Journal of Thoracic Oncology:
Letters to the Editor
EBUS-TBNA for the Mediastinal Staging of Non-small Cell Lung Cancer
Navani, Neal MA, MRCP; Spiro, Stephen G. MD, FRCP; Janes, Sam M. MRCP, MSc, PhD
Centre for Respiratory Research, University College London, United Kingdom, firstname.lastname@example.org
Disclosure: The authors declare no conflicts of interest.
To the Editor:
The mediastinal staging of non-small cell lung cancer is an important process that distinguishes operable from inoperable candidates. In their retrospective study, Rintoul et al.1 report the utility of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of positron emission tomography (PET) positive mediastinal and hilar lymph nodes. They demonstrate a sensitivity of EBUS-TBNA of 91% when reference pathology was available.
The high false-positive rate of PET for the detection of mediastinal metastases demands that PET-positive mediastinal nodes should be invasively sampled and proven to contain metastatic disease before radical treatment is precluded. However, in addition to a high false-positive rate, it is increasingly recognized that PET is associated with a significant false-negative rate. The pooled sensitivity of PET for detecting mediastinal metastases from a meta-analysis was 0.74 (95% CI 0.69-0.79) and therefore PET scanning fails to detect over a quarter of mediastinal metastases in non-small cell lung cancer.2 This is reflected by current guidelines which suggest that all mediastinal lymph nodes ≥1 cm should be sampled preoperatively, regardless of fluorodeoxyglucose-avidity.3 Emerging data also suggests that malignancy can be detected in PET negative mediastinal nodes that are less than 1 cm in short axis.4 Therefore, a strategy where PET positive mediastinal lymph nodes alone are sampled should not be advocated.
The value of PET lies in its ability to detect radiographically occult extrathoracic metastases5 and should be applied preoperatively in all cases. However, EBUS-TBNA has a higher sensitivity for the detection of mediastinal metastases than PET. Therefore restricting the application of EBUS-TBNA to only PET positive mediastinal nodes would miss mediastinal metastases preoperatively and result in futile thoracotomies.
Neal Navani, MA, MRCP
Stephen G. Spiro, MD, FRCP
Sam M. Janes, MRCP, MSc, PhD
Centre for Respiratory Research
University College London
1. Rintoul RC, Tournoy KG, El Daly H, et al. EBUS-TBNA for the clarification of PET positive intra-thoracic lymph nodes-an international multi-centre experience. J Thorac Oncol 2009;4:44–48.
2. Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest 2007;132:178S–201S.
3. Detterbeck FC, Jantz MA, Wallace M, Vansteenkiste J, Silvestri GA. Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007;132:202S–220S.
4. Herth FJ, Eberhardt R, Krasnik M, Ernst A. 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;133:887–891.
5. Macmanus MP, Hicks RJ, Matthews JP, et al. High rate of detection of unsuspected distant metastases by pet in apparent stage III non-small-cell lung cancer: implications for radical radiation therapy. Int J Radiat Oncol Biol Phys 2001;50:287–293.
© 2009International Association for the Study of Lung Cancer