EJCTS Click here to go to Edwards website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Eur J Cardiothorac Surg 2009;35:332-336. doi:10.1016/j.ejcts.2008.09.022
Copyright © 2009, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jaroslaw Kuzdzal
Marcin Zielinski
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Szlubowski, A.
Right arrow Articles by Zielinski, M.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Szlubowski, A.
Right arrow Articles by Zielinski, M.
Related Collections
Right arrow Lung - cancer
Right arrow Mediastinum

Endobronchial ultrasound-guided needle aspiration in the non-small cell lung cancer staging

Artur Szlubowskia, Jaroslaw Kuzdzala,*, Marcin Kolodzieja, Jerzy Sojab, Juliusz Pankowskic, Anna Obrochtaa, Piotr Kopinskid, Marcin Zielinskia

a Department of Thoracic Surgery, Sokolowski Pulmonary Hospital, Zakopane, Poland
b Department of Medicine, Jagiellonian University, Kraków, Poland
c Department of Pathology, Sokolowski Pulmonary Hospital, Zakopane, Poland
d Department of Gene Therapy, Nicolaus Copernicus University of Torun, Collegium Medium of Bydgoszcz, Poland

Received 5 June 2008; received in revised form 8 September 2008; accepted 17 September 2008.

* Corresponding author. Address: Department of Thoracic Surgery, Pulmonary Hospital Zakopane, ul. Gladkie 1, 34-500 Zakopane, Poland. Tel.: +48 663 430242; fax: +48 18 20 14632. (Email: j.kuzdzal{at}mp.pl).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 
Objective: The aim of the study was to assess the diagnostic yield of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-NA) in the mediastinal staging in non-small cell lung cancer (NSCLC) patients. Methods: Consecutive NSCLC patients with enlarged or normal mediastinal nodes on CT scans underwent EBUS-NA. All patients with negative EBUS-NA subsequently underwent the transcervical extended bilateral mediastinal lymphadenectomy (TEMLA) as a confirmatory test. Results: Two hundred and twenty-six patients underwent EBUS-NA between 1.02.07 and 30.04.08. There were 320 mediastinal lymph nodes biopsied (stations: 2R – 8, 4R – 83, 2L – 1, 4L – 61, 7 – 167). EBUS-NA revealed metastatic lymph node involvement in 129/226 patients (57.1%) and in 171/320 biopsies (53.4%). In 97 patients with negative EBUS-NA, who underwent subsequent TEMLA, metastatic nodes were diagnosed in 16 patients (7.1%) – in 12 (5.3%) in stations accessible for EBUS-NA (stations: 4R – 3, 4L – 2, 7 – 8) and in 4 (1.8%) in stations not accessible for EBUS-NA (stations: 5 – 4, 6 – 1). All positive N2 nodes diagnosed by the TEMLA contained only small metastatic deposits. A diagnostic sensitivity, specificity, accuracy, PPV and NPV of EBUS-NA were 89.0%, 100%, 92.9%, 100% and 83.5%, respectively. No complications of EBUS-NA were observed. Conclusions: (1) EBUS-NA is an effective and safe technique for mediastinal staging in NSCLC patients. (2) In patients with negative results of EBUS-NA, surgical exploration of the mediastinum should be performed.

Key Words: Mediastinum • Non-small cell lung cancer • Staging • EBUS-NA


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 
The real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-NA) is a recently introduced method of biopsy of the mediastinal, hilar and interlobar lymph nodes. Endobronchial ultrasound enables very accurate localization of the extrabronchial structures, including vessels (using the power Doppler imaging) and lymph nodes. Using 10–40 mm long needles makes a biopsy of nodes located in a relatively remote position from the bronchial wall possible.

The radial bronchoscopic ultrasound probes, introduced in 1992, did not allow for a real-time biopsy [1]. These probes are still in use, particularly in assessment of the peripheral lung lesions and depth of neoplasmatic infiltration of the mediastinal structures [2,3]. At the beginning of the twenty-first century the linear bronchoscopic ultrasound probes were introduced, which enable the real-time biopsy of lymph nodes and are used mainly for NSCLC staging. Since the introduction of this method the interest in EBUS-NA has continuously been increasing. In many centers its use has significantly reduced the need for surgical exploration of the mediastinum; mainly mediastinoscopies [4–8].

