Efficacy and cost effectiveness of rapid on site examination (ROSE) in management of patients with mediastinal lymphadenopathies.

BACKGROUND: The diagnostic and staging approach for the mediastinal lymphadenopathies, with or whithout pulmonary lesions endoscopically visible, is based on transbronchial needle aspiration (TBNA) during fiberoptic bronchoscopy and on mediastinoscopy. One important factor impacting on TBNA sensitivity is the rapid on site cytological examination (ROSE). AIM: The aim of this study was to evaluate the economic impact of TBNA and TBNA + ROSE, in the diagnosis of these lesions. PATIENTS AND METHODS: 120 patients, affected by mediastinal lymphadenopathies suspected for lung cancer, underwent TBNA during fiberoptic bronchoscopy: 60 patients without ROSE (group A) and other 60 with ROSE (group B). Whenever needle aspirations failed to provide diagnosis, the patient underwent mediastinoscopy. The economic impact of the diagnostic process was performed. RESULTS: In group A, 39 patients (65%) obtained a diagnosis with TBNA while 21 patients (35%) required mediastinoscopy. In group B, 48 patients (80%) obtained a diagnosis with TBNA + ROSE, while 12 patients (20%) required mediastinoscopy. With regards to the costs of the procedures performed in the diagnostic process, the use of TBNA with ROSE as first diagnostic approach has saved a considerable amount of euros (19,413) compared to the use of TBNA without ROSE and the combined procedure increased (p < 0.02; chi square test) the sensitivity of TBNA by 15%. CONCLUSIONS: ROSE significantly impacts on the diagnostic yield, as well as on the overall management costs of patients with mediastinal lymphadenopathy, suspected for lung cancer.

Use of endobronchial ultrasound and endoscopic ultrasound to stage the mediastinum in early-stage lung cancer.

Lung cancer remains the deadliest cancer, with more than 160,000 deaths and 226,000 newly diagnosed cases estimated in 2012. Because treatment and survival are directly linked to disease stage, accurate staging in all patients is crucial. The proper staging of early-stage lung cancer involves investigation for the presence of metastatic spread via lymph nodes within the thorax. Initial steps include CT and PET. Mediastinoscopy has previously been considered the gold standard for mediastinal lymph node sampling; however, over the past 10 years the use of ultrasound-guided lymph node sampling has been shown to be at least as sensitive, and has the added advantage of being able to access significantly more stations. This article reviews the current standards of lung cancer staging in 2012.

A prospective study of conventional transbronchial needle aspiration: performance and cost utility.

BACKGROUND: Conventional transbronchial needle aspiration (TBNA) is a cheap, minimally invasive tool for lung cancer staging and diagnosis. Endobronchial ultrasound-guided TBNA (EBUS-TBNA) is more sensitive but is more expensive and less widely available. We describe a prospective analysis of TBNA diagnostic, staging and cost utility in a centre in the UK. OBJECTIVES: To illustrate the potential diagnostic, staging and cost utility of a low cost conventional TBNA service. METHODS: A prospective analysis of 79 TBNA procedures over a 2-year period was performed looking at performance and cost utility in a 'mixed' cohort with variable pre-test probability of malignancy (year 1) followed by a high probability cohort (year 2). RESULTS: TBNA avoided mediastinoscopy in 25% of the cases overall (37% in high probability vs. 13% in the 'mixed' cohort, p = 0.03). The overall prevalence of malignancy was 84%, sensitivity 79%, negative predictive value 58% and accuracy 85%. Diagnostic utility varied with pre-test probability and nodal station. TBNA down-staged 8% of lung cancer patients to receive surgery and confirmed the pre-treatment stage (inoperability) in 74%. TBNA led to theoretical cost savings of GBP 560 per patient. CONCLUSIONS: TBNA can achieve a high diagnostic sensitivity for cancer in high probability patients and stage the majority appropriately, thereby avoiding unnecessary mediastinoscopies and reducing costs. It may also down-stage a minority to have surgery. TBNA is cheap, routinely available and learnable. As EBUS-TBNA will take time to develop due to its costs, all respiratory centres should perform TBNA at flexible bronchoscopy in suspected lung cancer with accessible mediastinal adenopathy.

