Guideline:
The role of endoscopic ultrasound for evaluation of mediastinal adenopathy
Bibliographic Source(s)
- 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] PubMed
Guideline Status
This is the current release of the guideline.
Guideline Category
Diagnosis
Evaluation
Intended Users
Physicians
Guideline Objective(s)
To suggest appropriate situations for which endoscopic ultrasound (EUS) should be utilized in the evaluation of mediastinal adenopathy
Target Population
Patients with or suspected of having mediastinal adenopathy
Interventions and Practices Considered
Diagnosis/Evaluation
- Endoscopic ultrasound (EUS)
- Fine needle aspiration (FNA)
Major Outcomes Considered
Sensitivity and specificity of diagnostic tests
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
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.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
The guideline developers reviewed published cost-minimization studies. One cost-minimization model compared endoscopic ultrasound-fine needle aspiration (EUS-FNA) with positron emission tomography (PET) scanning computed tomography (CT)-guided FNA transbronchial FNA and mediastinoscopy in patients with non-small cell lung cancer (NSCLC) and enlarged subcarinal nodes visualized by CT. The model determined that EUS-FNA was the least costly method for diagnosing malignant adenopathy (specifically N2 disease) as long as the pretest likelihood of malignant adenopathy was at least 24% and EUS-FNA was at least 76% sensitive. Another model specifically compared mediastinoscopy with EUS-FNA for patients with malignant nodes in the subaortic (aortopulmonary window) para-aortic and subcarinal stations. EUS-FNA proved more cost-effective even if the negative predictive value of EUS-FNA was as low as 22%.
Method of Guideline Validation
Not stated
Description of Method of Guideline Validation
Not applicable
Major Recommendations
Each recommendation is followed by evidence grades (A-C) identifying the type of supporting evidence. Definitions of the evidence grades are presented at the end of the "Major Recommendations" field.
Recommendations
Endoscopic ultrasound-fine needle aspiration (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 (computed tomography [CT] magnetic resonance imaging [MRI] or positron emission tomography [PET]). EUS-FNA should also be considered in the preoperative staging of patients with non-small cell lung cancer without definite adenopathy on cross sectional imaging.
Summary
- EUS-FNA is a safe and accurate method for obtaining a tissue diagnosis in patients with mediastinal adenopathy (B).
- In patients with non-small cell lung cancer 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 non-small cell lung cancer without mediastinal abnormalities on cross sectional imaging (C).
Definitions
A - Prospective controlled trials
B - Observational studies
C - Expert opinion
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and classified for the recommendations using the following scheme:
A = Prospective controlled trials
B = Observational studies
C = Expert opinion
Potential Benefits
- Appropriate evaluation of mediastinal adenopathy
- Fine needle aspiration (FNA) of nodes improves the accuracy of endoscopic ultrasound (EUS) for determining malignant involvement and may change management (in particular avoiding mediastinoscopy or thoracotomy) in a significant number of patients.
Potential Harms
- False negative results of mediastinal endoscopic ultrasound-fine needle aspiration (EUS-FNA) have been reported in lung cancer renal cell cancer Hodgkin's disease and non-Hodgkin's lymphoma.
- Serious complications from EUS-FNA of mediastinal masses and lymph nodes have not been reported although there has been one case of candidal infection of a mediastinal cyst.
Qualifying Statements
- 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.
- The information in this guideline is intended only to provide general information and not as a definitive basis for diagnosis or treatment in any particular case. It is very important that individuals consult their doctors about specific conditions.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Bibliographic Source(s)
- 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] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Society for Gastrointestinal Endoscopy
Guideline Committee
Standards of Practice Committee
Composition of Group that Authored the Guideline
Committee Members: Douglas O. Faigel MD (Chair); Todd H. Baron MD (Vice Chair); 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
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Society for Gastrointestinal Endoscopy (ASGE) Web site.
Print copies: Available from the American Society for Gastrointestinal Endoscopy 1520 Kensington Road Suite 202 Oak Brook IL 60523
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on October 15 2004. The information was verified by the guideline developer on November 5 2004.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
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