According to the recent European Society of Thoracic Surgeons guidelines, mediastinoscopy is still the gold standard of invasive mediastinal staging [9]. However, mediastinoscopy only enables access to 5 out of 13 mediastinal nodal stations, and in any of the published studies assessing the value of the EBUS-NA in NSCLC staging, its sensitivity and negative predictive value (NPV) was confirmed by the mean of the bilateral mediastinal lymphadenectomy. So, some percentage of the negative results of the EBUS-NA must have been missed, causing a bias in the reported results.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 
2.1 Clinical question
What is the real sensitivity, accuracy and negative predictive value of the EBUS-NA, assessed using the bilateral mediastinal lymphadenectomy as the confirmatory test?

2.2 Design
Prospective cohort diagnostic study.

2.3 Location
Department of Thoracic Surgery, Sokolowski Pulmonary Hospital, Zakopane, Poland.

2.4 Patients
Inclusion criteria: a group of consecutive NSCLC patients (1) clinical stage I–IIIB; (2) with enlarged or normal mediastinal lymph nodes on CT scans; and (3) general condition enabling appropriate pulmonary resection.

Exclusion criteria: (1) histological diagnosis of small cell lung cancer; (2) lack of patient’s consent.

2.5 Intervention
Prior to the procedure the CT scans were carefully analyzed and local anesthesia and i.v. sedation (fentanyl 0.05–0.1 mg, midazolam 1–5 mg) were used. The EBUS-NA was performed using the BF-UC160F-OL8 videobronchoscope (Olympus Medical Systems Corporation, Tokyo, Japan). The videobronchoscope is 6.9 mm wide, has a 2 mm working channel, the 35° optical system and the EU-C60 7.5 MHz ultrasound processor, enabling 20–50 mm depth tissue imaging. As the ultrasound bronchoscope is not designed for detailed assessment of the bronchial tree, the examination was preceded by the standard videobronchoscopy. For the biopsy a cytological 22 G needle with guide wire and marking facilitating its visualization on the ultrasound image was used (NA-201SX-4022, Olympus Medical Systems Corporation, Tokyo, Japan).

The EBUS-NA of all lymph nodes ≥5 mm on the short axis was performed (criterion of feasibility of lymph node biopsy according to Herth and Yasufuku [10,11]). All the biopsies were performed through the macroscopically normal bronchial wall. The number of biopsied nodes in one patient was 1–3.

The cytological smear was performed and fixed using 96% ethanol. Then standard hematoxylin-eosin staining was used.

In patients with negative results of the EBUS-NA the bilateral transcervical extended mediastinal lymphadenectomy (TEMLA) was performed. The TEMLA includes bilateral dissection of all the mediastinal lymph nodes, except station 9. The use of a special retractor, elevating the sternum, enables access to the mediastinal structures and safe dissection of lymph nodes. The technique of the TEMLA is described in detail elsewhere [12,13]. The video presenting this technique is available at: www.mp.pl/download/wmv/temla.wmv.

In patients with negative results of the TEMLA, an appropriate pulmonary resection with dissection of the mediastinum was performed. The extent of the mediastinal dissection corresponded to the systematic lymph node dissection. However, due to the completeness of lymphadenectomy with the TEMLA technique, generally no nodes were found at thoracotomy.

The Mountain-Dresler lymph node classification was used [14].

2.6 Statistical analysis
Statistical calculations were carried out using StatisticaTM software (Statsoft Inc., USA).

Summary statistics were expressed as mean (M), standard deviation (SD). The chi-square test was used, where appropriate, to compare proportional data. The type I error was set at 0.05 for all analyses. Confidence intervals were calculated to 95% using standard formulae. The sensitivity, specificity, accuracy and NPV were calculated using the standard definitions.


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 5. Conclusions
 Appendix A
 References
 
There were 181 men and 45 women with a mean age of 62.5 ± 8.9 years (range 39–85). In these 226 patients 320 EBUS-NA were performed, and the diagnosis was established in 129 of them (57.1%).

The mean time of the procedure was 15 min.

There were no complications.

