|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 3 | Page : 572-573
Endobronchial ultrasound-transbronchial needle aspiration: It's prime time
Ria S Shah, Preyas J Vaidya, Prashant N Chhajed
Institute of Pulmonology, Medical Research and Development, Mumbai; Department of Pulmonology, Fortis Hiranadani Hospital, Navi Mumbai, Maharashtra, India
|Date of Submission||09-Aug-2021|
|Date of Decision||10-Aug-2021|
|Date of Acceptance||22-Sep-2021|
|Date of Web Publication||08-Oct-2021|
Prashant N Chhajed
Lung Care and Sleep Centre, 405, Sangam, Corner of S V Road and Saibaba Road, Santacruz West, Mumbai - 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shah RS, Vaidya PJ, Chhajed PN. Endobronchial ultrasound-transbronchial needle aspiration: It's prime time. Cancer Res Stat Treat 2021;4:572-3
Lung cancer is the leading cause of mortality worldwide and requires thorough and timely management. Mediastinal lymph node staging helps determine whether a lung cancer is operable. Chest computed tomography (CT) or positron emission tomography-CT alone is not sufficient to differentiate malignant from benign mediastinal lymph nodes in non-small-cell lung cancer (NSCLC), because of the occasional occurrence of coexisting granulomatous diseases in radiologically active nodes or the presence of an occult malignancy in normal lymph nodes. Hence, mediastinal staging is the defining step in treatment planning.
In a questionnaire-based study by Chandveettil et al., 70 clinicians including only 3 pulmonologists answered practical questions on the utility of endobronchial ultrasound (EBUS) and mediastinoscopy in the staging of NSCLC. The availability of EBUS was 60% and that of mediastinoscopy was 52.2%. About 48% (18) of the respondents suggested a decreasing trend in the utility of mediastinoscopy in the past 2 years and 36% suggested an increase in the use of EBUS-transbronchial needle aspiration (TBNA). This reinforces that the application of mediastinoscopy is becoming limited. It not only requires general anesthesia, hospitalization, and longer waiting time but also costs more. Complications occur in 1.5%–3% of the cases and include hemorrhage, pneumothorax, airway and vascular injury, recurrent laryngeal nerve injury, esophageal injury, tumor spread, and air embolism. EBUS-TBNA comparably is a much safer procedure, even in older patients aged more than 70 years and in patients with superior vena cava syndrome.,
The accessibility of cervical mediastinoscopy is restricted to the stations 2R, 2L, 4R, 4L, and 7. Extended mediastinoscopy is required to access the aortopulmonary nodes. EBUS-TBNA can sample the stations 2R, 2L, 4R, 4L, 7, 10, 11, and 12. The sensitivity of both the procedures is equivalent. Moreover, all nodes larger than 5 mm in transverse diameter are targetable by EBUS-TBNA. Additionally, endobronchial staging for planning of surgery in centrally located tumors can also be performed in the same setting.
In patients with N0 disease and peripheral tumor size <3 cm, mediastinal staging is not recommended. However, pathological upstaging has been documented in up to 35% of the clinically N0 cases on EBUS-TBNA. This underscores the need for EBUS-TBNA even in clinically N0 disease. EBUS-TBNA is treatment altering in patients with clinically N2/N3 disease. N3 hilar involvement, which cannot be accessed by mediastinoscopy, can be easily evaluated by EBUS-TBNA. In these patients, adequate material for molecular testing can be obtained in the same procedure. With the advent of newer targeted therapies not just for patients with stage-III/IV disease but the neoadjuvant or adjuvant setting, EBUS-TBNA. EBUS-TBNA provides an adequate sample for molecular testing of the epidermal growth factor receptor, anaplastic lymphoma kinase, KRAS, etc., in over 90% of the cases. The preserved RNA, DNA, and proteins obtained from the EBUS-TBNA sample can be used for further genetic studies and assessment of chemosensitivity in case of disease recurrence.
Mediastinal restaging is important in stage-IIIA/N2 disease after neoadjuvant chemotherapy for the reassessment of surgery and in recurrent disease in previously treated lung malignancy. In patients who have previously received intervention or treatment, mediastinoscopy can be challenging because of mediastinal fibrosis, adhesions, or anatomical distortion. In such cases, EBUS-TBNA can be considered as the first modality for restaging.
We appreciate the authors, for highlighting the lacunae and dissimilarities in the management of lung cancer in India. Mediastinoscopy may be considered in EBUS-TBNA negative nodes with a high pretest probability for malignant involvement. However, EBUS-TBNA should be considered as the first diagnostic modality for mediastinal staging in NSCLC owing to its safety and profound diagnostic scope even in patients with N0 disease, small tumors, and all adenocarcinomas. As highlighted by the questionnaire, there is a lack of awareness about the utility and availability of EBUS-TBNA among clinicians. Therefore, there is a great need to spread awareness about this modality and ensure adherence to guidelines related to the use of EBUS-TBNA in lung cancer management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Krishnamurthy A. Bridging the gap between guidelines and practice for invasive mediastinal staging in non-small-cell lung cancers. Cancer Res Stat Treat 2021;4:360-2. [Full text]
Chandveettil J, Kattepur A, Pareekutty NM, Kumbakara R, Balasubramanian S. Changing trends of invasive mediastinal evaluationin India: A questionnaire-based survey. Cancer Res Stat Treat 2021;4:231-7. [Full text]
Hanna WC, Yasufuku K. Mediastinoscopy in the era of endobronchial ultrasound: When should it be performed? Curr Respir Care Rep 2013;2:40-6.
Vaidya PJ, Kate AH, Yasufuku K, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer diagnosis and staging. Expert Rev Respir Med 2015;9:45-53.
Wong MK, Tam TC, Lam DC, Ip MS, Ho JC. EBUS-TBNA in patients presented with superior vena cava syndrome. Lung Cancer 2012;77:277-80.
Sehgal IS, Agarwal R, Dhooria S, Prasad KT, Aggarwal AN. Role of EBUS TBNA in staging of lung cancer: A clinician's perspective. J Cytol 2019;36:61-4.
] [Full text]