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CLINICAL SCIENCE
Endoscopic ultrasound-guided biopsies for mediastinal lesions and lymph node diagnosis and staging
José Celso Ardengh
Corresponding author
jcelso@uol.com.br

Tel.: 55 11 5055-7134
, Ricardo H. Bammann, Matheus de Giovani, Filadelfio Venco, Artur A. Parada
Endoscopy Service and Thoracic Surgery Clinic, Hospital 9 de Julho, São Paulo/SP, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">The association between endoscopic techniques and ultrasound first developed in the 1980s&#46; The repercussions and clinical impact of this minimally invasive technological advance have been broadly highlighted in the international scientific literature and more recently expanded to pulmonology and thoracic oncology&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">Endobronchial ultrasound &#40;known as EBUS&#41; has faced greater technical bottlenecks&#44; related to the smaller diameters of the bronchoscope&#44; its working channel&#44; the patients&#39; airways and&#44; especially&#44; the interface between the ultrasound and air&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> The first sectorial echobronchoscope was launched on the international market only in the middle of the first decade of 2000&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">Gastrointestinal endosonography &#40;known as EUS&#41;&#44; on the other hand&#44; has been in use as a routine procedure for more than 15 years at large hospitals performing high-complexity procedures&#44; including those in Brazil&#46;<a class="elsevierStyleCrossRefs" href="#bib2">2&#8211;4</a> Its diagnostic and therapeutic range has been well established for pancreatic and pelvic diseases&#59; mediastinal lesions can also be approached through the intrathoracic esophagus&#46;<a class="elsevierStyleCrossRefs" href="#bib5">5&#44;6</a> Fine-needle aspiration &#40;FNA&#41; of masses and lymph nodes through the esophageal wall has been performed at specialized centers&#44; with minimal risks of infection or bleeding and without great technical difficulty&#46;<a class="elsevierStyleCrossRefs" href="#bib5">5&#8211;8</a> The importance and usefulness of EUS for the mediastinal staging of primary lung cancer has been well known since 1996&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a> The main limitation of EUS is its inability to access the anterior mediastinum because of the interference of air present in the trachea&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;7&#44;8</a></p><p id="para40" class="elsevierStylePara elsevierViewall">This study aims to assess the performance of EUS-guided FNA in diagnosing mediastinal tumor lesions &#40;including lymph node enlargements&#41; and to describe some advantages and particularities of the technique&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">MATERIAL AND METHODS</span><p id="para50" class="elsevierStylePara elsevierViewall">This observational&#44; retrospective&#44; and cross-sectional experience analysis reports the experience of a single endosonography service linked to a private hospital in Sao Paulo City between February 1997 and January 2011&#46; All clinical data &#40;including copies of radiological and endosonography images&#41; were obtained from the service&#39;s computerized database&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">The demands for EUS for mediastinal assessment purposes were spontaneous because the patients&#39; own physicians referred them due to pathological findings on chest-Computerized tomography &#40;CT&#41; and&#44; in some more recent cases&#44; on Positron emission tomography &#40;PET&#41; scans&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">For the sake of this study&#44; patients were classified into two groups according to the purpose of the examination&#58; Group 1&#8212;EUS-FNA performed for mediastinal staging of previously known malignant tumors&#59; and Group 2&#8212;EUS-FNA performed for diagnostic definition of lymph nodes or suspected mediastinal masses&#46; No technical or logistic differences occurred when the procedure was accomplished in both groups&#44; which always followed the same service routine&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">All examinations took