Bad news for IP guys? Incidental mediastinal lymphadenopathy may not need routine biopsy

(image: Wikipedia)

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.

J Thorac Oncol 2011;6:1345-1349

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.