Chest
Volume 123, Issue 2, February 2003, Pages 442-451
Journal home page for Chest

Clinical Investigations
CANCER
Mediastinal Lymph Node Involvement in Potentially Resectable Lung Cancer*: Comparison of CT, Positron Emission Tomography, and Endoscopic Ultrasonography With and Without Fine-Needle Aspiration

https://doi.org/10.1378/chest.123.2.442Get rights and content

Purpose:

A prospective comparison of three imaging techniques: thoracic CT, positron emission tomography (PET), and endoscopic ultrasonography (EUS) with fine needle aspiration (FNA), each performed under routine conditions, for the detection of metastatic lymph nodes metastases in patients with lung cancer considered for operative resection.

Patients and methods:

Following bronchoscopic evaluation, CT, PET, and EUS were performed to evaluate potential mediastinal involvement in 33 consecutive patients with bronchoscopic biopsy/cytology proven (n = 25) or radiologically suspected (n = 8) lung cancer prior to surgery. Surgical histology was used as “gold standard” to confirm the diagnosis of the primary tumor and the mediastinal status in all patients. Histology proved non-small cell lung cancer in 30 patients, neuroendocrine tumor in 1 patient, and benign disease in 2 patients.

Results:

The mean age of the study group was 61.5 years (range, 41 to 80 years; 23 male patients). CT, PET, and EUS detected mediastinal lymph nodes (size, 0.4 to 1.6 cm) in 15, 14, and 27 patients (21 of which were suspected to be malignant on EUS), respectively. With respect to the correct prediction of mediastinal lymph node stage, the sensitivities of CT, PET, and EUS were 57%, 73%, and 94%. Specificities were 74%, 83%, and 71%. Accuracies were 67%, 79%, and 82%. Results of PET could be improved when combined with CT (sensitivity, 81%; specificity, 94%; accuracy, 88%). The specificity of EUS (71%) was improved to 100% by FNA cytology (EUS-guided FNA), which gave a tissue diagnosis including tumor type, without complications.

Conclusions:

No single imaging method alone was conclusive in evaluating potential mediastinal involvement in apparently operable lung cancer and routine clinical conditions. A tissue diagnosis is extremely helpful. Because FNA can be performed at the same time as EUS, this combination emerged as the most useful technique in the evaluation of even very small mediastinal metastases of lung cancer. CT seems necessary additionally to evaluate the pretracheal region as well as the rest of the thorax, and PET may be valuable to detect distant metastases.

Section snippets

Patients

From May 2000 to August 2001, a total of 117 patients were referred and investigated for suspected lung cancer. All patients underwent thoracic CT, EUS and, if necessary, EUS-FNA for diagnosis and/or staging, this being the routine workup for patients with suspected lung cancer prior to therapy in the University Hospital Hamburg-Eppendorf. Of the total number of 33 consecutive patients (23 men and 10 women; mean age, 61.5 years; age range, 41 to 80 years) with clinical suspicion of or proven

Results

Sixteen of 33 patients (48%) had mediastinal nodal metastases proven by surgical histology. The size of the lymph nodes varied from 0.4 to 1.6 cm in diameter (median, 1.0 cm). In 14 patients, metastases ipsilateral to the tumor were seen; in an additional 2 patients, EUS-FNA detected contralateral involvement. These two patients underwent thoracoscopy only without resection, which confirmed N3 status. Final diagnosis was NSCLC in 30 patients, neuroendocrine tumor in 1 patient, and benign

Conclusion

CT alone was not reliable in the diagnosis of mediastinal lymph node metastases. PET alone was also inconclusive due to fp and fn results, nor was EUS alone useful, because of its relatively low specificity. The combination of CT and PET resulted in a significantly better evaluation of the mediastinum. Since thoracic CT allows evaluation of the pretracheal region as well as the rest of the thorax, and EUS-FNA yields staging information and tissue diagnosis, the combination of CT and EUS-FNA was

REFERENCES (58)

  • NC Gupta et al.

    Mediastinal lymph node sampling following positron emission tomography with fluorodeoxyglucose imaging in lung cancer staging

    Chest

    (2001)
  • M Okada et al.

    Induction therapy for non-small cell lung cancer with involved mediastinal nodes in multiple stations

    Chest

    (2000)
  • CF Mountain

    The new International Staging System for Lung Cancer

    Surg Clin North Am

    (1987)
  • MF Catalano et al.

    Endosonographic features predictive of lymph node metastasis

    Gastrointest Endosc

    (1994)
  • M Barawi et al.

    EUS-guided fine-needle aspiration in the mediastinum

    Gastrointest Endosc

    (2000)
  • GM Arluk et al.

    EUS and fine-needle aspiration in the evaluation of mediastinal masses superior to the aortic arch

    Gastrointest Endosc

    (2001)
  • MS Bhutani et al.

    A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for diagnosis of malignant lymph node invasion

    Gastrointest Endosc

    (1997)
  • GL Colice

    Chest CT for known or suspected lung cancer

    Chest

    (1994)
  • CS White et al.

    Transbronchial needle aspiration: guidance with CT fluoroscopy

    Chest

    (2000)
  • M Patelli et al.

    Role of fiberoptic transbronchial needle aspiration in the staging of N2 disease due to non-small cell lung cancer

    Ann Thorac Surg

    (2002)
  • H Okamoto et al.

    Endobronchial ultrasonography for mediastinal and hilar lymph node metastases of lung cancer

    Chest

    (2002)
  • EF Haponik et al.

    Underutilization of transbronchial needle aspiration: experiences of current pulmonary fellows

    Chest

    (1997)
  • A Dasgupta et al.

    Transbronchial needle aspiration: an underused diagnostic technique

    Clin Chest Med

    (1999)
  • UB Prakash et al.

    Bronchoscopy in North America: the ACCP survey

    Chest

    (1991)
  • TC Mc Loud et al.

    Bronchogenic carcinoma: analysis of staging in the mediastinum with CT by correlative lymph-node mapping and sampling

    Radiology

    (1992)
  • B Dillemans et al.

    Value of computed tomography and mediastinoscopy in preoperative evaluation of mediastinal nodes in non-small cell lung cancer

    Eur J Cardiothorac Surg

    (1994)
  • B Gross et al.

    Bronchogenic carcinoma metastatic to normal sized lymph nodes: frequency and significance

    Radiology

    (1988)
  • F Gress et al.

    Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study

    Ann Intern Med

    (1997)
  • H Minn et al.

    Prediction of survival with fluorine-18-fluorodeoxyglucose and PET in head and neck cancer

    J Nucl Med

    (1997)
  • Cited by (201)

    • Unforeseen N2 Disease after Negative Endosonography Findings with or without Confirmatory Mediastinoscopy in Resectable Non–Small Cell Lung Cancer: A Systematic Review and Meta-Analysis

      2019, Journal of Thoracic Oncology
      Citation Excerpt :

      A total of 31 studies or subgroups with use of endosonography only (without additional surgical staging) were included (Fig. 2). Of these studies, 12 evaluated EBUS,11–22 seven evaluated EUS,13,23–28 and 12 evaluated combined EBUS and EUS as a staging method.13,29–37 One study was a randomized controlled trial (RCT) comparing staging by EBUS followed by EUS versus EUS followed by EBUS, and one study was an observational study comparing EBUS plus EUS versus EBUS plus EUS with use of the EBUS scope.

    • Extraintestinal Endosonography

      2019, Clinical Gastrointestinal Endoscopy
    • Clinical Aspects of Lung Cancer

      2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
    View all citing articles on Scopus
    View full text