(Chest. 2004;126:2020-2022.)
© 2004
American College of Chest Physicians
Endoscopic and Endobronchial Ultrasound Real-time Fine-Needle Aspiration for Staging of the Mediastinum in Lung Cancer*
Robert C. Rintoul, PhD;
Kristopher M. Skwarski, MD;
John T. Murchison, MD;
Adam Hill, MD;
William S. Walker, MD and
Ian D. Penman, MD
* From the Respiratory Medicine Unit (Drs. Rintoul, Skwarski, and Hill), and the Departments of Radiology (Dr. Murchison) and Thoracic Surgery (Dr. Walker), Royal Infirmary of Edinburgh; and the Gastrointestinal Unit (Dr. Penman), Western General Hospital, Edinburgh, UK.
Correspondence to: Robert C. Rintoul, PhD, Respiratory Medicine Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK; e-mail: robertrintoul{at}yahoo.co.uk
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Abstract
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Mediastinal lymph node metastases in patients with non-small cell lung cancer are a critical determinant of operability. Mediastinoscopy is invasive, requires general anesthesia, and carries appreciable morbidity. The development of minimally invasive techniques for the pathologic staging of lung cancer is important. We report a one-stop minimally invasive method for the pathologic diagnosis and staging of the majority of the mediastinum under conscious sedation using a novel prototype endobronchial ultrasound probe with a real-time fine-needle aspiration (FNA) facility in combination with conventional endoscopic ultrasound FNA.
Key Words: endobronchial ultrasound • endoscopic ultrasound • fine-needle aspiration • lung cancer • mediastinal lymphadenopathy
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Introduction
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In the absence of distant metastases, mediastinal lymph node metastases in patients with non-small cell lung cancer (NSCLC) are a critical determinant of operability, occurring in up to 38% of cases at diagnosis.1 Until now, mediastinoscopy has been the investigation of choice for the diagnosis and staging of middle mediastinal lymph nodes, but it is invasive, requires a general anesthetic, and has a complication rate of 1 to 3%.2 The development of minimally invasive techniques for the pathologic staging of the mediastinum offers increased patient safety as well as potential savings in time and cost. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA), while extremely effective for biopsies of posterior and inferior mediastinal lymph node stations, does not allow access to stations anterior and superior to the trachea or main bronchi.3
Here, we describe the use of a novel prototype linear array endobronchial ultrasound (EBUS) probe with a fine-needle biopsy facility for real-time imaging and aspiration biopsy of pretracheal, peritracheal, and hilar lymph nodes, which, when used in combination with EUS-FNA, allows the minimally invasive diagnosis and staging of the majority of the mediastinum with the patient under conscious sedation.
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Case Reports
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Case Report 1
A 68-year-old ex-smoker presented with a short history of lethargy. A CT scan of his chest revealed right paratracheal (station 4R) and subcarinal lymphadenopathy (station 7), although no primary mass lesion was apparent. Under conscious sedation, the pretracheal, peritracheal, subcarinal, and hilar lymph node stations (stations 1, 2, 3, 4, 7, and 10) were examined using a novel prototype linear array ultrasonic bronchoscope (model XBF-UC260F-OL8; Olympus Ltd; Tokyo, Japan) [Fig 1
]. The instrument, which is similar to a standard fiberoptic bronchoscope, has a maximum outer diameter of 6.9 mm, 30° oblique forward-viewing optics, and a 2.0-mm instrument channel. An electronic convex array ultrasound transducer is mounted at the distal tip and is covered by a balloon sheath. Scanning is performed at a frequency of 7.5 MHz and allows a penetration of 20 to 50 mm. After insertion via the mouth, the probe was passed through the vocal cords to the main carina, the balloon was partially inflated (0.5 to 1.0 mL water), and the regional lymph node stations of the middle mediastinum and hilar were systematically imaged during the slow withdrawal and rotation of the transducer.4 Enlarged right paratracheal (station 4R) lymph nodes were identified, and FNA was performed by passing a dedicated prototype 22-gauge needle (model XNA-200C; Olympus Ltd) through the airway wall and into the lymph nodes under real-time ultrasound control (Fig 2
). Color flow Doppler ultrasound was used to exclude intervening vessels immediately prior to puncture. Under the same sedation, EUS using a linear array echoendoscope (Olympus GF-UCP240; KeyMed Ltd; Southend-on-Sea, UK) was performed to examine the posterior and inferior mediastinal lymph node stations (stations 5, 7, 8, and 9). EUS examination further demonstrated a small primary paraesophageal lesion deep to the subcarinal nodes invading the pleura, and core biopsy specimens of the lesion and lymph node station 7 were obtained using a 19-gauge needle. The combined ultrasound examinations staged the patient as T3N2, and histology from the EBUS-FNA and EUS core biopsy specimens confirmed stage IIIA NSCLC. The patient tolerated the procedures well and without complication, was discharged home the same day, and commenced combination chemotherapy within a week.
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Figure 1. Distal end of the prototype EBUS probe showing the curved array ultrasound transducer with balloon inflated and a 22-gauge aspiration needle protruding from the biopsy channel.
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Figure 2. Top, A: EBUS image of a lymph node from case 1. The node, which appears to be hypoechoic, homogeneous, and rounded, was shown by cytology to be malignant. Bottom, B: EBUS image of a lymph node from case 1 showing the needle lying within the node (arrow).
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Case Report 2
A 45-year-old man presented with hemoptysis. CT scanning revealed a 4 x 3 cm mass in the left upper lobe with mediastinal lymphadenopathy. Bronchoscopy revealed a squamous cell carcinoma in the left upper lobe. Using the linear array EBUS probe, the pretracheal, peritracheal, subcarinal, and hilar lymph node stations (stations 1, 2, 3, 4, 7, and 10) were sequentially examined and a cluster of enlarged pretracheal (station 3) lymph nodes (maximum short axis diameter, 1.5 cm) was identified. The findings of EBUS-FNA of the pretracheal lymph nodes were negative for malignancy. Under the same sedation, linear array EUS was performed to examine the lymph node stations of the posteroinferior mediastinum (stations 5, 7, 8, and 9), and the deep preesophageal subcarinal lymph nodes (inferoposterior station 7) were identified (short-axis diameter, 1.8 cm) and sampled. These findings were also negative for malignancy. Subsequent surgery with frozen section did not reveal any mediastinal metastases, and the patient underwent a completion left intrapericardial pneumonectomy. The final pathologic staging was pT2N1, with the enlarged pretracheal and subcarinal node clusters showing reactive inflammatory changes only. Therefore, the EBUS-FNA and EUS-FNA specimens were confirmed as true-negative results.
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Discussion
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This is the first report of a one-stop approach for the pathologic diagnosis and staging of the hilar and middle lymph node stations and the posteroinferior mediastinum using minimally invasive techniques under conscious sedation. The combined use of EBUS and EUS offers more comprehensive access to the mediastinal and hilar lymph nodes than is currently available with the "gold standard" mediastinoscopy, which is confined to the middle mediastinum.
Until now, EBUS probes have been mechanical radial mini-probes that were passed through the working channel of a flexible bronchoscope. While these devices allow target visualization for sequential "blind" transbronchial needle aspiration (TBNA), real-time TBNA is not possible. As a result, traditional blind TBNA for lesions < 1 cm suffers from variable sensitivity.5 However, real-time ultrasound-guided needle aspiration should considerably increase the utility and sensitivity of TBNA and bring it into line with EUS-FNA, in which experience has shown that it is possible to identify and sample lesions as small as 3 to 5 mm in diameter.6
Despite the potential utility of these combined techniques for upstaging patients, the possibility of false-negative cytology results with FNA techniques remains, and it is recognized that some patients may still require a surgical staging procedure prior to undergoing definitive surgery. However, we believe that for many patients a combined EBUS and EUS approach will avoid a general anesthetic and surgical procedure with potential savings in both time and cost. Finally, these techniques may allow diagnosis and staging in patients who are medically unfit to undergo surgical diagnostic procedures.
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Conclusions
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EBUS-FNA under real-time ultrasound guidance can be undertaken at the same time as bronchoscopy and/or EUS-FNA under conscious sedation. EBUS-FNA has the potential for accurate sampling of lymph nodes and masses in the middle mediastinum and, when combined with EUS-FNA, offers the possibility of minimally invasive staging of the majority of the mediastinum. Larger studies of this new technique to define further its role in the staging of NSCLC are warranted.
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Acknowledgements
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The authors thank Judith Wilson, Jennifer Matthews, and Helen Chisholm of the Endoscopy Unit at the Royal Infirmary of Edinburgh for their help in the evaluation of the prototype EBUS probe.
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Footnotes
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Abbreviations: EBUS = endobronchial ultrasound; EUS = endoscopic ultrasound; FNA = fine-needle aspiration; NSCLC = non-small cell lung cancer; TBNA = transbronchial needle aspiration
Received for publication December 11, 2003.
Accepted for publication July 6, 2004.
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References
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- Luke, WP, Pearson, FG, Todd, TR, et al Prospective evaluation of mediastinoscopy for assessment of carcinoma of the lung. J Thorac Cardiovasc Surg 1986;91,53-56[Abstract]
- Silvestri, GA, Hoffman, BJ, Bhutani, MS, et al Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg 1996;61,1441-1446[Abstract/Free Full Text]
- Mountain, CF, Dresler, CM Regional lymph node classification for lung cancer staging. Chest 1997;111,1486-1487[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]
- Williams, DB, Sahai, AV, Aabakken, L, et al Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut 1999;44,720-726[Abstract/Free Full Text]
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R. C. Rintoul, K. M. Skwarski, J. T. Murchison, W. A. Wallace, W. S. Walker, and I. D. Penman
Endobronchial and endoscopic ultrasound-guided real-time fine-needle aspiration for mediastinal staging
Eur. Respir. J.,
March 1, 2005;
25(3):
416 - 421.
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Abstract
Introduction