Among these 320 biopsies there were 167 subcarinal node (station 7) biopsies, 83 right lower paratracheal node (4R) biopsies, 61 left lower paratracheal node (4L) biopsies, 8 right upper paratracheal node (2R) biopsies and 1 left upper paratracheal node (2L) biopsy. The mean dimensions of the biopsied nodes were 19.1 ± 11.4 mm in the long axis and 13.8 ± 9 mm in the short axis. In 94 patients (41.6%) biopsy of more than one node was performed.

In 171 out of 320 biopsies the cytological diagnosis of a cancer was established, and the biopsy was technically successful in 306 cases (95.6%).

In 129 patients (57.1%) metastatic involvement of the lymph node was confirmed in 171 nodes (in some patients more than one node was involved). The numbers of metastatic nodes in particular stations were as follows: station 7 – 86, 4R – 49, 4L – 31, 2R – 4 and 2L – 1.

In 81 patients (35.8%) the result of mediastinal lymph node biopsy was true negative. The number of these true negative biopsies was 136: 73 in station 7, 31 in station 4R, 28 in station 4L and 4 in station 2R. In this group the cytological diagnosis of benign, reactive lymph node enlargement was subsequently confirmed by the histological examination of the TEMLA operative specimen and in 54 patients with negative results of the TEMLA, additionally mediastinal dissection during thoracotomy was performed.

In 16 patients (5.3%) the result of EBUS-NA was false negative. In 12 patients TEMLA revealed metastases in nodal stations accessible for EBUS-NA (station 4R – 3 patients, station 4L – 2 and station 7 – 8 patients) and in the next 4 patients (1.8%) in nodal stations not accessible for EBUS-NA (station 5 – 4 patients and station 6 – 1 patient). In 19 out of 20 nodal stations with false negative results of the EBUS-NA, the extent of metastatic involvement was low (mean 38.8 ± 25.4% of the nodes, Table 1 ).


View this table:
[in this window]
[in a new window]

  		Table 1 Patients with false negative results of EBUS-NA verified by the TEMLA.
 
The overall sensitivity of the EBUS-NA calculated per patient was 89% (95% CI – 82–93); specificity, 100% (95% CI – 95–100); accuracy, 92% and NPV, 83.5% (95% CI – 75–90). However, if calculated for the nodal stations accessible for EBUS-NA, these figures were: sensitivity, 91.5% (95% CI – 86–96); specificity, 100% (95% CI – 96–100); accuracy, 94.7% and NPV, 87.6% (95% CI – 79–93).

The diagnostic yield of the EBUS-NA calculated per station is presented in Table 2 .


View this table:
[in this window]
[in a new window]

  		Table 2 Results of EBUS-NA in NSCLC staging in different groups of mediastinal lymph nodes calculated by numbers of biopsies.
 
The prevalence of mediastinal lymph node metastases in the present study was 60.9%.

EBUS-NA changed the clinical stage in 64 patients (28.3%): down-staged from N2 to N1 or N0 disease in 56 patients and up-staged from N0 or N1 to N2 disease in 7 patients and from N2 to N3 disease in 1 patient (Table 3 ).


View this table:
[in this window]
[in a new window]

  		Table 3 The radiological (R) and EBUS-NA-based (EBUS) clinical TNM staging in 226 patients.
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
5. Conclusions
 Appendix A
 References
 
The use of the EBUS-NA in NSCLC staging is gaining increasing acceptance due to its efficiency and low invasiveness. Proponents of this method believe that in the near future it may become the gold standard in diagnosis of mediastinal adenopathy, replacing in many cases mediastinoscopy and other invasive techniques such as VATS, Chamberlain procedure and thoracotomy [4,5,11,15,16]. As the risk of complications related to the EBUS-NA is very low, this procedure may be performed in the outpatient settings [8,17].

Gaining skill and experience in the endobronchial ultrasound imaging and performing the biopsy is more time-consuming than in the conventional bronchoscopy. This makes appropriate training necessary. However, because of the real-time imaging, the results are less operator-dependent than these of the blind TBNA. This relation is shown by the wide range of the sensitivity of the blind TBNA (24–89%) [18–21], whereas the reported range of the sensitivity of the EBUS-NA is much narrower (88–95%) [5,7,10,11]. Our results show the 89% sensitivity of the EBUS-NA.

