支气管内超声引导针吸活检术在肺癌分期中的应用

目的 探讨支气管内超声引导针吸活检术(EBUS-TBNA)在肺癌分期中的应用价值.方法 回顾性总结2009年9月至2010年2月,52例胸部CT均发现纵隔淋巴结肿大≥1.0 cm肺癌病人经EBUS-TBNA检查的临床资料.结果 经EBUS-TBNA检查证实纵隔淋巴结转移(阳性)者41例,未见纵隔淋巴结转移(阴性)者11例.阳性者放弃手术,予以化疗.阴性者接受胸腔镜或开胸手术,行肺叶切除或肺楔形切除加纵隔淋巴结清扫.术后病理证实,9例纵隔淋巴结确实末见转移,2例纵隔淋巴结可见癌转移,即EBUS-TBNA检查假阴性.EBUS-TBNA的敏感性、特异性、准确性、阳性预测价值及阴性预测价值分别为95.3%、100%、96.2%、100%及81.8%.该检查耐受良好,无任何相关并发症发生.结论 EBUS-TBNA是一种安全、有效的肺癌分期方法.

Abstract：

Objective To determine the value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging of lung cancer. Methods The study was retrospective, a total of 52 patients underwent EBUSTBNA for known or suspected lung cancer. All patients were detected enlarged mediastinal lymph nodes on CT scan ( ≥ 1.0cm). Results Of the 52 patients, 41 patients were found with N2 or N3 disease on EBUS-TBNA. 11 patients with negative EBUS-TBNA underwent thoracoscopy or thoracotomy for pulmonary resection and mediastinal lymph node dissection, 9 patients were confirmed N0 by pathology, whereas 2 patients had metastatic lymph node. The diagnostic sensitivity, specificity, accuracy, positive predictive value and negative predictive value of EBUS-TBNA for the mediastinal staging of lung cancer were 95.3%, 100%, 96.2%, 100%, and 81.8%, respectively. The procedure was uneventful, and there were no postoperative complications. Conclusion EBUS-TBNA is an effective and safe technique for mediastinal staging in lung cancer patients.     

Transbronchial needle aspiration under direct endobronchial ultrasound guidance of PET-positive isolated mediastinal adenopathy in patients with previous malignancy

Background  The diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of isolated mediastinal lymphadenopathy in patients with previous malignancy is not well defined. Positron emission tomography scanning has been proven to be a significant advance, but false-positive results are common. The purpose of this prospective and controlled study was to assess the yield of endobronchial ultrasound-guided transbronchial needle aspiration to reveal mediastinal lymph node metastases in patients with previous malignancy and possible mediastinal involvement on computed tomography and positron emission tomography. Methods  Seventy-three lymph nodes were tested by transbronchial needle aspiration on 48 consecutive patients, each patient underwent to mediastinoscopy or thoracoscopy immediately after needle aspiration for histological confirmation. A cytological sampling adequate for diagnosis was obtained in 45 patients (93.7%); the three cases of inadequate sampling resulted as negative for cancer. Results  The endobronchial ultrasound guided transbronchial needle aspiration gives a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 97.4%, 100%, 100%, 87.5%, and 97.7% respectively. Disease prevalence was 84.4%. All the endoscopic procedures were well tolerated and no immediate complications were recorded. Conclusions  Transbronchial needle aspiration under endobronchial ultrasound guidance is a valuable technique for cytological diagnosis of isolated mediastinal lymphadenopathy in patients with history of malignancy. Tissue sampling by invasive surgical procedures (mediastinoscopy or thoracoscopy) remains mandatory in case of inadequate or negative transbronchial needle aspiration cytology. This work has been performed at Thoracic Surgery and Lung Transplant Unit, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Padiglione Zonda, Via F. Sforza 35, 20122 Milan, Italy.     

