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The role of EUS for evaluation of mediastinal adenopathy
American Society For Gastrointestinal Endoscopy
The role of EUS for evaluation of mediastinal adenopathy This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. INTRODUCTION Mediastinal lymphadenopathy may be detected by CT, by chest radiograph, or by the presence of extrinsic compression of the esophagus detected during EGD. Its causes reflect both benign processes (e.g., sarcoidosis, tuberculosis, histoplasmosis) and malignant processes (e.g., metastatic cancer, lymphoma). In addition, mediastinal adenopathy may be suspected in patients with lung or esophageal cancer despite prior negative imaging. EUS can both identify adenopathy and guide FNA of nodes as small as 5 mm.1 This guideline suggests appropriate situations for which EUS should be used in the evaluation of mediastinal adenopathy. The role of EUS in the evaluation of esophageal cancer is discussed in a separate guideline.2 EUS DIAGNOSIS EUS can readily identify lymph nodes in the subcarinal, paraesophageal, and paratracheal regions, but not the pretracheal space or intrapulmonary regions. When examining nodes by EUS, particular findings may predict malignant nodal involvement, including a hypoechoic echotexture, a sharply demarcated border, a rounded contour, and VOLUME 58, NO. 6, 2003
a size greater than 1 cm.3,4 While these individual findings are predictive, accuracy exceeds 80% only when all 4 are present, however all features are present in a minority of cases.3,5 In one study, image interpretation alone for the diagnosis of lung cancer metastases to mediastinal lymph nodes was specific (97.5%) but not sensitive (53.6%).6 In a large series of patients with mediastinal adenopathy, EUS features alone could not distinguish between benign and malignant lesions.7 It is, therefore, recommended that FNA be performed whenever mediastinal adenopathy is being evaluated during EUS if the results will alter management. FNA of mediastinal nodes FNA of nodes improves the accuracy of EUS for determining malignant involvement8,9 and may change management (in particular, avoiding mediastinoscopy or thoracotomy) in a significant number of patients.10-13 EUS-FNA has been shown to yield a diagnosis even when prior studies, including positron emission tomography (PET) scanning, CTguided FNA, bronchoscopy, pleurocentesis, and mediastinoscopy are negative or inconclusive.14-16 FNA of mediastinal nodes can provide a specimen adequate for interpretation in over 95% of cases7,10 and has a complication rate of less than 1%.7,10,12,15,17 The specificity of EUS-FNA for malignancy is close to 100%, and the sensitivity for detecting malignancy in mediastinal nodes is 88% to 96%.15,18 False-negative results of mediastinal EUS-FNA have been reported in lung cancer, renal cell cancer, Hodgkin’s disease, and non-Hodgkin’s lymphoma.7,13,15,19 To minimize the number of FNA passes made, a cytopathologist should be available to determine the adequacy of specimens obtained. When this is not feasible, at least three FNA passes should be made to maximize sensitivity.20 In the event that there are multiple nodes, FNA should be performed on that which is most suspicious in appearance. Alternatively, when staging lung cancer, a contralateral node should be sought before a subcarinal or ipsilateral node to detect the highest N stage. When infection is being considered, special stains and cultures (e.g., for acidfast bacilli, fungi) should be used in the evaluation of aspirated material. If lymphoma is suspected, flow GASTROINTESTINAL ENDOSCOPY
819