Endobronchial ultrasound-guided transbronchial needle aspiration versus mediastinoscopy for mediastinal staging of lung cancer: A systematic review of economic evaluation studies.

INTRODUCTION: The emergence of endobronchial ultrasound (EBUS) changed the approach to staging lung cancer. As a new method being incorporated, the use of EBUS may lead to a shift in clinical and costs outcomes. OBJECTIVE: The aim of this systematic review is to gather information to better understand the economic impact of implementing EBUS. METHODS: This review is reported according to the PRISMA statement and registered on PROSPERO (CRD42019107901). Search keywords were elaborated considering descriptors of terms related to the disease (lung cancer / mediastinal staging of lung cancer) and the technologies of interest (EBUS and mediastinoscopy) combined with a specific economic filter. The literature search was performed in MEDLINE, EMBASE, LILACS, Cochrane Library of Trials, Web of Science, Scopus and National Health System Economic Evaluation Database (NHS EED) of the Center for Reviews and Dissemination (CRD). Screening, selection of articles, data extraction and quality assessment were carried out by two reviewers. RESULTS: Seven hundred and seventy publications were identified through the database searches. Eight articles were included in this review. All publications are full economic evaluation studies, one cost-effectiveness, three cost-utility, and four cost-minimization analyses. The costs of strategies using EBUS-TBNA were lower than the ones using mediastinoscopy in all studies analyzed. Two of the best quality scored studies demonstrate that the mediastinoscopy strategy is dominated by the EBUS-TBNA strategy. CONCLUSION: Information gathered in the eight studies of this systematic review suggest that EBUS is cost-effective compared to mediastinoscopy for mediastinal staging of lung cancer.

Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy.

BACKGROUND: There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort. METHODS: We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis. RESULTS: Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776). CONCLUSIONS: When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.

Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy.

PURPOSE OF REVIEW: There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative. RECENT FINDINGS: EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses. SUMMARY: Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.

Endobronchial ultrasound-guided transbronchial needle aspiration versus mediastinoscopy for mediastinal staging of lung cancer: A protocol for a systematic review of economic evaluation studies.

BACKGROUND: Lung cancer is a major health problem, with estimates of 1.6 million tumor-related deaths annually worldwide. The emergence of endobronchial ultrasound (EBUS), a minimally invasive procedure capable of providing valuable information for primary tumor diagnosis and mediastinal staging, significantly changed the approach of pulmonary cancer, becoming part of the routine mediastinal evaluation of lung cancer in developed countries. Some economic evaluation studies published in the last 10 years have already analyzed the incorporation of the EBUS technique in different health systems. The aim of this systematic review is to synthesize the relevant information brought by these studies to better understand the economic effect of the implementation of this staging tool. METHODS: The systematic review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Eletronic databases (Medline, Lilacs, Embase, Cochrane Library of Trials, Web of Science, Scopus, National Health System Economic Evaluation Database) will be searched for full economic analyses regarding the use of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) compared to the surgical technique of mediastinoscopy for the mediastinal staging of lung cancer. Two authors will perform the selection of studies, data extraction, and the assessment of risk of bias. Occasionally, a senior reviewer will participate, if necessary, on study selection or data extraction. RESULTS: Results will be published in a peer-reviewed journal. CONCLUSION: This review may influence a more cost-effective mediastinal staging approach for patients with lung cancer around the world and help health decision makers decide whether the EBUS-TBNA technique should be incorporated into their health systems and how to do it efficiently. PROTOCOL REGISTRY: PROSPERO 42019107901.

Outpatient thoracic surgical programme in 300 patients: clinical results and economic impact.