Preoperative axillary staging in breast cancer-saving time and resources

Abstract:  This study was performed to assess the feasibility and accuracy of ultrasound guided fine needle aspiration biopsy for axillary staging in invasive breast cancer. Data were collected prospectively from June 2005 to June 2006. In all, 197 patients with invasive breast cancer and clinically nonsuspicious axillary lymph nodes were included. Patients with suspicious nodes on ultrasound had fine needle aspiration biopsy. Those with fine needle aspiration biopsy positive for malignancy were planned for axillary nodes clearance otherwise they had sentinel node biopsy. Patients (41) had ultrasound guided fine needle aspiration biopsy. Three cases were excluded for being nonconclusive. Postoperative histology showed 18/38 cases (47.4%) axillary lymph nodes positive and 20/38 cases (52.6%) axillary nodes negative. Ultrasound guided fine needle aspiration biopsy was positive in 8/38 cases (21.1%), negative in 30/38 cases (78.9%). The sensitivity of ultrasound guided fine needle aspiration biopsy was found to be 47.1%, specificity 100%, positive predictability 100%, negative predictability 70%, and overall accuracy 76.3%. Ultrasound guided fine needle aspiration biopsy was found to be more accurate and sensitive when two or more nodes were involved, raising the sensitivity to 80% and negative predictability to 93.3%. Preoperative axillary staging with ultrasound guided fine needle aspiration biopsy in invasive breast cancer patients is very beneficial in diagnosing nodes positive cases. These cases can be planned for axillary lymph nodes clearance straightaway therefore saving patients from undergoing further surgery as well as time and resources.     

支气管内超声引导针吸活检术在非小细胞肺癌术前分期中的临床应用

目的探讨支气管内超声引导针吸活检术(EBUS-TBNA)在非小细胞肺癌纵隔淋巴结分期中的应用价值。 方法2010年9月至2012年9月,北京大学人民医院利用EBUS-TBNA对术前确诊或CT扫描高度怀疑非小细胞肺癌且伴有纵隔淋巴结肿大(N₂站淋巴结短径≥1.0cm,或N₁站淋巴结短径≥1.0cm且N₂多站短径≥0.5cm者),有手术切除可能,术前无放、化疗史的126例患者进行纵隔淋巴结分期。最终入组82例非小细胞肺癌患者。 结果该组82例患者,经EBUS-TBNA检查证实纵隔淋巴结转移(阳性)者54例,未见纵隔淋巴结转移(阴性)者28例。EBUS-TBNA在该组肺癌术前纵隔淋巴结分期中的敏感度、特异度和准确性分别为94.7%(54/57)、100.0%(25/25)和96.3%(79/82),阳性预测值及阴性预测值分别为100.0%(54/54)和89.3%(25/28)。而CT对于本组患者纵隔淋巴结分期中的敏感度、特异度和准确性分别为98.2%(55/56)、38.5%(10/26)和79.3%(65/82),阳性预测值及阴性预测值分别为77.5%(55/71)和90.9%(10/11)。CT在术前纵隔淋巴结分期中的假阳性率为22.5%(16/71)。全组中,16例(19.5%)肺癌患者因EBUS-TBNA病理结果改变了治疗策略。 结论EBUS-TBNA用于非小细胞肺癌纵隔淋巴结分期的敏感性、特异性和准确性较高。EBUS-TBNA可以作为非小细胞肺癌术前分期、指导治疗策略的检查手段。     

Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung

Background. Endoscopic ultrasound (EUS)-guided fine needle aspiration is a safe, cost-effective procedure that can confirm the presence of mediastinal lymph node metastases and mediastinal tumor invasion. We studied the accuracy of EUS in a large population of lung cancer patients with and without enlarged mediastinal lymph nodes on computed tomographic (CT) scan.

Methods. From 1996 to 2000 all patients referred to our institution with lung tumors and no proven distant metastases were considered for EUS and surgical staging. Patients had endoscopic ultrasound with fine needle aspiration of abnormal appearing mediastinal lymph nodes and evaluation for mediastinal invasion of tumor (stage III or IV disease). Patients without confirmed stage III or IV disease had surgical staging.

Results. Two hundred seventy-seven patients met the inclusion criteria, including 121 who had EUS. Endoscopic ultrasound and fine needle aspiration detected stage III or IV disease in 85 of 121 (70%). Among patients with enlarged lymph nodes on CT, 75 of 97 (77%) had stage III or IV disease detected by EUS. Among a small cohort of patients without enlarged mediastinal lymph nodes on CT, 10 of 24 (42%) had stage III or IV disease detected by EUS. For mediastinal lymph nodes only, the sensitivity of endoscopic ultrasound and CT was 87%. The specificity of EUS (100%) was superior to that of CT (32%) (p < 0.001).

