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      Predictors of malignancy in EUS-guided FNA for mediastinal lymphadenopathy in patients without history of lung cancer

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          Abstract

          BACKGROUND:

          Mediastinal lymphadenopathy (ML) poses a great diagnostic challenge.

          OBJECTIVE:

          To investigate the predictors of malignancy in endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of ML in patients without known lung cancer.

          DESIGN:

          Retrospective study.

          SETTING:

          Tertiary referral center.

          METHODS:

          One hundred eight patients without known lung cancer who underwent EUS guided-FNA for ML between 2000 and 2007. All subjects underwent EUS-guided FNA. Data was collected on patients′ demographics, and lymph node (LN) characteristics. Diagnosis of LN malignancy was based on FNA findings and clinical follow-up.

          RESULTS:

          One hundred eight patients were analyzed; 58 (54%) were men and 87 (79%) were Caucasian. Mean age was 55 years. Prior malignancy was present in 48 (43%) patients. A total of 126 FNA samples from 126 distinct LNs were performed. Twenty-five (20%) LNs were positive for malignancy. Mean short and long-axis for LNs were 13 and 29 mms respectively. Round shape and sharp borders were found in 29 (15%) and 25 (22%) LNs, correspondingly. Independent predictors of a malignant FNA were: Prior cancer (OR 13.10; 95% CI 2.7-63.32; P = 0.001), short axis (OR 1.10; 95% CI 1.00-1.22; P = 0.041) and sharp LN borders (OR 5.47; 95% CI 1.01-29.51; P = 0.048). Age, race, gender, long axis, round shape were not associated with cancer in our cohort.

          LIMITATIONS:

          Retrospective design and lack of surgical gold standard.

          CONCLUSIONS:

          Increased risk of malignancy was associated with prior history of cancer, larger LN short axis and presence of LN sharp borders. These predictors may help guide endoscopists perform FNA in malignant LNs, increasing the overall efficiency of EUS-FNA for ML.

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          Most cited references17

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          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.

          The purpose of this study was to re-evaluate echo features of lymph nodes during endoscopic ultrasound and assess the utility of these echo features and endoscopic ultrasound-guided fine-needle aspiration in predicting malignant lymph node invasion. Thirty-five lymph nodes in 25 patients with lung, esophageal, and pancreatic cancer were evaluated by endoscopic ultrasound. Endoscopic ultrasound examinations were performed with a radial scanning echoendoscope. Confirmation of benign lymph nodes was obtained by surgical resection while malignant lymph nodes were confirmed by real-time endoscopic ultrasound-guided fine-needle aspiration with a linear array echoendoscope. Nineteen benign lymph nodes and 16 malignant lymph nodes in the mediastinum, celiac axis, and the peripancreatic area were included in the study. The following echo features were compared between benign and malignant lymph nodes: size greater than 1 cm, hypoechoic, distinct margins, and round shape. No single feature independently predicted malignant invasion. When all four of the above features were present in the same lymph node, the accuracy for predicting malignant invasion was 80%. However, all four features of malignant involvement were present in only 25% (4 of 16) of malignant lymph nodes. Our study also suggests that the above echo features may be a less reliable predictor of malignant invasion in pulmonary malignancies when compared to gastrointestinal cancers. Endoscopic ultrasound-guided fine-needle aspiration of lymph nodes in 22 patients revealed malignant lymph node invasion in 16 and benign cells in 6 patients. Endoscopic ultrasound-guided fine-needle aspiration is an important adjunct for accurate lymph node assessment for malignancy.
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            Endosonographic features predictive of lymph node metastasis.

            Endosonographic features that are thought to characterize lymph node metastasis were evaluated in 100 patients with esophageal carcinoma. Subjects underwent preoperative endoscopic ultrasonography to assess depth of tumor invasion (T stage) and lymph node metastasis (N stage). Endosonographically imaged lymph nodes were evaluated according to the following parameters: size, shape, border demarcation, and central echo pattern. Sensitivity and specificity of endosonography in detecting lymph node metastasis were 89.1% and 91.7%, respectively, when stringent criteria were used. When lymph nodes were imaged endosonographically, regardless of the specific features, the likelihood of N1 disease, was 86%, whereas when no lymph nodes were imaged, the chance of N0 disease was 79%. Endosonographic features predictive of malignancy in increasing order of importance were echo-poor (hypoechoic) structure, sharply demarcated borders, rounded contour, and size greater than 10 mm. Collectively, the EUS features produced an additive effect with respect to accuracy in the prediction of malignant lymph node involvement; malignancy could be predicted with 100% accuracy when all four features were present. These results demonstrate that a careful and systematic approach to the endosonographic assessment of lymph node metastasis can improve staging accuracy.
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              Dynamic analysis of EUS used for the differentiation of benign and malignant lymph nodes.

              EUS elastography was reported to offer supplemental information that allows a better characterization of tissue, and that might enhance conventional EUS imaging. Our purpose was to apply real-time elastography during EUS examinations and to assess the accuracy of the differentiation of benign versus malignant lymph nodes. Prospective cross-sectional feasibility study. Department of Surgical Gastroenterology, Gentofte University Hospital, Hellerup, Denmark. Patients diagnosed by EUS with cervical, mediastinal, or abdominal lymph nodes were included, with a total number of 78 lymph nodes examined. The final diagnosis of the type of lymph node was obtained by EUS-FNA cytologic analysis or by surgical pathologic examination and by a minimum 6 months of follow-up. Hue histogram analysis of the average images computed from EUS elastography movies was used to assess the color information inside the region of interest and to consequently differentiate benign and malignant lymph nodes. Differentiate between malignant and benign lymph nodes. By using mean hue histogram values, the sensitivity, specificity, and accuracy for the differential diagnosis were 85.4%, 91.9%, and 88.5%, respectively, on the basis of a cutoff level of 166 (middle of green-blue rainbow scale). The proposed method might be useful to avoid color perception errors, moving artifacts, or possible selection bias induced by analysis of still images. Lack of the surgical standard in all cases. Computer-enhanced dynamic analysis based on hue histograms of the EUS elastography movies represents a promising method that allows the differential diagnosis of benign and malignant lymph nodes, offering complementary information added to conventional EUS imaging.
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                Author and article information

                Journal
                Ann Thorac Med
                ATM
                Annals of Thoracic Medicine
                Medknow Publications (India )
                1817-1737
                1998-3557
                Jul-Sep 2011
                : 6
                : 3
                : 126-130
                Affiliations
                [1] Department of Medicine, Division of Gastroenterology and Hepatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
                Author notes
                Address for correspondence: Prof. Mohamad Eloubeidi, Professor of Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El Solh 110 72020 Beirut, Lebanon. E-mail: me75@ 123456aub.edu.lb
                Article
                ATM-6-126
                10.4103/1817-1737.82442
                3131754
                21760843
                4d976e61-8c75-422a-8b88-30a00fa0ee28
                Copyright: © Annals of Thoracic Medicine

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 11 December 2010
                : 20 February 2011
                Categories
                Original Article

                Respiratory medicine
                endoscopic ultrasound,lung cancer,fine needle aspiration,staging,mediastinal lymphadenopathy

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