Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: A systematic review and meta-analysis

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Abstract

Study objectives

Recently, less invasive methods have emerged as potential alternatives for staging with tissue confirmation of suspected metastatic mediastinal lymph nodes in lung cancer. The objective of this review was to assess the overall diagnostic accuracy of EBUS-TBNA in detecting metastatic mediastinal lymph node in lung cancer with a meta-analysis.

Methods

The MEDLINE, EMBASE, Cancerlit and Cochrane Library database, from January 1995 to September 2008, were searched for studies evaluating EBUS-TBNA accuracy. Meta-analysis methods were used to pool sensitivity and specificity and to construct summary receiver-operating characteristic.

Results

A total of 11 studies with 1299 patients, who fulfilled all of the inclusion criteria, were considered for the analysis. No publication bias was found. EBUS-TBNA had a pooled sensitivity of 0.93 (95% CI, 0.91–0.94) and a pooled specificity of 1.00 (95% CI, 0.99–1.00). The subgroup of patients who were selected on the basis of CT or PET positive results had higher pooled sensitivity (0.94, 95% CI 0.93–0.96) than the subgroup of patients without any selection of CT or PET (0.76, 95% CI 0.65–0.85) (p < 0.05). Study sensitivity was not correlated with the prevalence of lymph node metastasis. Only two complications occurred (0.15%).

Conclusion

EBUS-TBNA was an accurate, safe and cost-effective tool in lung cancer staging. The selection of patients who had positive results of suspected lymph node metastasis in CT or PET may improve the sensitivity of EBUS-TBNA. High-quality prospective studies regarding EBUS-TBNA in lung cancer staging are still needed to be conducted.

Introduction

Lung cancer is the leading cause of cancer death with a 5-year survival rate of only 15%.1 The stage of disease dictates the choice of therapy. Surgery is most appropriate for patients in whom disease is confined to the lung and hilar lymph nodes. For patients with ipsilateral mediastinal lymph node metastases, the benefit of surgery as primary therapy is questionable. For patients with contralateral mediastinal lymph node metastases, surgery is generally not indicated, and chemotherapy, radiotherapy or both are considered the standard of care.2 Therefore, adequate staging before surgery is of paramount importance to better stratify the therapeutic approach and to limit the number of futile thoracotomies.

Mediastinoscopy has been the diagnostic standard for staging with tissue confirmation of suspected metastatic mediastinal lymph nodes.3 However, less invasive methods have emerged as potential alternatives. Recently, Micames and colleagues4 have reported in a meta-analysis of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in lung cancer mediastinal staging indicating that EUS-FNA is an accurate, cost-effective means of evaluating patients with lung cancer. Nevertheless, the research also pointed out that the main limitation of EUS-FNA was the inability to visualise mediastinal lymph nodes anterior to the trachea. Unlike EUS-FNA, endo-bronchial ultrasound-guided fine-needle aspiration (EBUS-TBNA) can precisely detect anterior mediastinal lymph nodes, since it is also a minimally invasive method, EBUS-TBNA is possible to be a valuable tool for mediastinal lymph node staging in lung cancer.

Since a large number of studies exploring the role of EBUS-TBNA in staging of lung cancer have been published, a comprehensive systematic review would be useful to synthesise the currently available bulk of information. The objective of this review was to assess the overall diagnostic value of EBUS-TBNA in detecting metastatic mediastinal lymph node in lung cancer with a meta-analysis, which to our knowledge, had not previously been studied.

Section snippets

Literature search

A comprehensive computer literature search5 was performed to identify articles about the diagnostic performance of EBUS-TBNA in detecting mediastinal lymph nodes in lung cancer. The MEDLINE and EMBASE databases, from January 1995 to September 2008, were used with the following key words: ‘endobronchial ultrasound’ OR ‘endoscopic ultrasound’ OR ‘endosonography’ OR ‘transbronchial ultrasound’, and ‘fine-needle’ OR ‘fine-needle aspiration’. Other databases such as Cancerlit, Cochrane Library were

Literature search and study design characteristics

Our research yielded 121 primary studies, of which 101 were excluded after reviewing the title and abstract, nine articles were excluded after reviewing the full article (Fig. 1), the reasons for exclusion were (a) EBUS-TBNA was used for restaging of mediastinal lymph nodes in patients after chemotherapy/radiotherapy or for detecting lymph node in patients with metastatic lung tumour.12, 13, 14 (b) Data or subsets of data were presented in more than one article, the article with fewest details

Discussion

Accurate staging of lung cancer is essential in order to plan effective treatment and to optimise survival rate. Generally, the procedures for lymph node staging can be divided into non-invasive and invasive strategies. Invasive techniques are further subdivided into surgical and non-surgical (minimally invasive) procedures.

Non-invasive methods such as CT and PET are safe but have limited sensitivity and specificity. Dwamena and colleagues31 conducted a meta-analysis, which included 29 studies

Conclusion

EBUS-TBNA was an accurate, safe and cost-effective tool in lung cancer staging. The selection of patients who had positive results of suspected lymph node metastasis in CT or PET may improve the sensitivity of EBUS-TBNA. High-quality prospective studies regarding EUBS-TBNA in lung cancer staging are still needed to be conducted.

Conflict of interest statement

We would like to submit the enclosed paper entitled “Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Staging of Lung Cancer: A Systematic Review and Meta-analysis”. It is submitted to be considered for publication as an origin article in European Journal of Cancer.

This paper is original. Neither the entire paper nor any part of its content has been published or has been accepted elsewhere. We disclose any financial and personal relationships with other people or

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