• Lorraine D Cornwell, Faisal G Bakaeen, Charlie K W Lan, Shuab Omer, Ourania Preventza, Brent Pickrell, Alex Nguyen, and Roberto F Casal.
• Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas2Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
• JAMA Surg. 2013 Nov 1;148(11):1024-9.

ImportanceRecently, preoperative lung cancer staging has evolved to include endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) biopsies of the hilar and mediastinal lymph nodes, but the feasibility and usefulness of the procedure have not been well studied in the veteran population.ObjectiveTo determine the safety and effectiveness of EBUS-TBNA as a key component of a preoperative staging algorithm for lung cancer in veterans.Design, Setting, And ParticipantsReview of a prospectively maintained thoracic surgery database that includes patients who underwent lung resection for lung cancer between January 1, 2009, and December 31, 2012, at a single Veterans Affairs medical center among a consecutive cohort of 166 patients with clinically early-stage (I or II) lung cancer who underwent lobectomy with nodal dissection.InterventionsEndobronchial ultrasonography-guided transbronchial needle aspiration mediastinal staging (EBUS group) in 62 patients (37.3%) was compared with noninvasive nodal staging plus integrated positron emission tomography-computed tomography only (PET/CT-only group) in 104 patients (62.7%). The accuracy of nodal staging was assessed by comparison with the final pathological staging after complete nodal dissection (the gold standard).Main Outcomes And MeasuresPrimary outcomes were feasibility, safety, accuracy, and negative predictive value of EBUS-TBNA for preoperative nodal staging. A secondary outcome was the rate of nontherapeutic lung resection for occult N2 disease, with comparison between the EBUS group and the PET/CT-only group.ResultsNo significant complications were attributable to the EBUS-TBNA procedure. In the EBUS group, 258 lymph node stations were sampled. N1 hilar metastases were diagnosed in 8 patients (12.9%) before surgery, and the remainder were staged N0. Accuracy and negative predictive value of EBUS-TBNA were 93.5% (58 of 62) and 92.6% (50 of 54), respectively. The overall rate of nontherapeutic lung resection performed in patients with occult N2 disease was 10.8% (18 of 166) (8.1% in the EBUS group and 12.5% in the PET/CT-only group) (P = .37).Conclusion And RelevanceA preoperative lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective in a veteran population, resulting in a low rate of nontherapeutic operations because of occult N2 nodal disease.

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