Transesophageal endoscopic ultrasound (EUS) in pulmonary medicine

Abstract

Endoscopic ultrasound (EUS) is a safe and minimally invasive procedure, allowing ultrasound-guided needle aspirates in real-time, with high-sensitivity diagnostics. EUS is an instrument available to the pulmonologist for the diagnosis of mediastinal neo-plasms, benign and malignant, including the mediastinal lymph node staging of non-small cell lung cancer (NSCLC), with a specific sensitivity up to 90%. EUS allows to detect and to sample even small lesions with a diameter of 3 mm, which are not visible at usual imaging. The most recent guidelines on mediastinal nodal staging of lung cancer report endoscopic and trans-bronchial ultrasound (EUS and EBUS) as a viable and valid minimally invasive alternative to the “classical” surgical staging with mediastinoscopy, resulting in significant savings in diagnostic invasive surgical procedures, and unnecessary thoracotomy, with a consequent high economical impact. EUS-FNA, as EBUS-TBNA, has been shown to be able to give in one time the diagnosis, the typing, staging, and genotyping of lung cancer with a single diagnostic procedure. However, it must be highlighted that in the mediastinal nodal re-staging of NSCLC, the sensitivity of EUS-FNA significantly decreases, being <50%. Therefore, in all cases of negativity at the re-staging a surgical mediastinoscopy should be performed before therapeutical decisions. EUS should be performed in referral centres, so patients should be referred to centres of reference for a complete endoscopic staging with EBUS/ EUS. All patients, except those with a known pathologic esophageal stenosis, might be investigated by EUS, even on an outpatient basis, in mild sedation with midazolam, or deep sedation with anaesthesia care based on the internal structure organization, and complications are very rare.