTICIPANTS

Systematic search of MEDLINE, HealthStar, and Cochrane Library databases to July 2001 and print bibliographies. Included were studies comparing staging results of TBNA, TTNA, EUS-NA, or mediastinoscopy against either tissue histologic confirmation or long-term clinical follow-up (> or = 1 year). Patients included were those with NSCLC or small cell lung cancer.

MEASUREMENT AND RESULTS

For patients with lung cancer, the pooled sensitivity for TBNA was 0.76, the pooled specificity was 0.96, and the negative predictive value (NPV) was 0.71. For TTNA, the pooled sensitivity was 0.91, with an NPV of 0.78. EUS-NA had a pooled sensitivity of 0.88, a pooled specificity of 0.91, and an NPV of 0.77. For standard cervical mediastinoscopy, the pooled sensitivity was 0.81, with an NPV of 0.91. The addition of either extended cervical mediastinoscopy or anterior mediastinotomy to standard cervical mediastinoscopy appeared to improve the sensitivity of any of the procedures alone.

CONCLUSIONS

Invasive clinical staging of NSCLC can be performed effectively by TBNA, TTNA, EUS-NA, or mediastinoscopy. Selection of the appropriate study is dependent on the degree of suspicion for metastatic disease, the patient's comorbid illnesses, and the availability and performance characteristics of procedural options.

Performance characteristics of different modalities for diagnosis of suspected lung cancer: summary of published evidence

STUDY OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

A systematic search of MEDLINE, HealthStar, and Cochrane Library databases to July 2001 and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspirate (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer.

MEASUREMENT AND RESULTS

For sputum cytology, the pooled specificity was 0.99 and the pooled sensitivity was 0.66, but sensitivity was higher for central lesions than for peripheral lesions (0.71 vs 0.49, respectively). Studies on bronchoscopic procedures provided data only on diagnostic yield (sensitivity). The diagnosis of endobronchial disease by bronchoscopy in 30 studies showed the highest sensitivity for endobronchial biopsy (0.74), followed by cytobrushing (0.59) and washing (0.48). The sensitivity for all modalities combined was 0.88. Thirty studies reported on peripheral lesions. Cytobrushing demonstrated the highest sensitivity (0.52), followed by transbronchial biopsy (0.46) and BAL/washing (0.43). The overall sensitivity for all modalities was 0.69. Peripheral lesions < 2 cm or > 2 cm in diameter showed sensitivities of 0.33 and 0.62, respectively. Updating a previous meta-analysis with 19 studies revealed a pooled sensitivity of 0.90 for TTNA. A trend toward lower sensitivity was noted for lesions that were < 2 cm in diameter. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive and false-negative rates were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions that are < 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease. The distinction between small cell lung cancer and non-small cell lung cancer by cytology appears to be accurate.

Diagnosis of lung cancer: the guidelines

Lung cancer is usually suspected in individuals who have abnormal chest radiograph findings or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer or non-small cell lung cancer), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. Achieving a diagnosis and staging are usually done in concert because the most efficient way to make a diagnosis often is dictated by the stage of the cancer. The best sequence of studies and interventions in a particular patient involves careful judgment of the probable reliability of a number of presumptive diagnostic issues, so as to maximize the sensitivity and to avoid performing multiple or unnecessary invasive procedures. In this article, we consider all manner of clinical presentations of lung cancer in light of currently available diagnostic procedures. Published data supporting a particular diagnostic approach is weighed based on the quality of the benefit as well as the estimated net benefit. Recommendations are graded in terms of strength to provide clinicians with guidance as to the most efficient and approach to the diagnosis of lung cancer in individual patients.

Transbronchial needle aspiration in diagnosing and staging lung cancer: how many aspirates are needed?

Transbronchial needle aspiration has emerged as a key technique for sampling mediastinal adenopathy but variable yields are reported. To determine the number of aspirates needed to optimize yield, we prospectively studied transbronchial needle aspiration and the sequential effect of each successive specimen on diagnostic yield in 79 patients with known or suspected lung carcinoma and mediastinal adenopathy. A total of 451 aspirates were performed in 79 patients (mean, 5.7 aspirates per patient; range, 2-13) with 45 cases (57%) positive for malignancy. A cytologically positive transbronchial needle aspiration occurred with the first aspirate in 42% of patients in whom this procedure established mediastinal nodal involvement. All positive results were achieved with seven or fewer aspirates. Similar yields were obtained for small cell and non-small cell lung cancer after seven aspirates. Rapid on-site specimen cytologic evaluation was used in 55 of 79 cases (70%), with a positive diagnosis obtained in 39 of 55 cases (71%) with on-site evaluation compared with six of 24 cases (25%) performed without on-site evaluation. The data suggest there is a plateau in yield after seven transbronchial needle aspirates, which may be sufficient to obtain an optimal yield in assessing patients with lung cancer and mediastinal adenopathy.

