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Jouke Annema

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    OA01 - Advanced Diagnostic Approaches for Intrathoracic Lymph Nodes and Peripheral Lung Tumors (ID 117)

    • Event: WCLC 2019
    • Type: Oral Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Now Available
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      OA01.01 - Predictive Value of EBUS Strain Elastography in Mediastinal Lymph Node Staging; The E-Predict Multicenter Study Results (Now Available) (ID 1620)

      10:30 - 12:00  |  Author(s): Jouke Annema

      • Abstract
      • Presentation
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      Systematic assessment of lymph nodal involvement by EBUS-TBNA is indicated for suspected and proven lung cancers. Nodal size and PET characteristics help guide which lymph nodes to sample. Especially smaller lymph nodes remain challenging, since PET is of limited value due to low resolution. Additional ultrasound B-mode features such as lymph node size, margin or node heterogeneity have shown variable predictive outcomes. Ultrasound strain elastography (EBUS-SE) is a promising technique. By monitoring tissue deformation over time using ultrasound imaging, a relative tissue strain can be computed. Lower tissue strain is shown to correlate to malignancy. Using a standardized measurement procedure (RespirationDOI: 10.1159/000494143), we aimed to assess the value of strain elastography for predicting lymph node malignancy in addition to size information.


      This multicenter prospective international trial [NCT02488928] included patient with suspected or proven lung cancer in five hospitals. Measurements were obtained following to a standardized operating procedure using Pentax-Hitachi EBUS systems. Nodal cytopathology combined with follow up imaging (>6 months) or surgery were used as reference standard. If uncertainty in outcome remained, nodes were excluded in final analysis.


      EBUS-SE was performed in 416 patients and 525 lymph nodes (June 2016 – July 2018). Final diagnoses showed 272 benign and 253 malignant nodes. Mean lymph node size was 12.3 mm. B-mode size and mean strain correlated to risk of malignancy with AUC of 78% and 76.8% (95% CI 0.73-0.81). Using a clinical work-up setting with 10mm and 8mm size cut-offs for aspiration, short axis size higher than 8 or 10mm resulted in respective sensitivity of 85% and 72%, specificity of 52% and 71%, PPV of 62% and 70% and NPV of 79% and 73%. Addition of strain elastography (mean<90) to EBUS-short-axis size (<10mm) increased overall sensitivity from 72% to 90% and NPV from 73% to 81%. More nodes were found false positive, specificity decreased from 71% to 42% and PPV went from 70% to 59%. Addition of strain (mean<78) to EBUS-size (<8mm) increased sensitivity from 85% to 94% and NPV from 79% to 85%. Specificity decreased from 52% to 32% and PPV from 63% to 55%.


      EBUS strain elastography is of added value in guiding nodal sampling. Strain and size combined can help identify more malignant nodes, although it will ultimately also lead to more false positive sampling. Strain information may especially be of potential value in nodes of small size, where PET resolution is limited.

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