place in an outpatient setting&#44; under general anesthesia&#44; starting with conventional upper digestive endoscopy&#46; Then echoendoscopy was used to identify the mediastinal lesions previously detected on radiology exams&#46; Under a direct and real-time ultrasound view&#44; one single lesion &#40;the largest in cases of multiple identified lesions&#41; was punctured with a dedicated 22-gauge endoscopic needle&#46; Once guided into the target lesion&#44; the needle was moved back and forth within the mass while applying suction with a 20-ml syringe&#46; At least three needle punctures were made to obtain adequate tissue specimens&#46; Frozen-section examination was not performed during the procedure in any of the cases&#46; The aspirated material was fixed in formaldehyde and analyzed through the cell-block technique&#46; In case of inconclusive cytopathology results&#44; the patient&#39;s physician-in-charge was asked for further information on clinical monitoring&#44; other diagnostic methods&#44; and the respective final diagnosis in each case&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Approval for this study was obtained from the local Institutional Review Board in compliance with the National Health Council Resolution 196&#47;96&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">RESULTS</span><p id="para100" class="elsevierStylePara elsevierViewall">Out of 1&#44;639 gastrointestinal endosonographies performed during the study period&#44; 51 &#40;3&#46;1&#37;&#41; looked for mediastinal lesions&#46; This series involved 37 &#40;72&#46;5&#37;&#41; men and 14 women between 26 and 87 years old &#40;median 65 years&#41;&#46; Out of these 51 patients&#44; 23 &#40;45&#46;1&#37;&#41; manifested thoracic symptoms &#40;dysphagia&#44; dyspnea&#44; thoracic pain&#41;&#44; 22 &#40;43&#46;1&#37;&#41; reported nonspecific signs and symptoms &#40;fever and weight loss&#41;&#44; and 6 &#40;11&#46;8&#37;&#41; were asymptomatic&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">The forwarding physicians included 22 &#40;43&#46;1&#37;&#41; oncologists&#44; 18 &#40;35&#46;3&#37;&#41; clinical pulmonologists and thoracic surgeons&#44; and 11 &#40;21&#46;6&#37;&#41; others &#40;general clinicians&#44; digestive surgeons&#44; and cardiologists&#41;&#46; It should be highlighted that out of the 51 EUS performed for mediastinal assessment purposes&#44; 23 &#40;45&#46;1&#37;&#41; happened in the final four years of the research period&#44; and these cases were mostly referred by pulmonologists and thoracic surgeons&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">Endoscopic alterations &#40;extrinsic compression&#41; were found in 24 &#40;47&#46;1&#37;&#41; patients&#44; three of whom already displayed esophageal stenosis&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">In Group 1 &#40;with previously known malignant disease&#44; forwarded for mediastinal staging&#41;&#44; 17 patients were included&#44; 9 with primary lung tumors&#44; 4 with breast tumors&#44; 2 with kidney tumors&#44; 1 with a colon tumor&#44; and 1 with a bladder tumor&#46; Out of these 17 patients&#44; a previous PET scan had been done in only 4&#44; all of whom were considered &#8220;positive&#8221; for the suspected mediastinal lesion&#46; The diameter of the punctured lesions ranged from 1&#46;1 to 6&#46;8 cm&#44; with an average of 3&#46;7 cm&#46; Their location &#40;Mountain&#44; 1997&#41;<a class="elsevierStyleCrossRef" href="#bib9">9</a> corresponded to stations 2R &#40;2 cases&#41;&#44; 2L &#40;1&#41;&#44; 4R &#40;1&#41;&#44; 4L &#40;2&#41;&#44; &#35;5 &#40;1&#41;&#44; &#35;6 &#40;1&#41;&#44; &#35;7 &#40;3&#41;&#44; &#35;8 &#40;2&#41;&#44; 10R &#40;1&#41;&#44; and 10L &#40;3&#41;&#46; EUS-FNA demonstrated metastatic involvement in 15 out of 17 &#40;88&#46;2&#37;&#41; patients in Group 1&#46; One case was negative&#44; and another was inconclusive&#8212;the respective lymph node stations sampled by EUS were the paraesophageal &#40;&#35;8&#41; and the left hilar &#40;10L&#41;&#46; Both cases were later submitted to classical cervical mediastinoscopy&#44; which identified metastases in lower paratracheal lymph nodes &#40;&#35;4&#41; that were previously undetected through EUS&#46;</p><p id="para140" class="elsevierStylePara elsevierViewall">Group 