Lung cancer staging

Accurate staging of lung cancer is essential for proper treatment and management of the disease, and allows predictions for patient survival. Several different invasive and noninvasive modalities exist for staging, and the determination of the best approach of one or a combination of those methods depends on the clinical situation and the clinician's assessment of the most appropriate means of staging evaluation. This review discusses the elements and framework of lung cancer staging, with particular emphasis on those newer modalities, especially positron emission tomography and endoscopic ultrasound needle biopsy, which will be expected to be used increasingly more common in clinical practice.

Bronchoscopy and needle biopsy techniques for diagnosis and staging of lung cancer

Lung cancer is the leading cause of cancer deaths in the United States. The individual therapeutic approach and prognosis depends on accurate diagnosis and staging. Flexible bronchoscopy (FB) and transthoracic needle biopsy (TNB) are the most widely used techniques for this purpose. This article provides a critical overview of indications, diagnostic yield, and limitations of bronchoscopy and TNB in the diagnosis of lung cancer.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy

OBJECTIVE

To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC).

METHODS

A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT).

RESULTS

The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not.

CONCLUSIONS

Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.

Role of fiberscopic transbronchial needle aspiration in the staging of N2 disease due to non-small cell lung cancer

BACKGROUND

Transbronchoscopic needle aspiration (TBNA) can offer a unique opportunity to identify surgically unresectable lung cancer and to avoid surgical mediastinal exploration in many patients with mediastinal lymph node extension of the tumor. The aim of this study was to assess the yield of TBNA performed with either histology or cytology needles in mediastinal staging of N2 disease due to non-small cell lung cancer (NSCLC).

METHODS

Retrospective chart review was carried out on 194 TBNA procedures performed between January 1997 and September 2000 at a single institution. Inclusion criteria were pathologic evidence of NSCLC; contrast enhancement computed tomography scan of the chest suggesting N2 disease; and negative bronchoscopic examination for possible neoplastic lesions at the site of

RESULTS

Overall sensitivity and diagnostic accuracy were 71% and 73%, respectively, with no significant differences between 19-gauge and 22-gauge cytology needles. Procedures performed for right paratracheal and subcarinal lymph node stations had a significantly higher yield than those for the left paratracheal station.

CONCLUSIONS

TBNA mediastinal staging, performed during the initial diagnostic evaluation of NSCLC, can spare costs and risks of more invasive procedures in patients with inoperable tumors, in patients who are not candidates for operation because of coexistent significant comorbidities, and in patients with N2 disease.

Current status of diagnostic and therapeutic endoscopic ultrasonography

Endoscopic ultrasonography is firmly established as an imaging modality that can be used for diagnosing and staging both malignant and nonmalignant disorders of the pancreas, gastrointestinal tract, biliary tree, and mediastinum. In the future, as more physicians are trained and as technologic developments continue to advance, endosonography will likely assume a greater role in therapeutic management.

Lung Cancer: A Bronchoscopic Approach

The unfavourable epidemiological data of lung cancer has not been changed during the past ten years. The only possibility to cure this malignancy is surgical resection. The five year survival rate after surgery is highly dependent on early discovery of the tumor. Today, bronchoscopy plays a central role in the diagnosis staging and therapy of lung cancer. The main indications of diagnostic bronchoscopy are the identification of the tumor and the determination of its extent. The aim of therapeutic bronchoscopy - laser photocoagulation, high dose rate afterloading irradiation and stent implantation - is to provide an acceptable quality of life and to manage symptoms such as bleeding, cough and dyspnea.

Mediastinal lymphadenopathy: diagnostic yield of transbronchial mediastinal lymph node biopsy with CT fluoroscopic guidance-initial experience

PURPOSE

To determine whether the use of computed tomographic (CT) fluoroscopy to guide transbronchial needle aspiration (TBNA) of mediastinal lymph nodes can improve the diagnostic yield.

