Endobronchial ultrasonography (EBUS)—Its role in staging of non–small cell lung cancer and who should do it? Rafael S. Andrade, MD, David D. Odell, MD,

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Endobronchial ultrasonography (EBUS)—Its role in staging of non–small cell lung cancer and who should do it? Rafael S. Andrade, MD, David D. Odell, MD, MMSc, Jonathan D'Cunha, MD, PhD, Michael A. Maddaus, MD The Journal of Thoracic and Cardiovascular Surgery Volume 144, Issue 3, Pages S9-S13 (September 2012) DOI: 10.1016/j.jtcvs.2012.03.068 Copyright © 2012 Terms and Conditions

Figure 1 A, Algorithm for the use of endobronchial ultrasonography with transbronchial needle aspiration biopsy (EBUS-TBNA) as a staging modality in patients with non–small cell lung cancer (NSCLC) based on pretest probability of disease by imaging. Diagnostic approach in patients with normal computed tomographic (CT) imaging stratified by high (Figure 1, B) and low (Figure 1, C) probability of disease. B, High-probability normal computed tomographic (CT) scan. CT scan and matching positron emission tomographic/computed tomographic (PET-CT) scan images of a patient with a centrally located, intensely PET-positive right upper lobe adenocarcinoma and a radiologically normal mediastinum. In such a patient, a cytologically adequate endobronchial ultrasonogram with a transbronchial needle aspiration biopsy (EBUS-TBNA) sample that is negative for cancer should be verified with surgical biopsy. C, Low-probability normal computed tomographic (CT) scan. CT scan of a patient with a less than 2-cm left upper lobe non–small cell lung cancer (NSCLC) and normal-appearing mediastinal lymph nodes in 4L. Inasmuch as the probability of N2 disease is low, a cytologically adequate endobronchial ultrasonography with transbronchial needle aspiration biopsy (EBUS-TBNA) that is negative for malignancy can be accepted with minimal concern for a false negative result. The Journal of Thoracic and Cardiovascular Surgery 2012 144, S9-S13DOI: (10.1016/j.jtcvs.2012.03.068) Copyright © 2012 Terms and Conditions

Figure 2 A, Approach to patients with abnormal computed tomographic/positron emission tomographic (CT/PET) imaging and either high (Figure 2, B) or low (Figure 2, C) probability of malignancy. B, High-probability abnormal computed tomographic (CT) scan. CT scan and matching positron emission tomographic/computed tomographic (PET-CT) scan images of a patient with cytologically confirmed N2 metastases in stations 4R and 7, but endobronchial ultrasonography with transbronchial needle aspiration biopsy (EBUS-TBNA) samples from 4L revealed normal lymphocytes. A surgical biopsy is recommended to confirm that 4L is indeed negative. C, Low-probability abnormal computed tomographic (CT) scan. CT scan and matching positron emission tomographic/computed tomographic (PET-CT) scan images of a patient with a mildly PET-positive left upper lobe non–small cell lung cancer (NSCLC) and diffusely enlarged, partially calcified, PET-positive mediastinal lymph nodes (MLNs) that also involve the opposite hilum. In this patient the mediastinal findings could be explained by granulomatous disease; an endobronchial ultrasonogram with transbronchial needle aspiration biopsy (EBUS-TBNA) sample that demonstrates granulomatous disease would be trustworthy. However, samples with only normal lymphocytes or nondiagnostic samples should prompt the operator to pursue a surgical biopsy. The Journal of Thoracic and Cardiovascular Surgery 2012 144, S9-S13DOI: (10.1016/j.jtcvs.2012.03.068) Copyright © 2012 Terms and Conditions