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Michael B. Wallace, MD, MPH; Jorge M. S. Pascual, MD; Massimo Raimondo, MD; Timothy A. Woodward, MD; Barbara L. McComb, MD; Julia E. Crook, PhD; Margaret M. Johnson, MD; Mohammad A. Al-Haddad, MD; Seth A. Gross, MD; Surakit Pungpapong, MD; Joy N. Hardee, CCRA; John A. Odell, MD

JAMA. 2008;299(5):540-546.

Context  In patients with suspected lung cancer, the presence of mediastinal lymph node metastasis is a critical determinant of therapy and prognosis. Invasive staging with pathologic confirmation is recommended. Many methods for staging exist; mediastinoscopy, an invasive procedure requiring general anesthesia, is currently regarded as the diagnostic standard.

Objective  To compare the diagnostic accuracy of 3 methods of minimally invasive endoscopic staging (and their combinations): traditional transbronchial needle aspiration (TBNA), endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA), and transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). In particular, we aimed to compare EBUS-FNA with TBNA.

Design, Setting, and Participants  Invasive staging of the mediastinum among consecutive patients with suspected lung cancer at a US academic medical center from November 2004 through October 2006.

Intervention  TBNA, EBUS-FNA, and EUS-FNA performed sequentially as a single combined procedure.

Main Outcome Measure  Sensitivity for detecting mediastinal lymph node metastases, using pathologic confirmation and 6- to 12-month clinical follow-up as the criterion standard.

Results  Among 138 patients who met all study criteria, 42 (30%) had malignant lymph nodes. EBUS-FNA was more sensitive than TBNA, detecting 29 (69%) vs 15 (36%) malignant lymph nodes (P = .003). The combination of EUS-FNA and EBUS-FNA (EUS plus EBUS) had higher estimated sensitivity (93% [39/42]; 95% confidence interval, 81%-99%) and negative predictive value (97% [96/99]; 95% confidence interval, 91%-99%) compared with either method alone. EUS plus EBUS also had higher sensitivity and higher negative predictive value for detecting lymph nodes in any mediastinal location and for patients without lymph node enlargement on chest computed tomography.

Conclusions  These findings suggest that EBUS-FNA has higher sensitivity than TBNA and that EUS plus EBUS may allow near-complete minimally invasive mediastinal staging in patients with suspected lung cancer. These results require confirmation in other studies but suggest that EUS plus EBUS may be an alternative approach for mediastinal staging in patients with suspected lung cancer.

Author Affiliations: Division of Gastroenterology and Hepatology (Drs Wallace, Raimondo, Woodward, Al-Haddad, and Gross), Department of Pulmonary Medicine (Drs Pascual and Johnson), Department of Radiology (Dr McComb), Biostatistics Unit (Dr Crook), Department of Critical Care (Dr Johnson), Clinical Studies Unit (Ms Hardee), and Division of Transplant Surgery (Dr Odell), Mayo Clinic, Jacksonville, Florida; and Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota (Dr Pungpapong).

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