Bronchoscopic and Endobronchial Ultrasound Procedures in Management of Lung Cancers

Lung cancer is the most common cause of cancer death worldwide. The clinical staging oflung identifies treatment options and guides disease prognosis. In patients with non-small-cell lungcancer with no evidence of extra-thoracic spread, the disease status of the mediastinal lymph nodescan be used to establish a patient s suitability for treatment with curative intent.Several invasive and non-invasive techniques are available to support the diagnosis and staging oflung cancer. About 50% of patients present with metastatic disease that is evident outside the thoraxand, in these patients, a biopsy sample taken from the safest most accessible location isrecommended. However, in patients with solely intrathoracic disease evident on the initial CT scan,the diagnostic and staging algorithm is more complex. A sample of the primary lesion is generallytaken by bronchoscopy or CT-guided biopsy before attention turns to mediastinal nodal staging.PET-CT is reliable if mediastinal lymph nodes that are less than 1 cm in the short axis are negative.However, invasive sampling of mediastinal lymphadenopathy is recommended when lymph nodesare avid for 18F-fluorodeoxyglucose (18F-FDG), the tumor is central, there is a PET-positive hilarlymph node, or any mediastinal node is larger than 1 cm in the short axis (irrespective of 18F-FDGuptake).The diagnosis and staging of patients with intrathoracic disease can therefore need severalinvestigative procedures, including bronchoscopy, radiology-guided biopsy sampling, PET-CT, andmediastinoscopy. This process often takes several weeks and is a time of great anxiety for patients.Further time will elapse before a treatment decision has been made which could mean that they areunfit for oncological treatments by the time a treatment decision has been reached.Previous approach to mediastinal staging of non-small-cell lung cancer (CT, PET-CT, andmediastinoscopy) can result in inaccurate nodal staging in 25% of operable patients, perhaps because the sensitivity for the detection of mediastinal metastases by CT scan is 51%, by PET-CT is74%, and by mediastinoscopy is 78%.Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is anewer technique that allows minimally invasive sampling of all intrathoracic lymph nodes adjacentto the bronchial tree. A pooled analysis of 1299 patients with known or suspected non-small-celllung cancer undergoing EBUS-TBNA showed that the procedure had a sensitivity of 90% for thedetection of mediastinal nodal metastases. Now, guidelines recommended EBUS-TBNA as analternative to mediastinoscopy for patients who needed invasive mediastinal sampling after a PETCTscan. Invasive mediastinal sampling is also recommended for staging patients with centraltumors or patients with enlarged or 18F-FDG-avid hilar lymphadenopathy.