cytometry or cytogenetics should be considered, which may require preprocedure consultation with the pathology department. Serious complications from EUS-FNA of mediastinal masses and lymph nodes have not been reported, although there have been cases of serious infection involving mediastinal cysts.21,22 EUS-FNA for adenopathy of unknown origin There have been several series published documenting the utility of EUS-FNA for evaluating idiopathic mediastinal adenopathy found by CT scanning, chest radiography, or EUS for other reasons.7,10-12,15,17 In some of these cases, lung cancer was suspected based upon imaging but no diagnosis had yet been made. In addition, some patients had a history of prior malignancy. Malignant adenopathy was diagnosed by EUS-FNA in 42% to 72% of cases. When performing EUS for evaluation of pancreatobiliary masses, metastatic mediastinal involvement should be sought because this may be found in 6% of cases.23 The infections most frequently diagnosed by EUS-FNA are caused by mycobacteria and histoplasmosis. EUS-FNA in lung cancer staging Lung cancer is the most frequent cause of cancerrelated mortality in the world. Its diagnosis and staging typically involve either CT-guided FNA, transbronchial FNA, mediastinoscopy with biopsy, or thoracoscopy. The staging system established by the American Joint Committee on Cancer requires the determination of the presence and location of nodal metastases in the mediastinum. Subcarinal or ipsilateral malignant adenopathy (N2) conveys stage IIIA disease, while contralateral nodal metastases (or direct mediastinal invasion by tumor, i.e., T4) conveys stage IIIB disease. Management of these two substages in non-small-cell lung cancer (NSCLC) is institutionally dependent, but, generally, patients with stage IIIB disease are unlikely to benefit from surgical intervention. EUS-FNA has been shown to be an accurate (>90%) and a safe method for nodal staging in patients with previously documented lung cancer.12,13,19,24 Even patients without mediastinal nodes visualized by CT may harbor malignant adenopathy detectable by EUS-FNA.19 One costminimization model compared EUS-FNA with PET scanning, CT-guided FNA, transbronchial FNA, and mediastinoscopy in patients with NSCLC and enlarged subcarinal nodes visualized by CT.25 The model determined that EUS-FNA was the least costly method for diagnosing malignant adenopathy (specifically N2 disease) as long as the pretest likelihood 820
GASTROINTESTINAL ENDOSCOPY
of malignant adenopathy was at least 24% and EUSFNA was at least 76% sensitive. Another model specifically compared mediastinoscopy with EUSFNA for patients with malignant nodes in the subaortic (aortopulmonary window), para-aortic and subcarinal stations.26 EUS-FNA proved more cost-effective even if the negative predictive value of EUS-FNA was as low as 22%. Recommendations EUS-FNA is indicated for the evaluation of adenopathy and masses of the posterior mediastinum. It is the procedure of choice for tissue sampling of such lesions in the subcarinal, subaortic (aortopulmonary window), and periesophageal stations found on cross sectional imaging (CT, MRI, or PET). EUS-FNA also should be considered in the preoperative staging of patients with NSCLC without definite adenopathy on cross sectional imaging. SUMMARY For the following points: (A), prospective controlled trials; (B), observational studies; (C), expert opinion. EUS-FNA is a safe and accurate method for obtaining a tissue diagnosis in patients with mediastinal adenopathy. (B) In patients with NSCLC, EUS-FNA is an accurate and cost-saving method for nodal staging in patients with documented posterior mediastinal adenopathy. (B) EUS-FNA is the procedure of choice for the evaluation of posterior mediastinal nodes and masses seen on cross-sectional imaging and may have a role in the preoperative staging of patients with NSCLC without mediastinal abnormalities on cross sectional imaging. (C) REFERENCES 1. Vilmann P. Endoscopic ultrasonography-guided fine-needle aspiration biopsy of lymph nodes. Gastrointest Endosc 1996; 43:S24-9. 2. ASGE. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2003;57: 817-22. 3. Catalano M, Sivak M, Rice T, Gragg L, Van Dam J. Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc 1994;40:442-6. 4. Faigel D. EUS in patients with benign and malignant lymphadenopathy. Gastrointest Endosc 2001;53:593-8. 5. Bhutani M, Hawes R, Hoffman B. A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for the diagnosis of malignant lymph node invasion. Gastrointest Endosc 1997;45:474-9. 6. Kondo D, Imaizumi M, Abe T, Naruke T, Suemasu K. Endoscopic ultrasound examination for mediastinal lymph node metastases of lung cancer. Chest 1990;98:586-93. VOLUME 58, NO. 6, 2003