MATERIALS AND METHODS

CT fluoroscopy was used to guide TBNA in 12 consecutive patients with mediastinal lymphadenopathy who had previously undergone nondiagnostic conventional TBNA. CT fluoroscopy was used to confirm the location of the biopsy needle by using a "quick-check" technique (ie, fluoroscopy was performed sparingly after needle insertion). The location of each needle, the total procedural and fluoroscopic times, and any complications were recorded.

RESULTS

All CT fluoroscopic procedures were performed in less than 1 hour, and a tissue diagnosis was established in all patients. Eighteen lymph nodes with a diameter of 0.8-2.4 cm were sampled with 116 needle passes. CT fluoroscopy documented inadequate positioning in 48 of the 116 (41.3%) needle passes. Eighteen (15.5%) needles did not fully penetrate the tracheobronchial tree. Six needles (5.2%) were placed into the great vessels. Malignant disease was diagnosed in nine patients, and benign disease was diagnosed in three. The mean fluoroscopic exposure time was 20.5 seconds +/- 12.7. No pneumothoraces or substantial hemorrhage were observed.

CONCLUSION

CT fluoroscopic guidance for TBNA procedures is a safe and efficient means of providing diagnostic material and should be considered for patients who have previously undergone nondiagnostic blinded TBNA.

CT fluoroscopy for thoracic interventional procedures

In the past several years, CT fluoroscopy has proved a valuable new technique in guiding the performance of intrathoracic procedures. Several approaches to using CT fluoroscopy are discussed. We have found an interrupted, real-time technique optimal to facilitate biopsy of percutaneous lung nodules, particularly small lesions. The technique is also valuable in assisting thoracic drainage procedures. This article also discusses the use of CT fluoroscopy to guide transbronchial needle aspiration, which is another potentially important application.

Transbronchial needle aspiration. An underused diagnostic technique

Despite its proven usefulness, TBNA is not widely used. An American College of Chest Physicians (ACCP) survey showed that only 11.8% of pulmonologists use TBNA. Most pulmonologists in the 1980s were not formally trained in TBNA. This lack of training has unfortunately translated to minimal emphasis on TBNA in current training programs in a large number of institutions. Technical problems with the procedure (faulty site selection, incomplete needle penetration, catheter kinking that prevents adequate suction, etc.), the confusing array of needles, low diagnostic yields, unproven concerns regarding the safety of the procedure, inadequate cytopathology support, and bronchoscopic damage have all perpetuated the image of limited usefulness for this procedure. Limitations to the practice of TBNA are: Lack of training during fellowship Technical inadequacies Lack of cytopathologists trained in TBNA interpretation Fear of bronchoscope damage Safety issues Failure to reproduce published successes Reservations regarding usefulness of TBNA results Hands-on experience with TBNA, developing familiarity and expertise with only a few needles, and paying careful attention to anatomy, procedure techniques, and specimen acquisition may all help to increase yield. The following lists how better results can be obtained with TBNA: Preprocedure Review TBNA instruction tapes Attend hands-on courses Practice with lung models Review patient's CAT scans Familiarize with one-two cytology and histology needle Obtain a trained assistant Procedural Identify target site Needle to airway angle at least greater than 45 degrees Insert entire length of the needle Use scope channel to support the catheter Release suction before withdrawing needle (for staging) Specimen acquisition Avoid delay in preparing slides Adequate sampling (at least two) Use smear method for cytology specimen Analyze all samples flush solutions cell block Postprocedure Find an experienced cytopathologist Review your procedure (by watching video) Review pathology slides Acquisition of skills with cytology needles should precede the use of the histology needle. Increasing education and experience can also increase diagnostic yields. Transbronchial needle aspiration has been proven to be accurate in staging lung cancers, identifying inoperable carcinomas, and diagnosing a variety of lung diseases. Few complications have been encountered and the technique is less invasive and less costly than surgical procedures. Drawing on evidence from published literature, we suggest the following guidelines for TBNA: All patients presenting with mediastinal or hilar adenopathy or both, should have 22-ga and/or 19-ga TBNA as the initial procedure. These procedures would help diagnose malignant and nonmalignant diseases, and stage lung cancers. All patients with evidence of submucosal and peribronchial disease should have 22-ga needle cytology sampling. In patients with visible endobronchial disease, 22-ga TBNA should be optional. In the presence of a necrotic or a hemorrhagic tumor, or in a patient with a bleeding diathesis, TBNA would be helpful. In all patients with Type III and IV peripheral nodules, TBNA should be the initial diagnostic procedure. There remains no doubt about the diagnostic usefulness of TBNA. Guidelines must be developed to ensure that pulmonary fellows are adequately trained in this procedure. Regional workshops with hands-on experience targeted to practicing pulmonologists organized by the ACCP would help popularize the procedure. Initial low yields should not discourage pulmonologists from using the procedure. Collaboration between thoracic surgeons, oncologists, and pulmonary physicians is essential to set up TBNA programs within institutions. With time, as more and more pulmonologists attain expertise in TBNA, the full potential of this nonsurgical, cost-effective, and safe procedure will be realized.