2 &#40;undiagnosed lymph node enlargements or mediastinal masses&#41; comprised 34 patients&#46; The diameter of the punctured lesions varied from 1&#46;6 to 9&#46;8 cm &#40;average 4&#46;0 cm&#41;&#46; Their location &#40;Mountain&#44; 1997&#41;<a class="elsevierStyleCrossRef" href="#bib9">9</a> corresponded to stations 2L &#40;one case&#41;&#44; 4R &#40;3&#41;&#44; 4L &#40;1&#41;&#44; &#35;5 &#40;11&#41;&#44; &#35;6 &#40;5&#41;&#44; &#35;7 &#40;6&#41;&#44; &#35;8 &#40;6&#41;&#44; and 10L &#40;1&#41;&#46; Among the 34 patients in Group 2&#44; 22 &#40;64&#46;7&#37;&#41; &#8220;new&#8221; tumors were diagnosed through EUS-FNA&#44; including epidermoid carcinoma &#40;10&#41;&#44; adenocarcinoma &#40;5&#41;&#44; oat-cell &#40;3&#41;&#44; lymphoma &#40;2&#41;&#44; sarcoma &#40;1&#41;&#44; and neuroendocrine carcinoma &#40;1&#41;&#46; Other diagnoses established in this group included tuberculosis &#40;5&#41; and duplication cyst &#40;2&#41;&#46; Cytology was not malignant &#40;but without a specific diagnosis&#41; in three cases and inconclusive in two others&#8212;these five patients were later submitted to mediastinoscopy&#44; which identified two other cases of oat-cell carcinoma&#44; one non-Hodgkin B-cell lymphoma&#44; and one ganglionic cryptococcosis&#44; in addition to confirming one case of non-specific reactive lymphadenitis&#46; <a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a> displays a flow chart that summarizes the procedures and diagnoses in this study&#46; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2A</a> illustrates a clinical case from Group 1&#59; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2B</a> illustrates a clinical case from Group 2&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia><p id="para150" class="elsevierStylePara elsevierViewall">There were no complications related to the method&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">DISCUSSION</span><p id="para160" class="elsevierStylePara elsevierViewall">Despite its technical and commercial availability&#44; EUS is still rather underused in the treatment of thoracic illnesses&#46; Aside from its well-established importance for lung cancer staging&#44;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;10</a> its indication extends to other clinical situations&#44; such as mediastinal lymph node enlargement of unknown causes or primary tumor masses and cystic lesions &#40;for diagnostic or symptom relief purposes&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a></p><p id="para170" class="elsevierStylePara elsevierViewall">Considering each patient&#39;s final diagnosis as the gold standard&#44; the general sensitivity of EUS-FNA in our study was 88&#46;0&#37;&#44; with 11&#46;7&#37; false negative cases&#46; These rates still apply if the sample is limited to the 17 cases in Group 1&#46; In a recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib6">6</a> restricted to lung cancer cases&#44; the general EUS-FNA sensitivity was 84&#37; for metastasis detection &#40;N2 and&#47;or N3&#41;&#44; with a global false-negative rate of 19&#37;&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">The only other Brazilian publication found that addressed this issue<a class="elsevierStyleCrossRef" href="#bib12">12</a> assessed 25 EUS-FNA performed for the sake of diagnostic clarification of mediastinal masses and lymph nodes&#46; Most &#40;48&#37;&#41; lesions were neoplastic&#44; while 24&#37; were inflammatory or infectious&#46; Normal lymphatic tissue was obtained in three cases &#40;12&#37;&#41; and&#44; in four others &#40;16&#37;&#41;&#44; insufficient material was sampled&#46; No data are available on other complementary methods used to define the diagnosis for inconclusive cases&#46;</p><p id="para190" class="elsevierStylePara elsevierViewall">The comparison between different methods &#40;EUS&#44; EBUS&#44; and surgical mediastinoscopy&#41; in mediastinal staging for primary lung cancer has been a recurrent and widely discussed theme&#46; This technical choice depends&#44; among other factors&#44; on the patient&#39;s clinical condition&#44; the degree of suspected mediastinal involvement&#44; the location of the primary tumor&#44; the histological type&#44; diameter and level of the biopsied lymph