Role of transesophageal endosonography-guided fine-needle aspiration in the diagnosis of lung cancer

STUDY OBJECTIVE: Bronchoscopic methods fail to diagnose lung cancer in up to 30% of patients. We studied the role of transesophageal endosonography (EUS)-guided fine-needle aspiration (FNA; EUS-FNA) in such patients. DESIGN: Prospective study. The final diagnosis was confirmed by cytology, histology, or clinical follow-up. SETTING: University hospital. PATIENTS: Thirty-five patients (30 male and 5 female; mean age, 60.9 years; range, 34 to 88 years) with suspected lung cancer in whom bronchoscopic methods failed. Patients with a known diagnosis, recurrence of lung cancer, or mediastinal metastasis from an extrathoracic primary were excluded. INTERVENTIONS: EUS and guided FNA of mediastinal lymph nodes. RESULTS: The procedure was uneventful, and material was adequate in all. The final diagnosis by EUS-FNA was malignancy in 25 patients (11 adenocarcinoma, 10 small cell, 3 squamous cell, and 1 lymphoma) and benign disease in 9 patients (5 inflammatory, 2 sarcoidosis, and 2 anthracosis). Another patient with a benign result had signet-ring cell carcinoma diagnosed on pleural fluid cytology (probably false-negative in EUS-FNA). The sensitivity, specificity, accuracy, and positive and negative predictive values were 96, 100, 97, 100, and 90%, respectively. There were no complications. Reviewing the EUS morphology, the nodes were predominantly located in levels 7 and 8 of American Thoracic Society mediastinal lymph node mapping (subcarinal and paraesophageal region). In seven patients, the punctured nodes were < 1 cm (four malignant and three benign), which are difficult to sample by other methods. The malignant nodes had a hypoechoic, homogenous echotexture. CONCLUSIONS: EUS-FNA is a safe, reliable, and accurate method to establish the diagnosis of suspected lung cancer when bronchoscopic methods fail, especially in the presence of small nodes.     

A descriptive analysis of EUS-FNA for mediastinal lymphadenopathy: an emphasis on clinical impact and false negative results

OBJECTIVES: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been shown to accurately diagnose mediastinal lymph node pathology. We investigated the clinical impact of EUS-FNA in the management of patients with mediastinal lymphadenopathy, and determined the nature and clinical consequences of false negative results. METHODS: We analyzed a cohort of patients who were found to have mediastinal lymph nodes by EUS and underwent FNA. The diagnostic standard included FNA cytology, histopathology, and clinical follow-up. RESULTS: Sixty EUS-FNAs of mediastinal lymph nodes were performed on 59 patients (mean age 61 years old, 74.5% men) over a 24-month period. Prior to EUS, 20 (34%) patients had known malignancy. The most frequent indication for EUS was failed diagnosis by bronchoscopy (54%). EUS-FNA of lymph nodes showed malignant cells in 38%. The diagnostic accuracy of EUS-FNA was 84%. Among the 47 patients who were available for follow-up, EUS-FNA provided new information by changing the clinical diagnosis, and subsequently changed the management in 18 (38%) patients. The false negative rate was 20% (95% exact CI, 8.4-31.6%). Two of the 7 false negative cases received empiric chemoradiation without tissue diagnosis, and 4 received palliative treatment for advanced malignancy. CONCLUSION: The most common indication for EUS-FNA of the mediastinum in our institution is nondiagnostic transbronchial FNA. EUS-FNA is a valuable diagnostic method for sampling mediastinal lymph nodes and affecting management. False negative results do not appear to delay appropriate treatment or adversely affect clinical outcome.     

