The Role of Endobronchial Ultrasound for Mediastinal Staging in Mesothelioma

Our plain-English summary of The Role of Endobronchial Ultrasound for Mediastinal Staging in Mesothelioma, by D. Steimer, P. Tramontozzi, P. Gedeon, et al (Annals of Thoracic Surgery Short Reports, 2024).

The study

• Authors: D. Steimer, P. Tramontozzi, P. Gedeon, M. Pommerening, A. DeSimone, R. Bueno, H. Tsukada
• Journal: Annals of Thoracic Surgery Short Reports
• Published: 2024;2(4):613-617
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Invasive mediastinal staging is a crucial component of the preoperative evaluation for potential surgical candidates with pleural mesothelioma (PM). Endobronchial ultrasound (EBUS) is less invasive than mediastinoscopy for staging; however, its accuracy in patients with PM remains undefined. We present our institutional experience with EBUS staging in patients with PM.

Methods: Patients with PM who underwent EBUS for mediastinal staging between January 2017 and February 2021 (Brigham and Women's Hospital, Boston, MA) followed by surgical resection were retrospectively reviewed. EBUS cytology was compared with final pathology reports for the corresponding lymph node removed at the time of pleurectomy to assess EBUS accuracy.

Results: During the study period, 91 patients with PM met inclusion criteria. EBUS diagnostic yield was highest at nodal station 7 (84%) and lowest at station 4L (40%). There were 74 patients taken for surgical resection, and 41 patients had matching lymph nodes for analysis. In our series, EBUS had a sensitivity of 81%, a specificity of 93%, a positive predictive value of 90%, and a negative predictive value of 84%.

Conclusions: EBUS is a reasonable alternative to mediastinoscopy for mediastinal staging in patients with mesothelioma.

In plain English

This retrospective single-hospital study (Brigham and Women's Hospital, Boston) examined how accurately endobronchial ultrasound (EBUS)-guided lymph node biopsy detected cancer before surgery for pleural mesothelioma. Between January 2017 and February 2021, 296 patients were evaluated for surgery and 91 had EBUS. EBUS found positive lymph nodes in 12 patients (13%). Of 74 patients taken to the operating room, 41 had at least one lymph node that could be matched to an EBUS sample. Across 327 nodal stations biopsied, EBUS gave a diagnostic result 63% of the time, highest at station 7 (84%) and lowest at station 4L (40%). Compared with surgical pathology, EBUS had a sensitivity of 81% (21 of 26) and a specificity of 93% (27 of 29). Seventeen patients with negative EBUS had positive nodes at surgery. Stations EBUS could not reach held 52% of the nodal metastases found at surgery. The authors concluded that EBUS is a reasonable alternative to mediastinoscopy at high-volume centers with experienced staff, but that mediastinoscopy should remain standard at lower-volume centers. They noted that one highly experienced surgeon performed all EBUS procedures. Asbestos exposure was not studied.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective single-institution case series assessing the diagnostic yield and accuracy of EBUS staging against surgical pathology
• Who was studied: Patients with biopsy-proven pleural mesothelioma evaluated for surgical resection at Brigham and Women's Hospital, Boston, between January 2017 and February 2021. Of 296 evaluated, 91 underwent EBUS; the cohort was predominantly male, White, and of epithelioid subtype.
• Exposure: No asbestos or fiber exposure was studied. The study evaluated EBUS-guided biopsy of mediastinal lymph nodes 4R, 4L and 7 in all patients, with hilar nodes 11L and 11R sampled selectively. Results were compared with nodes removed at pleurectomy and decortication.
• Main results:
  • Among the 91 patients who had EBUS, EBUS found positive lymph nodes in 12 patients (13%); 6 of these had disease at more than one station.
  • Of 74 patients taken to the operating room, 60 (81%) had resectable disease, and 41 had at least one lymph node pair matching an EBUS sample.
  • Across 327 nodal stations biopsied, the overall EBUS diagnostic yield was 63%.
  • Diagnostic yield was highest at station 7 (84%) and lowest at station 4L (40%).
  • In patients with matching nodes, EBUS sensitivity was 81% (21 of 26), specificity 93% (27 of 29), positive predictive value 90% (19 of 21), and negative predictive value 84% (27 of 32).
  • Larger lymph nodes (about 10 mm, the size cutoff in the article) had positive cytology more often than smaller nodes (24% vs 4%).
  • Twenty patients had positive lymph nodes at pleurectomy. Seventeen of them had been node negative by EBUS and were upstaged at surgery.
  • Stations 5, 6, 8 and 9 could not be biopsied by EBUS. These stations accounted for 52% of nodal metastases found at surgery.
  • Preoperative PET-CT poorly predicted nodal metastasis at EBUS-inaccessible stations (sensitivity 25%, positive predictive value 36%).
• The authors' conclusion: The authors concluded that EBUS is a reasonable alternative to cervical mediastinoscopy for staging mesothelioma in patients at high-volume centers. They said it requires an experienced cytopathologist and an experienced EBUS operator. At lower-volume centers, they said mediastinoscopy should remain standard practice, or patients should be referred to a high-volume center.
• Limitations the authors state:
  • Retrospective analysis from a single institution.
  • One highly experienced surgeon performed all EBUS cases, which may have raised the sensitivity and specificity observed. Results may be hard to reproduce at lower-volume centers.
  • Limited surgical specimens at some nodal sites led to patients being excluded and to smaller groups for analysis.
  • EBUS results at station 4L could not be checked against surgery because that station was not removed during pleurectomy.
  • The rarity of mesothelioma prevents study of larger patient groups.

Topics

Medical terms in this study, explained in our Lexicon: Ultrasound, Staging, Mesothelioma, Pleural Mesothelioma, Mediastinoscopy, Brigham and Women's Hospital, Surgical Resection, Cytology.

Related studies

• The role of endobronchial ultrasound guided transbronchial needle aspiration cytology in the investigation of mediastinal lymphadenopathy and masses, the North Tees experience — S. Natu, J. Hoffman, et al. (2010)
• "Dry" pleural mesothelioma successfully diagnosed on endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) — F. Lococo, G. Rossi, et al. (2014)
• Endobronchial ultrasound-guided transbronchial needle aspiration with the flexible 19-gauge needle — R. Trisolini, F. Natali, et al. (2018)
• Endobronchial ultrasound-guided transbronchial needle aspiration in a patient with pericardial mesothelioma — H. Ashinuma, M. Shingyoji, et al. (2015)
• Diagnostic usefulness of endobronchial ultrasound-guided transbronchial needle aspiration in a case with malignant pleural mesothelioma — J. Hamamoto, D. Notsute, et al. (2010)
• The role of endobronchial ultrasound-guided fine needle aspiration in the diagnosis of pleural mesothelioma — M.R. Ghigna, A. Crutu, et al. (2016)

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