nodes&#44; the number of samples obtained and&#44; most importantly&#44; the availability of different methods at each institution&#44; as well as the respective results the local team has achieved&#46;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;13</a></p><p id="para200" class="elsevierStylePara elsevierViewall">A larger number of recent EUS have been performed at the request of chest physicians&#8212;we believe this change resulted from these specialists&#39; recent contact with the large-scale dissemination of EBUS in the international literature&#44; particularly regarding clinical repercussions&#46; Both EUS and EBUS are recommended by the main thoracic oncology guidelines on the invasive mediastinal staging of primary lung cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;14&#44;15</a></p><p id="para210" class="elsevierStylePara elsevierViewall">Yet other facts and peculiarities should be reminded&#58;<ul class="elsevierStyleList" id="celist10"><li class="elsevierStyleListItem" id="celistitem10"><span class="elsevierStyleLabel">-</span><p id="para220" class="elsevierStylePara elsevierViewall">Any invasive sampling method is more specific than CT scan and PET scan alone&#46;<a class="elsevierStyleCrossRef" href="#bib16">16</a></p></li><li class="elsevierStyleListItem" id="celistitem20"><span class="elsevierStyleLabel">-</span><p id="para230" class="elsevierStylePara elsevierViewall">The association between EUS and EBUS in the same patient reaches accuracy levels of more than 95&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib17">17&#44;18</a> These rates are quite encouraging&#44; but combining both sets of equipment&#44; logistics&#44; training&#44; and the availability of human and technical resources can hardly be justified in commercial terms&#46;</p></li><li class="elsevierStyleListItem" id="celistitem30"><span class="elsevierStyleLabel">-</span><p id="para240" class="elsevierStylePara elsevierViewall">Mediastinoscopy continues to be an obligatory complementary method whenever the above techniques reveal a negative result&#46;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;14&#44;15</a> Some authors defend the position that if the main goal is the <span class="elsevierStyleUnderline">diagnostic confirmation of suspected metastatic disease</span> detected through CT or PET scan&#44; then endosonography methods &#40;EUS and&#47;or EBUS&#41;&#44; if available&#44; are an excellent alternative&#44; with high sensitivity and low morbidity levels&#46; However&#44; if the main goal of invasive staging is to <span class="elsevierStyleUnderline">confirm the absence of mediastinal involvement</span>&#44; in most cases&#44; surgical mediastinoscopy seems to be the best option&#46;<a class="elsevierStyleCrossRef" href="#bib13">13</a></p></li></ul></p><p id="para250" class="elsevierStylePara elsevierViewall">Based on Mountain&#39;s former lymph node map<a class="elsevierStyleCrossRef" href="#bib9">9</a> &#40;which was the gold standard used during the study period&#41;&#44; EUS can assess and obtain samples from the upper and lower paratracheal levels &#40;stations &#35;2 and &#35;4&#41;&#44; aortic window &#40;&#35;5&#41;&#44; subcarinal level &#40;&#35;7&#41;&#44; paraesophageal level &#40;&#35;8&#41;&#44; inferior pulmonary ligament &#40;&#35;9&#41;&#44; and pulmonary hilum &#40;&#35;10&#41;&#46; It should be noted that EUS also permits staging &#40;and biopsying&#41; of primary pulmonary lesions when located near &#40;or eventually invading&#41; the mediastinum&#46;<a class="elsevierStyleCrossRef" href="#bib19">19</a> It has also been capable of detecting &#40;and biopsying&#41; metastatic disease in subdiaphragmatic lesions&#44; such as those affecting the left adrenal gland&#44; celiac lymph nodes&#44; and liver&#46;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;8</a></p><p id="para260" class="elsevierStylePara elsevierViewall">The experience reported here includes a considerable number &#40;six cases&#41; of samples obtained from the para-aortic level &#40;station &#35;6&#41;&#44; which deserves more careful and detailed analysis&#46; Strictly speaking&#44; station &#35;6 corresponds to the lymph nodes anterior and lateral to the ascending aorta&#44; between a line tangent to the superior