EUS-FNA and FDG-PET are complementary procedures in the diagnosis of enlarged mediastinal lymph nodes

BACKGROUND AND STUDY AIMS: Transoesophageal endosonography with fine needle aspiration (EUS-FNA) and 2-deoxy-2-[fluorine-18]fluoro-D-glucose positron emission tomography (FDG-PET) are now standard diagnostic procedures of the mediastinum. Our aim was to compare their value in the assessment of enlarged mediastinal lymph nodes detected by computed tomography. PATIENTS AND METHODS: Forty consecutive patients with a suspicion of cancer or a history of pulmonary, digestive, urogenital or mammary neoplasia and presenting with supracentimetric lymph nodes on computed tomography underwent whole body FDG-PET and EUS-FNA. Final diagnosis of malignancy was obtained by cytology, surgery or long-term follow-up. RESULTS: EUS-FNA showed a sensitivity, specificity and accuracy for detection of malignancy of 793, 100 and 85%, respectively. The biopsy material was adequate for cytological examination in 37 patients. Sensitivity, specificity and accuracy of PET were 100, 54.5 and 87.5%, respectively. FDG-PET correctly diagnosed the primary site in 27 patients, and showed additional unknown extrathoracic metastatic sites in 15 patients. The five false positive results observed with FDG-PET consisted in a final diagnosis of sarcoidosis, tuberculosis, anthracosilicosis and reactive lymph nodes, respectively. The association of FDG-PET and EUS-FNA avoided more invasive procedures (mediastinoscopies or staging surgery) in 34 patients. CONCLUSIONS: EUS-FNA and FDG-PET are complementary diagnostic procedures combining the high sensitivity of FDG-PET and the high specificity of EUS-FNA to accurately diagnose malignancy in enlarged mediastinal lymph nodes identified by CTscan. The combination of the two procedures in selected cases with pulmonary cancer or extra-thoracic tumours avoided more invasive diagnostic and surgical procedures.     

Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of sarcoidosis.

The objective of the current study was to assess the yield of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for the diagnosis of sarcoidosis in a large patient group. Bronchoscopy with transbronchial lung biopsy (TBLB) is nondiagnostic in 30% of patients with suspected sarcoidosis and has a risk of pneumothorax and haemoptysis. In order to obtain a diagnosis, mediastinoscopy is often performed as the next diagnostic procedure. EUS-FNA provides a nonsurgical alternative for the demonstration of noncaseating granulomas by aspirating mediastinal lymph nodes from the oesophagus. In total, 51 patients with suspected sarcoidosis stage I and II underwent EUS-FNA. Thirty-six patients (71%) previously underwent a nondiagnostic bronchoscopy. All patients were clinically followed (median 18 months) and surgical-pathological verification occurred in those patients with EUS aspirates that contained unrepresentative material. EUS-FNA demonstrated noncaseating granulomas without necrosis in 41 of 50 patients (82%) with the final diagnosis of sarcoidosis. Specific ultrasound features of clustered, well-demarcated iso-echoic lymph nodes were observed in 64% of patients with sarcoidosis. No complications occurred. Endoscopic ultrasound-guided fine-needle aspiration has a high yield in diagnosing sarcoidosis and qualifies as the next diagnostic step after a nondiagnostic bronchoscopy. The current authors expect that endoscopic ultrasound-guided fine-needle aspiration will reduce the number of mediastinoscopies for the diagnosis of sarcoidosis dramatically.     

The utility and the safety of EUS-guided FNA in the evaluation of duplication cysts

BACKGROUND: Diagnosis of a foregut duplication cyst is of great clinical impact. A definitive diagnosis of a foregut duplication cyst can avert the need for major thoracic surgery in the otherwise asymptomatic individual. This study sought to evaluate the safety and the utility of EUS and EUS-guided FNA (EUS-FNA) in the diagnosis of foregut duplication cysts. METHODS: Over a period of 4 years, 4771 patients underwent EUS for various indications at two EUS referral centers. EUS findings were consistent with a mediastinal cyst in 30 cases. EUS-FNA was performed in 22 patients. A definitive diagnosis was established based on cytology, surgical pathology, and/or clinical follow-up. FNA was done with 22-gauge needles and antibiotic prophylaxis. RESULTS: The appearance of cyst contents on EUS ranged from completely anechoic (23 cases) to hypoechoic (7 cases). Hypoechoic cystic lesions contained echogenic foci. All anechoic lesions were confirmed as benign duplication cysts based on cytology, pathology, and clinical follow-up. Hypoechoic cystic lesions were confirmed to be benign duplication cysts in 4 cases. Three cases proved to be malignant or granulomatous necrotizing lymph nodes. No periprocedural complications occurred. CONCLUSIONS: Variation exists in the EUS appearance of benign mediastinal cysts. EUS-FNA of mediastinal cysts with smaller-gauge needles, and antibiotic prophylaxis appears safe and can provide a definitive diagnosis in atypical mediastinal cystic lesions.     