7. Fritscher-Ravens A, Sriram PV, Bobrowski C, Pforte A, Topalidis T, Krause C, et al. Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNAbased differential cytodiagnosis in 153 patients. Am J Gastroenterol 2000;95:2278-84. 8. Eloubeidi M, Wallace M, Reed C, Hadzijahic N, Lewin DN, Van Velse A, et al. The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single center experience. Gastrointest Endosc 2001;54:714-9. 9. Vazquez-Sequeiros E, Norton ID, Clain JE, Wang KK, Affi A, Allen M, et al. Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma. Gastrointest Endosc 2001;53:751-7. 10. Catalano MF, Rosenblatt ML, Chak A, Sivak MV Jr, Scheiman J, Gress F. Endoscopic ultrasound-guided fine needle aspiration in the diagnosis of mediastinal masses of unknown origin. Am J Gastroenterol 2002;97:2559-65. 11. Catalano MF, Nayar R, Gress F, Scheiman J, Wassef W, Rosenblatt ML, et al. EUS-guided fine needle aspiration in mediastinal lymphadenopathy of unkown origin. Gastrointest Endosc 2002;55:863-9. 12. Larsen SS, Krasnik M, Vilmann P, Jacobsen GK, Pedersen JH, Faurschou P, et al. Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management. Thorax 2002;57:98-103. 13. Gress F, Savides TJ, Sandler A, Kesler K, Conces D, Cummings O, et al. Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of nonsmall-cell lung cancer: a comparison study. Ann Intern Med 1997;127:604-12. 14. Pedersen BH, Vilmann P, Folke K, Jacobsen GK, Krasnik M, Milman N, et al. Endoscopic ultrasonography and real-time guided fine-needle aspiration biopsy of solid lesions of the mediastinum suspected of malignancy. Chest 1996;110: 539-44. 15. Wiersema MJ, Vazquez-Sequeiros E, Wiersema LM. Evaluation of mediastinal lymphadenopathy with endoscopic USguided fine-needle aspiration biopsy. Radiology 2001;219: 252-7. 16. Rosenberg JM, Perricone A, Savides TJ. Endoscopic ultrasound/fine-needle aspiration diagnosis of a malignant subcarinal lymph node in a patient with lung cancer and a negative positron emission tomography scan. Chest 2002;122:1091-3. 17. Devereaux BM, LeBlanc JK, Yousif E, Kesler K, Brooks J, Mathur P, et al. Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy. Gastrointest Endosc 2002;56:397-401.
VOLUME 58, NO. 6, 2003
18. Barawi M, Gress F. EUS-guided fine-needle aspiration in the mediastinum. Gastrointest Endosc 2000;52:S12-7. 19. Wallace MB, Silvestri GA, Sahai AV, Hawes RH, Hoffman BJ, Durkalski V, et al. Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung. Ann Thorac Surg 2001;72:1861-7. 20. Wallace M, Kennedy T, Durkalski V, Eloubeidi MA, Etamad R, Matsuda K, et al. Randomized controlled trial of EUSguided fine needle aspiration techniques for the detection of malignant lymphadenopathy. Gastrointest Endosc 2001; 54:441-7. 21. Ryan A, Zamar V, Roberts S. Iatrogenic candidal infection of a medistinal foregut cyst following endoscopic ultrasoundguided fine-needle aspiration. Endoscopy 2002;34:838-9. 22. Wildi SM, Hoda RS, Fickling W, Schmulewitz N, Varadarajulu S, Roberts SS, et al. Diagnosis of benign cysts of the mediastinum: the role and risks of EUS and FNA. Gastrointest Endosc 2003;58:362-8. 23. Hahn M, Faigel DO. Frequency of mediastinal lymph node metastases in patients undergoing EUS evaluation of pancreaticobiliary masses. Gastrointest Endosc 2001;54:331-5. 24. Silvestri GA, Hoffman BJ, Bhutani MS, Hawes RH, Coppage L, Sanders-Cliette A, et al. Endoscopic ultrasound with fineneedle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg 1996;61:1441-5. 25. Harewood GC, Wiersema MJ, Edell ES, Liebow M. Costminimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy. Mayo Clin Proc 2002;77:155-64. 26. Aabakken L, Silvestri GA, Hawes R, Reed CE, Marsi V, Hoffman B. Cost-efficacy of endoscopic ultrasonography with fine-needle aspiration vs. mediasinotomy in patients with lung cancer and suspected mediastinal adenopathy. Endoscopy 1999;31:707-11.