Methodologic standards for diagnostic test research in pulmonary medicine

STUDY OBJECTIVES

To determine conformance with methodologic standards in the evaluation of diagnostic tests.

DATA SOURCES

MEDLINE database search (1992 to 1997) of nine prominent general medicine and six subspecialty journals for articles that report discriminative properties of diagnostic tests in pulmonary medicine.

STUDY SELECTION

Articles were eligible if they reported discriminative properties of diagnostic tests in humans, diagnostic tests were intended for the detection of existing conditions, and the target disorder was relevant to pulmonary medicine.

DATA EXTRACTION

Each study was critically reviewed independently by two observers.

DATA SYNTHESIS

Of the 1,029 retrieved articles, 41 met study inclusion criteria. The median number of the 12 major standards for design fulfilled by study articles was 6 (range, 1 to 12, 25th to 75th percentile, 5.0 to 8.5) and only 2 articles fulfilled all 12 standards. Seven (17%) articles did not report any standard measures of diagnostic accuracy and 7 (17%) provided data only for sensitivity and specificity. Only 4 of 17 articles (24%) that compared different tests used standard statistical methods.

CONCLUSION

These results indicate that greater methodologic rigor is needed for studies that evaluate diagnostic tests in pulmonary medicine. Existing deficiencies in methodology risk the introduction of invalid tests into clinical practice.

Transbronchial needle aspiration (TBNA) in patients infected with HIV

Transbronchial needle aspiration (TBNA) of intrathoracic lymph nodes has been shown to be useful in the diagnosis and staging of bronchogenic carcinoma. With the exception of sarcoidosis, the usefulness of TBNA has not been widely investigated in other clinical settings. We investigated the utility of TBNA with a 19-gauge histology needle in HIV-infected patients with mediastinal and hilar adenopathy at Bellevue Hospital Center. We performed 44 procedures in 41 patients. Adequate lymph node sampling was obtained in 35 of 44 (80%), and diagnostic material was obtained in 23 of 44 (52%) procedures. TBNA was the exclusive means of diagnosis in 13 of 41 (32%) patients. Of the 44 procedures, 23 (52%) were performed in patients with mycobacterial disease, with TBNA providing the diagnosis in 20 of 23 (87%). In these patients, positive TBNA specimens included smears of aspirated materials for acid-fast bacilli in 11, mycobacterial culture in 14, and histology in 15. In other diseases, TBNA diagnosed sarcoidosis with noncaseating granulomata in 2 of 4 patients and non-small cell lung cancer in 1 of 2 patients. TBNA was not helpful in other diseases including Pneumocystis carinii pneumonia, infection with Cryptococcus or Nocardia, bacterial pneumonia, viral pneumonia, and Kaposi's sarcoma. No pulmonary diagnosis was established in five patients. No complications of TBNA occurred. We conclude that TBNA through the flexible bronchoscope is safe and effective in the diagnosis of intrathoracic adenopathy in HIV-infected patients, and is particularly efficacious in the diagnosis of mycobacterial disease. Furthermore, TBNA may provide the only diagnostic specimen in almost one-third of HIV-infected patients, thereby sparing these patients more invasive procedures such as mediastinoscopy.