EUS-guided fine needle aspiration in mediastinal lymphadenopathy of unknown etiology

BACKGROUND: EUS-guided fine needle aspiration (EUS-FNA) has significantly expanded the diagnostic capability of GI EUS. FNA technology can also be helpful in the diagnosis of non-GI disorders. The role of EUS-guided FNA in the diagnosis of mediastinal lymphadenopathy of unknown etiology has not been described. The aim of this study was to evaluate the diagnostic accuracy and impact on subsequent evaluation and therapy of EUS-FNA in mediastinal lymphadenopathy of unknown cause. METHODS: Sixty-two patients (40 men, 22 woman; mean age 56 years, range 16-91 years) with mediastinal lymphadenopathy of unknown etiology underwent EUS-FNA at 6 tertiary referral centers. Presenting symptoms included the following: dysphagia, 6 patients; night sweats, 14; cough, 8; chest pain, 10; odynophagia, 10; fever, 6; weight loss, 8; and asymptomatic/abnormal radiograph, 12. A final diagnosis by EUS-FNA, surgery, autopsy, or long-term follow-up was available for all patients. EUS-FNA results were classified under 3 disease categories: (1) benign/infectious; (2) malignant pulmonary; and (3) malignant mediastinal (e.g., lymphoma, metastatic malignancy). Four EUS features were used as criteria for lymph node metastases: size greater than 1 cm, round shape, sharp border, and homogeneous/hypoechoic echo pattern. RESULTS: Final diagnoses included benign/infectious lymph nodes, 26; malignant pulmonary, 24; and malignant mediastinal, 12. EUS-FNA established a tissue diagnosis in 56 of 62 patients (90%). EUS criteria for malignant lymph nodes were more frequently present in malignant pulmonary (mean 2.6 features) and malignant mediastinal (mean 2.8) than benign/infectious (mean 1.9) lymph nodes. EUS results influenced subsequent evaluation in 87% and therapy in 87% of patients. There was no complication of EUS-FNA. CONCLUSIONS: EUS-FNA in patients with mediastinal lymphadenopathy is safe and guides subsequent therapy in the great majority of cases. Transesophageal EUS-FNA of mediastinal lymph nodes provides minimally invasive tissue sampling, obviating the need for mediastinoscopy or bronchoscopy.     

Endoscopic ultrasound-guided fine needle aspiration in the evaluation of suspected lung cancer

BACKGROUND AND AIM: The role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the diagnosis and staging of lung cancer is still not fully explored. This prospective study aimed to define the effectiveness of EUS-FNA as an adjunct to computer tomography (CT) and bronchoscopy in the evaluation of suspected lung cancer in routine clinical practice. METHODS: Over a period of 20 weeks, the data of 16 consecutive patients suspected of lung cancer on account of respiratory symptoms, and/or the findings of either a mass or mediastinal lymph nodes on helical CT, who were referred for evaluation by EUS, were prospectively collected. Fourteen of these patients underwent sequential bronchoscopy followed by EUS-FNA in the same setting. RESULTS: Bronchoscopy was performed in 15 patients, while EUS was performed in all 16 patients. Bronchoscopy diagnosed 9 cases of non-small-cell lung cancer (NSCLC) but was falsely negative in 3 cases of malignancies, which were all established by EUS-FNA of mediastinal lymph nodes (2 cases of NSCLC and 1 case of esophageal squamous cell cancer). EUS-FNA also diagnosed advanced NSCLC in another patient who did not undergo bronchoscopy, such that eventually 13 patients were diagnosed to have malignancies. Distant metastases were diagnosed by EUS-FNA in 4 cases of NSCLC (2 cases of left adrenal gland and 2 cases of pancreatic metastases). Two patients were diagnosed to have sarcoidosis and 1 patient was diagnosed to have pneumoconiosis eventually. CONCLUSIONS: EUS-FNA is useful as an adjunct to CT and bronchoscopy in the evaluation of suspected lung cancer.     

Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma

BACKGROUND: Preoperative identification of lymph node metastases associated with esophageal carcinoma may influence treatment. EUS is the most accurate method for locoregional staging of these tumors. The impact of EUS-guided fine-needle aspiration (EUS-FNA) on lymph node staging in esophageal carcinoma is unclear. METHODS: From May 1996 to May 1999, 74 patients with esophageal carcinoma underwent preoperative EUS. After October 1998 EUS-guided FNA was performed on nonperitumoral lymph nodes greater than 5 mm in width. The results of EUS with and without FNA were retrospectively reviewed and compared. Final diagnosis was based on surgical results or EUS-guided FNA malignant cytology. Ten of the 74 patients had to be excluded for lack of lymph node stage confirmation. Final diagnosis was obtained in the remaining 64 patients (33 from the EUS only group and 31 from the EUS-FNA group). RESULTS: The results of EUS versus EUS-FNA for lymph node staging were sensitivity 63% versus 93% (p = 0.01), specificity 81% versus 100% (not significant), and accuracy 70% versus 93% (p = 0.02), respectively. Complications comprised 1 patient who developed self-limited bleeding after dilation that did not preclude completion of the EUS (1%, 95% CI [0%, 7%]). CONCLUSIONS: EUS-FNA is more sensitive and accurate than EUS alone for preoperative staging of locoregional and celiac lymph nodes associated with esophageal carcinoma. EUS-FNA of nonperitumoral lymph nodes in patients with esophageal carcinoma is safe and should be routinely performed when treatment decisions will be affected by nodal stage.     

Diagnostic value of transbronchial needle aspiration by Wang 22-gauge cytology needle in intrathoracic lymphadenopathy

OBJECTIVES: The aim of this study was to investigate the diagnostic value of transbronchial needle aspiration (TBNA) performed with a Wang 22-gauge cytology needle in patients with mediastinal and/or hilar adenopathy. DESIGN: Cross-sectional study. SETTING: Tertiary care training hospital. PATIENTS: TBNA procedures were performed using a flexible bronchoscope and a 22-gauge Wang needle in 60 consecutive patients (36 women and 24 men; mean age, 39 +/- 16 years [+/- SD]) who had mediastinal or hilar adenopathy identified on CT of the chest. RESULTS: Adequate lymph node sampling was obtained from 59 of 60 patients (98%). We were able to make a diagnosis in 45 of 60 patients (75%). TBNA was the only tool of diagnosis in 30 of the 60 patients (50%). Diagnoses included tuberculosis (n = 21), sarcoidosis (n = 21), carcinoma (n = 15), and lymphoma (n = 3). Adequate material was obtained from 20 of 21 patients with tuberculosis. The diagnosis made by TBNA was tuberculosis in 13 of 20 cases (65%). In 12 patients, diagnosis of tuberculosis was made cytologically; for the remaining 1 patient, mycobacterial culture was used. TBNA was the only diagnostic tool utilized in 8 of 20 patients with tuberculosis (40%). Diagnostic material was obtained from 16 of 21 patients with sarcoidosis (76%). In sarcoidosis, TBNA provided the only diagnostic specimen in 13 of 21 patients (62%). In all 15 patients with carcinoma (100%), diagnostic materials were obtained. Adequate but nondiagnostic samples were obtained from two patients with lymphoma, and one patient had lymphoma successfully diagnosed with TBNA. No complications were seen except minimal bleeding. CONCLUSION: TBNA performed with a Wang 22-gauge cytology needle is an effective and safe way of obtaining cytologic specimens from intrathoracic lymph nodes and can rapidly provide diagnosis, both in malignant and benign mediastinal diseases. Hopefully, this technique will reduce further need for more invasive surgical procedures.     

