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Transesophageal Endoscopic Ultrasound with Fine Needle Aspiration in the Preoperative Staging of Malignant Pleural Mesothelioma

Authors' Affiliations: ¹ Department of Respiratory Medicine and Lung Oncology Network, Ghent University Hospital, Ghent, Belgium; ² Departments of Thoracic Oncology and Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; and ³ Department of Respiratory Medicine, Leiden University Medical Center, Leiden, the Netherlands

Requests for reprints: Kurt Tournoy, Department of Respiratory Medicine, Ghent University Hospital, Building 7K12 I.E., De Pintelaan 185, 9000 Ghent, Belgium. Phone: 32-9-3322611; Fax: 32-9-3322341. E-mail: kurt.tournoy{at}UGent.be.

Purpose: Surgical resection as part of a multimodality approach in malignant pleural mesothelioma (MPM) has a high morbidity and mortality. Because mediastinal lymph node (MLN) metastases are a negative prognostic factor, preoperative staging is of paramount importance. Transesophageal endoscopic ultrasound with real-time guided fine needle aspiration (EUS-FNA) enables accurate MLN staging in lung cancer.

Experimental Design: The feasibility and yield of EUS-FNA in MLN staging were prospectively analyzed in patients with presumed early-stage MPM considered for multimodality therapy. MLN reference pathology was defined by either pathologic staging or the formal demonstration of malignant cells by either EUS-FNA or mediastinoscopy.

Results: Thirty-two consecutive patients (81% males; median age, 61 years) with proven MPM underwent EUS-FNA. In 11 (34%) patients, a negative EUS-FNA or mediastinoscopy was not confirmed by surgical MLN dissection because of clinical deterioration or disease progression. In 21 (66%) patients, a formal pathology of the MLN was obtained and staging with EUS-FNA was positive in 4 (19%). Mediastinoscopy did not result in a greater yield of MLN metastasis as compared with EUS-FNA. Thoracotomy with complete lymph node dissection was done in 17 (81%). The overall prevalence of MLN metastasis was 24%, and the sensitivity of EUS-FNA was 80% (95% confidence interval, 28-99%) with a specificity of 100% (95% confidence interval, 79-100%). One patient had esophageal perforation related to EUS-FNA.

Conclusions: EUS-FNA is feasible and sensitive for MLN staging in patients with MPM who are candidate for multimodality treatment. These data warrant further evaluation.