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Bad news for IP guys? Incidental mediastinal lymphadenopathy may not need routine biopsy
With increasing use of chest CT, incidental mediastinal lymphadenopathy seems to be frequently discovered and subsequently biopsied using EBUS. The "if it's enlarged, stick a needle in it" mantra is challenged by a paper by Stigt et al.
83 people (age ~59) with at least one incidentally discovered mediastinal lymph node > 1 cm were enrolled. None had an associated mass.
In 43%, a CT-angiogram for suspected pulmonary embolus identified the incidental lymphadenopathy.
Most (>50%) had at least 3 stations with lymph nodes > 10 mm.
Most (77%) had hilar lymphadenopathy, too.
PET was done in 29, and showed high uptake in mediastinal nodes in 25 (87%).
All got endoscopic ultrasound / endobronchial ultrasound with fine needle aspiration. 76 of the 83 had adequate samples. The main results:
55 reactive lymph nodes
18 granulomatous disease, likely sarcoidosis
1 non-TB mycobacterial infection
1 metastatic breast cancer - who had a history of breast cancer and a loculated (cytology-negative) pleural effusion
No new diagnoses of cancer
Follow-up CTs (~4 months later) were available for 36 of the 62 patients deemed to have no final diagnosis from the biopsy:
24 of the 36 had unchanged lymphadenopathy.
In 9, it went away.
2 had progressive lymphadenopathy. Further biopsies revealed metastatic lung cancer in both. Both initial EUS/EBUS biopsies were negative, with adequate samples. A harder look back at the original CT scans revealed ... still no masses identifiable.
When it comes to staging known lung cancer, EBUS / EUS looks equal or superior to mediastinoscopy, and (if it becomes standard care) could prevent thousands of unnecessary mediastinoscopies and thoracotomies. See recent articles in JAMA and CHEST.