Conclusions. Endoscopic ultrasound with fine needle aspiration identified and histologically confirmed mediastinal disease in more than two thirds of patients with carcinoma of the lung who have abnormal mediastinal CT scans. Although mediastinal disease was more likely in patients with an abnormal mediastinal CT, EUS also detected mediastinal disease in more than one third of patients with a normal mediastinal CT and deserves further study. Endoscopic ultrasound should be considered a first line method of presurgical evaluation of patients with tumors of the lung.     

Comparison of Integrated Positron Emission Tomography/Computed Tomography and Mediastinoscopy in Mediastinal Staging of Non-Small Cell Lung Cancer: Analysis of 212 Patients

Background : Mediastinal staging is crucial to determine the prognosis and treatment options for patients with non-small cell lung cancer (NSCLC). In this study, we compared the results of integrated positron emission tomography-computerised tomography (PET/CT) with those of mediastinoscopy in mediastinal staging of NSCLC patients. Methods : PET/CT and mediastinoscopy was performed on 250 consecutive patients diagnosed with NSCLC between September 2005 and March 2008. Thirty-eight patients were excluded from the study. Standard cervical mediastinoscopy was performed in all patients, and simultaneous extended cervical mediastinoscopy was performed in 52 patients with left sided lesions. Patients with negative mediastinoscopy underwent resection. The pathological results were correlated with PET/CT findings.

Results : A total of 212 patients (199 male, 13 female; mean age: 58.3 years) were evaluated. In PET/CT analysis 60 true-positive, 45 false-positive, 103 true-negative and 4 false-negative patients were found. The rate of PET/CT positivity of mediastinal lymph nodes was 49.5%. The sensitivity, specificity, positive and negative predictive values and accuracy for PET/CT were 93.8%, 69.6%, 57.1%, 96.3% and 76.9% respectively. The incidence of N2 disease in NSCLC patients with negative mediastinal lymph node uptake on PET/CT was 3.7% (4 of 107). In univariate analysis, right upper lobe tumours were significantly (p < 0.05) more associated with occult N2 disease.

Conclusions : In patients with positive mediastinal lymph node uptake on PET/CT invasive mediastinal staging appears necessary for exact staging. Mediastinoscopy can be omitted in NSCLC patients with negative mediastinal uptake on PET/CT in regions where the rate of PET/CT positivity of mediastinal lymph nodes is high.     

Endoscopic ultrasound-guided fine-needle aspiration in the staging and diagnosis of patients with lung cancer

With the advent of endobronchial and esophageal endoscopic ultrasound (EUS), current data suggest that most mediastinal stations can be reached with minimally invasive staging with the exception of stations 5 and 6. EUS fine-needle aspiration (FNA) is a minimally invasive technique that allows sampling of mediastinal lymph nodes relevant to lung cancer staging, particularly in the subcarinal area (station 7), lower paraesophageal lymph nodes (station 8), inferior pulmonary ligament lymph nodes (station 9), and celiac lymph nodes. In addition, EUS-FNA is capable of sampling metastatic, sarcoidosis, and lymphoma harboring lymph nodes. The left adrenal gland is easily sampled by EUS-FNA through the transgastric approach. EUS-FNA is also able to sample central primary lung masses abutting the esophagus, particularly when other techniques fail. By working in a multidisciplinary fashion with colleagues in thoracic surgery, pulmonary, and oncology, the best initial staging approach for each patient can be individualized.     

支气管内超声引导针吸活检术在纵隔淋巴结CT阳性肺癌分期中的价值

目的 评价支气管内超声引导下针吸活检术(EBUS-TBNA)在纵隔淋巴结CT阳性肺癌病例分期中的应用价值.方法 2009年9月至12月共对28例胸部CT纵隔淋巴结阳性(短径≥1 cm)的肺癌病人行EBUS-TBNA检查.总结穿刺结果,评价该方法的诊断价值和安全性.结果 28例共穿刺淋巴结40组,淋巴结穿刺取材满意率96.3%(27/28例),无任何相关并发症.EBUS-TBNA阳性(取得恶性细胞病理学证据)20例,阴性(未取得恶性细胞病理学证据)8例;阴性者接受进一步外科手术,术后证实纵隔淋巴结转移2例(EBUS-TBNA假阴性).EBUS-TBNA检查准确率92.9%(26/28例),灵敏度90.9%(20/22例),特异度100%(6/6例),阳性预测值100%(20/20例),阴性预测值75%(6/8例).结论 EBUS-TBNA是评价纵隔淋巴结CT阳性肺癌分期的安全有效方法.     

Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer

BACKGROUND: Positron emission tomography (PET) is accurate for mediastinal staging of lung cancer but has a moderate positive predictive value, necessitating pathological verification. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) is a technique for tissue verification of mediastinal and upper retroperitoneal abnormalities. The use of EUS-FNA may decrease the number of surgical procedures and thereby staging costs. METHODS: EUS-FNA was used prospectively for the cytological assessment of mediastinal and/or upper retroperitoneal PET hot spots in patients with suspected lung cancer. Only if EUS-FNA was positive for malignancy was subsequent mediastinoscopy or exploratory thoracotomy cancelled. The cost effectiveness of EUS-FNA was determined. RESULTS: Of 488 consecutive patients with suspected lung cancer, 81 were enrolled with mediastinal and/or upper retroperitoneal PET hot spots. EUS-FNA was positive in 50 (62%) patients, negative in six, and inconclusive in 25. Of the 31 negative or inconclusive patients, 26 underwent surgical staging (resulting in 14 patients with and 12 without mediastinal malignancy), while five patients had mediastinal metastases during follow up. No EUS-FNA related morbidity or mortality was encountered. The accuracy of the decision to proceed to surgery (or not) on the basis of EUS-FNA was 77% (95% CI 68 to 86). EUS-FNA detected more mediastinal abnormalities than PET except for the upper mediastinal region. Addition of EUS-FNA to conventional lung cancer staging reduced staging costs by 40% per patient, mainly due to a decrease in surgical staging procedures. CONCLUSION: EUS-FNA can replace more than half of the surgical staging procedures in lung cancer patients with mediastinal and/or upper retroperitoneal PET hot spots, thereby saving 40% of staging costs.     

PET imaging for lymph node dissection in prostate cancer

The detection of neoplastic lymph nodal involvement in prostate cancer (PCa) patients has relevant therapeutic and prognostic significance, both in the clinical settings of primary staging and restaging. Lymph nodal dissection (LND) currently represents the gold standard for evaluating the presence of lymph nodal involvement. However, this procedure is invasive, associated with morbidity, and may fail in detecting all potential lymph nodal metastatic regions. Currently the criteria for lymph nodal detection using conventional imaging techniques mainly rely on morphological assessment with unsatisfactory diagnostic accuracy. Positron emission tomography (PET) represents a helpful imaging technique for a proper staging of lymph nodal status. The most investigated PET radiotracer is choline, although many others have been explored as guide for both primary and salvage LND, such as fluorodeoxyglucose, acetate, fluorocyclobutanecarboxylic acid and prostate-specific membrane antigen. In the present review, a comprehensive literature review addressing the role of PET for LND in PCa patients is reported, with the use of the above-mentioned radiotracers.     

Endoscopic ultrasound in lung cancer patients with a normal mediastinum on computed tomography

BACKGROUND: Computed tomography (CT) is the most common method of staging lung cancer. We have previously shown endoscopic ultrasound guided fine-needle aspiration (EUS-FNA) to be highly accurate in staging patients with nonsmall cell lung cancer (NSCLC) who have enlarged mediastinal lymph nodes on CT scan. In this study we report the accuracy and yield of EUS-FNA in staging patients without enlarged mediastinal lymph nodes by CT. METHODS: Patients with NSCLC and CT scan showing no enlarged mediastinal lymph nodes (> 1 cm for all nodes except > 1.2 cm for subcarinal) in the mediastinum underwent EUS. Fine needle aspiration was performed on at least one lymph node, if present, in the upper mediastinum, aortopulmonary window, subcarinal, and periesophagus regions. Each specimen was evaluated with on-site cytopathology and confirmed with complete cytopathologic examination. RESULTS: Sixty-nine patients without enlarged mediastinal lymph nodes were evaluated. Endoscopic ultrasound detected malignant mediastinal lymph nodes in 14 of 69 patients as well as other advanced (American Joint Committee on Cancer [AJCC] stage III/IV) in 3 others (1 left adrenal, and 2 with mediastinal invasion of tumor) for a total of 17 of 69 (25%, 95% confidence interval: 16% to 34%) patients. Eleven additional patients were found to have advanced disease by bronchoscopy (2), mediastinoscopy (2), and thoracotomy with mediastinal lymph node dissection (7). The sensitivity of EUS for advanced mediastinal disease was 61% (49% to 75%), and the specificity was 98% (95% to 100%). CONCLUSIONS: Endoscopic ultrasound guided fine needle aspiration can detect advanced mediastinal disease and avoid unnecessary surgical exploration in almost one of four patients who have no evidence of mediastinal disease on CT scan. In addition to previously reported results in patients with enlarged lymph nodes on CT, these data suggest that all potentially operable patients with nonmetastatic NSCLC may benefit from EUS staging.     

