1. Felix J. F. Herth, Mark Krasnik, Nicolas Kahn, Ralf Eberhardt and Armin Ernst Chest 2010;138;790-794; Prepublished online February 12, 2010; DOI 10.1378/chest.09-2149 R1 김광열

2. Lung cancer - one of most common neoplasm in the western world - Treatment depend on histologic type and stage of disease - mediastinal LN involved in 28% to 38% of NSCLC - mediastinoscopy or thoracoscopy: diagnostic standard(mediastinal LN metastasis) Endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA) -paratracheal, subcarinal, hilar LN Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA) - mediastinal LN located adjacent to the esophagus.

3. Combining EBUS-TBNA and EUS-FNA has higher staging accuracy than either procedure alone Both procedure could be performed through a single bronchoscope in the same setting by the same operator

4. Approved by local institutional review boards, procedure were performed by all authors. Patients - Between January 2004 and December 2006 - enlarged lymph nodes, known or suspected NSCLC, no evidence of extrathoracic metastasis - before the endoscopy-> underwent a Chest CT(e): all patients - PET-CT: individual basis as required - enlarged LN: short-axis diameter ≥ 1cm (CT scan)

5. Endoscopy - flexible linear ultrasound bronchoscope(UF olympus Medical: Tokyo,Japan) -ultrasound scanner(EU-C60; UF Olympus Medical or Prosound α 5;Aloka, Japan) Patients receiving moderate sedation or general anesthesia EBUS-TBNA  EUS-FNA Lt. adrenal gland and Lt. liver lobe: not examined Power Doppler examination: to prevent puncture of vessle Rapid on-site cytopathologic examination was not performed Tissue diagnosis was confirmed: open thoracotomy, thoracoscopy or follow-up over 6 to 12 months. SPSS11.5 statistical software package(SPSS Inc;IL)

6. LN Ao PA Endobronchial view

7. LN Ao Endoesophageal veiw

8. Extrathoracic malignancy: 3 Small cell lung cancer: 3 Sarcoidosis:2 Cryptogenic organizing pneumonia:1 Refused surgery: 2

12. Mediastinoscopy - requiring general anesthesia - current diagnostic standard for staging mediastinal LN - negative predictive value: 89%, positive predictive value: 100% - pretracheal,paratracheal LN :suitable - Inferior and posterior mediastinum, Aortopulmonary window LN:access limited - 2% risk of major mobidity, 0.08% risk of mortality

13. EBUS-TBNA & EUS-FNA - alternative for primary mediastinal staging  high diagnostic yield, access to nodes beyond the reach of the mediastinoscope, low morbidity - EBUS-TBNA : access hilar LN as well - EUS-FNA: access sites of periesophageal, - as complementary rather than competitive procedure - combined approach: higher sensitivity(93%), higher negative predictive value(97%)  the combined approach more useful.

14. To date, combining requires the use of two different and expensive system, additional training  use of one scope for both application  feasible, safe, very effective Shortcoming of this approach - cannot access some LN: station3, esp AP window - cannot reach extrathoracic site of dis.(Lt. adrenal area): bronchoscopy too short  development of a dedicated “staging ultrasound-endoscopy” : add some length

15. Combining esophageal and endobronchial endoscopic staging with a single, dedicated linear ultrasound bronchoscope in a single setting performed by an experienced endoscopist is feasible, safe, effective This approach could be the primary staging procedure for patients with lung cancer