Prepared by: STANDARDS OF PRACTICE COMMITTEE Brian C. Jacobson, MD, MPH William K. Hirota, MD Jay L. Goldstein, MD Jonathan A. Leighton, MD J. Shawn Mallery, MD J. Patrick Waring, MD Todd H. Baron, MD, Vice Chair Douglas O. Faigel, MD, Chair
GASTROINTESTINAL ENDOSCOPY
821
The role of EUS for evaluation of mediastinal adenopathy This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. INTRODUCTION Mediastinal lymphadenopathy may be detected by CT, by chest radiograph, or by the presence of extrinsic compression of the esophagus detected during EGD. Its causes reflect both benign processes (e.g., sarcoidosis, tuberculosis, histoplasmosis) and malignant processes (e.g., metastatic cancer, lymphoma). In addition, mediastinal adenopathy may be suspected in patients with lung or esophageal cancer despite prior negative imaging. EUS can both identify adenopathy and guide FNA of nodes as small as 5 mm.1 This guideline suggests appropriate situations for which EUS should be used in the evaluation of mediastinal adenopathy. The role of EUS in the evaluation of esophageal cancer is discussed in a separate guideline.2 EUS DIAGNOSIS EUS can readily identify lymph nodes in the subcarinal, paraesophageal, and paratracheal regions, but not the pretracheal space or intrapulmonary regions. When examining nodes by EUS, particular findings may predict malignant nodal involvement, including a hypoechoic echotexture, a sharply demarcated border, a rounded contour, and VOLUME 58, NO. 6, 2003
a size greater than 1 cm.3,4 While these individual findings are predictive, accuracy exceeds 80% only when all 4 are present, however all features are present in a minority of cases.3,5 In one study, image interpretation alone for the diagnosis of lung cancer metastases to mediastinal lymph nodes was specific (97.5%) but not sensitive (53.6%).6 In a large series of patients with mediastinal adenopathy, EUS features alone could not distinguish between benign and malignant lesions.7 It is, therefore, recommended that FNA be performed whenever mediastinal adenopathy is being evaluated during EUS if the results will alter management. FNA of mediastinal nodes FNA of nodes improves the accuracy of EUS for determining malignant involvement8,9 and may change management (in particular, avoiding mediastinoscopy or thoracotomy) in a significant number of patients.10-13 EUS-FNA has been shown to yield a diagnosis even when prior studies, including positron emission tomography (PET) scanning, CTguided FNA, bronchoscopy, pleurocentesis, and mediastinoscopy are negative or inconclusive.14-16 FNA of mediastinal nodes can provide a specimen adequate for interpretation in over 95% of cases7,10 and has a complication rate of less than 1%.7,10,12,15,17 The specificity of EUS-FNA for malignancy is close to 100%, and the sensitivity for detecting malignancy in mediastinal nodes is 88% to 96%.15,18 False-negative results of mediastinal EUS-FNA have been reported in lung cancer, renal cell cancer, Hodgkin’s disease, and non-Hodgkin’s lymphoma.7,13,15,19 To minimize the number of FNA passes made, a cytopathologist should be available to determine the adequacy of specimens obtained. When this is not feasible, at least three FNA passes should be made to maximize sensitivity.20 In the event that there are multiple nodes, FNA should be performed on that which is most suspicious in appearance. Alternatively, when staging lung cancer, a contralateral node should be sought before a subcarinal or ipsilateral node to detect the highest N stage. When infection is being considered, special stains and cultures (e.g., for acidfast bacilli, fungi) should be used in the evaluation of aspirated material. If lymphoma is suspected, flow GASTROINTESTINAL ENDOSCOPY
819