EBUS-NA enables biopsy of stations 2R, 2L, 3P, 4R, 4L and 7 (also N1 stations 10R, 10L, 11R and 11L inaccessible for other invasive techniques which is a unique advantage of EBUS-NA). Although imaging and biopsy of paratracheal nodes (particularly on the left side) are technically more difficult than the subcarinal or hilar nodes, the diagnostic yield of the EBUS-NA was higher in our group in the paratracheal nodes (Table 2). The difficulty in the imaging of the paratracheal nodes is due to the problems with stable positioning of the tip of the endoscope in contact with the wall of the distal trachea and the main bronchi. The second reason is the adherence of the nodes to big vessels.

Stations not accessible using EBUS-NA are: 3A, 5, 6, 8 and 9. In our experience posterior and inferior part of the station 7 and 4L nodes are also difficult to visualize and to biopsy. This may be the reason for some of the false negative results. In such circumstances the endoscopic ultrasound fine needle aspiration (EUS-NA) may be a valuable supplement, which is very useful in assessment of the stations 4L, 7, 8 and 9. Using both EBUS-NA with EUS-NA, or EUS-NA with mediastinoscopy enables more accurate assessment of the mediastinum and increases the diagnostic yield [17,22].

The rate of false negative biopsies was only 4.1%. In most of these cases, noted mainly in the station 7, the extent of metastatic nodal involvement was limited, what was confirmed by the pathological examination of the TEMLA specimen (Table 1). Similar correlation between the percentage of the metastatic nodes in a particular station and the sensitivity of biopsy was observed for the blind TBNA [21].

According to the largest series published to date, the NPV of the EBUS-NA is 85–96%, and for the EUS-NA – 73–83% [9,11,16,23,24]. In our group the NPV of the EBUS-NA was 83%. The reason is probably the use of the TEMLA procedure as the confirmatory test, which is much more accurate in detecting the missed metastatic nodes than the commonly used standard mediastinoscopy.

For NSCLC patients with negative EBUS-NA the surgical staging of the mediastinum may be indicated. It is, however, doubtful, if the standard mediastinoscopy should be used for this purpose [13,25]. Perhaps, in patients with negative results of both EBUS-NA and EUS-NA, additional staging procedures may be omitted, particularly if the PET-CT was also negative. According to the recent guidelines of the American College of Chest Physicians, in patients with moderately enlarged mediastinal lymph nodes and no evidence of distant metastases, invasive mediastinal staging is recommended, using one of the following techniques: mediastinoscopy, EUS-NA, EBUS-NA or the trans thoracic needle aspiration. However, in patients with negative results of the needle biopsy, mediastinoscopy is recommended [16].


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
Appendix A
 References
 
(1) EBUS-NA is an effective and safe technique for mediastinal staging in NSCLC patients. (2) In patients with negative results of EBUS-NA, surgical exploration of the mediastinum should be performed.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
References
 
Conference discussion

Dr Rami-Porta (Barcelona, Spain): In the paper that you quoted from Paul De Leyn and co-workers regarding the European Society of Thoracic Surgeons (ESTS) guidelines on preoperative staging, we tried to evaluate what good clinical practice would be in mediastinoscopy. There were several opinions that are described in the paper, and finally we arrived at the conclusion that at least three nodal stations should be biopsied, both paratracheal stations and the subcarinal station. Based on your results, when there is no suspicion of any pathological node and you want to confirm clinical N0, what would be the ideal procedure in your hands?

Dr Szlubowski: This is our second favorite technique, which we use during the staging technique. So we join together EBUS and EUS, because the left side, especially group No. 4L, and additionally group 8 and group 9, and also the posterior part of group 7, can be reached by EUS, and our initial experiences of sensitivity of the joint methods is more than 94% of sensitivity and NPV is about 92.5. Well, of course, there is the possibility to join bioptic methods with PET-CT. It could be too expensive for all the patients with non-small cell lung cancer. But at this moment I would like to point out that mediastinoscopy is not really the best method for referring to bioptic methods. I think lymphadenectomy, well, we show TEMLA, is the best way to verify bioptic methods. So coming back to your question, next biopsy method, EUS or PET joined together, but after then, if there is negative, lymphadenectomy.

Dr S. Mattioli (Bologna, Italy): Yesterday we were told that in nodes smaller than 1.5 cm at the CT scan the performance of EBUS is low, but I see that your performance is very good, because you have 5.6 false negatives in spite of the fact that you have evaluated all the nodes or even those smaller than that. Can you comment on that, please?