Mediastinal lymph node involvement in potentially resectable lung cancer: comparison of CT,positron emission tomography,and endoscopic ultrasonography with and without fine-needle aspiration

PURPOSE: A prospective comparison of three imaging techniques: thoracic CT, positron emission tomography (PET), and endoscopic ultrasonography (EUS) with fine needle aspiration (FNA), each performed under routine conditions, for the detection of metastatic lymph nodes metastases in patients with lung cancer considered for operative resection. PATIENTS AND METHODS: Following bronchoscopic evaluation, CT, PET, and EUS were performed to evaluate potential mediastinal involvement in 33 consecutive patients with bronchoscopic biopsy/cytology proven (n = 25) or radiologically suspected (n = 8) lung cancer prior to surgery. Surgical histology was used as "gold standard" to confirm the diagnosis of the primary tumor and the mediastinal status in all patients. Histology proved non-small cell lung cancer in 30 patients, neuroendocrine tumor in 1 patient, and benign disease in 2 patients. RESULTS: The mean age of the study group was 61.5 years (range, 41 to 80 years; 23 male patients). CT, PET, and EUS detected mediastinal lymph nodes (size, 0.4 to 1.6 cm) in 15, 14, and 27 patients (21 of which were suspected to be malignant on EUS), respectively. With respect to the correct prediction of mediastinal lymph node stage, the sensitivities of CT, PET, and EUS were 57%, 73%, and 94%. Specificities were 74%, 83%, and 71%. Accuracies were 67%, 79%, and 82%. Results of PET could be improved when combined with CT (sensitivity, 81%; specificity, 94%; accuracy, 88%). The specificity of EUS (71%) was improved to 100% by FNA cytology (EUS-guided FNA), which gave a tissue diagnosis including tumor type, without complications. CONCLUSIONS: No single imaging method alone was conclusive in evaluating potential mediastinal involvement in apparently operable lung cancer and routine clinical conditions. A tissue diagnosis is extremely helpful. Because FNA can be performed at the same time as EUS, this combination emerged as the most useful technique in the evaluation of even very small mediastinal metastases of lung cancer. CT seems necessary additionally to evaluate the pretracheal region as well as the rest of the thorax, and PET may be valuable to detect distant metastases.     

Malignant mediastinal lymphadenopathy detected by staging EUS in patients with pancreaticobiliary cancer

BACKGROUND: In patients with pancreatic cancer, the presence of malignant mediastinal lymphadenopathy (MML) would preclude definitive resection. A recent study suggested routine evaluation for mediastinal lymph-node metastases in all patients being evaluated for pancreaticobiliary masses. In our practice, we routinely assess for mediastinal lymph-node metastases in all patients undergoing EUS for pancreaticobiliary cancer. METHODS: We retrospectively evaluated the presence of MML by EUS-guided FNA (EUS-FNA) in 160 consecutive patients with a definite diagnosis of pancreaticobiliary cancer (pancreatic and periampullary cancers) who underwent EUS-FNA by a single operator from 2000 to 2004. Lymph nodes that were round and hypoechoic with sharp margins were considered suspicious and were sampled by FNA. RESULTS: Of the 160 patients included in this study, 78 had peripancreatic lymph nodes (49%: 95% CI[41%, 58%]), 25 had celiac lymph nodes (16%: 95% CI[10%, 22%]), and 14 patients had mediastinal lymph nodes (9%: 95% CI[4%, 13%]) that were suspicious for malignancy by morphologic criteria. In 8 of 14 patients with suspicious mediastinal lymph nodes, FNA documented MML in 5%: 95% CI[2%, 8%]. Only one of these 8 patients with MML had other sites of documented distant metastases by CT and/or positron emission tomography scans. However, 7 of 8 patients had locally advanced cancers. CONCLUSIONS: MML is detected by staging EUS-FNA in 5% of patients with pancreaticobiliary cancer. Because of its important implications, endosonographers should routinely assess for MML in patients who undergo staging EUS for pancreaticobiliary malignancy.     

The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience.

BACKGROUND: The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients. METHODS: The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses. RESULTS: EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement. CONCLUSION: EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.     