cytometry or cytogenetics should be considered, which may require preprocedure consultation with the pathology department. Serious complications from EUS-FNA of mediastinal masses and lymph nodes have not been reported, although there have been cases of serious infection involving mediastinal cysts.21,22 EUS-FNA for adenopathy of unknown origin There have been several series published documenting the utility of EUS-FNA for evaluating idiopathic mediastinal adenopathy found by CT scanning, chest radiography, or EUS for other reasons.7,10-12,15,17 In some of these cases, lung cancer was suspected based upon imaging but no diagnosis had yet been made. In addition, some patients had a history of prior malignancy. Malignant adenopathy was diagnosed by EUS-FNA in 42% to 72% of cases. When performing EUS for evaluation of pancreatobiliary masses, metastatic mediastinal involvement should be sought because this may be found in 6% of cases.23 The infections most frequently diagnosed by EUS-FNA are caused by mycobacteria and histoplasmosis. EUS-FNA in lung cancer staging Lung cancer is the most frequent cause of cancerrelated mortality in the world. Its diagnosis and staging typically involve either CT-guided FNA, transbronchial FNA, mediastinoscopy with biopsy, or thoracoscopy. The staging system established by the American Joint Committee on Cancer requires the determination of the presence and location of nodal metastases in the mediastinum. Subcarinal or ipsilateral malignant adenopathy (N2) conveys stage IIIA disease, while contralateral nodal metastases (or direct mediastinal invasion by tumor, i.e., T4) conveys stage IIIB disease. Management of these two substages in non-small-cell lung cancer (NSCLC) is institutionally dependent, but, generally, patients with stage IIIB disease are unlikely to benefit from surgical intervention. EUS-FNA has been shown to be an accurate (>90%) and a safe method for nodal staging in patients with previously documented lung cancer.12,13,19,24 Even patients without mediastinal nodes visualized by CT may harbor malignant adenopathy detectable by EUS-FNA.19 One costminimization model compared EUS-FNA with PET scanning, CT-guided FNA, transbronchial FNA, and mediastinoscopy in patients with NSCLC and enlarged subcarinal nodes visualized by CT.25 The model determined that EUS-FNA was the least costly method for diagnosing malignant adenopathy (specifically N2 disease) as long as the pretest likelihood 820
GASTROINTESTINAL ENDOSCOPY
of malignant adenopathy was at least 24% and EUSFNA was at least 76% sensitive. Another model specifically compared mediastinoscopy with EUSFNA for patients with malignant nodes in the subaortic (aortopulmonary window), para-aortic and subcarinal stations.26 EUS-FNA proved more cost-effective even if the negative predictive value of EUS-FNA was as low as 22%. Recommendations EUS-FNA is indicated for the evaluation of adenopathy and masses of the posterior mediastinum. It is the procedure of choice for tissue sampling of such lesions in the subcarinal, subaortic (aortopulmonary window), and periesophageal stations found on cross sectional imaging (CT, MRI, or PET). EUS-FNA also should be considered in the preoperative staging of patients with NSCLC without definite adenopathy on cross sectional imaging. SUMMARY For the following points: (A), prospective controlled trials; (B), observational studies; (C), expert opinion. EUS-FNA is a safe and accurate method for obtaining a tissue diagnosis in patients with mediastinal adenopathy. (B) In patients with NSCLC, EUS-FNA is an accurate and cost-saving method for nodal staging in patients with documented posterior mediastinal adenopathy. (B) EUS-FNA is the procedure of choice for the evaluation of posterior mediastinal nodes and masses seen on cross-sectional imaging and may have a role in the preoperative staging of patients with NSCLC without mediastinal abnormalities on cross sectional imaging. (C) REFERENCES 1. Vilmann P. Endoscopic ultrasonography-guided fine-needle aspiration biopsy of lymph nodes. Gastrointest Endosc 1996; 43:S24-9. 2. ASGE. The role of endoscopy in the assessment and treatment of esophageal cancer. Gastrointest Endosc 2003;57: 817-22. 3. Catalano M, Sivak M, Rice T, Gragg L, Van Dam J. Endosonographic features predictive of lymph node metastasis. Gastrointest Endosc 1994;40:442-6. 4. Faigel D. EUS in patients with benign and malignant lymphadenopathy. Gastrointest Endosc 2001;53:593-8. 5. Bhutani M, Hawes R, Hoffman B. A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for the diagnosis of malignant lymph node invasion. Gastrointest Endosc 1997;45:474-9. 6. Kondo D, Imaizumi M, Abe T, Naruke T, Suemasu K. Endoscopic ultrasound examination for mediastinal lymph node metastases of lung cancer. Chest 1990;98:586-93. VOLUME 58, NO. 6, 2003