[Usefulness of transbronchial punction and mediastinoscopy in mediastinal nodal staging of non-microcytic bronchogenic carcinoma. Preliminary study]

Preliminary study to compare the sensitivity and specificity of transbronchial needle aspiration (TBNA) and mediastinoscopy/anterior mediastinotomy (MED/AMED) and/or thoracotomy for staging of mediastinal nodes in non-small cell carcinoma. To determine the sensitivity and specificity of computerized tomography (CT) as a screening technique. Thirty-three patients with non-small cell carcinoma but no remote metastasis and good lung function were evaluated. A chest CT scan was performed before bronchoscopy in 27 patients and before surgery in the others. Nodular areas considered diseased based on CT images were staged by TBNA. When CT images were not available before bronchoscopy. TBNA for staging was performed in the subcarinal region. Results by TBNA were compared with those obtained by MED/AMED and/or thoracotomy. The prevalence of metastatic nodular disease was 47%. CT detected enlarged mediastinal nodes in 24 patients; the images were considered normal in 9 patients. Sensitivity and specificity of CT was 93% and 54%, respectively, with a positive predictive value (PPV) of 68% and negative predictive value (NPV) of 87.5%. The sensitivity and specificity of MED/AMED were 73% and 100%, respectively; PPV was 100% and NPV was 75%. The sensitivity and specificity of TBNA were 36% and 92%, respectively; PPV was 83% and NPV was 57%. The pneumothorax with pleural empyema suffered by one patient after MED could have been avoided, given that the earlier TBNA was positive. TBNA is a safe, useful technique for staging nodes in non-small cell carcinoma. Although the sensitivity of TBNA is lower than that of MED, regions that are difficult to reach with the latter technique can be sampled by TBNA. Furthermore, MED can be rendered unnecessary by positive TBNA results. CT imaging of the chest is sensitive but its specificity is low for detecting ganglial metastasis.

Thoracic nodal staging with PET imaging with 18FDG in patients with bronchogenic carcinoma

PURPOSE

To assess the role of positron emission tomographic (PET) imaging with 18-fluoro-2-deoxyglucose (18FDG) in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma.

MATERIALS AND METHODS

Over a 2-year period, any patient presenting to our institution with newly diagnosed bronchogenic carcinoma who was to have thoracic nodes sampled was considered eligible. All PET studies were performed prior to nodal sampling and areas of increased uptake were mapped according to the American Thoracic Society classification. Studies were correlated with CT and pathology. Sensitivity and specificity for predicting nodal metastases was calculated.

RESULTS

Forty-two patients had 62 nodal stations (40 hilar/lobar, 22 mediastinal) sampled. The sensitivity and specificity for hilar/lobar lymph node station metastases using PET imaging was 73% and 76%, respectively. With CT, the sensitivity and specificity were 27% and 86%. The sensitivity and specificity using PET imaging for mediastinal node station metastases was 92% and 100%, respectively, while with CT the figures were 58% and 80%. The sensitivity and specificity for combined thoracic nodal station metastases using PET imaging was 83% and 82%, respectively, while with CT it was 43% and 85%. There was a strong statistical relationship between positive PET imaging and lymph node abnormalities.

CONCLUSIONS

18FDG-PET imaging is accurate in detecting thoracic lymph node metastases in patients with bronchogenic carcinoma. Normal results of PET studies virtually preclude the need for mediastinal nodal sampling prior to surgery, whereas abnormal results of studies most likely represent mediastinal metastases. Treatment can be based on the extent of disease suggested by PET imaging.

Diagnosis and staging of bronchogenic carcinoma by transtracheal and transbronchial needle aspiration

Transbronchial needle aspiration (TBNA) has been used in diagnosis and staging of bronchogenic carcinoma. However, its true effectiveness seems uncertain and some models of needles are expensive. The aim of this study was to procure new experiences on this method. TBNA was performed in 194 patients with bronchogenic carcinomas. Two models of cheap, re-usable, cytological needles were used. In diagnostic application, TBNA was positive in 34 of 39 (87%) central tumors and in 31 of 45 (69%) peripheral nodules or masses. In 19 patients, TBNA was the only positive sample. In staging application, TBNA was positive in 41 of the 90 cases (46%) in which the spread of the tumor compressed the wall of the airway. When the trachea or bronchus was endoscopically normal at the site of the puncture, TBNA was only positive in 3 of 20 cases (15%). These results suggest that TBNA is effective as a diagnostic tool. However, it appears to be less effective in staging, where the attainment of a good yield with TBNA probably demands a positive computed tomography and the use of a histological needle.