• Users Online:430
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
EDITORIAL
Year : 2013  |  Volume : 2  |  Issue : 4  |  Page : 179-180

Endobronchial ultrasound: First choice for the mediastinum


Department of Pneumology and Critical Care Medicine, Thoraxklinik, Translational Lung Research Center Heidelberg, University of Heidelberg, D-69126 Heidelberg, Germany

Date of Submission10-Oct-2013
Date of Acceptance24-Oct-2013
Date of Web Publication15-Nov-2013

Correspondence Address:
Felix J. F. Herth
Department of Pneumology and Critical Care Medicine, Thoraxklinik, Translational Lung Research Center Heidelberg, University of Heidelberg, D-69126 Heidelberg
Germany
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.121235

Rights and Permissions

How to cite this article:
Herth FJ. Endobronchial ultrasound: First choice for the mediastinum. Endosc Ultrasound 2013;2:179-80

How to cite this URL:
Herth FJ. Endobronchial ultrasound: First choice for the mediastinum. Endosc Ultrasound [serial online] 2013 [cited 2018 Dec 17];2:179-80. Available from: http://www.eusjournal.com/text.asp?2013/2/4/179/121235

The world's first curved linear array ultrasonic bronchoscope was introduced to the market by Olympus in 2004. The development of the endoscope had started more than 5 years earlier based on a request to Olympus Medical Tokyo to miniaturise existing endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) technology to be applied for diagnosis of lesions within the bronchial system. The appeal was born out of the necessity to improve mediastinal staging results.

Computed tomography (CT) and positron emission tomography (PET) are the most widely used non-invasive means for mediastinal lymph nodes. However, based on their reported specificities, CT and PET findings should be verified by cytohistologic sampling. [1]

The 60-year-old transbronchial needle aspiration (TBNA) technology has proved its efficacy, safety and cost-effectiveness particularly in diagnosing and staging lung cancer as well as in diagnosing benign granulomatous disease, but unfortunately the technique was always underused. Mainly safety concerns have been the reason. [2],[3]

The success story of endobronchial ultrasound (EBUS)-TBNA starts in 2003 with a publication in the journal Thorax by Krasnik et al. [4] This article gave the first description of the principle of EBUS-TBNA. In the same journal, Herth et al. [2] chronicled their study on 502 patients that showed that EBUS-TBNA resulted in 93% diagnostic yield, a sensitivity of 94%, specificity of 100% and accuracy of 94%, with a positive predictive value at 100% and negative predictive value at 11%. A further interesting outcome of the study was that no significant difference between ultrasound diagnosis under local and general anaesthesia was identified.

With the strong acceptance of EBUS-TBNA as a reliable diagnostic tool for enlarged lymph nodes in patients with non-small cell lung cancer (NSCLC), it soon became clear that EBUS provides the best lymph nodes access.

The technique was also examined against mediastinoscopy. In a study by Ernst et al. [5] it was shown that EBUS-TBNA can have a superior yield compared with cervical mediastinoscopy, which leads to the conclusion that mediastinoscopy is not necessarily of additional diagnostic benefit to evaluate negative EBUS-TBNA staged lymph nodes.

A lot of very important work was also done by Nakajima et al. [6],[7],[8],[9] He and his group have shown strong dedication to evaluate the benefits of EBUS-TBNA samples for immunohistochemical analysis, molecular staging and reported encouraging results with cell cycle related proteins in chemotherapy patients.

In several published meta-analysis, EBUS-TBNA has been shown to have a high-pooled sensitivity of 93% and specificity of 100%. [10],[11],[12]

Multiple publications have shown that even in patients with lymph nodes <1 cm in diameter (which had been termed N0 by CT criteria), with the use of EBUS-TBNA a large percentage could still be shown to have N2/N3 disease (some despite also being negative on PET-CT). [13],[14]

Complications such as bleeding or infection are very rare and have only been reported as case reports.

At least it was the work of Annema et al. [15] which also convinced guidelines authorities. In a randomized controlled multicenter trial patient either underwent a surgical staging or an endosonography (combined transesophageal and [EUS-FNA and EBUS-TBNA]) followed by surgical staging in case no nodal metastases were found at endosonography. Thoracotomy with lymph node dissection was performed when there was no evidence of mediastinal tumor spread. The group showed that among patients with (suspected) NSCLC, a staging strategy combining endosonography and surgical staging compared with surgical staging alone resulted in a greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies.

