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  MS06 - An Interdisciplinary Approach to Optimal Nodal Staging (ID 69)

  • Event: WCLC 2019
  • Type: Mini Symposium
  • Track: Staging
  • Presentations: 1
  • Now Available
  • Moderators:Roser Saumench Perramon, Souheil Boubia
  • Coordinates: 9/09/2019, 11:00 - 12:30, Toronto (1985)

  • 29593

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    MS06.02 - Endoscopic Nodal Staging (Now Available) (ID 3468)

    11:00 - 12:30  |  Presenting Author(s): Jose Sanz Santos
    • Abstract
    • Presentation
    • Slides

    Abstract
    

    1. INTRODUCTION.

    Endoscopic ultrasound (EUS) and endobronchial ultrasound (EBUS) were first described in the early 1980’s and 1990’s respectively. However, their incorporation into clinical practice began some years later, after the development of echoendoscopes and echobronchoscopes.

    2. PROCEDURE.

    EBUS-TBNA allows the sampling of retrotracheal (3P), upper paratracheal (2L,2R), lower paratracheal (4L/4R) and subcarinal (7) nodal stations. Moreover, EBUS-TBNA can access hilar (10L/10R) and interlobar nodal stations (11L/11R). EUS-FNA can access stations 2 and 4, subaortic (5), 7, paraesophageal (8L/8R) and pulmonary ligament (9L/9R).

    EBUS-TBNA/EUS-FNA is usually performed under conscious sedation or general anaesthesia in an outpatient setting. The reported complications rate for EBUS and EUS is < 1%.

    The current international guidelines for preoperative mediastinal staging of lung cancer¹ recommends, for an endoscopy-based mediastinal staging procedure, as a minimum requirement, sampling the largest LN in 4R, 4L and 7 stations, as well as positron emission tomography (PET) positive LNs within each of these stations. Thus, 3 nodes is the minimum sampling requirement for an endoscopy-based staging procedure.

    3. MEDIASTINAL STAGING OF LUNG CANCER THROUGH ENDOSONOGRAPHY.

    3.1 EUS-FNA

    Overall, the reported pooled sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of EUS-FNA for lung cancer staging is 0.83, 0.97, 0.78 and 0.98 respectively².

    3.2 EBUS-TBNA

    Two meta-analysis focussed on EBUS-TBNA in lung cancer staging were published ten years ago^3,4. Most of the studies included patients with abnormal mediastinum on CT and/or PET/CT and thereby a high prevalence of disease. The reported pooled sensitivity was 0.9 and 0.93, respectively, ranging from 0.69 to 0.99.

    More recently, two meta-analysis^5,6 have analysed the usefulness of EBUS-TBNA in lung cancer staging in patients with radiologically normal mediastinum. Both have shown similar pooled results for sensitivity (0.49, 0.495) and NPV (0.99, 0.93) with a similar median prevalence of N2/N3 disease (15.2%, 12.8%).

    3.3 Combined EUS/EBUS

    EBUS and EUS are complementary techniques that can access to different nodal stations. Thus, combination of both techniques may result in an increase of the sensitivity. A meta-analysis that included 2395 patients⁷ reported a mean sensitivity of the combined approach of 0.86 with a mean NPV of 0.92. Depending on the order of both techniques, the addition of EUS(B) to EBUS increased sensitivity by 0.12, and addition of EBUS to EUS(B) increased sensitivity by 0.22. However, no differences in sensitivity and NPV were shown between studies that performed EBUS first and studies that performed EUS first.

    3.4 Combined EUS-B/EBUS

    Combining EBUS with EUS has several limitations: usually needs to be performed by two different operators (pulmonologist/thoracic surgeon or gastroenterologist), in different settings, increasing the cost and waiting time of the procedure. These problems can be solved using a single scope (EBUS), in the same setting, by the same operator, by introducing the EBUS scope into the esophagus (EUS(B)). Several studies have demonstrated that EUS(B) combined with EBUS-TBNA results in an increase of the sensitivity compared with EBUS-TBNA alone⁸.

    4. THE N1 ELEMENT

    On the last years, several lung-sparing treatments for lung cancer have been developed. To select candidates for these techniques, accurate staging not only of the mediastinal nodes but also of the hilar nodes is crucial. One of the advantages of EBUS-TBNA is the ability to access N1 nodes.

    A study conducted by Yasufuku et al.⁹ that included patients with clinically N0/N1 disease eligible for surgical resection demonstrated that EBUS-TBNA can accurately access the hilar and interlobar LNs with a reported sensitivity, specificity, diagnostic accuracy and NPV of 0.76, 1, 0.96, and 0.96 respectively.

    5. HOT TOPICS

    Currently there are two questions that have to be answered:

    5.1 Must the combination EBUS/EUS (B) be performed routinely? In which order?

    As mentioned before⁷, EUS (B) needs to be added to EBUS in 25 patients and EBUS to EUS (B) in 14 patients to detect one additional patient with mediastinal nodal disease that would not have been detected if only one test had been performed.

    5.2 After an EBUS-TBNA procedure showing no mediastinal involvement, must patients undergo confirmatory mediastinoscopy?

    One recent meta-analysis¹⁰ studied the rate of unforeseen N2 disease in patients with lung cancer with or without mediastinoscopy after negative endosonography. In patients with EBUS and or EUS alone, the rate of unforeseen N2 was 9.3% for EBUS, and 13.4% for EUS. In patients with confirmatory mediastinoscopy the rate of unforeseen N2 disease after negative findings of EBUS (plus mediastinoscopy) was 11.2%, and after negative EUS (plus mediastinoscopy) was 14.9%.

    REFERENCES:

    1.De Leyn, et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small cell lung cancer. Eur J Cardiothorac Surg. 2014 May;45(5):787-98.

    2.Micanes CG, et al. Endoscopic ultrasound-guided fine-needel aspiration for non-small cell lung cancer staging. A systematic review and metaanalysis. Chest 2007;131:539-548.

    3.Gu P, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis. Eur J Cancer. 2009 May;45(8):1389-9.

    4.Dong X, et al. Endobronchial ultrasound-guided transbronchial needle aspiration in the mediastinal staging of non-small cell lung cancer: a meta-analysis. Ann Thorac Surg 2013;96:1502-07.

    5.Leong TL, et al. Preoperative staging by EBUS in cN0/N1 lung cancer systematic review and meta-analysis. J Bronchol Intervent Pulmonol [Epub ahead of print]

    6.El-Osta H, et al. Endobronchial ultrasound for nodal staging of patients with non-small-cell lung cáncer with radiologically normal mediastinum a meta-analyisis. Ann Am Thorac Soc 2018;15:864-874.

    7.Korevaar DA, et al. Added value of combined endobronchial and oesophagueal endosonography for mediastinal nodal staging in lung cancer: a systematic review and meta-analysis. Lancet Respir Med 2016;4:960-68.

    8.Dhooria S, et al. Utility and safety of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration in mediastinal lymph node sampling: systematic review and meta-analysis. Respir Care 2015;60(7):1040-1050.

    9.Yasufuku K, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for differentiating N0 versus N1 lung cancer. Ann Thorac Surg 2013;96:1756-60.

    10.Bousema JE, et al. 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. J Thorac Oncol. 2019 Jun;14(6):979-992

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