border and another to the inferior border of the aortic arch&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a> Hence&#44; although station &#35;6 can indeed be visualized through EUS&#44; it is rather difficult to obtain samples through the esophageal route&#44; as that would imply transection of the pulmonary artery or the aorta itself with the puncture needle&#46; This location may therefore have not been very precise under the EUS view&#44; so that some lymph nodes attributed to the para-aortic position &#40;if not all of them&#41; may include lesions from stations 4L&#44; &#35;5 and even &#35;8&#46;</p><p id="para270" class="elsevierStylePara elsevierViewall">Because esophageal endosonography does not offer easy anatomical reference points&#44; the endoscopist&#39;s experience and knowledge of regional topography are fundamental for a successful examination&#46; Identifying and sampling lesions located at the subcarinal level &#40;&#35;7&#41;&#44; for example&#44; will hardly represent any difficulty because of its central position&#44; which is always anterior to the middle esophagus&#46; It is known that FNA of station &#35;7 guided by endosonography techniques &#40;both EUS and EBUS&#41; does not obtain better results than a simple&#44; &#8220;blind&#8221; transtracheal puncture&#46;<a class="elsevierStyleCrossRef" href="#bib20">20</a> The pulmonary hilar levels &#40;&#35;10&#41;&#44; on the other hand&#44; are frequently mixed up with the inferior paratracheal stations &#40;&#35;4&#41;&#44; especially on the right&#46; Such inadequate staging can radically change therapeutic decisions&#8212;this means a possible N2 false-positive result&#46; In lung cancer patients&#44; if the lymph nodes of stations 10 R&#47;L &#40;classified as N1&#41; are unintentionally interpreted as belonging to stations 4 R&#47;L &#40;classified as N2&#41;&#44; a malignant aspirate may exclude the option for a radical surgical resection and the potential for cure&#46;<a class="elsevierStyleCrossRefs" href="#bib8">8&#44;13</a></p><p id="para280" class="elsevierStylePara elsevierViewall">There are further issues related to the routine adopted at our service&#44; which remains limited to the puncturing of a single suspect lesion &#40;the largest in case of multiple identified lesions&#41;&#46; Hence&#44; it is recommended that&#44; in all cases&#44; samples be obtained from at least two lymph node zones as recently mapped by the International Association for the Study of Lung Cancer &#40;IALSC&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib21">21</a> always including the subcarinal zone &#40;station &#35;7&#41;&#44; to improve prognostic definitions&#46;</p><p id="para290" class="elsevierStylePara elsevierViewall">Equipment costs &#40;especially disposable needles&#41; and the learning curve for use of the technique are highlighted as the main difficulties that EBUS will still have to face before achieving greater availability and widespread use&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> International and Brazilian experiences with EUS-FNA&#44; on the other hand&#44; have already demonstrated the method&#39;s ability to avoid surgical procedures &#40;mediastinoscopy&#44; videothoracoscopy or even exploratory thoracotomy&#41; in a considerable number of patients&#8212;86&#46;3&#37; of cases in this study&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">CONCLUSION</span><p id="para300" class="elsevierStylePara elsevierViewall">EUS-FNA is an excellent alternative for mediastinal lesion diagnosis and staging&#46; Not only endoscopists but also oncologists&#44; pulmonologists&#44; and thoracic surgeons should consider its reliable potential and current availability&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "titulo" => "INTRODUCTION"
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          "titulo" => "MATERIAL AND METHODS"
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          "titulo" => "RESULTS"
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          "titulo" => "DISCUSSION"
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          "titulo" => "CONCLUSION"
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          "titulo" => "REFERENCES"
