Implementation of endoscopic ultrasound for lung cancer staging

Presented in part at Digestive Disease Week, May 22, 2007, Chicago Illinois, European Respiratory Society, September 16, 2007, Stockholm, Sweden, American Thoracic Society, May 20, 2008, Toronto, Ontario, Canada, and American Society of Clinical Oncology, May 20, 2008, Chicago, Illinois.

Received 11 March 2009; accepted 15 July 2009. published online 11 November 2009.

Background

EUS-guided FNA is currently advocated in lung cancer staging guidelines as an alternative for surgical staging to prove mediastinal metastases. To date, training requirements for chest physicians to obtain competency in EUS for lung cancer staging are unknown.

Objective

To test a training and implementation strategy for EUS for the diagnosis and staging of lung cancer.

Design

Prospective national multicenter implementation trial. Nine (chest) physicians from 5 hospitals participated in a dedicated EUS educational program (investigation of 50 patients) for the diagnosis and staging of lung cancer. EUS outcomes of trainees were compared with those of the training center.

Setting

Four general hospitals, the national cancer center (implementation centers), and a tertiary referral center (expert center).

Patients

This study involved 551 consecutive patients with (suspected) lung cancer, all candidates for surgical staging, who underwent EUS in 1 of the 5 implementation centers (n = 346) or the single expert center (n = 205). Surgical-pathological staging was the reference standard in case no mediastinal metastases were found.

Results

EUS had a sensitivity of 83% versus 82% and accuracy of 89% versus 88% for mediastinal nodal staging (implementation center vs expert center). Surgery was spared because of EUS findings in 51% versus 54% of patients. A single complication occurred in each group.

Limitation

Surgical-pathological verification of mediastinal nodes was not available in all patients staged negative at EUS.

Conclusion

Chest physicians who participate in a dedicated training and implementation program for EUS in lung cancer staging can obtain results similar to those of experts for mediastinal nodal staging.

Leiden, The Netherlands

Abbreviations: EBUS, endobronchial ultrasound, EUS-FNA, EUS-guided FNA, N2, metastasis in ipsilateral mediastinal/subcarinal lymph nodes, N3, metastasis in contralateral mediastinal lymph nodes, PET, positron emission tomography, T4, mediastinal tumor invasion

Current affiliations: Divisions of Pulmonary Medicine (J.T.A., K.F.R.) and Clinical Epidemiology (O.M.D.), Leiden University Medical Center, Leiden, Biometrics Department (R.B., H.v.T.), Pulmonary Medicine (S.B.), Gastero-enterology (M.S., B.T.), Netherlands Cancer Institute Amsterdam, Pulmonary Medicine Medical Center, Leeuwarden (B.V., H.N.), Pulmonary Medicine, St. Catherine's Hospital Eindhoven (B.v.d.B., R.v.B.), Pulmonary Medicine, Medical Center Alkmaar (T.H., A.W.), Pulmonary Medicine, Meander Medical Center Amersfoort (G.S.), The Netherlands

Reprint requests: Jouke T. Annema, MD, PhD, Department of Pulmonology C3 P, Albinusdreef 2, PO box 9600, 2300 RC, Leiden University Medical Center, Leiden, The Netherlands.

DISCLOSURE: Supported by a grant from The Netherlands Organisation for Health Research and Development (Zon-Mw), provided to Dr Annema and Dr Rabe. The current study was supported within an initiative of implementation programs aiming to investigate how methods with proven accuracy and cost-effectiveness could be implemented into clinical practice. Zon-Mw had no role in the design of the study, data collection, analysis, or reporting. All authors had full access to the data. All authors disclosed no financial relationships relevant to this publication.

If you would like to chat with an author of this article, you may contact Dr. Annema at j.t.annema@lumc.nl.

PII: S0016-5107(09)02269-X

doi:10.1016/j.gie.2009.07.027

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