2. Objective Comparison of direct real-time endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA), PET, CT for detection of mediastinal and hilar lymph node metastasis in patients with lung cancer considered for surgical resection

3. Methods  Design: Prospective study ( December 2003 to March 2005 )  Patients: 102 /280 potentially operable patients with proven ( 96) or radiologically suspected ( 6) lung cancer  Interventions: CT, PET, and EBUS-TBNA  Surgical histology :The “gold standard” to confirm lymph node metastasis ( expect N3 or extensive N2 disease proven by EBUS-TBNA

4. Methods CT  MDCT ; 5mm   Resectability; Evaluation of LN or distant metastases  Radiologist ( blinded )  Positive node:  Positive node: short axis 1 cmFDG-PET/CT  300 MBq  Positive: SUV > 2.5

5. Methods EBUS-TBNA  Linear scanning transducer (7.5 MHz)  Connection with ultrasound scanner ( Doppler – flower imaging)  Performed by the same operator under sedation  #1,2,4,7 & #10,11  Short diameter >5mm  sampling ( 22-qauge)  N3->N2->N1  Result : positive, negative, inconclusive

8. Methods Operable  Stage I, II or minimal Stage IIIA (single-station N2 ) Inoperable  Extrathoracic spread disease  Extensive N2 ( bulky disease, multiple N2 )  N3 disease

9. Results

10. Results

12. Discussion FDG-CT More sensitive, less specificity( 61%vs 79% ; 85% vs 90%) More sensitive, less specificity( 61%vs 79% ; 85% vs 90%) Specificity is lower than previously reported Specificity is lower than previously reported Mediastinal nodes, distal metastasis, inflammatory reaction Mediastinal nodes, distal metastasis, inflammatory reaction False positive  tissue conformation False positive  tissue conformation 23 false positive  correctly diagnosis by EBUS-TBNA 23 false positive  correctly diagnosis by EBUS-TBNA False positive : related to size of node and volume of macrophage False positive : related to size of node and volume of macrophage 16/23 : CT(+); PET(+) 16/23 : CT(+); PET(+)

13. Discussion EBUS-TBNA High sensitive & specific High sensitive & specific A single procedure for staging A single procedure for staging 40/147 mediastinal nodes <5 mm 40/147 mediastinal nodes <5 mm Avoid mediastinoscopy and VATS Avoid mediastinoscopy and VATS False positive: contamination in TBNA process False positive: contamination in TBNA process internal sheath : avoid contamination internal sheath : avoid contamination Limitation : no compare other procedures ( TBNA, EUS-FNA) Limitation : no compare other procedures ( TBNA, EUS-FNA) : # 5,6,8,9 : # 5,6,8,9

14. Discussion   TBNA is a fairly “ blind ” procedure   TBNA guided by CT fluoroscopy  EUS-FNA   US-guided needle aspiration

16. Conclusion   EBUS-TBNA has a high sensitivity & pecificity compared to CT or PET for mediastinal staging in patients with potentially resectable lung cancer   Tissue confirmation obtained by EBUS-TBNA is especially important for accurate staging.