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Robert J. Cerfolio - One of the best experts on this subject based on the ideXlab platform.
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The Safety and Efficacy of Mediastinoscopy When Performed by General Thoracic Surgeons
The Annals of Thoracic Surgery, 2014Co-Authors: Benjamin Wei, Ayesha S. Bryant, Douglas J. Minnich, Robert J. CerfolioAbstract:Background Previous publications suggest that mediastinoscopy only obtains a biopsy of lymph node tissue in about 50% of patients; however, those data included results from nonthoracic surgeons. Methods A retrospective cohort study was performed using a database of a consecutive series of patients who underwent mediastinoscopy or video mediastinoscopy by general thoracic surgeons only. Results Between January 1997 and September 2013, 1,970 patients underwent mediastinoscopy (video mediastinoscopy in the last 243). The indications were staging for known or suspected lung cancer in 68.5%. Morbidity occurred in 25 patients (1.3%). Significant bleeding occurred in 5 patients (0.25%): 2 patients required sternotomy, and bleeding in the other 3 was controlled with packing alone. No patients required transfusion. There were no 30-day operative deaths. Median operative time was 18 minutes, and 96.1% of operations were performed as outpatient procedures. Lymph node tissue was obtained from all patients, and biopsy specimens from at least two mediastinal stations were obtained for 98% who had non-small cell lung cancer. The false-negative rate for N2 lymph nodes that were accessible by mediastinoscopy was 8.2% when lymph nodes dissected at the time of pulmonary resection were used as the reference standard. Conclusions In the hands of general thoracic surgeons mediastinoscopy provides lymph node tissue from multiple stations essentially 100% of the time; has minimal morbidity and essentially no deaths; and is a short outpatient procedure. Specialty-specific data (and not national databases) should be used when the efficacy of mediastinoscopy is compared with endobronchial ultrasound.
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routine mediastinoscopy and esophageal ultrasound fine needle aspiration in patients with non small cell lung cancer who are clinically n2 negative a prospective study
Chest, 2006Co-Authors: Robert J. Cerfolio, Ayesha S. Bryant, Mohamad A EloubeidiAbstract:Background Despite normal mediastinal (N2) lymph nodes shown on positron emission tomography (PET) and CT, some physicians routinely perform mediastinoscopy and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) in patients with non-small cell lung cancer (NSCLC). Methods A prospective trial on patients with NSCLC who were clinically staged N2 negative by both integrated PET/CT and CT scan. All underwent mediastinoscopy and EUS-FNA and if N2 negative underwent thoracotomy with thoracic lymphadenectomy. Results There were 153 patients (107 men). Of these, 136 patients were clinically staged N0 and 17 patients were clinically staged N1. Of the 136 patients who were staged as N0, 5 patients (3.7%) had positive EUS-FNA results (three in the subcarinal node), and 4 patients (2.9%) had positive mediastinoscopy results (all in the #4R node; one was N3). Six of the remaining 127 patients (4.7%) had N2 disease after resection. Seventeen patients were clinically staged as N1 by integrated PET/CT. Four patients (23.5%) had positive EUS-FNA results (two in the subcarinal node), 3 patients (17.6%) had positive mediastinoscopy results (all in #4R node; two were N2 and one was N3), and none of the remaining 10 patients had N2 disease after resection. Patients with unsuspected N2 disease were twice as likely (relative risk, 2.1; 95% confidence interval, 1.24 to 2.51; p = 0.02) to have a maximum standardized uptake value (maxSUV) > 10 and poorly differentiated cancer (relative risk, 2.1; 95% confidence interval, 1.14 to 2.38; p = 0.03). Conclusion We do not recommend routine mediastinoscopy or EUS-FNA in patients who are clinically staged as N0 after both integrated PET/CT and CT. However, these procedures should both be considered in patients clinically staged as N1 after PET/CT, and/or in those with adenocarcinoma, upper-lobe tumors, or tumors with a maxSUV ≥ 10.
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endoscopic ultrasound guided fine needle aspiration in patients with non small cell lung cancer and prior negative mediastinoscopy
The Annals of Thoracic Surgery, 2005Co-Authors: Mohamad A Eloubeidi, Ashutosh Tamhane, Victor K Chen, Robert J. CerfolioAbstract:Background Mediastinoscopy and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) are complementary for staging non-small cell lung cancer (NSCLC) patients. We assessed (1) the yield of EUS-FNA of malignant lymph nodes in NSCLC patients with combined anterior and posterior lymph nodes that had already undergone mediastinoscopy and (2) the cost implications associated with alternative initial strategies. Methods All patients underwent chest computed tomography (CT) and/or positron emission tomography (PET), and mediastinoscopy. Then, the posterior mediastinal stations (7, 8, and 9) or station 5 were targeted with EUS-FNA. The reference standard included thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging, or long-term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of NSCLC. Results Thirty-five NSCLC patients met inclusion criteria (median age 65 years; 80% men). Endoscopic ultrasound-guided FNA was performed in 53 lymph nodes in various stations, the subcarinal station (7) being the most common (47.3%). Of the 35 patients who had a prior negative mediastinoscopy, 13 patients (37.1%) had malignant N2 or N3 lymph nodes. Accuracy of EUS-FNA (98.1%) was significantly higher than that of CT (41.5%; p p Conclusions In patients with NSCLC and combined anterior and posterior lymph nodes, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Endoscopic ultrasound-guided FNA is a safe outpatient procedure that is less invasive and less costly than mediastinoscopy.
S Agrawal - One of the best experts on this subject based on the ideXlab platform.
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endobronchial ultrasound guided transbronchial needle aspiration ebus tbna applications in chest disease
Respirology, 2010Co-Authors: Andrew R L Medford, J A Bennett, C M Free, S AgrawalAbstract:Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) offers a minimally invasive option for staging the mediastinum in suspect lung cancer but also in the diagnosis of mediastinal lesions accessible from the airway. This review is aimed at centres considering establishing an EBUS service that may not be so familiar with the technique. It focuses primarily on technical aspects of EBUS-TBNA, training issues, cost considerations, indications, advantages and disadvantages compared with other mediastinal sampling techniques as well as some reference to its performance in clinical studies. In summary, EBUS-TBNA is primarily used for staging non-small cell lung cancer, especially for bulky mediastinal disease and discrete N2 or N3 disease on CT, but also used for the diagnosis of unexplained mediastinal lymphadenopathy. For radical treatment staging, mediastinoscopy is still used at many centres and negative EBUS-TBNA results should be corroborated by mediastinoscopy. In the future, EBUS-TBNA may be used for staging the radiologically normal mediastinum and in re-staging. It is a procedure that can be taught with ease by an experienced operator, has numerous advantages over mediastinoscopy and is potentially cost saving by reducing the number of mediastinoscopies and associated peri-operative support required.
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mediastinal staging procedures in lung cancer ebus tbna and mediastinoscopy
Current Opinion in Pulmonary Medicine, 2009Co-Authors: Andrew R L Medford, J A Bennett, C M Free, S AgrawalAbstract:PURPOSE OF REVIEW There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative. RECENT FINDINGS EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses. SUMMARY Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.
Mohamad A Eloubeidi - One of the best experts on this subject based on the ideXlab platform.