Accuracy of EUS criteria and primary tumor site for identification of mediastinal lymph node metastasis from non-small-cell lung cancer

BACKGROUND: EUS with FNA is useful for staging non-small-cell lung cancer. However, benign mediastinal adenopathy is common. The aims of this study were to identify clinical factors, especially primary tumor location, and EUS lymph nodal characteristics predictive of aortopulmonary window and subcarinal lymph node metastases of non-small-cell lung cancer. METHODS: Patients with known or suspected non-small-cell lung cancer underwent EUS staging at which EUS-FNA was performed for all identified mediastinal lymph nodes. Clinical characteristics, primary tumor data, EUS findings, and histopathology were reviewed. Exact tests were performed for both aortopulmonary window and subcarinal lymph nodes to identify factors predictive of malignant cytology. RESULTS: Ninety-two patients with non-small-cell lung cancer were included. Fifty-one had aortopulmonary window, and 73 had subcarinal lymph nodes on EUS. The EUS with FNA specimens were interpreted as suspicious or diagnostic for malignancy for 9 aortopulmonary window and 9 subcarinal lymph nodes. When comparing benign vs. malignant EUS with FNA findings for aortopulmonary window and subcarinal lymph nodes, only lymph node size of 1 cm or greater and sharp lymph nodal edges were associated with malignancy in lymph nodes at both sites, whereas primary tumor site, lymph node shape, and echogenicity were associated with malignant subcarinal nodes. When 4 classic lymph nodal features of malignancy were evaluated, the presence of 3 or more typical features had positive and negative predictive values of, respectively, 41% and 96%. CONCLUSIONS: Although tumor location and EUS lymph nodal characteristics are associated with malignant involvement of lymph nodes, the accuracy of these predictors does not obviate the need for cytologic evaluation. EUS with FNA should be performed for all lymph nodes when an abnormal finding will alter management.     

Esophageal endoscopic ultrasound with fine-needle aspiration with an on-site cytopathologist: high accuracy for the diagnosis of mediastinal lymphadenopathy

STUDY OBJECTIVES: To analyze the accuracy of esophageal endoscopic ultrasound (EUS) with real-time, guided fine-needle aspiration (EUS-FNA) with an on-site cytopathologist in patients with (presumed) lung cancer presenting with mediastinal lymphadenopathy (ML) or a suspect left adrenal gland (LAG). DESIGN: A single-center prospective study. PATIENTS: Sixty-seven outpatients with (presumed) lung cancer with ML or a suspect LAG on either CT and/or positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) scan. INTERVENTIONS: All patients underwent EUS-FNA under conscious sedation. A cytopathologist was present during all procedures. MEASUREMENTS: EUS with and without fine-needle aspiration (FNA) as compared to FDG-PET was evaluated for accuracy in diagnosing cancer, safety, and rate of avoidance for further surgery. RESULTS: Of 67 consecutive patients (56 men; median age, 64 years), malignant ML or LAG were found in 47 patients (70.1%). In 20 patients (29.9%) without EUS-FNA proof of malignancy, confirmation was obtained by surgical procedure in 13 patients (sarcoidosis [n = 5], infection [n = 1], lung cancer [n = 7]) or by clinical follow-up in 5 patients suggesting benign disease. Sixty-five patients were included in the calculation of test characteristics. With malignancy as an end point, the accuracy for EUS-FNA was 100%. This was better than EUS without FNA (accuracy, 75.4%; p < 0.001) or FDG-PET (accuracy, 75.0% [n = 28]; p = 0.0011). When using final histopathologic diagnosis as an end point, the accuracy of EUS-FNA was 92.3%, since EUS-FNA was unable to show noncaseating granulomas in those patients with sarcoidosis diagnosed after mediastinoscopy. Related to the presence of the in situ cytopathologist, there were no inconclusive samples. No adverse events were recorded, and 67.7% of surgical interventions were avoided following EUS-FNA. CONCLUSIONS: The accuracy in this series of EUS-FNA with cytopathologist-assisted rapid on-site evaluation is high. The technique is safe and greatly reduces the number of surgical interventions.     

Ultrasound techniques in the evaluation of the mediastinum,part I: endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS) and transcutaneous mediastinal ultrasound (TMUS), introduction into ultrasound techniques

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography (EUS and EBUS) should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [EBUS combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [EUS fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all mediastinal lymph nodes can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review, in two integrative parts, is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part I is dealing with an introduction into ultrasound techniques, mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques and part II with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.     

