This is the current release of the guideline.

This release updates a previously published guideline: Jacobson BC, Hirota WK, Goldstein JL, Leighton JA, Mallery JS, Waring JP, Baron TH, Faigel DO. The role of EUS for evaluation of mediastinal adenopathy. Gastrointest Endosc 2003 Dec;58(6):819-21. [24 references]

Mediastinal adenopathy

To address the role of endoscopic ultrasound (EUS) and endobronchial ultrasound (EBUS) in the evaluation of mediastinal adenopathy

Patients with known or suspected mediastinal adenopathy

Diagnosis/Evaluation

1. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA)
2. Endobronchial ultrasound-guided (EBUS)-FNA
3. Tissue assessment
   • Flow cytometry
   • Special stain and culture

In preparing this guideline, a search of the medical literature was performed using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is placed on results from large series and reports from recognized experts. The updated literature time frame is 1990 to 2011.

Not stated

Grading of Recommendations Assessment, Development, and Evaluation (GRADE) System for Rating the Quality of Evidence for Guidelines

Adapted from Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.

Not stated

Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted.

The strength of individual recommendations is based both on the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "The Practice Committee suggests," whereas stronger recommendations are typically stated as "The Practice Committee recommends."

Cost analyses compared endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA), and combined EUS/EBUS-FNA with mediastinoscopy in the evaluation of mediastinal adenopathy with suspected lung cancer. One study suggested that EUS-FNA is more cost-effective than mediastinoscopy, provided that the location of potential mediastinal metastases is in station 5, 6, or 7. A second study determined that EUS-FNA was more cost-effective than mediastinoscopy, but assumes that EUS-FNA always successfully detects and samples the abnormal node on computed tomography (CT) scan and that 50% of mediastinoscopies are performed on an inpatient basis. A third study determined that EUS-FNA is most cost-effective if the probability of lymph node metastases is less than 32%; above this, combined EUS and EBUS are preferred. However, the study also assumes that 50% of mediastinoscopies are performed on an inpatient basis.

Not applicable

Definitions for the quality of the evidence (++++, +++O, ++OO, and +OOO) and for the strength of the recommendations ("recommends" or "suggests") are provided at the end of the "Major Recommendations" field.

1. In patients with known or suspected potentially resectable lung cancer whose imaging reveals mediastinal adenopathy, the Practice Committee suggests that endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) be performed in patients with paraesophageal, posterior, and inferior mediastinal adenopathy, if the expertise if available. (++OO) Similarly, the Practice Committee suggests that endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) be performed in patients with paratracheal mediastinal adenopathy if this information adds to the staging of the lung cancer. (++OO) EUS-FNA and EBUS-FNA have been shown to be safe, and potentially cost-effective compared with mediastinoscopy, although individually each has a high false-negative rate that warrants surgical confirmation before proceeding with resection.
2. In patients with known or suspected potentially resectable lung cancer whose imaging shows no evidence of mediastinal adenopathy, the Practice Committee suggests combined EUS-FNA/EBUS-FNA for staging. (++OO) Combined EUS-FNA/EBUS-FNA has been shown to have a negative predictive value comparable to that of mediastinoscopy. However, expertise in both modalities is not readily available at most institutions.
3. In patients who require evaluation of station 5 nodes, the Practice Committee suggests EUS-FNA as a safe and cost-effective first-line approach. (++OO)
4. When EUS-FNA is performed for suspected lymphoma, the Practice Committee suggests that specimens be sent for flow cytometry and, if technically possible, that EUS core biopsy specimens be obtained because immunophenotyping and histology are often required for diagnosis and subtyping of lymphoma. (++OO)
5. When EUS-FNA of mediastinal adenopathy is performed in patients with suspected infected nodes, the Practice Committee recommends that aspirate be sent for special stain and culture (e.g., acid-fast stain, fungal culture). (+OOO)

Definitions:

Grading of Recommendations Assessment, Development, and Evaluation (GRADE) System for Rating the Quality of Evidence for Guidelines

Adapted from Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6.

Recommendation Strength

The strength of individual recommendations is based both on the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as "the Practice Committee suggests," whereas stronger recommendations are typically stated as "the Practice Committee recommends."

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Appropriate use of endoscopic ultrasound (EUS) and endobronchial ultrasound (EBUS) for evaluation of mediastinal adenopathy

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American Society for Gastrointestinal Endoscopy

Standards of Practice Committee

Committee Members: Jason A. Dominitz, MD, MHS (Chair); Terry L. Jue, MD Ravi N. Sharaf, MD; Vasundhara Appalaneni, MD; Michelle A. Anderson, MD; Tamir Ben-Menachem, MD; G. Anton Decker, MD; Robert D. Fanelli, MD (SAGES Representative); Norio Fukami, MD; Steven O. Ikenberry, MD; Rajeev Jain, MD; Khalid M. Khan, MD (NASPHAGAN Representative); Mary L. Krinsky, DO; Phyllis M. Malpas, RN (SGNA Representative); John T. Maple, DO; Deborah Fisher, MD; Joo Ha Hwang, MD; Dayna Early, MD; John A. Evans, MD

The following authors disclosed financial relationships relevant to this publication:

Dr Decker: consultant to Facet Biotechnology; Dr Fanelli: honoraria from Ethicon, consultant to RTI; owner/governor: New Wave Surgical Corp; Dr Jain: research support from Barrx; Dr Evans: consultant to Cook Medical. The other authors disclosed no financial relationships relevant to this publication.

This is the current release of the guideline.

This release updates a previously published guideline: Jacobson BC, Hirota WK, Goldstein JL, Leighton JA, Mallery JS, Waring JP, Baron TH, Faigel DO. The role of EUS for evaluation of mediastinal adenopathy. Gastrointest Endosc 2003 Dec;58(6):819-21. [24 references]

Electronic copies: Available from the American Society for Gastrointestinal Endoscopy Web site .

Print copies: Available from the American Society for Gastrointestinal Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

The following is available:

• Role of EUS for the evaluation of mediastinal adenopathy. CME course. Available from the American Society for Gastrointestinal Endoscopy Web site .

None available

This NGC summary was completed by ECRI on October 15, 2004. The information was verified by the guideline developer on November 5, 2004. This NGC summary was updated by ECRI Institute on September 14, 2012.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.