OBJECTIVE: To evaluate clinical aspects, results and the economic impact of the outpatient thoracic surgery programme (OTSP) developed in our Department. METHODS: Prospective study of 300 patients who entered in the OTSP from April 2001 to March 2005. The procedures performed were video-mediastinoscopy (MC), video-thoracoscopic lung biopsy (LB) and video-thoracoscopic bilateral thoracic sympathectomy (TS). All procedures were performed under general anaesthesia and patients were discharged in 4-6h. We analyse demographic data, the substitution index (SI), the admission rate (AR) and readmission rate (RR) after the procedure. We calculate the economic impact of stay expenses on our hospital and on other Spanish hospitals. RESULTS: The female/male ratio of the 300 patients was 83/217, with a mean age of 58.1 years (range: 15-85 years). There were no deaths. Mediastinoscopy was performed as outpatient procedure in 210 patients (mean age: 65.6 years) out of 244 total MC (SI=86.1%). Two patients were admitted (AR=0.95%) to observe a minimal pneumothorax and because of late night end. There were no readmissions after MC (RR=0%). We included 32 ambulatory patients for lung biopsy (mean age: 61.5 years) out of 64 total LB (SI=50.0%). One patient was admitted because of air leak (AR=3.1%) and there were no readmissions after LB (RR=0%). Fifty-eight patients were included in the OTSP for bilateral sympathectomy (mean age: 27.1 years) out of 83 total TS (SI=69.9%); there were no admissions (AR=0%) and one patient was readmitted after 9 days because of a hemothorax (RR=1.7%). Sixty-four patients out of the 91 not included in the OTSP were included in an 'afternoon surgical programme' and dismissed the morning after surgery, without contraindication for their inclusion in the OTSP. The hospital's total stay saving was 12,668 euros (88,226 euros if performed elsewhere), 42 euros per patient (294 euros per patient if performed elsewhere). CONCLUSION: Video-assisted mediastinoscopy, lung biopsy and bilateral sympathectomy can be included safely in outpatient thoracic surgical programmes. The impact of the economic benefit of OTSP over the conventional hospitalisation depends on the Department's previous policy on hospital stays. Further experience is needed to increase the substitution index and expand the OTSP to other procedures.

Should mediastinoscopy actually be incorporated into the FDG PET strategy for patients with non-small cell lung carcinoma?

BACKGROUND: Incorporating mediastinoscopy (MS) into the PET-based strategy for non-small cell lung carcinoma (NSCLC) patients might be cost-effective because MS can allow unnecessary thoracotomies to be avoided. The objective of our study was to assess the cost-effectiveness of incorporating MS into a PET strategy for NSCLC patients. METHODS: To determine life expectancy (LE), quality adjusted life years (QALY), and the incremental cost-effectiveness ratio (ICER), a decision-tree sensitivity analysis was designed for histopathologically confirmed NSCLC patients with M0 disease, based on the three competing strategies of chest CT only vs. PET + CT vs. PET + CT + MS. A simulation of 1000 NSCLC patients was created using baselines of other relevant variables in regard to sensitivity, specificity, mortality, LE, utilities and cost from published data. One-way sensitivity analyses were performed to determine the influences of mediastinal metastasis prevalence on LE, QALY and ICER. RESULTS: The LE and QALY per patient in the CT only strategy, PET + CT strategy and PET + CT + MS strategy were 4.79 and 4.35, 5.33 and 4.93 and 5.68 and 5.33 years, respectively, with a 20% prevalence of mediastinal metastasis. The ICERs were 906.6 yen x 10(3) (7555 US dollars)/QALY/patient at a 20% mediastinal metastasis prevalence, and 2194 yen x 10(3) (18,282 US dollars)/QALY/patient at a 50% prevalence, but exceeded 5280 yen x 10(3) (44,000 US dollars)/QALY/ patient at 80%. CONCLUSIONS: Our study quantitatively showed the CT + PET + MS strategy in place of the PET + CT strategy in managing NSCLC patients to be cost-effective. MS should be incorporated into the PET + CT strategy for NSCLC patients except in those highly suspected of having mediastinal disease on chest CT or PET.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy.