Dr Szlubowski: Well, Professor Herth showed the work in 2006 that the sensitivity of EBUS-TBNA in nodes less than 7 mm was 94%, and the prevalence in this group was about 20%. So it showed that this is really a sensitive method, even in smaller nodes. Well, in our opinion, we can puncture nodes where the diameter is less than 5 mm.

Dr T. Lerut (Leuven, Belgium): Just one additional question as to the lymphadenectomy. Your 5.6% false negative, i.e. 16 patients, what would have been the added value of the TEMLA vs a classic mediastinoscopy in those 16 patients? Did you look at that?

Dr Szlubowski: Well, from 16 patients, 7 or 8 of them, they – well, all of them went for chemotherapy and radiotherapy.

Dr Lerut: That is not the question. The question is what was the added value of doing the TEMLA vs doing a classic mediastinoscopy in those specific 16 patients? Did you look at that?

Dr Szlubowski: No, of course not.


   Footnotes
 
{star} Presented at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2008.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 5. Conclusions
 Appendix A
 References
 

  1. Hürter T, Hanrath P. Endobronchial sonography: feasibility and preliminary results. Thorax 1992;47:565-567.[Abstract/Free Full Text]
  2. Shannon JJ, Bude RO, Orens JB, Becker FS, Whyte RI, Rubin JM, Quint LE, Martinez FJ. Endobronchial ultrasound-guided needle aspiration of mediastinal adenopathy. Am J Respir Crit Care Med 1996;153:1424-1430.[Abstract]
  3. Kurimoto N, Murayama M, Yoshioka S, Nishisaka T, Inai K, Dohi K. Assessment of usefulness of endobronchial ultrasonography in determination of depth of tracheobronchial tumor invasion. Chest 1999;115:1500-1506.[Abstract/Free Full Text]
  4. Herth FJ, Eberhardt R, Vilmann P, Krasnik M, Ernst A. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax 2006;61:795-798.[Abstract/Free Full Text]
  5. Krasnik M, Vilmann P, Larsen SS, Jacobsen GK. Preliminary experience with a new method of endoscopic with a new method of endoscopic transbronchial real-time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions. Thorax 2003;58:1083-1086.[Abstract/Free Full Text]
  6. Larsen SS, Krasnik M, Vilmann P, Jacobsen GK, Pedersen JH, Faurschou P, Folke K. Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management. Thorax 2002;57:98-103.[Abstract/Free Full Text]
  7. Rintoul RC, Skwarski KM, Murchison JT, Wallace WA, Walker WS, Penman ID. Endobronchial and endoscopic ultrasound-guided real-time fine-needle aspiration for mediastinal staging. Eur Respir J 2005;25:416-421.[Abstract/Free Full Text]
  8. Yasufuku K, Chiyo M, Koh E, Moriya Y, Iyoda A, Sekine Y, Shibuya K, Iizasa T, Fujisawa T. Endobronchial ultrasound guided transbronchial needle aspiration for staging of lung cancer. Lung Cancer 2005;50:347-354.[CrossRef][Medline]
  9. De Leyn P, Lardinois D, Van Schil P, Rami-Porta R, Passlick B, Zielinski M, Waller D, Lerut T, Weder W, ESTS European trends in preoperative and intraoperative nodal staging: ESTS guidelines. J Thorac Oncol 2007;2:357-361.[CrossRef][Medline]
  10. Herth FJ, Ernst A, Eberhardt R, Vilmann P, Dienemann H, Krasnik M. Endobronchial ultrasound-guided transbronchial needle-aspiration of lymph nodes in the radiologically normal mediastinum. Eur Respir J 2006;28:910-914.[Abstract/Free Full Text]
  11. Yasufuku K, Nakajima T, Motoori K, Sekine Y, Shibuya K, Hiroshima K, Fujisawa T. Comparison of endobronchial ultrasound, positron emission tomography, and CT for lymph node staging of lung cancer. Chest 2006;130:710-718.[Abstract/Free Full Text]
  12. Kuzdzal J, Zielinski M, Papla B, Szlubowski A, Hauer L, Nabialek T, Sosnicki W, Pankowski J. Transcervical extended mediastinal lymphadenectomy-the new operative technique and early results in lung cancer staging. Eur J Cardiothorac Surg 2005;27:384-390.[Abstract/Free Full Text]