Diagnostic imaging in the preoperative management of lung cancer

Surgical resection is the accepted standard of care for patients with non-small cell lung cancer (NSCLC). Several imaging modalities play central roles in the detection and staging of the disease. The aim of this review is to evaluate the utility of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and PET/CT for NSCLC staging. Radiographic staging refers to the use of CT as a non-invasive diagnostic technique. However, while the vast majority of patients undergo only CT, CT is a notoriously inaccurate means of tumor and nodal staging in many situations. PET/CT clearly improves the staging, particularly nodal staging, compared to CT or PET alone. In addition, as a result of the increased soft-tissue contrast, MRI is superior to CT for distinguishing between tissue characteristics. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which is a minimally invasive technique, also has pathological diagnostic potential. Extensive research and the resultant improvements in the understanding of genetics, histology, molecular biology and oncology are transforming our understanding of lung cancer, and it is clear that imaging modalities such as CT, MRI, PET and PET/CT will have an important role in its preoperative management. However, thoracic surgeons should also be aware of the limitations of these techniques.     

Ultrasound-guided transbronchial and transesophageal needle biopsy in the mediastinal staging of lung cancer

This review presents the current state of two endosonographic techniques, endobronchial ultrasonography (EBUS) and endoscopic ultrasonography (EUS), and their application in the mediastinal staging of patients with lung cancer. The technique for these procedures is presented and their diagnostic yield is discussed, based on the published evidence. EBUS and EUS, especially in combination with needle aspiration biopsy, emerge as the primary modalities for mediastinal staging because of their high diagnostic yield, minimal invasiveness, low cost, and avoidance of disruption of mediastinal lymphatic pathways before the final treatment.     

Current concepts in the mediastinal lymph node staging of nonsmall cell lung cancer

OBJECTIVE: To review the current concepts in the mediastinal staging of nonsmall cell lung cancer (NSCLC), evaluating traditional and modern staging modalities. SUMMARY BACKGROUND DATA: Staging of NSCLC includes the assessment of mediastinal lymph nodes. Traditionally, computed tomography (CT) and mediastinoscopy are used. Modern staging modalities include magnetic resonance imaging (MRI), positron emission tomography (PET), and endoscopic ultrasound with fine-needle aspiration (EUS-FNA) METHODS: Literature was searched with PubMed and SUMSearch for original, peer-reviewed, full-length articles. Studies were evaluated on inclusion criteria, sample size, and operating characteristics. Endpoints were accuracy, safety, and applicability of the staging methods. RESULTS: CT had moderate sensitivities and specificities. With few exceptions magnetic resonance imaging (MRI) offered no advantages when compared with CT, against higher costs. PET was significantly more accurate than CT. Mediastinoscopy and its variants were widely used as gold standard, although meta-analyses were absent. Percutaneous transthoracic needle biopsy (PTNB) and transbronchial needle biopsy (TBNA) were moderately sensitive and specific. EUS-FNA had high sensitivity and specificity, is a safe and fast procedure, and is cost-effective. EUS-FNA evaluates largely a nonoverlapping mediastinal area compared with mediastinoscopy. CONCLUSIONS: PET has the highest accuracy in the mediastinal staging of NSCLC, but is not generally used yet. EUS-FNA has the potential to perform mediastinal tissue sampling more accurate than TBNA, PTNB, and mediastinoscopy, with fewer complications and costs. Although promising, EUS-FNA is still experimental. Mediastinoscopy is still considered as gold standard for mediastinal staging of NSCLC.     

