A cost-effective and minimally-invasive approach to mediastinal lymphadenopathy

Introduction: To determine the optimal approach to cytopathologic evaluation of mediastinal lymphadenopathy utilizing transbronchial needle aspiration (TBNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA).

Design: Sequentially controlled study.

Patients: We studied 60 consecutive patients with mediastinal lymphadenopathy on CT chest requiring cytopathologic evaluation

Interventions: The first algorithm involved bronchoscopy and TBNA with rapid onsite cytopathologic evaluation (ROSE). If this was unrevealing, immediate EUS-FNA was performed, also with ROSE. The second algorithm involved either bronchoscopy and TBNA or EUS-FNA as the first procedure. This was determined by the pulmonologist based on lymph node location and whether a bronchoscopy was indicated.

Results: Our results with the first 20 of 33 patients utilizing the first algorithm have been reported in part (Gastrointest Endosc 2006;63:215–20). With this algorithm, the overall diagnostic yield was 76%. In the second algorithm, the overall diagnostic yield was comparable at 78%. Cost analysis for the procedures revealed the second algorithm to have an average cost-saving of 128USD (not significant) and significantly fewer procedures were needed (1.3±0.47 vs. 1.1±0.32, p<0.05).

Conclusions: We conclude that with careful patient selection by a pulmonologist, an optimized minimally-invasive algorithm can be cost-effective in addition to providing diagnostic yields approaching 80%.