The role of endobronchial ultrasound transbronchial needle aspiration in patients candidate to pneumonectomy

Background: Lung cancer remains the leading cause of cancer, both in incidence and mortality. Surgery is the mainstay in the treatment of lung cancer and for locally advanced disease the removal of the entire lung (pneumonectomy) may be required. Careful patient staging is pivotal to determine appropriate surgery feasibility, complete resection probability and to evaluate neoadjuvant treatment. Methods: We retrospectively reviewed 230 patients undergoing pneumonectomy for non-small-cell lung cancer (NSCLC) treatment from 2012–2019 at our Institution. The main objective of the study was to evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the management of this group of patients. The Ethics Committee approved data collection and analysis and waived the need for written consent. Results: Eighty patients (60 males, 75%) with a median age of 70 (range, 24–92) years were included at the analysis. Mediastinal staging was performed to achieve the histological cell type and staging in 49 patients (61.3%), for mediastinal staging alone in 14 cases (17.5%), to evaluate endobronchial and lymph node involvement in 5 (6.3%) cases, 6 (7.5%) cases of cN3 suspicious investigation and in 6 patients (7.5%) for cell type diagnosis, staging and a panel of mutations assessment. One hundred and nine mediastinal stations were sampled during mediastinal staging procedures, with 136 lymph nodes sampled. The most frequent station analyzed was the subcarinal (48.6%), followed by the right lower paratracheal station (24.8%) or both of them (21.0%). Neoadjuvant treatment was indicated in 41 (51.3%) patients after mediastinal staging that confirmed the mediastinal lymph node involvement. Sensitivity, negative predicted value and diagnostic accuracy were respectively 86.7%, 94.4% and 95.9%. The surgical resection type included 68 standard pneumonectomies, 46 extended resections, 3 sleeve pneumonectomies and 10 extended sleeve pneumonectomies’ for pericardium, superior vena cava, atrium or diaphragm resection with bronchoplastic. A lymph node downstaging promoted by the neoadjuvant treatment was observed in 11 patients (26.8%). The follow-up of patients was possible in all cases, with a median survival of 21.8 months. Conclusions: In patients with lung cancer that require major surgical procedures, mediastinal staging plays an essential role. EBUS-TBNA is a minimally invasive procedure able to characterize the disease in terms of cell type and a full molecular analysis guiding the best neoadjuvant treatment without altering the surgical field with no major complications.