Comparison of EUS-guided fine needle aspiration and integrated PET-CT in restaging after treatment for locally advanced non-small cell lung cancer
Introduction
Several studies demonstrated that down-staging mediastinal node metastases predicted prolonged survival after induction therapy with chemotherapy and chemo-radiotherapy in patients with locally advanced non-small cell lung cancer (NSCLC) [1], [2], [3], [4], [5], [6]. Concurrent chemo-radiotherapy seems the most effective way to clear tumor cells from nodal stations in stage III disease [6]. Diagnostic procedures for restaging vary in performance and the way they come to conclusions. It is important to determine down-staging of mediastinal nodes and subsequently for selecting patients for surgery. Restaging is difficult especially when mediastinoscopy has been performed previously. Remediastinoscopy gives inadequate information caused by incomplete procedures in 40% of patients due to fibrosis [7]. PET–CT is by far superior to remediastinoscopy [8]. Restaging mediastinal metastases with PET as described in four studies show sensitivities of 50–71% after various induction therapies reflecting the need for pathologic confirmation [9]. A study in 93 patients, restaged after chemo-radiotherapy with repeated PET–CT and various biopsy techniques (including EUS) demonstrated a false negative rate of 20% and a false-positive rate of 25%. Repeated PET–CT was more accurate than repeated CT for all stages [10].
Endoscopic techniques are of interest because they can be performed repeatedly and deliver material for cytopathologic analysis through transbronchial fine needle aspirations (TBNA). Recently a study was published on restaging with TBNA after induction chemo-radiotherapy [11]. A correct diagnosis was obtained in 71% of patients. Nowadays this technique can be performed under guidance of linear ultrasound bronchoscopes (EBUS-TBNA). This technique is very useful in staging the mediastinum in patients without a prior treatment [12], [13]. A recent study described the experience with EBUS-TBNA in restaging the mediastinum after induction chemotherapy in patients with stage IIIA NSCLC [14]. A sensitivity, specificity, positive and negative predictive value and diagnostic accuracy of 76%, 100%, 100%, 20% and 77% respectively were found.
Also endoscopic ultrasound (EUS) is feasible in mediastinal restaging after induction chemotherapy as demonstrated in a study of 19 patients with a reported sensitivity of 75% and accuracy of 83% [15]. This sensitivity is lower than sensitivities reported in the pre-treatment analysis [16]. EUS-FNA for restaging after chemo-radiotherapy has been described in two studies [10], [17]. One study described restaging results in 93 patients but did not report data on the accuracy of EUS in this setting [10]. One study in 14 patients reported a diagnostic accuracy of 86% [17].
The paucity of articles describing the use of EUS for restaging might be caused by a reluctance to perform this procedure on patients with a radiation esophagitis.
In this prospective study, both PET–CT and EUS-FNA were used for restaging patients with stage III NSCLC after induction therapy (chemotherapy or concurrent chemo-radiotherapy).
The performance of both tests was compared with those of surgical dissection of the mediastinum.
Section snippets
Entry criterion
Between February 2006 and May 2008 patients with stage III NSCLC were included after a written informed consent was obtained.
All patients were initially staged with MRI or CT of the brain and integrated PET–CT. Subsequently the mediastinal nodal status was verified with EUS-FNA in 26 patients, cervical mediastinoscopy in 1 patient and transbronchial needle aspiration in 1 patient. Patients were eligible if the pathologically proven metastatic site determined the disease stage and could be
Patient characteristics
Table 1 shows the characteristics of the 28 patients included.The median number of nodal sites biopsied during initial staging procedures was 3 (range 1–6).
Six patients received chemotherapy and 22 patients concurrent chemo-radiotherapy as induction treatment. In 13 of the patients who received concurrent chemo-radiotherapy, two courses of full dose chemotherapy preceded chemo-radiotherapy.
Restaging EUS-FNA and PET–CT was performed within 2 weeks from last treatment date (median 10 respectively
Discussion
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a mediastinal staging modality that has been developed in the last decade. High sensitivities and specificities have been reported in a large number of studies and in a recently reported meta-analysis [16]. Since resolution of ultrasound techniques is high and fine needle aspirations are performed in real-time, EUS and EBUS or combinations of both with FNA have higher diagnostic accuracies than blind TBNA and PET–CT. Therefore
Conflict of interest
The authors declare no conflict of interest.
Acknowledgement
Remco Boksem is acknowledged by the authors for the statistical analysis of survival data.
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