Bad news for IP guys? Incidental mediastinal lymphadenopathy may not need routine biopsy - PulmCCM
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Dec 302012
 
lung cancer review interventional pulmonology  Bad news for IP guys? Incidental mediastinal lymphadenopathy may not need routine biopsy
(image: Wikipedia)

With increasing use of chest CT, incidental mediastinal lymphadenopathy seems to be frequently discovered and subsequently biopsied using EBUS. The “if it’s enlarged, stick a needle in it” mantra is challenged by a paper by Stigt et al.

83 people (age ~59) with at least one incidentally discovered mediastinal lymph node > 1 cm were enrolled. None had an associated mass.

  • In 43%, a CT-angiogram for suspected pulmonary embolus identified the incidental lymphadenopathy.
  • Most (>50%) had at least 3 stations with lymph nodes > 10 mm.
  • Most (77%) had hilar lymphadenopathy, too.
  • PET was done in 29, and showed high uptake in mediastinal nodes in 25 (87%).

All got endoscopic ultrasound / endobronchial ultrasound with fine needle aspiration. 76 of the 83 had adequate samples. The main results:

  • 55 reactive lymph nodes
  • 18 granulomatous disease, likely sarcoidosis
  • 1 non-TB mycobacterial infection
  • 1 metastatic breast cancer – who had a history of breast cancer and a loculated (cytology-negative) pleural effusion
  • No new diagnoses of cancer

Follow-up CTs (~4 months later) were available for 36 of the 62 patients deemed to have no final diagnosis from the biopsy:

  • 24 of the 36 had unchanged lymphadenopathy.
  • In 9, it went away.
  • 2 had progressive lymphadenopathy. Further biopsies revealed metastatic lung cancer in both. Both initial EUS/EBUS biopsies were negative, with adequate samples. A harder look back at the original CT scans revealed … still no masses identifiable.

J Thorac Oncol 2011;6:1345-1349

When it comes to staging known lung cancer, EBUS / EUS looks equal or superior to mediastinoscopy, and (if it becomes standard care) could prevent thousands of unnecessary mediastinoscopies and thoracotomies. See recent articles in JAMA and CHEST.

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