Section III: endoscopic and other staging techniques

Accurate staging of esophageal cancer is important as disease survival closely correlates with TNM stage. The optimal management of patients with esophageal cancer utilizes stage-dependent algorithms. The primary diagnosis of esophageal cancer is established by upper endoscopy and biopsy. Computed tomography (CT) is typically the next test performed and is most valuable at detecting metastatic (M) distant disease, particularly in the liver, lungs, and bone. Positron emission tomography (PET) scanning with 18-fluorodeoxyglucose also is useful in detecting distant disease. Endoscopic ultrasound (EUS) combines endoscopy with high-frequency ultrasonography to obtain detailed images of the tumor and surrounding structures. EUS is the most accurate technique for the locoregional (T and N) staging of esophageal cancer. The recent availability of EUS-directed fine needle aspiration (FNA) has allowed a tissue diagnosis of lymph nodes both periesophageal and in the celiac axis. EUS-FNA can also sample liver metastases. Laparoscopic and thoracoscopic techniques can also be used to sample thoracic and celiac axis lymph nodes. Optimal staging strategies for esophageal cancer combine EUS FNA with either CT or PET scans.     

The value of mediastinal staging with endobronchial ultrasound-guided transbronchial needle aspiration in patients with lung cancer

Objective: To evaluate the diagnostic yield, the learning curve and the safety of endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) in mediastinal staging of patients with lung cancer. Methods: Mediastinal staging was performed with EBUS-TBNA according to the Danish national guidelines in patients fulfilling one or more of the following criteria: (1) central tumour; (2) enlarged (>10 mm) mediastinal lymph nodes on computed tomography; or (3) positron emission tomography (PET)-positive mediastinal lymph nodes. The study period began in January 2006 when EBUS-TBNA was introduced in the department and ended in December 2007. All records were reviewed retrospectively. None of the four examiners had any previous experience with EBUS-TBNA or ultrasound when the study began. All examinations were performed under general anaesthesia. Patients without useful cytological material from the EBUS-TBNA were subjected to a supplementary standard cervical mediastinoscopy if the mediastinal lymph nodes were found to be enlarged (>10 mm), PET positive or if the examiner was insecure of the result of the EBUS-TBNA. Patients with mediastinal lymph node involvement, detected by EBUS-TBNA or standard cervical mediastinoscopy, were referred to oncological treatment, while those without mediastinal lymph node involvement underwent – if they were otherwise eligible for surgery – resection and systematic lymph node sampling either by thoracotomy or by video-assisted thoracoscopy. Final mediastinal staging was defined as positive if mediastinal lymph node involvement was detected by EBUS-TBNA, standard cervical mediastinoscopy or surgery, or defined as negative otherwise. Results: A total of 157 patients were included in the study. N2/N3 disease was found in 67 patients (42.6%). EBUS-TBNA missed the mediastinal spread in 10 patients. Five of the ten patients had lymph node metastases in station 5, 6 or 8 – out of reach of EBUS-TBNA or standard cervical mediastinoscopy. EBUS-TBNA had a sensitivity of 0.85 (0.74–0.93) and a negative predictive value of 0.90 (0.82–0.95). No complications occurred from EBUS-TBNA. The number of supplementary standard cervical mediastinoscopies decreased significantly in the study period. Conclusion: The results of this study suggest that staging of the mediastinum with EBUS-TBNA is safe and easy to learn – even without previous experience with ultrasound. The diagnostic yield of EBUS-TBNA is in accordance with the yield of standard cervical mediastinoscopy reported in the literature. We do not find any indications in the present study of the recommended necessity for mediastinoscopy in all EBUS-TBNA-negative patients.     

淋巴管造影对前列腺癌盆腔淋巴结转移的诊断价值

目的 评价淋巴管造影在诊断前列腺癌盆腔淋巴结转移的价值。方法 61例前列腺癌患者行足背淋巴管造影，对10例阳性、4例可疑及47例阴性患者行细针穿刺抽吸细胞学检查和淋巴结活检。结果 10例淋巴管造影阳性者，经细针穿刺抽吸细胞学检查和病理证实淋巴结转移9例，假阳性1例。4例可疑患者，经细针穿刺抽吸细胞学检查和前列腺癌根治术后病理证实无淋巴结转移。47例阴性者中，经细针穿刺抽吸细胞学检查和病理证实假阴性4例（8．5％）。结论 淋巴管造影对前列腺癌淋巴结转移有较高的诊断价值，对阳性或可疑淋巴结细针穿刺抽吸细胞学检查可避免假阳性，但有一定的假阴性。     

Axillary staging using positron emission tomography in breast cancer patients qualifying for sentinel lymph node biopsy

Axillary lymph node dissection (ALND) is the standard of care for nodal staging of patients with invasive breast cancer. Due to significant somatic and psychological side effects, replacement of ALND with less invasive techniques is desirable. The goal of this study was to evaluate the clinical usefulness of axillary lymph node (ALN) staging by means of positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) in breast cancer patients qualifying for sentinel lymph node biopsy (SLNB). FDG-PET was performed within 1 week before surgery in 24 clinically node-negative breast cancer patients with tumors smaller than 3 cm. Sentinel lymph nodes (SLNs) were identified by preoperative lymphoscintigraphy following peritumoral technetium 99m-labeled colloid albumin injection, and by intraoperative gamma detector and blue dye localization. Following SLNB, a standard ALND was performed. Serial sectioning and immunohistochemistry of the SLN as well as standard histologic examination of the non-SLN was performed. FDG-PET detected all primary breast cancers. Staging of ALNs by PET was accurate in 15 of 24 patients (62.5%), whereas PET staging was false negative in 8 of 10 node-positive patients and false-positive in 1 patient. The sensitivity, specificity, positive predictive value, and negative predictive value of FDG-PET for nodal status was 20%, 93%, 67%, and 62%, respectively. The mean diameter of false-negative ALN metastases was 7.5 mm (range 1-15 mm). Lymph node staging using FDG-PET is not accurate enough in clinically node-negative patients with breast cancer qualifying for SLNB and should not be used for this purpose.     

Does endoesophageal ultrasound-guided fine-needle aspiration replace mediastinoscopy in mediastinal staging of thoracic malignancies?

OBJECTIVE: To determine the impact of endoesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) on management of thoracic malignancies. METHODS: One hundred and twenty patients referred for invasive diagnostic and resection of thoracic malignancies were studied prospectively. Negative and inconclusive EUS-FNA findings were assessed by video-assisted mediastinoscopic lymphadenectomy (VAMLA) or open lymphadenectomy. RESULTS: One hundred and twenty patients, aged 64.1 years (range 38-85) underwent 120 EUS-FNA, 53 video-assisted mediastinoscopic and 48 open lymphadenectomies for diagnosis and treatment of 99 lung carcinoma, six lung metastases, five mesothelioma, three lymphoma, and eight other conditions. EUS-FNA showed T4 in 15/120 and adrenal or hepatic metastases in 9/120 cases. Prevalence of mediastinal lymph node metastases was 51.7%. EUS-FNA false-negative rate was 25.3%. EUS-FNA sensitivity was 91.7%, 78.1% and 43.8% for bulky disease, enlarged mediastinal nodes or normal nodes on CT scan, 50% and 96.6% for right- and left-sided tumours, and 80.6%, 78.9%, 23.8% and 25.0% for the lymph node stations 7, 5/6, 4R, and 4L. A 38.3% respectively 100% cut-down of mediastinoscopies leads in 7.5% respectively 20.8% to incorrect treatment decisions. CONCLUSIONS: EUS-FNA sensitivity depends on the localisation of the primary tumour, and extent and location of mediastinal disease. For left-sided tumours, EUS-FNA improves mediastinal staging by assessing stations 5 and 6 inaccessible to conventional mediastinoscopy. For extended mediastinal disease, mediastinoscopy can be avoided or spared for restaging after neoadjuvant therapy. Exclusion of mediastinal involvement requires mediastinoscopy or open lymphadenectomy. Beyond mediastinal nodal staging, EUS-FNA may detect T4 and M1 situations. Thus, EUS-FNA is a useful supplement to and not the replacement of mediastinoscopy.     

PET staging of mediastinal lymph nodes in thoracic oncology

There is an extensive and growing body of literature about the role of positron emission tomography (PET) in the management of non-small cell lung cancer and esophageal cancer. This article focuses on the use of PET in mediastinal staging of these common thoracic malignancies. PET is the most accurate noninvasive approach to staging mediastinal lymph nodes in non-small cell lung cancer. The role of PET in mediastinal lymph node staging in esophageal cancer is less clear, since it has been largely supplanted by endoscopic ultrasonography. A review of the evidence for and against the use of PET in mediastinal staging is provided and the use of PET in practice is discussed.