Diagnosis of benign cysts of the mediastinum: the role and risks of EUS and FNA

BACKGROUND: Benign mediastinal cysts, which account for approximately 20% of mediastinal masses, may be diagnostic challenges. Information regarding the use of EUS and EUS-guided FNA in this setting is limited. The aim of this study was to demonstrate the value and potential risks of EUS and EUS-FNA in the diagnosis of mediastinal foregut cysts. METHODS: The EUS database of a single tertiary referral center was reviewed for the diagnosis of benign mediastinal cysts. Twenty patients were identified who underwent 23 EUS examinations for suspected mediastinal cysts (n = 4), for follow-up of a known cyst (n = 3), or for a mediastinal mass of unknown origin (n = 16). RESULTS: In 19 patients, the definite diagnosis of a mediastinal cyst was established by EUS. Twelve cysts appeared anechoic, 6 were hypoechoic, and one anechoic cyst contained small echoic foci. CT (n = 17) or magnetic resonance imaging (n = 1) was performed in 18 cases; only 4 of these were diagnostic of a cyst. In 3 cases, the cyst contents were aspirated by EUS-FNA. In a fourth case, a solid-appearing duplication cyst, misdiagnosed by EUS, was sampled with FNA and core biopsy. This patient developed severe sepsis secondary to mediastinitis 4 days later. Thoracotomy revealed an infected bronchogenic cyst. CONCLUSIONS: EUS provides a minimally invasive approach to the diagnosis of benign mediastinal cysts and may be more accurate than CT or other imaging modalities. Aspiration of suspected cysts should be undertaken with caution, given the risk of infection.     

Esophageal tuberculosis: role of endoscopic ultrasound in diagnosis

Esophageal involvement by tuberculosis is rare and is commonly secondary to mediastinal lymph nodal involvement. Endoscopic ultrasound (EUS) is a good modality for evaluation of both esophageal wall and mediastinal lymph nodes. The objectives were to study the role of EUS in diagnosing esophageal tuberculosis, to differentiate primary from secondary form, and to assess the response. Retrospective analysis of data over 7 years (i.e. from 2003 to 2009) was used. The study was set in a tertiary care referral institute and focused on patients diagnosed with esophageal tuberculosis. Interventions used included endoscopy, EUS, EUS‐FNA (fine needle aspiration) followed by antituberculosis treatment. The main outcome measurements were symptoms, endoscopic features, EUS features, pathological yield, and response to treatment. There were 32 cases of esophageal tuberculosis. The primary symptom was dysphagia, and endoscopy showed ulcers in 18/32 (56.25%) and extrinsic bulge in 20/32 (62.5%) in middle one third of esophagus. EUS showed lymph nodes adjacent to esophageal pathology in all cases. Subcarinal region was the most common site of lymphadenopathy and they were matted, heterogeneous with predominantly hypoechoic center. Histopathology of endoscopic biopsy of ulcers and EUS‐FNA of lymph nodes provided the diagnosis of tuberculosis in 27/32 (84.35%). All patients were treated with antitubercular treatment and showed good clinical, endoscopic and endosonographic response. This is a retrospective study, and PCR and culture for Mycobacterium tuberculosis were not done. Esophageal tuberculosis does not appear to be a primary disease and is most likely secondary to mediastinal nodal tuberculosis. A conglomerated mass of heterogeneous with predominantly hypoechoic lymph nodes with intervening hyperechoic strands and foci on EUS appears to be characteristic of mediastinal tuberculosis.     

Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS.

