. Step 6 of 41
Clinical Stem 3
A patient with right upper lobe adenocarcinoma progressing on biomarker-directed therapy

Answer C
In patients with an abnormal PET scan, evaluation of the mediastinum with sampling of abnormal lymph nodes should be performed prior to surgical resection of the primary tumor. Results from a large, randomized trial show that a combined sonographic approach has greater sensitivity for detecting nodal metastases than mediastinoscopy alone. EBUS-TBNA can access mediastinal and hilar nodes with a diagnostic yield similar to mediastinoscopy alone. For patients with suspected nodal involvement, staging and diagnosis can be performed in a single setting.

Non-diagnostic EBUS or EUS-guided TBNA, defined as specimens that contain neither malignant cells nor lymphocytes, occurs in as many as 20% of individual aspirates and 10% of cases overall. Mediastinoscopy is likely warranted in these cases.
References:
  1. Annema JT, van Meerbeeck JP, Rintoul RC, et al. Mediastinoscopy vs. endosonography for mediastinal nodal staging of lung cancer: a randomized trial. JAMA 2010; 304: 2245?2252.
  2. Yasufuku K, Pierre A, Darling G, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011; 142: 1393-400.
  3. Stoll LM, Yung RC, Clark DP, et al. Cytology of endobronchial ultrasound-guided transbronchial needle aspiration versus conventional transbronchial needle aspiration. Cancer Cytopathol 2010;118: 278?286.
  4. Alsharif M, Andrade RS, Groth SS, et al. Endobronchial ultrasound-guided transbronchial fine-needle aspiration: the University of Minnesota experience, with emphasis on usefulness, adequacy assessment, and diagnostic difficulties. Am J Clin Pathol 2008;130:434?443.
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