  13. Zielinski M. Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non-small cell lung cancer. J Thorac Oncol 2007;4:370-372.
  14. Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest 1997;111:1718-1723.[Abstract/Free Full Text]
  15. Toloza EM, Harpole L, Detterbeck F, McCrory DC. Invasive staging of non-small cell lung cancer: a review of the current evidence. Chest 2003;123:157S-166S.[CrossRef][Medline]
  16. Detterbeck FC, Jantz MA, Wallace M, Vansteenkiste J, Silvestri GA. Invasive mediastinal staging of lung cancer. ACCP evidence-based clinical practice guidelines. Chest 2007;132:202S-220S.[Abstract/Free Full Text]
  17. Annema JT, Versteegh MI, Veselic M, Voigt P, Rabe KF. Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of lung cancer and its impact on surgical staging. J Clin Oncol 2005;23:8357-8361.[Abstract/Free Full Text]
  18. Harrow EM, Oldenburg Jr. FA, Lingenfelter MS, Smith Jr. AM. Transbronchial needle aspiration in clinical practice. A five-year experience. Chest 1989;96:1268-1272.[Abstract/Free Full Text]
  19. Herth FJ, Becker HD, Ernst A. Conventional vs endobronchial ultrasound guided transbronchial needle aspiration: a randomized trial. Chest 2004;125:322-325.[Abstract/Free Full Text]
  20. Mehta AC, Kavuru MS, Meeker DP, Gephardt GN, Nunez C. Transbronchial needle aspiration for histology specimens. Chest 1989;96:1228-1232.[Abstract/Free Full Text]
  21. Szlubowski A, Kuzdzal J, Soja J, Laczynska E, Hauer J, Kopinski P, Tomaszewska R, Zielinski M. Transbronchial needle aspiration as a diagnostic method in lung cancer and non-malignant mediastinal adenopathy. Pneumonol Alergol Pol 2007;75:5-12.[Medline]
  22. Annema JT, Versteegh MI, Veseliç M, Welker L, Mauad T, Sont JK, Willems LN, Rabe KF. Endoscopic ultrasound added to mediastinoscopy for preoperative staging of patients with lung cancer. JAMA 2005;294:931-936.[Abstract/Free Full Text]
  23. Micames CG, McCrory DC, Pavey DA, Jowell PS, Gress FG. Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging. A systematic review and meta-analysis. Chest 2007;131:539-548.[Abstract/Free Full Text]
  24. Vilmann P, Krasnik M, Larsen SS, Jacobsen GK, Clementsen P. Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-NA) biopsy: a combined approach in the evaluation of mediastinal lesions. Endoscopy 2005;37:833-839.[CrossRef][Medline]
  25. Kuzdzal J, Zielinski M, Papla B, Urbanik A, Wojciechowski W, Narski M, Szlubowski A, Hauer L. The transcervical extended mediastinal lymphadenectomy versus cervical mediastinoscopy in non-small cell lung cancer staging. Eur J Cardiothorac Surg 2007;31:88-94.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 ICVTSHome page
M. Zielinski, J. Hauer, L. Hauer, J. Pankowski, T. Nabialek, and A. Szlubowski
Staging algorithm for diffuse malignant pleural mesothelioma
Interactive CardioVascular and Thoracic Surgery, February 1, 2010; 10(2): 185 - 189.
[Abstract] [Full Text] [PDF]

Home page
 Postgrad. Med. J.Home page
A R L Medford, J A Bennett, C M Free, and S Agrawal
Endobronchial ultrasound guided transbronchial needle aspiration
Postgrad. Med. J., February 1, 2010; 86(1012): 106 - 115.
[Abstract] [Full Text] [PDF]

Home page
 QJMHome page
A.R.L. Medford, S. Agrawal, C.M. Free, and J.A. Bennett
A performance and theoretical cost analysis of endobronchial ultrasound-guided transbronchial needle aspiration in a UK tertiary respiratory centre
QJM, December 1, 2009; 102(12): 859 - 864.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jaroslaw Kuzdzal
Marcin Zielinski
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Szlubowski, A.
Right arrow Articles by Zielinski, M.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Szlubowski, A.
Right arrow Articles by Zielinski, M.
Related Collections
Right arrow Lung - cancer
Right arrow Mediastinum

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS