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Original Research: F. J. F. Herth, R. Eberhardt, M. Krasnik, and A. Ernst Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Lymph Nodes in the Radiologically and PET Normal Mediastinum in Patients with Lung Cancer Chest 2008; 0: chest.07-2535v1-0 [Abstract] [PDF]

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EBUS for all suspected lung cancer

Douglas Arenberg   (9 April 2008)

EBUS for all suspected lung cancer 9 April 2008
Douglas Arenberg, Associate Professor University of Michigan Send letter to journal: Re: EBUS for all suspected lung cancer darenber{at}umich.edu Douglas Arenberg	Dr. Herth and colleagues report on a consecutive series of over 1200 patients with suspected lung cancer, and selected 100 using the criteria that both PET scans and CT scans suggested the absence of mediastinal lymph node involvement. Their findings that 10 patients had clinically unsuspected lymph node (N2) metastasis led them to conclude "...that EBUS- TBNA should be considered in the preoperative staging of all patients with and without mediastinal lymph node enlargement on CT scan and with or without PET activity in the mediastinum." While their conclusions would seem to be supported by their data, one must evaluate their findings in the context of current practice of thoracic oncology. Should patients with "minimal N2" disease (as defined in this report by positive TBNA in the absence of mediastinal involvement by PET and standard CT scans) be denied surgery? Alternatively, should these patients be given neo-adjuvant therapy? Answers to these important oncologic questions are not provided by the current available data in this field. Only in the context of a clear answer to these questions should EBUS (or combined EBUS and EUS) be considered the standard of care for patients with normal mediastinal imaging on CT and PET. To reach that conclusion, one would have to find that the mortality of a group denied surgery on the basis of minimal N2 disease in the face of negative CT and PET imaging equivalent to a similarly treated group with more bulky N2 disease. Current experience would suggest this is not the case. Alternatively, finding that neo-adjuvant therapy improves survival in patients with minimal N2 disease relative to surgery alone would support routine use of endoscopic ultrasound-based staging of all patients with suspected lung cancer. Reaching these endpoints would require a large, multi-center study. Such a study would have to be powered to detect differences in outcome that are likely to be small, similar in size to the multi-center trials on adjuvant chemotherapy. The current study of 100 patients from three centers required 1,217 patients screened over a three-and-a-half year period. Completing the definitive study to justify the approach that Herth and colleagues seem to be advocating would be expensive and prolonged. Without such a study, the findings of the present study by Herth and colleagues cannot be used to change our current practice.