(Chest. 2002;122:1091-1093.)
© 2002
American College of Chest Physicians
Endoscopic Ultrasound/Fine-Needle Aspiration Diagnosis of a Malignant Subcarinal Lymph Node in a Patient With Lung Cancer and a Negative Positron Emission Tomography Scan*
Jana M. Rosenberg, MD;
Anthony Perricone, MD, FCCP and
Thomas J. Savides, MD
* From the Divisions of Gastroenterology (Drs. Rosenberg and Savides) and Cardiothoracic Surgery (Dr. Perricone), University of California San Diego, San Diego, CA.
Correspondence to: Thomas J. Savides, MD, UCSD Gastroenterology, (8413) 200 West Arbor Dr, San Diego, CA 92103-8413; e-mail: tsavides{at}ucsd.edu
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Abstract
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Transesophageal, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) and positron emission tomography (PET) scanning are new modalities for staging non-small cell lung cancer (NSCLC), the roles of which are still being defined. A 78-year-old man with a right lower lobe (RLL) mass and mediastinal adenopathy seen on CT scan had a PET scan that revealed only a RLL hypermetabolic area. EUS/FNA cytology of a subcarinal lymph node (LN) revealed the presence of NSCLC. This is a case of a false-negative PET scan for nodal involvement in NSCLC that was diagnosed with EUS/FNA. Patients with NSCLC and suspicious lymphadenopathy may benefit from EUS/FNA of enlarged posterior mediastinal LNs, even with negative findings of PET scanning.
Key Words: endosonography • fine-needle aspiration • mediastinal lymphadenopathy • non-small cell lung cancer • positron emission tomography
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Introduction
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Positron emission tomography (PET) scanning is being used increasingly in the preoperative staging of non-small cell lung cancer (NSCLC) because of a reported sensitivity and specificity of 95%.1
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3
Transesophageal, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has also been found recently to be very accurate in the cytologic diagnosis as well as the staging of NSCLC.4
5
We present the case of a patient with NSCLC and nodal metastases, which had been diagnosed by EUS/FNA of an enlarged subcarinal lymph node (LN), who had a false-negative PET scan finding for nodal disease.
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Case Report
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A 78-year-old man, who was a former cigarette smoker, presented to his primary care physician with worsening dyspnea on exertion. A chest CT scan revealed a 5-cm density with irregular margins involving the right lower lobe (RLL), a 1.5-cm right hilar LN, and two 1.0 to 1.5-cm subcarinal LNs (Fig 1
). An 18F-fluorodeoxyglucose PET scan revealed a heterogeneously hypermetabolic area in the right lower lung field, which is consistent with the mass seen in the same area on CT scan (Fig 2
). However, the PET scan did not show any focal hypermetabolic lesions in the mediastinum.
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Figure 2.. PET scan revealing a hypermetabolic area in the RLL, which is consistent with the 5-cm mass seen on a CT scan. Of note, there are no focal hypermetabolic areas found in the mediastinum.
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Because there was a high index of suspicion for malignant lymphadenopathy with the CT scan findings, the patient underwent a transesophageal EUS, which revealed a 19 mm x 7 mm subcarinal LN at 30 cm from the incisors (Fig 3
). Transesophageal EUS/FNA using a 22-gauge needle was performed, with cytology revealing NSCLC. Based on these EUS/FNA cytology findings, nonsurgical management was implemented.
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Discussion
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The false-negative rate for PET scans diagnosing malignant mediastinal LNs in patients with suspected or proven NSCLC and mediastinal lymphadenopathy has been reported to be 7 to 9%.1
2
False-negative findings have been thought to be due to a minimal foci of metastatic cells in the particular LN or an inability of the PET scan to distinguish between the centrally located, primary tumor and the adjacent mediastinal LNs.1
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3
In contrast, the reported false-negative rate for EUS/FNA of posterior mediastinal adenopathy is < 5%.4
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As expected, the false-negative rate with this technique tends to be higher with LNs < 10 mm in diameter, due to the smaller focus of malignant cells.5
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This report demonstrates a case in which transesophageal EUS/FNA was able to diagnose malignant posterior mediastinal LNs that had not been detected by PET scan. For mediastinal adenopathy, EUS/FNA has an advantage over PET scanning in that actual tissue sampling is performed, thereby providing both radiologic and cytologic diagnoses in one safe and effective procedure. Prospective studies are needed to compare the accuracy of PET scans vs EUS/FNA for the diagnosis of malignant posterior mediastinal LNs in patients with suspected or proven NSCLC. Until such head-to-head studies are completed, cytologic confirmation is still indicated for those mediastinal LNs that appear suspicious on CT scans, even after a negative finding on a PET scan.
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Footnotes
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Abbreviations: EUS = endoscopic ultrasound; FNA = fine-needle aspiration; LN = lymph node; NSCLC = non-small cell lung cancer; PET = positron emission tomography; RLL = right lower lobe
Received for publication December 14, 2001.
Accepted for publication January 28, 2002.
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References
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- Vansteenkiste, JF, Stroobants, SG, De Leyn, PR, et al (1997) Mediastinal lymph node staging with FDG-PET scan in patients with potentially operable non-small cell lung cancer: a prospective analysis of 50 cases. Chest 112,1480-1486[Abstract/Free Full Text]
- Gupta, NC, Tamim, WJ, Graeber, GG, et al Mediastinal lymph node sampling following positron emission tomography with fluorodeoxyglucose imaging in lung cancer staging. Chest 2001;120,521-527[Abstract/Free Full Text]
- Pieterman, RM, van Putten, JWG, Meuzelaar, JJ, et al Preoperative staging of non-small-cell lung cancer with positron-emission tomography. N Engl J Med 2000;343,254-261[Abstract/Free Full Text]
- Wiersema, MJ, Vazquez-Sequeiros, E, Wiersema, LM Evaluation of mediastinal lymphadenopathy with endoscopic US-guided fine-needle aspiration biopsy. Radiology 2001;219,252-257[Abstract/Free Full Text]
- Gress, FG, Savides, TJ, Sandler, A, et al 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. Ann Intern Med 1997;127,604-612[Abstract/Free Full Text]
- Williams, DB, Sahai, AV, Aabakken, L, et al Endoscopic ultrasound guided fine needle aspiration biopsy: a large single center experience. Gut 1999;44,720-726[Abstract/Free Full Text]
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Endoscopic Ultrasound in Non-Small Cell Lung Cancer and Negative Mediastinum on Computed Tomography
Am. J. Respir. Crit. Care Med.,
January 15, 2005;
171(2):
177 - 182.
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Abstract
Introduction
