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It's All About US: (E)US, (EB)US, and Their US(age)

We read with interest the article by Pankaj Singh and colleagues wherein they have assessed the role of endoscopic ultrasound (EUS) and guided fine needle aspiration (FNA) in the diagnosis and staging of lung cancer (1). There are certain issues related to the current study, however, which need further clarification.

First, the authors have excluded from the analysis cases (n = 12) in which an increase in the size of lung mass was evident on repeat imaging, and in which a definitive diagnosis of malignancy could not be established. This exclusion could be responsible for the emergence of a procedural diagnostic yield that is higher than the actual yield, since it is possible that some or all of these cases were of lung cancer. If these cases are included in the final analysis, the overall sensitivity of EUS in patients with a lung mass falls from 70% (95% confidence interval [CI], 61–78%) to 63.2% (95% CI, 54.5–71.1%).

Second, a majority (80%) of the patients with non–small cell lung cancer (NSCLC) in this study were in stages III and IV. Although the sensitivity of EUS-FNA was 100% with distant metastases, it was low among patients with a normal mediastinum (57%) or patients with mediastinal lymph node enlargement (MLNE) (79%) on computed tomography (CT). The overall sensitivity of EUS-FNA was also lower for NSCLC (65%) in comparison to SCLC (94%).

A recent prospective study that used routine EUS-FNA in patients with NSCLC found no benefit in patients who were clinically staged as N0 after both CT and integrated positron emission tomography (PET)-CT. However, patients clinically staged as N1 after PET-CT and/or those with adenocarcinoma, upper-lobe tumors, or tumors with a standardized uptake value (SUV) of 10 showed benefit with the addition of mediastinoscopy or EUS-FNA (2). On the other hand, endobronchial ultrasound (EBUS)–guided transbronchial needle aspiration (TBNA) of lymph nodes has been shown to have a sensitivity and specificity of 92.3% and 100%, respectively, even in patients with a normal mediastinum on CT (3), while combined TBNA and PET has been shown to have a sensitivity of 100% in patients with NSCLC with MLNE ( 1 cm) (4). Therefore, the usefulness of EUS-FNA in patients with early NSCLC (stages I and II) needs to be evaluated in future studies. The point is that although minimally invasive techniques for the diagnosis and staging of lung cancer continue to gain importance with time, the prioritization and combination of different invasive and noninvasive procedures is yet to be defined.

Navneet Singh and Ajmal Khan

Postgraduate Institute of Medical Education and Research, Chandigarh, India

FOOTNOTES

Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

1. Singh P, Camazine B, Jadhav Y, Gupta R, Mukhopadhyay P, Khna A, Reddy R, Zheng Q, Smith DD, Khode R, et al. Endoscopic ultrasound as a first test for diagnosis and staging of lung cancer: a prospective study. Am J Respir Crit Care Med 2007;175:345–354.[CrossRef][Medline]
2. Cerfolio RJ, Bryant AS, Eloubeidi MA. Routine mediastinoscopy and esophageal ultrasound fine-needle aspiration in patients with non-small cell lung cancer who are clinically N2 negative: a prospective study. Chest 2006;130:1791–1795.[CrossRef][Medline]
3. Herth FJ, Ernst A, Eberhardt R, Vilmann P, Dienemann H, Krasnik M. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum. Eur Respir J 2006;28:910–914.[Abstract/Free Full Text]
4. Bernasconi M, Chhajed PN, Gambazzi F, Bubendorf L, Rasch H, Kneifel S, Tamm M. Combined transbronchial needle aspiration and positron emission tomography for mediastinal staging of NSCLC. Eur Respir J 2006;27:889–894.[Abstract/Free Full Text]

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