7. Fritscher-Ravens A, Sriram PV, Bobrowski C, Pforte A, Topalidis T, Krause C, et al. Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNAbased differential cytodiagnosis in 153 patients. Am J Gastroenterol 2000;95:2278-84. 8. Eloubeidi M, Wallace M, Reed C, Hadzijahic N, Lewin DN, Van Velse A, et al. The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single center experience. Gastrointest Endosc 2001;54:714-9. 9. Vazquez-Sequeiros E, Norton ID, Clain JE, Wang KK, Affi A, Allen M, et al. Impact of EUS-guided fine-needle aspiration on lymph node staging in patients with esophageal carcinoma. Gastrointest Endosc 2001;53:751-7. 10. Catalano MF, Rosenblatt ML, Chak A, Sivak MV Jr, Scheiman J, Gress F. Endoscopic ultrasound-guided fine needle aspiration in the diagnosis of mediastinal masses of unknown origin. Am J Gastroenterol 2002;97:2559-65. 11. Catalano MF, Nayar R, Gress F, Scheiman J, Wassef W, Rosenblatt ML, et al. EUS-guided fine needle aspiration in mediastinal lymphadenopathy of unkown origin. Gastrointest Endosc 2002;55:863-9. 12. Larsen SS, Krasnik M, Vilmann P, Jacobsen GK, Pedersen JH, Faurschou P, et al. Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management. Thorax 2002;57:98-103. 13. Gress F, Savides TJ, Sandler A, Kesler K, Conces D, Cummings O, et al. Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of nonsmall-cell lung cancer: a comparison study. Ann Intern Med 1997;127:604-12. 14. Pedersen BH, Vilmann P, Folke K, Jacobsen GK, Krasnik M, Milman N, et al. Endoscopic ultrasonography and real-time guided fine-needle aspiration biopsy of solid lesions of the mediastinum suspected of malignancy. Chest 1996;110: 539-44. 15. Wiersema MJ, Vazquez-Sequeiros E, Wiersema LM. Evaluation of mediastinal lymphadenopathy with endoscopic USguided fine-needle aspiration biopsy. Radiology 2001;219: 252-7. 16. Rosenberg JM, Perricone A, Savides TJ. Endoscopic ultrasound/fine-needle aspiration diagnosis of a malignant subcarinal lymph node in a patient with lung cancer and a negative positron emission tomography scan. Chest 2002;122:1091-3. 17. Devereaux BM, LeBlanc JK, Yousif E, Kesler K, Brooks J, Mathur P, et al. Clinical utility of EUS-guided fine-needle aspiration of mediastinal masses in the absence of known pulmonary malignancy. Gastrointest Endosc 2002;56:397-401.
VOLUME 58, NO. 6, 2003
18. Barawi M, Gress F. EUS-guided fine-needle aspiration in the mediastinum. Gastrointest Endosc 2000;52:S12-7. 19. Wallace MB, Silvestri GA, Sahai AV, Hawes RH, Hoffman BJ, Durkalski V, et al. Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung. Ann Thorac Surg 2001;72:1861-7. 20. Wallace M, Kennedy T, Durkalski V, Eloubeidi MA, Etamad R, Matsuda K, et al. Randomized controlled trial of EUSguided fine needle aspiration techniques for the detection of malignant lymphadenopathy. Gastrointest Endosc 2001; 54:441-7. 21. Ryan A, Zamar V, Roberts S. Iatrogenic candidal infection of a medistinal foregut cyst following endoscopic ultrasoundguided fine-needle aspiration. Endoscopy 2002;34:838-9. 22. Wildi SM, Hoda RS, Fickling W, Schmulewitz N, Varadarajulu S, Roberts SS, et al. Diagnosis of benign cysts of the mediastinum: the role and risks of EUS and FNA. Gastrointest Endosc 2003;58:362-8. 23. Hahn M, Faigel DO. Frequency of mediastinal lymph node metastases in patients undergoing EUS evaluation of pancreaticobiliary masses. Gastrointest Endosc 2001;54:331-5. 24. Silvestri GA, Hoffman BJ, Bhutani MS, Hawes RH, Coppage L, Sanders-Cliette A, et al. Endoscopic ultrasound with fineneedle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg 1996;61:1441-5. 25. Harewood GC, Wiersema MJ, Edell ES, Liebow M. Costminimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy. Mayo Clin Proc 2002;77:155-64. 26. Aabakken L, Silvestri GA, Hawes R, Reed CE, Marsi V, Hoffman B. Cost-efficacy of endoscopic ultrasonography with fine-needle aspiration vs. mediasinotomy in patients with lung cancer and suspected mediastinal adenopathy. Endoscopy 1999;31:707-11.
Prepared by: STANDARDS OF PRACTICE COMMITTEE Brian C. Jacobson, MD, MPH William K. Hirota, MD Jay L. Goldstein, MD Jonathan A. Leighton, MD J. Shawn Mallery, MD J. Patrick Waring, MD Todd H. Baron, MD, Vice Chair Douglas O. Faigel, MD, Chair
GASTROINTESTINAL ENDOSCOPY
821