Endobronchial ultrasound-guided transbronchial needle aspiration mediastinal lymph node staging in malignant pleural mesothelioma

Background: Given poor survival of patients with malignant pleural mesothelioma (MPM) and extrapleural nodal metastasis, pre-operative mediastinal lymph node (LN) staging has been advocated. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) may be a useful preoperative adjunct in patients with MPM. This study aims to assess performance of EBUS-TBNA for mediastinal LN staging in MPM. Methods: A retrospective chart review of patients with diagnosis of MPM referred to the mesothelioma program at a tertiary Canadian cancer center between January 1, 2012 and December 31, 2014 who received mediastinal LN staging with EBUS-TBNA. Results: Forty-eight patients were included. Average age was 70 years (range, 48-84 years). Mesothefioma subtypes were as follows: epithefioid 34/48 (70.8%), sarcomatoid 4/48 (8.3%), biphasic 7/48 (14.6%) and other 3/48 (6.3%). Stage distribution was as follows: I 18.8%, II 10.4%, III 47.9%, and W 22.9%. On average 3.4 LNs were sampled per patient (range, 1-5). The mean short axis of a sampled LN was 6.8 +/- 3.8 mm. Rapid on Site Evaluation (ROSE) was available in 75.0% (36/48) of the assessments. Prevalence of N2/N3 disease was 35.4% (17/48). EBUS-TBNA sensitivity, specificity, positive predictive value (PIN), negative predictive value (NPV) and diagnostic accuracy were: 16.7%, 100%, 100%, 68.8%, and 70.6%, respectively. EBUS-TBNA mediastinal LN staging prevented unnecessary surgery in 18.8% (9/48 patients) by detection of N2/N3 disease (8 patients) and metastatic secondary malignancy (1 patient). There were no EBUS-TBNA related complications. Conclusions: EBUS-TBNA mediastinal LN staging may impact significantly management of patients with MPM by detecting mediastinal metastatic disease, therefore, preventing morbidity and mortality of surgical management.