ObjectiveObjective Comparison of direct real-time endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA), PET, CT for detection of mediastinal and hilar lymph node metastasis in patients with lung cancer considered for surgical resection

Methods Methods

Design: Prospective study (December 2003 to March 2005)

Patients: 102 /280 potentially operable patients with proven ( 96) or radiologically suspected ( 6) lung cancer

Interventions: CT, PET, and EBUS-TBNA

Surgical histology :The “gold standard” to confirm lymph node metastasis (expect N3 or extensive N2 disease proven by EBUS-TBNA

Methods Methods

CTCT MDCT ; 5mmMDCT ; 5mm Resectability; Evaluation of LN or distant metastases Radiologist ( blinded ) Radiologist ( blinded ) Positive node: Positive node: short axis 1 cm

FDG-PET/CT FDG-PET/CT 300 MBq 300 MBq Positive: SUV > 2.5Positive: SUV > 2.5

Methods Methods

EBUS-TBNA EBUS-TBNA Linear scanning transducer (7.5 MHz)Linear scanning transducer (7.5 MHz) Connection with ultrasound scanner Connection with ultrasound scanner

( Doppler –flower imaging)( Doppler –flower imaging) Performed by the same operator under Performed by the same operator under

sedationsedation #1,2,4,7 & #10,11 #1,2,4,7 & #10,11 Short diameter >5mm Short diameter >5mm sampling ( 22- sampling ( 22-

qauge) qauge) N3->N2->N1N3->N2->N1 Result : positive, negative, inconclusiveResult : positive, negative, inconclusive

Methods Methods

Operable Operable Stage I, II or minimal Stage IIIA (single-Stage I, II or minimal Stage IIIA (single-

station N2 )station N2 )

Inoperable Inoperable Extrathoracic spread disease Extrathoracic spread disease Extensive N2 ( bulky disease, multiple Extensive N2 ( bulky disease, multiple

N2 )N2 ) N3 disease N3 disease

Results Results

Results Results

Discussion Discussion

FDG-CT FDG-CT More sensitive, less specificity( 61%vs 79% ; 85% vs More sensitive, less specificity( 61%vs 79% ; 85% vs

90%)90%) Specificity is lower than previously reportedSpecificity is lower than previously reported Mediastinal nodes, distal metastasis, inflammatory Mediastinal nodes, distal metastasis, inflammatory

reaction reaction False positive False positive tissue conformation tissue conformation 23 false positive 23 false positive correctly diagnosis by EBUS-TBN correctly diagnosis by EBUS-TBN

AA False positive : related to size of node and volume of False positive : related to size of node and volume of

macrophage macrophage 16/23 : CT(+); PET(+)16/23 : CT(+); PET(+)

DiscussionDiscussion

EBUS-TBNAEBUS-TBNA High sensitive & specific High sensitive & specific A single procedure for staging A single procedure for staging 40/147 mediastinal nodes <5 mm 40/147 mediastinal nodes <5 mm Avoid mediastinoscopy and VATS Avoid mediastinoscopy and VATS False positive: contamination in TBNA process False positive: contamination in TBNA process internal sheath : avoid contaminationinternal sheath : avoid contamination Limitation : no compare other procedures ( TBNA, EUS-Limitation : no compare other procedures ( TBNA, EUS-

FNA) FNA) : # 5,6,8,9: # 5,6,8,9

DiscussionDiscussion

TBNA is a fairly “blind” procedure TBNA guided by CT fluoroscopy EUS-FNAEUS-FNA

US-guided needle aspiration

ConclusionConclusion

EBUS-TBNA has a high sensitivity & pecificity compared to CT or PET for mediastinal staging in patients with potentially resectable lung cancer

Tissue confirmation obtained by EBUS-TBNA is especially important for accurate staging.