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routine mediastinoscopy and esophageal ultrasound fine needle aspiration in patients with non small cell lung cancer who are clinically n2 negative a prospective study
Chest, 2006Co-Authors: Robert J. Cerfolio, Ayesha S. Bryant, Mohamad A EloubeidiAbstract:Background Despite normal mediastinal (N2) lymph nodes shown on positron emission tomography (PET) and CT, some physicians routinely perform mediastinoscopy and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) in patients with non-small cell lung cancer (NSCLC). Methods A prospective trial on patients with NSCLC who were clinically staged N2 negative by both integrated PET/CT and CT scan. All underwent mediastinoscopy and EUS-FNA and if N2 negative underwent thoracotomy with thoracic lymphadenectomy. Results There were 153 patients (107 men). Of these, 136 patients were clinically staged N0 and 17 patients were clinically staged N1. Of the 136 patients who were staged as N0, 5 patients (3.7%) had positive EUS-FNA results (three in the subcarinal node), and 4 patients (2.9%) had positive mediastinoscopy results (all in the #4R node; one was N3). Six of the remaining 127 patients (4.7%) had N2 disease after resection. Seventeen patients were clinically staged as N1 by integrated PET/CT. Four patients (23.5%) had positive EUS-FNA results (two in the subcarinal node), 3 patients (17.6%) had positive mediastinoscopy results (all in #4R node; two were N2 and one was N3), and none of the remaining 10 patients had N2 disease after resection. Patients with unsuspected N2 disease were twice as likely (relative risk, 2.1; 95% confidence interval, 1.24 to 2.51; p = 0.02) to have a maximum standardized uptake value (maxSUV) > 10 and poorly differentiated cancer (relative risk, 2.1; 95% confidence interval, 1.14 to 2.38; p = 0.03). Conclusion We do not recommend routine mediastinoscopy or EUS-FNA in patients who are clinically staged as N0 after both integrated PET/CT and CT. However, these procedures should both be considered in patients clinically staged as N1 after PET/CT, and/or in those with adenocarcinoma, upper-lobe tumors, or tumors with a maxSUV ≥ 10.
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endoscopic ultrasound guided fine needle aspiration in patients with non small cell lung cancer and prior negative mediastinoscopy
The Annals of Thoracic Surgery, 2005Co-Authors: Mohamad A Eloubeidi, Ashutosh Tamhane, Victor K Chen, Robert J. CerfolioAbstract:Background Mediastinoscopy and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) are complementary for staging non-small cell lung cancer (NSCLC) patients. We assessed (1) the yield of EUS-FNA of malignant lymph nodes in NSCLC patients with combined anterior and posterior lymph nodes that had already undergone mediastinoscopy and (2) the cost implications associated with alternative initial strategies. Methods All patients underwent chest computed tomography (CT) and/or positron emission tomography (PET), and mediastinoscopy. Then, the posterior mediastinal stations (7, 8, and 9) or station 5 were targeted with EUS-FNA. The reference standard included thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging, or long-term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of NSCLC. Results Thirty-five NSCLC patients met inclusion criteria (median age 65 years; 80% men). Endoscopic ultrasound-guided FNA was performed in 53 lymph nodes in various stations, the subcarinal station (7) being the most common (47.3%). Of the 35 patients who had a prior negative mediastinoscopy, 13 patients (37.1%) had malignant N2 or N3 lymph nodes. Accuracy of EUS-FNA (98.1%) was significantly higher than that of CT (41.5%; p p Conclusions In patients with NSCLC and combined anterior and posterior lymph nodes, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Endoscopic ultrasound-guided FNA is a safe outpatient procedure that is less invasive and less costly than mediastinoscopy.
Thomas A Damico - One of the best experts on this subject based on the ideXlab platform.
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nine year single center experience with cervical mediastinoscopy complications and false negative rate
The Annals of Thoracic Surgery, 2006Co-Authors: Anthony Lemaire, Ivana Nikolic, Thomas H Petersen, John C Haney, Eric M Toloza, David H Harpole, Thomas A Damico, William R BurfeindAbstract:Background Mediastinoscopy is a valuable tool for evaluating mediastinal pathology and is essential for establishing treatment strategies in most patients with lung cancer. We sought to determine the complication and false negative rate for mediastinoscopy in an institution that routinely performs this procedure. Methods We performed a retrospective review of 2,145 consecutive mediastinoscopies at a single institution between April 1996 and April 2005. Demographics and complications were analyzed. In patients with lung cancer who underwent subsequent resection, the false negative rate was calculated. Results Mean patient age was 61 ± 0.4 years, and 58% (n = 1,253) were male. Pathology included lung cancer (n = 1,459), metastatic disease (n = 78), lymphoma (n = 51), and other benign disease (n = 557). Twenty-three patients (1.07%) experienced complications including hemorrhage (n = 7, 0.33%), vocal cord dysfunction (n = 12, 0.55%), tracheal injury (n = 2, 0.09%), and pneumothorax (n = 2, 0.09%). There was 1 death (0.05%) after pulmonary artery injury. Five of the 7 vascular injuries occurred during biopsy of level 4R. Three hundred and forty-three patients (23.5%) with lung cancer had positive mediastinoscopies. The false negative rate was 56 of 1,019 (5.5%) among lung cancer patients undergoing resection. Thirty-two (57%) of the false negatives were due to metastatic disease in lymph nodes not normally biopsied during cervical mediastinoscopy (levels 5, 6, 8, or 9). Conclusions Although invasive, mediastinoscopy identified locally advanced disease in a significant percentage of this lung cancer population and was associated with a low false negative rate. Complications after mediastinoscopy were uncommon. These results support the continued routine use of mediastinoscopy.
