. Step 6 of 41
Clinical Stem 1
Non-smoking female with a new right upper lobe lung mass and three PET-positive mediastinal lymph nodes

Answer B
Any of the four procedures could be performed for diagnosis, so the decision may depend on the availability of equipment and/or expertise, or institutional bias. For lymph node station 4L, the yield is usually higher using EBUS-TBNA than using conventional TBNA. Data from a meta-analysis of EBUS-TBNA for patients with confirmed or suspected NSCLC showed that a subgroup of patients selected on the basis of CT- or PET-positive results had a pooled sensitivity of 94%, which was greater than observed in a subgroup of patients who had not been selected according to CT or PET results.

This patient has an enlarged, PET-positive lymph node. The yield of EBUS-TBNA is expected to be greater than 90%. A negative EBUS-TBNA in patients with highly suspected mediastinal nodal metastases, however, should be followed by mediastinoscopy. Mediastinoscopy allows systematic exploration and biopsy under visual guidance of nodal stations 1, 2, 3, 4 and 7 but has associated morbidity in less experienced hands.

Diagnosis can probably be obtained bronchoscopically: stations 4R, 4L, and 7 can be accessed using conventional TBNA, especially using rapid on-site cytology examination, also known as ROSE. Diagnosis might also be possible using EUS-FNA to sample nodal stations 4L and 7.

Up to 28% of patients with known or suspected to have lung cancer and a high clinical suspicion of nodal disease might have mediastinal nodal metastases confirmed by mediastinoscopy following negative EBUS-TBNA.
References:
  1. Herth FJ, Lunn W, Eberhardt R, et al. Transbronchial versus transesophageal ultrasound-guided aspiration of enlarged mediastinal lymph nodes. Am J Respir Crit Care Med. 2005 May 15;171:1164-7
  2. Gu P, Zhao Y, Jiang L, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: A systematic review and meta-analysis. Eur J Cancer 2009; 45, 1389-1396
  3. Defranchi SA, Edell ES, Daniels C E et al. Mediastinoscopy in Patients with Lung Cancer and Negative Endobronchial Ultrasound Guided Needle Aspiration. Ann Thorac Surg 2010; 90: 1753-8.
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