BACKGROUND: Endosonography (EUS) is the most accurate modality for assessing depth of tumor invasion and local lymph node metastasis. However, its accuracy in the identification of metastatic (celiac axis) lymph nodes is less well defined. Our objective in this study was to determine the accuracy of Eus in detecting celiac axis lymph node metastasis in patients with esophageal carcinoma. METHODS: Two hundred fourteen patients with esophageal carcinoma underwent preoperative EUS. Of these, 145 underwent attempted surgical resection and staging, and 4 underwent EUS-guided fine-needle aspiration of mediastinal and celiac lymph nodes. Local (mediastinal) and distant (celiac axis) lymph nodes were assessed for malignancy on the basis of four criteria (larger than 1 cm, round, homogeneous echo pattern, sharp borders). Accuracy of EUS was determined by means of correlating histopathologic findings for the resected lymph nodes or results of EUS-guided fine-needle aspiration cytologic examination. RESULTS: Surgical exploration (n = 145) and fine-needle aspiration cytologic examination (n = 4) revealed metastatic celiac axis lymph nodes in 23 and metastatic mediastinal (local) lymph nodes in 93 of 149 patients with esophageal carcinoma. According to defined criteria for malignant lymph nodes, there were 19 true-positive and 4 falsenegative results. Sensitivity for the diagnosis of celiac lymph node metastasis with EUS was 83% with a 98% specificity. For the diagnosis of mediastinal lymph node metastasis, sensitivity was 79% and specificity was 63%. All patients with malignant celiac axis lymph nodes had local T3 (tumor breaching adventitia) or T4 (tumor invading adjacent organs) disease. CONCLUSION: EUS is an excellent modality in the evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma. These findings should be used in selecting options for treatment. Sensitivity for detecting malignancy is consistent with that of prior studies, and local and regional lymph nodes and specificity is significantly higher.     

应用纵隔镜检查术诊断纵隔淋巴结结核和结节病

目的寻找和探索一种区分良恶性纵隔淋巴结肿大,确诊纵隔淋巴结结核和结节病的有效方法。方法应用纵隔镜检查术对胸部ＣＴ或ＭＲＩ检查发现的纵隔淋巴结肿大、临床诊断不清疑为淋巴结结核或结节病者实施此检查,获取病理组织,做出明确诊断,以指导治疗。结果本组２５例患者接受纵隔镜检查,其中１６例被病理诊断为纵隔淋巴结结核,占６４％（其中增殖性结核１４例,占８８％;干酪性结核２例,占１２％）;８例诊为结节病,占３２％;１例难于确定为淋巴结结核或结节病,占４％。非典型的纵隔淋巴结结核与结节病在影像诊断上难于区别,而且在显微镜下也极易混淆。这两种疾病常与其他原因引起的纵隔淋巴结肿大（如恶性淋巴瘤、淋巴结转移性癌等）在影像检查中不易区分,极易误诊,造成误治。本组病例术前影像诊断及临床诊断大多考虑为恶性疾病,其中第一诊断为恶性疾病的占８４％（２１／２５）,有２例已在外院接受化疗。结论对于纵隔区域发现的肿大淋巴结,纵隔镜检查术是一种很有价值的确诊手段,治疗前应尽一切可能获取明确的病理诊断     

Endosonographically controlled fine needle aspiration cytology--indications and results in routine diagnosis]

The usefulness and clinical utility of routine EUS-guided fine needle aspiration cytology (FNA) in the diagnosis of lesions adjacent to the upper gastrointestinal tract was prospectively studied. METHODS: EUS/FNA was performed in 122 patients for 125 lesions: Mediastinal lymph nodes (n = 56), pancreatic lesions (n = 45), paragastric masses (n = 12), submucosal tumors (n = 4) and small hepatic lesions (n = 2) were successfully punctured for cytological diagnosis. RESULTS: Adequate material was gained in 119 out of 125 punctures (95%). Overall sensitivity, specifity, positive and negative predictive value were 90%, 98%, 98% and 89%. Results of EUS/FNA in mediastinal lymph nodes were superior (95%, 100%, 100%, 90%) to those in pancreatic lesions (80%, 100%, 100%, 80%). In paragastric masses sensitivity was 100% whereas specifity was only 67%--due to one false-positive result. Out of four submucosal tumors diagnosis was revealed in three. Two liver metastasis were successfully punctured. 35 out of 56 mediastinal nodes showed malignancy. 27 metastases of lung-, three of gastric-, two of renal cancer and three Non-Hodgkins's lymphoma were diagnosed. The cytological results of 45 pancreatic lesions showed cancer in 19 and chronic inflammation in 21, two abscesses and three benign cysts. There were no complications. 37 patients were treated on outpatient's basis. CONCLUSIONS: EUS-guided FNA is an accurate and safe technique to sample cytology from lesions adjacent to the wall of the upper gastrointestinal tract. New indications may be established for the diagnosis of lung cancer or metastases of other spreading out into the mediastinum or the celiac axis.