This is the current release of the guideline.

Mediastinal adenopathy

Diagnosis
Evaluation

Gastroenterology
Oncology

Physicians

To suggest appropriate situations for which endoscopic ultrasound (EUS) should be utilized in the evaluation of mediastinal adenopathy

Patients with or suspected of having mediastinal adenopathy

Diagnosis/Evaluation

1. Endoscopic ultrasound (EUS)
2. Fine needle aspiration (FNA)

Sensitivity and specificity of diagnostic tests

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

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.

Not stated

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus.

Not applicable

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%.

Not stated

Not applicable

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

None provided

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

• 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.

• 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.

• 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.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness

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

2003 Dec

American Society for Gastrointestinal Endoscopy - Medical Specialty Society

American Society for Gastrointestinal Endoscopy

Standards of Practice Committee

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

Not stated

This is the current release of the guideline.

None available

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