Combined EUS-FNA and US-Guided Transbronchial FNA (EBUS-FNA) Performed as a Single Outpatient Procedure: Yield, Time, and Safety

Abstract

Introduction: EUS-FNA and transbronchial needle biopsies are useful in the diagnosis and staging of lung cancer. Neither modality alone is capable of accessing all mediastinal lymph node stations. Lymph nodes stations not accessible by EUS include levels 2 and 4 pretracheal nodes which are readily imaged and sampled using bronchoscopic techniques. Aims: 1) To determine if combined EUS-FNA and EBUS-FNA increases the detection of malignancy in patients with cancer and enlarged mediastinal LNs. 2) To define the length and safety of a combined procedure. Methods: EBUS-TBNA was performed immediately preceeding EUS whenever enlarged LNs were seen in levels 2 or 4 on prior CT scan of the thorax. The duration of the EBUS-TBNA, nodal level, adequacy of sampling, yield, and safety were measured. Results: 11 patients underwent combined procedures. Bronchoscopy with EBUS and sampling of a single station added approximately 15 minutes to the procedure if EBUS was performed by a skilled operator and no teaching was involved. The time required to sample additional stations during EBUS was less than 10 minutes. The procedures performed by the trainee (BH) were on average five minutes longer. Five of the 11 patients had LN samples positive for malignancy. 1/11 EBUS-FNA was positive in an 11 R, contralateral, LN. There were 4 patients with malignancy detected via EUS-FNA. They were not in the same patients as the EBUS-FNA. There were two level 5 LNs, 1 level 7 LN and 1 celiac metastases detected by EUS-FNA. The combination of procedures identified metastases in 45% of the patients; EUS-FNA alone identified 36% of the malignancies. There were no complications. Conclusions: Minimally invasive staging of NSCLC and other mediastinal malignancy using the complementary modalities can be performed as a combined outpatient procedure with minimal increase in time. The combined-modality approach in patients with enlarged LNs increases the sensitivity for the detection of unresectable malignancy by endosonographically-guided biopsy without increasing patient inconvenience. Introduction: EUS-FNA and transbronchial needle biopsies are useful in the diagnosis and staging of lung cancer. Neither modality alone is capable of accessing all mediastinal lymph node stations. Lymph nodes stations not accessible by EUS include levels 2 and 4 pretracheal nodes which are readily imaged and sampled using bronchoscopic techniques. Aims: 1) To determine if combined EUS-FNA and EBUS-FNA increases the detection of malignancy in patients with cancer and enlarged mediastinal LNs. 2) To define the length and safety of a combined procedure. Methods: EBUS-TBNA was performed immediately preceeding EUS whenever enlarged LNs were seen in levels 2 or 4 on prior CT scan of the thorax. The duration of the EBUS-TBNA, nodal level, adequacy of sampling, yield, and safety were measured. Results: 11 patients underwent combined procedures. Bronchoscopy with EBUS and sampling of a single station added approximately 15 minutes to the procedure if EBUS was performed by a skilled operator and no teaching was involved. The time required to sample additional stations during EBUS was less than 10 minutes. The procedures performed by the trainee (BH) were on average five minutes longer. Five of the 11 patients had LN samples positive for malignancy. 1/11 EBUS-FNA was positive in an 11 R, contralateral, LN. There were 4 patients with malignancy detected via EUS-FNA. They were not in the same patients as the EBUS-FNA. There were two level 5 LNs, 1 level 7 LN and 1 celiac metastases detected by EUS-FNA. The combination of procedures identified metastases in 45% of the patients; EUS-FNA alone identified 36% of the malignancies. There were no complications. Conclusions: Minimally invasive staging of NSCLC and other mediastinal malignancy using the complementary modalities can be performed as a combined outpatient procedure with minimal increase in time. The combined-modality approach in patients with enlarged LNs increases the sensitivity for the detection of unresectable malignancy by endosonographically-guided biopsy without increasing patient inconvenience.