OBJECTIVE: To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC). METHODS: A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT). RESULTS: The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not. CONCLUSIONS: Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.

Combined bronchoscopy, mediastinoscopy, and thoracotomy for lung cancer: who benefits?

OBJECTIVES: Surgical staging and resection of lung cancer may be done as 1 operation (combined) or 2 (staged). This study evaluates the safety and efficiency of these treatment strategies. METHODS: From 1998 to July 2001, 343 patients underwent bronchoscopy, mediastinoscopy, and thoracotomy without induction chemoradiotherapy by 3 surgeons. Fifty-seven patients were staged and 286 combined. Staged patients had higher clinical stage (P <.001). Propensity-matched groups were compared to adjust for this and other differences. Factors associated with safety and efficiency were identified by propensity-adjusted multivariable analysis. RESULTS: Mortality and morbidity were similar for both strategies. Efficiency, measured by shorter operative time (1.2 hours) and lower cost (25%), was better for combined strategy (P <.001). Hospital stay was similar, but revenue was 12% higher for the staged strategy (P <.001). In propensity-matched comparisons excluding surgeon, results were similar to the above. Comparisons including surgeon demonstrated similar cost and revenue for both strategies. Increased mortality and morbidity were associated only with patient and tumor characteristics: male gender, worsening Eastern Cooperative Oncology Group performance status, and increasing pathological node classification. All measures of efficiency worsened with increasing pathological classifications. Staged strategy was associated with increased operative time and revenue, while one surgeon and patient smoking history were associated with increased hospital stay and costs. CONCLUSIONS: The combined strategy provides efficient, safe health care for clinically operable lung cancer patients, but it may not be as financially rewarding as the staged strategy. Treatment strategy is only 1 of many determinants of efficiency.

Mediastinoscopy in patients with presumptive stage I sarcoidosis: a risk/benefit, cost/benefit analysis.

STUDY OBJECTIVE: To determine whether persons with asymptomatic bilateral hilar lymphadenopathy (ABHL) and normal results of a physical examination should be observed with a presumptive diagnosis of stage 1 sarcoidosis (S1S) (ABHLps), its most frequent cause, or undergo mediastinoscopy to avoid overlooking an alternative diagnosis (AD) requiring treatment. DESIGN: We surveyed the English-language medical literature to estimate the proportion of persons with tuberculosis (TB), Hodgkin's disease (HD), and non-Hodgkin's lymphoma (NHL) who present with ABHL and calculated the number of mediastinoscopies required to identify each AD by computing the following ratio: incidence S1S/incidence of each AD presenting as ABHL (I(S1S)/I[ABHL-AD]). Risks of mediastinoscopy and benefits of earlier ascertainment of AD were derived from the published literature. Cost estimates were based on institutional charges. We conducted a regional survey of practicing pulmonologists to ascertain their diagnostic preferences. RESULTS: We estimate that if 33,000 persons with ABHL underwent mediastinoscopy, 32,982 (99.95%) would be found to have S1S or, very rarely, a disorder not requiring intervention; 407 would require hospitalization for complications at a cost in excess of $1 million; and 204 would experience major morbidity; 8 persons with TB, 9 with HD, and 1 with NHL would be identified at a cost of $100 to $200 million. The benefit for persons diagnosed as having AD would be minimal and likely offset by the procedural mortality. Seventy percent of pulmonologists responding to the survey favored observation over transbronchial lung biopsy or mediastinoscopy in patients with ABHL. CONCLUSION: A policy of continued observation of patients presenting with ABHL is preferable to diagnostic mediastinoscopy from both the risk/benefit and cost/benefit standpoint.

