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Endobronchial Ultrasound-guided Biopsy Performed Under Optimal Conditions in Patients With Known or Suspected Lung Cancer May Render Mediastinoscopy Unnecessary

Clementsen, Paul F. MD, DSc*; Skov, Birgit G. MD, DSc; Vilmann, Peter MD, DSc; Krasnik, Mark MD§

Journal of Bronchology & Interventional Pulmonology: January 2014 - Volume 21 - Issue 1 - p 21–25
doi: 10.1097/LBR.0000000000000028
Original Investigations

Background: Mediastinoscopy is the gold standard for preoperative mediastinal staging of patients with suspected or proven lung cancer. Since the development of endoscopic ultrasound-guided biopsy via the trachea (EBUS-TBNA), this status has been challenged. The purpose of the study was to examine whether mediastinoscopy is necessary, when EBUS-TBNA is performed in a center with (1) a high level of expertise, (2) “bed side” microscopy by a pathologist, (3) general anesthesia, and (4) achievement of representative tissue from station 4R, 7 and 4L, that is, the same mediastinal stations that mediastinoscopy gives access to.

Methods: A total of 95 consecutive patients with known or suspected lung cancer were referred for staging by EBUS-TBNA, which was performed as described.

Results: Benign and malignant disease was found in the mediastinum of 6 and 13 patients, respectively. The remaining 76 patients were operated, resulting in 9 benign and 67 malignant diagnoses; spread was found to station 4R, 5, and 5 and 6 in 4 patients. The negative predictive value (NPV) was 63/67=0.94. However, if you exclude station 5 and 6, as they cannot be reached by neither EBUS nor mediastinoscopy, NPV was 66/67=0.99. The sensitivity was 0.76, and the specificity was 1.0.

Conclusions: When EBUS-TBNA is performed under optimal conditions including general anesthesia and “bed side” microscopy performed by a pathologist resulting in representative biopsies from station 4R, 7, and 4L, the NPV is so high that mediastinoscopy seems unnecessary.

*Department of Pulmonary Medicine, Gentofte Hospital

Departments of Pathology

§Thoracic Surgery, Rigshospitalet, University of Copenhagen, Denmark

Department of Surgery, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark

Disclosure: P.V. receives consultancy fee from MEDI-GLOBE GmbH (EUS and EBUS needle company). The remaining authors declare that there is no conflict of interest or other disclosures.

Reprints: Paul F. Clementsen, MD, DSc, Department of Pulmonary Medicine, Gentofte Hospital, University of Copenhagen, 2900 Hellerup, Copenhagen, Denmark (e-mail:

Received July 2, 2013

Accepted November 12, 2013

© 2014 by Lippincott Williams & Wilkins.