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    "fechaRecibido" => "2011-03-28"
    "fechaAceptado" => "2011-05-30"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS"
          "identificador" => "xpalclavsec1582744"
          "palabras" => array:5 [
            0 => "Endoscopic ultrasound"
            1 => "Mediastinoscopy"
            2 => "Mediastinal Lymphadenopaty"
            3 => "Lung cancer&#44; Staging"
            4 => "Mediastinal Tumor"
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        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVES&#58;</span><p id="spara30" class="elsevierStyleSimplePara elsevierViewall">To disseminate transesophageal ultrasound-guided fine needle aspiration &#40;EUS-FNA&#41; as an alternative to investigate mediastinal tumoral lesions because it is an underused modality that has been available in Brazil for more than 15 years&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS&#58;</span><p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Descriptive analysis of a single endoscopy service&#39;s experience since 1997 in the accomplishment of EUS-FNA for mediastinal staging of previously known malignancies &#40;Group 1&#41; or diagnostic definition of suspect lymph nodes and masses &#40;Group 2&#41;&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS&#58;</span><p id="spara50" class="elsevierStyleSimplePara elsevierViewall">EUS-FNA was performed in 51 patients between 26 and 87 years of age&#46; The diameter of the lesions ranged between 1&#46;1 and 9&#46;8 cm &#40;mean 3&#46;9 cm&#41;&#46; Their location corresponded to the following stations&#58; higher paratracheal &#40;4 cases&#41;&#44; lower paratracheal &#40;7&#41;&#44; aortic window &#40;12&#41;&#44; para-aortic &#40;6&#41;&#44; subcarinal &#40;9&#41;&#44; paraesophageal &#40;8&#41;&#44; and hilar &#40;5&#41;&#46; In Group 1&#44; 17 patients had previously diagnosed primary lung &#40;9&#41;&#44; breast &#40;4&#41;&#44; kidney &#40;2&#41;&#44; colon &#40;1&#41;&#44; and bladder &#40;1&#41; cancer&#46; Fifteen of these punctures were positive for malignity&#46; Two others were later submitted to mediastinoscopy&#44; which identified metastases not detected by EUS-FNA&#46; Group 2 comprised 34 patients&#46; Among these patients&#44; EUS-FNA diagnosed 22 neoplasms&#44; five cases of tuberculosis and two duplication cysts&#46; Cytology was inconclusive or without a specific diagnosis in five other cases&#46; Mediastinoscopy identified two undiagnosed cases of oat-cell carcinoma&#44; one lymphoma and one cryptococcosis&#44; and confirmed one reactive lymphadenitis&#46; There were no complications related to the method&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSIONS&#58;</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">EUS-FNA obviated the need for surgical procedures in 86&#46;3&#37; of cases&#46; Therefore&#44; oncologists&#44; pulmonologists&#44; and thoracic surgeons should always remember the technique&#39;s potential and availability&#46;</p></span>"
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Endoscopic ultrasound-guided fine-needle aspiration &#40;<span class="elsevierStyleUnderline">EUS-FNA</span>&#41; results and complementary mediastinoscopy performed in 51 patients&#46;</p>"
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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">A A PET scan shows a 2-cm hypermetabolic lymph node &#40;station 10R&#41; in an 81-year-old male patient who had already been submitted to a lower right lobe segmentectomy &#40;adenocarcinoma&#41; 18 months prior&#46; EUS-FNA &#40;notice the needle piercing the lesion&#41; demonstrated metastatic disease&#46; <span class="elsevierStyleBold">B</span> A 46-year-old male presented chronic cough attributed to gastroesophageal reflux&#46; Subsequent hoarseness led to a CT scan that showed a large mediastinal mass in the subcarinal and paraesophageal stations&#46; EUS-FNA was effectively used to diagnose epidermoid carcinoma&#46;</p>"
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                      "titulo" => "Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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Article information
ISSN: 18075932
Original language: English
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