Combined endobronchial and esophageal endosonography for mediastinal staging in lung cancer: Systematic review and meta-analysis

Abstract

Introduction: Clinical guidelines recommend endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) and/or transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS) for mediastinal staging of lung cancer. The specificity of these tests is close to perfect, but sensitivity for mediastinal nodal metastases is less optimal. Objective: To systematically review studies investigating the diagnostic accuracy of the combined use of EBUS and EUS for mediastinal staging in patients with (suspected) lung cancer, and to evaluate the added value of the combination over either test in isolation. Methods: MEDLINE and EMBASE were searched (inception-01/2015). Data for 2x2 tables were extracted. Random effects meta-analysis was used to calculate summary estimates. Results: Our initial selection identified 11 studies (1,298 patients). Median prevalence of mediastinal nodal metastases was 33% (range 23-78%). Summary sensitivity of the combined approach was 90% (95%CI 84-94%). This was 84% (CI 77-89%) for 6 studies with an optimal reference standard (e.g. pulmonary resection with node dissection), and 96% (CI 92-99%) for 5 studies with a suboptimal standard (e.g. mediastinoscopy or follow-up). Median negative predictive value was 96% (range 85-100%). On average, adding EUS to EBUS increased sensitivity by 13% (CI 8-20%), and detection rate by 5% (CI 3-7%). Adding EBUS to EUS increased sensitivity by 21% (CI 13-30%), and detection rate by 7% (CI 5-9%). Five (0.4%) major complications occurred from EBUS/EUS. Conclusion: Combining EBUS and EUS further improves sensitivity for mediastinal nodal metastases and reduces the number of surgical interventions.