Endoscopic ultrasound-guided fine needle aspiration of mediastinal lymph node in patients with suspected lung cancer after positron emission tomography and computed tomography scans.

BACKGROUND: The treatment of patients with non-small cell lung cancer (NSCLC) depends on the stage. Positron emission and computed tomography (CT) scans can identify suspicious lymph nodes that require biopsy. We prospectively evaluated the yield and accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in sampling mediastinal lymph nodes and compared its accuracy to that of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and CT in staging NSCLC. METHODS: A consecutive series of patients with suspicious nodes on PET or CT scan in the posterior mediastinal lymph node stations (#5, 7, 8, or 9) were prospectively evaluated by EUS-FNA. The reference standard included thoracotomy with complete lymphadenectomy in patients with lung cancer or if EUS-FNA was benign, repeat clinical imaging, or long-term follow-up. RESULTS: There were 104 patients (63 men) with 125 lesions (117 lymph nodes, 8 left adrenal glands) who underwent EUS-FNA. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 92.5%, 100%, 100%, 94%, and 97%, respectively. EUS-FNA was more accurate and had a higher positive predictive value than the PET or CT (p < 0.001) scan in confirming cancer in the posterior mediastinal lymph nodes. EUS-FNA documented metastatic cancer to the left adrenal in all 4 patients with advanced disease. No deaths resulted from EUS-FNA. One patient experienced self-limited stridor. CONCLUSIONS: EUS-FNA is a safe, accurate, and minimally invasive technique that improves the staging of patients with NSCLC. It is more accurate and has a higher predictive value than either the PET scan or CT scan for posterior mediastinal lymph nodes.

Diagnosis of gastrointestinal tract lesions by endoscopic ultrasound-guided fine-needle aspiration biopsy.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) allows detailed imaging of both intramural and extramural structures of the gastrointestinal (GI) tract and also allows tissue samples to be obtained from masses and lesions in the GI tract. The objective of the current study was to determine the diagnostic utility of EUS-FNA in evaluating intramural and extramural GI tract lesions. METHODS: The authors evaluated all EUS-FNA specimens of GI tract lesions obtained over a 30-month period (from August 2000 to February 2003). Samples of pancreatic and intrabdominal/mediastinal lymph nodes were excluded from the study. A single endosonographer performed all procedures. An attending cytopathologist also was present on site to assess specimen adequacy. Cytologic diagnoses were analyzed for correlations with final diagnoses, which were based on histologic examination of biopsied/resected pathology materials and/or clinical follow-up findings. RESULTS: Sixty-two EUS-FNA specimens of intramural and extramural GI tract lesions were obtained from a total of 60 patients. The mean patient age was 58.8 years (standard deviation, 15.3 years). Thirty-six patients (60%) were male, and 24 (40%) were female. Twenty-eight patients had surgical pathologic evaluation of the corresponding lesions. The remaining 32 patients were followed clinically for a mean duration of 9.5 months (standard deviation, 7.7 months). The anatomic sites of the lesions were as follows: esophagus in 23 patients (37%), stomach in 13 patients (21%), duodenum in 15 patients (24%), and rectum/sigmoid in 11 patients (18%). It is noteworthy that 29 patients (43%) previously had experienced unsuccessful attempts at tissue diagnosis by endoscopic forceps biopsy. Of the 62 EUS-FNA specimens, 43, 4, and 15 were reported as being positive for a neoplasm, suspicious, and benign, respectively. Neoplastic lesions included carcinoma (n = 24), gastrointestinal stromal tumor (GIST; n = 18), neuroendocrine neoplasm (n = 2), and lymphoma (n = 1). There were two cases of endometriosis, three foregut duplication cysts, and one case of diverticulosis. There were two lesions that yielded false-negative findings (one gastric lymphoma and one GIST) secondary to sampling or interpretive error. There also were three cases that yielded false-positive findings (one case of endometriosis, one case of duodenal diverticula with smooth muscle hyperplasia, and one case of normal pancreas, which presented as a periduodenal mass). The sensitivity, specificity, and diagnostic accuracy of EUS-FNA in diagnosing GI tract neoplastic lesions were 89%, 88%, and 89%, respectively. CONCLUSIONS: EUS-FNA provides accurate tissue diagnosis in a wide variety of extraintestinal mass lesions and intramural GI tumors, particularly in patients for whom previous endoscopic forceps biopsy was unsuccessful in establishing a diagnosis.

Endoscopic ultrasound-guided fine needle aspiration biopsy of suspected cholangiocarcinoma.

BACKGROUND AND AIMS: Despite advances in endoscopic techniques for sampling bile duct strictures, the diagnosis of cholangiocarcinoma remains a challenge. The purpose of this study was to evaluate the yield of EUS-FNA and its impact on patient management for patients with suspected cholangiocarcinoma. METHODS: All patients undergoing EUS for the evaluation of suspected malignant biliary strictures were prospectively evaluated over a 23-month period. A single gastroenterologist performed all EUS-FNAs in the presence of a cytopathologist. Reference standard for final diagnosis included surgery, death from disease, and clinical and/or imaging follow-up. RESULTS: Twenty-eight patients (mean age 67 years [SD +/- 11], 72% male) were evaluated. Most patients (91%) presented with obstructive jaundice, and all except 1 had nondiagnostic sampling of the biliary lesions either at ERCP (88%), percutaneous transhepatic cholangiogram (n = 2), and/or computed tomography-guided biopsy (n = 1). Sixty-seven percent (14/21) had no definitive mass seen on prior abdominal imaging studies. The mean tumor size by EUS was 19 mm x 16 mm with a median number of passes to diagnosis of 3 (range 1-7). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86%, 100%, 100%, 57%, and 88%, respectively. EUS-FNA had a positive impact on patient management in 84% of patients: preventing surgery for tissue diagnosis in patients with inoperable disease (n = 10), facilitating surgery in patients with unidentifiable cancer by other modalities (n = 8), and avoiding surgery in benign disease (n = 4). CONCLUSIONS: Given the apparent accuracy and safety of EUS with FNA for imaging bile duct mass lesions and for obtaining a tissue diagnosis in patients with suspected cholangiocarcinoma, this technology may represent a new approach to diagnosis especially when other methods fail. The ability to obtain a definite diagnosis has a significant impact on patient management.