4466 Effectiveness of eus/fna for diagnosing lung cancer in a managed care setting.

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Background: Trans-esophageal endoscopic ultrasound-guided fine needle aspiration (EUS/FNA) is an accurate method to diagnose malignant posterior mediastinal lymph nodes. Previous studies have shown the efficacy of EUS/FNA for lung cancer nodes in tertiary referral centers. The purpose of this study was to assess the effectiveness of EUS/FNA for diagnosing patients with mediastinal adenopathy in a managed care setting. Methods: Patients who received care from a large staff-model HMO and had CT findings of enlarged posterior mediastinal lymph nodes (LN) located adjacent to the esophagus were referred by a pulmonologist and thoracic surgeon for EUS/FNA. All patients were candidates for surgical biopsy (mediastinoscopy, thoracotomy, etc) if EUS/FNA were negative. Patients with prior EUS/FNA or recent chemotherapy were excluded. Data was prospectively collected with follow-up at 3-month intervals. Results: 44 patients underwent EUS/FNA (25 male/19 female, mean age 64). 82% had prior bronchoscopy. FNA was performed in 54 sites (43 LN, 9 masses, 3 other). Malignancy was diagnosed in 28/54 (52%) of FNA sites. There were 23 nonsmall cell lung cancer (NSCLC), 3 small cell lung cancers, and 2 lymphomas diagnosed. EUS/FNA made a new cancer diagnosis in 25/44 (57%) (95% CI: 42%,71%) patients. Cancer was diagnosed in 11% of patients before EUS/FNA, and in 68% of patients after EUS/FNA. 15/25 (60%) (95% CI: 41%, 79%) of patients with a final diagnosis of NSCLC had stage N2 nodes diagnosed. A thoracic surgical procedure was subsequently performed in 9/44 (20%) (95% CI: 68%,91%) of patients during a median follow-up of 6.5 months (1-14 months). There was one false negative LN FNA which was later diagnosed by repeat EUS/FNA as small cell carcinoma. The sensitivity was 96%, specificity 100%, and accuracy 98% for diagnosing malignant LNs. There were no complications. Conclusion: 1) EUS/FNA made a new diagnosis of lung cancer in 57% of patients. 2) EUS/FNA diagnosed malignant lymph nodes in 60% of patients with NSCLC, making surgical benefit unlikely. 3) Only 20% of EUS/FNA patients underwent subsequent thoracic surgery, compared to an expected rate of 100% if EUS/FNA were not performed. 4) In this managed care setting, EUS/FNA of selected patients with mediastinal adenopathy was an accurate, safe, minimally invasive method of diagnosing and staging malignancy, and resulted in patients undergoing fewer thoracic surgical procedures. This work was supported by a grant from the ASGE/ADHF.