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Performance of EUS-FNA for mediastinal lymphadenopathy: impact on patient management and costs in low-volume EUS centers

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      Abstract

      BackgroundEndoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mediastinal lymphadenopathy has been shown to be a valuable diagnostic tool in high-volume EUS centers (≥50 mediastinal EUS-FNA/endoscopist/year). Our goal was to assess the diagnostic accuracy of EUS-FNA and its impact on clinical management and costs in low-volume EUS centers (<50 mediastinal EUS-FNA/endoscopist/year).MethodsConsecutive patients referred to two Dutch endoscopy centers in the period 2002–2008 for EUS-FNA of mediastinal lymphadenopathy were reviewed. The gold standard for a cytological diagnosis was histological confirmation or clinical follow-up of more than 6 months with repeat imaging. The impact of EUS-FNA on clinical management was subdivided into a positive impact by providing (1) adequate cytology that influenced the decision to perform surgery or (2) a diagnosis of a benign inflammatory disorder, and a negative impact which was subdivided into (1) false-negative or inconclusive cytology or (2) an adequate cytological diagnosis that did not influence patient management. Costs of an alternative diagnostic work-up without EUS-FNA, as established by an expert panel, were compared to costs of the actual work-up.ResultsIn total, 213 patients (71% male, median age = 61 years, range = 23–88 years) underwent EUS-FNA. Sensitivity, specificity, and negative and positive predictive values were 89%, 100%, 80%, and 100%, respectively. EUS-FNA had a positive impact on clinical management in 84% of cases by either influencing the decision to perform surgery (49%) or excluding malignant lymphadenopathy (35%), and a negative impact in 7% of cases because of inadequate (3%) or false-negative (4%) cytology. In 9% of cases, EUS-FNA was performed without an established indication. Two nonfatal perforations occurred (0.9%). Total cost reduction was €100,593, with a mean cost reduction of €472 (SD = €607) per patient.ConclusionsMediastinal EUS-FNA can be performed in low-volume EUS centers without compromising diagnostic accuracy. Moreover, EUS-FNA plays an important role in the management of patients with mediastinal lymphadenopathy and reduces total diagnostic costs.

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      Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment.

      Endosonography-guided fine-needle aspiration biopsy (EUS-FNA) permits cytological confirmation of EUS findings. A multicenter prospective evaluation of EUS-FNA for primary diagnosis, staging, and/or follow-up purposes was undertaken. EUS-FNA was performed in 457 patients with 554 lesions. Clinical (n = 218) or histopathologic (n = 256) confirmation was available in 192 lymph nodes, 145 extraluminal masses, 115 gastrointestinal wall lesions, and 22 cystic lesions. EUS-FNA sensitivity, specificity, and accuracy was 92%, 93%, and 92% for lymph nodes, 88%, 95%, and 90% for extraluminal masses, and 61%, 79%, and 67% for gastrointestinal wall lesions, respectively. The sensitivity and accuracy for lymph nodes and extraluminal masses was superior to that for gastrointestinal wall lesions. When EUS-FNA was compared with EUS size criteria in lymph node evaluation, specificity (93% vs. 24%) and accuracy (92% vs. 69%) were superior, whereas sensitivity (92% vs. 86%) was similar. The accuracy of EUS-FNA in patients with previously failed biopsy procedures was 81% (73 of 90). Five nonfatal complications occurred for a rate of 0.5% (95% confidence interval, 0.1%-0.8%) in solid lesions vs. 14% (95% confidence interval, 6%-21%) in cystic lesions. EUS-FNA accurately and safely evaluates solid peri-intestinal lesions and improves lymph node staging accuracy.
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        Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience.

        Endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) is a recent innovation in the evaluation of gastrointestinal and pulmonary malignancies. To review the experience with EUS-FNA of a large single centre. 333 consecutive patients underwent EUS-FNA. Follow up data were available on 327 lesions in 317 patients, including 160 lymph nodes, 144 pancreatic lesions, 15 extraintestinal masses, and eight intramural tumours. A primary diagnosis of malignancy was obtained by EUS-FNA in 62% of patients with clinically suspicious lesions. The overall accuracy of EUS-FNA for the diagnosis of malignancy was 86%, with sensitivity of 84% and specificity of 96%. With respect to lesion types, the sensitivity, specificity, and accuracy were 85%, 100%, and 89% for lymph nodes; 82%, 100%, and 85% for pancreatic lesions; 88%, 100%, and 90% for perirectal masses; and 50%, 25%, and 38% for intramural lesions, respectively. Compared with size and sonographic criteria, EUS-FNA in the evaluation of lymph nodes provided superior accuracy and specificity, without compromising sensitivity. Inadequate specimens were obtained from only six patients, including 3/5 with stromal tumors. Only one complication occurred. EUS-FNA is safe and can readily obtain tissue specimens adequate for cytopathological diagnoses. Compared with size and sonographic criteria, it is a superior modality for the detection of nodal metastases. While providing accurate diagnosis of pancreatic and perirectal malignancies, results suggest the technique is less useful for intramural lesions.
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          Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition).

          The treatment of non-small cell lung cancer (NSCLC) is determined by accurate definition of the stage. If there are no distant metastases, the status of the mediastinal lymph nodes is critical. Although imaging studies can provide some guidance, in many situations invasive staging is necessary. Many different complementary techniques are available. The current guidelines and medical literature that are applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee of the American College of Chest Physicians. Performance characteristics of invasive staging interventions are defined. However, a direct comparison of these results is not warranted because the patients selected for these procedures have been different. It is crucial to define patient groups, and to define the need for an invasive test and selection of the best test based on this. In patients with extensive mediastinal infiltration, invasive staging is not needed. In patients with discrete node enlargement, staging by CT or positron emission tomography (PET) scanning is not sufficiently accurate. The sensitivity of various techniques is similar in this setting, although the false-negative (FN) rate of needle techniques is higher than that for mediastinoscopy. In patients with a stage II or a central tumor, invasive staging of the mediastinal nodes is necessary. Mediastinoscopy is generally preferable because of the higher FN rates of needle techniques in the setting of normal-sized lymph nodes. Patients with a peripheral clinical stage I NSCLC do not usually need invasive confirmation of mediastinal nodes unless a PET scan finding is positive in the nodes. The staging of patients with left upper lobe tumors should include an assessment of the aortopulmonary window lymph nodes.
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            Author and article information

            Affiliations
            [1 ]Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
            [2 ]Department of Gastroenterology, Meander Medical Center, Amersfoort, Netherlands
            [3 ]Department of Pulmonology, University Medical Center Utrecht, Utrecht, Netherlands
            [4 ]Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
            Contributors
            m.m.c.hirdes@umcutrecht.nl
            Journal
            Surg Endosc
            Surgical Endoscopy
            Springer-Verlag (New York )
            0930-2794
            1432-2218
            23 February 2010
            23 February 2010
            September 2010
            : 24
            : 9
            : 2260-2267
            2939341
            20177920
            946
            10.1007/s00464-010-0946-9
            © The Author(s) 2010
            Categories
            Article
            Custom metadata
            © Springer Science+Business Media, LLC 2010

            Surgery

            accuracy, mediastinal lymphadenopathy, costs, eus-fna

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