Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy

Abstract

Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy Khay L. Khoo, Khek Y. Ho, Tow K. Lim Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a useful diagnostic tool in the evaluation of mediastinal lymphadenopathy, both as a primary modality and in cases of negative transbronchial needle aspiration (TBNA). Aim: To determine the utility of TBNA with rapid on-site cytopathologic evaluation (ROSE) combined with the option for immediate EUS-FNA in the diagnosis of mediastinal adenopathy of unknown etiology. Methods: We prospectively enrolled patients with mediastinal lymphadenopathy on CT scan who required cytologic evaluation. We first performed flexible videobronchoscopy with TBNA. If TBNA was inadequate on ROSE, EUS-FNA was performed immediately, all under topical anesthesia, conscious sedation, and in the same outpatient sitting. The same cytotechnologist was in attendance during both the consecutive procedures to make smears for instant examination. The procedures were terminated when adequate cellular specimens were achieved, or a maximum of six needle passages was done. Results: Twenty patients with mediastinal lymphadenopathy on chest CT underwent TBNA with ROSE. The TBNA specimens were adequate in 13 patients. In the remaining 7 patients, TBNA with ROSE was assessed to be inadequate; thus, EUS-FNA was also performed. Upon cytologic confirmation, TBNA with ROSE was falsely negative in one patient. The diagnostic yield of TBNA was thus 70%. EUS-FNA was positive in 6 of 7 patients, giving a diagnostic yield of 86%. Overall, this combined minimally invasive approach to mediastinal lymphadenopathy, which was well tolerated by all patients with no adverse effects, provided a diagnostic yield of 90%. The final diagnoses were non-small cell cancer (nZ 11), small cell cancer (nZ 2), metastatic adenocarcinoma (nZ 1), sarcoidosis (nZ 1), tuberculosis (nZ 1), and lymphoma (n Z 1). In the first case where this approach failed to give a diagnosis, TBNA showed lymphocytes but interval CT did not show progression of the lymphadenopathy. The second patient had non-small-cell lung cancer. Conclusions: TBNA with ROSE combined with the option for back-to-back EUS-FNA raised the diagnostic yield of TBNA alone from 70% to 90%. This combined approach is safe, convenient and potentially cost-effective for the patient, who needs not undergo another procedure on another day. Abstracts