All the work changed at the end of our daily doing. The recent published guideline of the American College of Chest Physicians (ACCP) is clearly pointed now. In the article by Silvestri et al.,[16] the ACCP recommends "In patients with high suspicion of N2 and 3 involvement, either by discrete mediastinal lymph node enlargement or PET uptake (and no distant metastases), a needle technique (EBUS-needle aspiration [NA], EUS-NA or combined EBUS/EUS-NA) is recommended over surgical staging as a best first test (Grade 1b)."

After 10 years and a lot of scientific work from several groups, a small scope becomes the state of the art.

 
  References Top

1.Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3 rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143: e142S-65.  Back to cited text no. 1
[PUBMED]    
2.Herth FJ, Eberhardt R, Vilmann P, et al. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax 2006; 61: 795-8.  Back to cited text no. 2
[PUBMED]    
3.Holty JE, Kuschner WG, Gould MK. Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: A meta-analysis. Thorax 2005; 60: 949-55.  Back to cited text no. 3
[PUBMED]    
4.Krasnik M, Vilmann P, Larsen SS, et al. Preliminary experience with a new method of endoscopic transbronchial real time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions. Thorax 2003; 58: 1083-6.  Back to cited text no. 4
[PUBMED]    
5.Ernst A, Anantham D, Eberhardt R, et al. Diagnosis of mediastinal adenopathy-real-time endobronchial ultrasound guided needle aspiration versus mediastinoscopy. J Thorac Oncol 2008; 3: 577-82.  Back to cited text no. 5
[PUBMED]    
6.Nakajima T, Anayama T, Shingyoji M, et al. Vascular image patterns of lymph nodes for the prediction of metastatic disease during EBUS-TBNA for mediastinal staging of lung cancer. J Thorac Oncol 2012; 7: 1009-14.  Back to cited text no. 6
[PUBMED]    
7.Nakajima T, Yasufuku K, Suzuki M, et al. Assessment of epidermal growth factor receptor mutation by endobronchial ultrasound-guided transbronchial needle aspiration. Chest 2007; 132: 597-602.  Back to cited text no. 7
[PUBMED]    
8.Sakairi Y, Nakajima T, Yasufuku K, et al. EML4-ALK fusion gene assessment using metastatic lymph node samples obtained by endobronchial ultrasound-guided transbronchial needle aspiration. Clin Cancer Res 2010; 16: 4938-45.  Back to cited text no. 8
[PUBMED]    
9.Mohamed S, Yasufuku K, Nakajima T, et al. Analysis of cell cycle-related proteins in mediastinal lymph nodes of patients with N2-NSCLC obtained by EBUS-TBNA: Relevance to chemotherapy response. Thorax 2008; 63: 642-7.  Back to cited text no. 9
[PUBMED]    
10.Cameron SE, Andrade RS, Pambuccian SE. Endobronchial ultrasound-guided transbronchial needle aspiration cytology: A state of the art review. Cytopathology 2010; 21: 6-26.  Back to cited text no. 10
[PUBMED]    
11.Adams K, Shah PL, Edmonds L, et al. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: Systematic review and meta-analysis. Thorax 2009; 64: 757-62.  Back to cited text no. 11
[PUBMED]    
12.Gu P, Zhao YZ, Jiang LY, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: A systematic review and meta-analysis. Eur J Cancer 2009; 45: 1389-96.  Back to cited text no. 12
[PUBMED]    
13.Herth FJ, Eberhardt R, Krasnik M, et al. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer. Chest 2008; 133: 887-91.  Back to cited text no. 13
[PUBMED]    
14.Herth FJ, Ernst A, Eberhardt R, et al. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum. Eur Respir J 2006; 28: 910-4.  Back to cited text no. 14
[PUBMED]    
15.Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs endosonography for mediastinal nodal staging of lung cancer: A randomized trial. JAMA 2010; 304: 2245-52.  Back to cited text no. 15
[PUBMED]    
16.Silvestri GA, Gonzalez AV, Jantz MA, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3 rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143: e211S-50.  Back to cited text no. 16
[PUBMED]    



This article has been cited by
1 Médiastinite secondaire à une ponction transbronchique échoguidée à l’aiguille : étiologie et prise en charge
D. Basille,F. De Dominicis,E. Magois,C. Andrejak,P. Berna,V. Jounieaux
Revue des Maladies Respiratoires. 2017;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   References

 Article Access Statistics
    Viewed2370    
    Printed54    
    Emailed1    
    PDF Downloaded2585    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]