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a comparative analysis of positron emission tomography and mediastinoscopy in staging non small cell lung cancer
The Journal of Thoracic and Cardiovascular Surgery, 2003Co-Authors: Gonzalo V Gonzalezstawinski, Anthony Lemaire, David H Harpole, Faisal Merchant, Elizabeth K Ohalloran, Edward R Coleman, Thomas A DamicoAbstract:Abstract Objectives Positron emission tomography has been demonstrated to improve the detection of distant metastases in patients with lung cancer. This study compares the efficacy of PET to mediastinoscopy in mediastinal staging of patients with non–small cell lung cancer. Methods Between May 1995 and May 2000, positron emission tomography was performed on 1988 patients with known or suspected non–small cell lung cancer at Duke University Medical Center. Cervical mediastinoscopy was subsequently performed in patients without demonstrable evidence of distant metastases. The efficacy of mediastinal staging was analyzed by comparing the prospective results of positron emission tomography with the histopathologic results of mediastinoscopy by nodal station. Results In this study 202 patients with non–small cell lung cancer (116 of whom were male) underwent mediastinoscopy after positron emission tomography. Of the 65 patients with positive results of positron emission tomography, only 29 patients had positive results of mediastinoscopy in the corresponding nodal station. Of the 137 patients with negative results of positron emission tomography, 16 patients were demonstrated to have N2 or N3 disease. The sensitivity, specificity, positive and negative predictive values, and accuracy for positron emission tomography were 64.4%, 77.1%, 44.6%, 88.3%, and 74.3%, respectively. Histologic findings in patients with non–small cell lung cancer and false-positive results of mediastinal positron emission tomography included granulomatous inflammation, sinus histiocytosis, and silicosis. Conclusions Positron emission tomography neither confirms nor excludes involvement of the mediastinum in patients with non–small cell lung cancer. Cervical mediastinoscopy with lymph node biopsy remains the criterion standard for mediastinal staging.
Andrew R L Medford - One of the best experts on this subject based on the ideXlab platform.
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endobronchial ultrasound guided transbronchial needle aspiration ebus tbna applications in chest disease
Respirology, 2010Co-Authors: Andrew R L Medford, J A Bennett, C M Free, S AgrawalAbstract:Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) offers a minimally invasive option for staging the mediastinum in suspect lung cancer but also in the diagnosis of mediastinal lesions accessible from the airway. This review is aimed at centres considering establishing an EBUS service that may not be so familiar with the technique. It focuses primarily on technical aspects of EBUS-TBNA, training issues, cost considerations, indications, advantages and disadvantages compared with other mediastinal sampling techniques as well as some reference to its performance in clinical studies. In summary, EBUS-TBNA is primarily used for staging non-small cell lung cancer, especially for bulky mediastinal disease and discrete N2 or N3 disease on CT, but also used for the diagnosis of unexplained mediastinal lymphadenopathy. For radical treatment staging, mediastinoscopy is still used at many centres and negative EBUS-TBNA results should be corroborated by mediastinoscopy. In the future, EBUS-TBNA may be used for staging the radiologically normal mediastinum and in re-staging. It is a procedure that can be taught with ease by an experienced operator, has numerous advantages over mediastinoscopy and is potentially cost saving by reducing the number of mediastinoscopies and associated peri-operative support required.
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mediastinal staging procedures in lung cancer ebus tbna and mediastinoscopy
Current Opinion in Pulmonary Medicine, 2009Co-Authors: Andrew R L Medford, J A Bennett, C M Free, S AgrawalAbstract:PURPOSE OF REVIEW There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative. RECENT FINDINGS EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses. SUMMARY Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.