Echo-endoscopic lymph node staging in lung cancer: an endoscopic alternative

Abstract

Surgical staging by mediastinoscopy has been considered the gold standard for staging the mediastinum in non-small-cell lung cancer; however, it is an invasive procedure which requires general anesthesia and is associated with significant risk. Endosonographic biopsy techniques are a minimally invasive alternative to surgical staging and may be even better than standard mediastinoscopy. Combined endosonographic procedures (EBUS/EUS) are safe, cost-effective, and superior to surgical mediastinal staging. It allows for the biopsy of lymph nodes and metastases that are unattainable with standard mediastinoscopy techniques thereby preventing futile thoracotomies. Combined endosonographic procedures (EBUS/EUS) are the new gold standard in mediastinal staging of non-small-cell lung cancer when performed by an experienced operator.

Keywords:

• combined (EBUS - EUS)
• endosonographic lung cancer staging
• endobronchial ultrasound
• endoscopic ultrasound
• lung cancer staging
• lymph node stations
• mediastinoscopy
• non–small-cell lung cancer
• station 6 lymph node biopsy
• transvascular lymph node biopsy

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Surgical staging by mediastinoscopy has been considered the gold standard for staging the mediastinum in non-small-cell lung cancer; however, it is an invasive procedure requiring general anesthesia and is associated with significant risk.

• Endosonographic biopsy techniques are a minimally invasive alternative to surgical staging and may be even better than standard mediastinoscopy. Combined EBUS/EUS is superior to standard mediastinoscopy because it allows for biopsy of lymph nodes and metastases unattainable with standard mediastinoscopy techniques, thereby preventing futile thoracotomy.

• The need for acquiring adequate tissue for tumor genotyping and to further subcategorize NSCLC is crucial for selection of appropriate therapy. The use of endosonography to obtain adequate samples for this purpose has been reported by several studies.

• The structures below the diaphragm, including the retroperitoneal lymph nodes close to aorta and the celiac axis, left lobe of the liver, and bilateral adrenal metastasis can be easily reached with EUS scope. Hence, combined staging using both EBUS and EUS is expected to be better. The two techniques are complementary and improve mediastinal staging and diagnosis in thoracic malignancy.

• EUS can also be performed using a convex probe EBUS scope and it improves sensitivity when added to EBUS.

• Transvascular lymph node needle aspiration approach can prevent surgery for the diagnosis of poorly situated perivascular lesions in selected patients.

• Our new technique of needle aspiration of station 6 lymph nodes can prevent surgery in carefully selected patients.

• Combined EBUS/EUS is safe, cost-effective, and superior to surgical mediastinal staging. It allows for biopsy of lymph nodes and metastases unattainable with standard mediastinoscopy techniques thereby preventing futile thoracotomies.

• Combined endosonographic procedures (EBUS/EUS) may be the new gold standard in mediastinal staging of NSCLC when performed by an experienced operator.

Notes