Accuracy and cost-effectiveness of [18F]-2-fluoro-deoxy-D-glucose-positron emission tomography scan in potentially resectable non-small cell lung cancer.

STUDY OBJECTIVES: This retrospective study of patients who were referred for surgical resection of non-small cell lung cancer (NSCLC) assessed the accuracy and cost-effectiveness of positron emission tomography (PET) with radiolabeled [18F]-2-fluoro-deoxy-D-glucose (FDG) in staging mediastinal lymph nodes (MLNs). DESIGN: From January 2001 to September 2002, 90 patients with suspected or proven NSCLC who had been referred for curative resection were retrospectively reviewed. All patients were without evidence of metastatic disease. Sixty-nine of the 90 patients had undergone thoracic FDG-PET imaging as part of their evaluation and are the focus of this study. Sensitivity, specificity, accuracy, and positive and negative predictive values for metastasis to the MLN were calculated for CT scanning vs FDG-PET scanning. Four algorithms for staging MLN with mediastinoscopy and/or FDG-PET scan were compared. MEASUREMENTS AND RESULTS: Sixty-nine patients underwent preoperative CT and FDG-PET scans, and 32 of 69 patients underwent mediastinoscopy. Fifty-seven patients underwent thoracotomy with complete mediastinal lymphadenectomy. Sensitivity, specificity, accuracy, and positive and negative predictive values for CT scans and FDG-PET scans were 46%, 86%, 78%, 43%, and 87%, and 62%, 98%, 91%, 89% and 92%, respectively. Mediastinoscopy was accurate in 32 of 32 patients (100%). Routine mediastinoscopy remains the most economically reasonable strategy with excellent sensitivity. Selective FDG-PET imaging improved the sensitivity of noninvasive staging for patients with normal MLNs on CT scans. CONCLUSIONS: Selective use of FDG-PET imaging improves staging accuracy compared to CT scanning alone and makes it a cost-effective adjunct to the preoperative staging of NSCLC. However, in patients with adenocarcinoma and MLNs of < 1 cm, FDG-PET scanning cannot yet replace mediastinoscopy.

Investigation for mediastinal disease in patients with apparently operable lung cancer. Canadian Lung Oncology Group.

BACKGROUND: The optimal approach to the investigation of mediastinal disease in patients with apparently operable non-small cell carcinoma of the lung is controversial. METHODS: We conducted a randomized, controlled trial in thoracic surgery services at mainly academic tertiary and secondary care general hospitals. We recruited 685 patients with apparently operable, suspected or proven, non-small cell carcinoma of the lung who underwent either mediastinoscopy or computed tomography. Depending on the apparent presence or absence of mediastinal nodes of greater than 1 cm, patients undergoing computed tomography either underwent mediastinoscopy or went directly to thoracotomy. The primary outcome was thoracotomy without cure, defined as resection with recurrence. Secondary outcomes included thoracotomies undertaken in patients with benign disease and costs of the two strategies. RESULTS: The relative risk of thoracotomy without cure in patients in the computed tomography group was 0.95 (95% confidence interval, 0.75 to 1.19). The relative risk of thoracotomy without cure or thoracotomy in patients with benign disease was 0.88 (95% confidence interval, 0.71 to 1.10). The mediastinoscopy strategy cost $708 more per patient (95% confidence interval, -$723 to $2,140). CONCLUSIONS: The computed tomography strategy is likely to produce the same number of or fewer unnecessary thoracotomies in comparison with doing mediastinoscopy on all patients, and is also likely to be as or less expensive.

Use of influence diagrams to structure medical decisions.

Influence diagrams are compact representations of decision problems that are mathematically equivalent to decision trees. The authors present five important principles for structuring a decision as an influence diagram: 1) start at the value node and work back to the decision nodes; 2) draw the arcs in the direction that makes the probabilities easiest to assess; 3) use informational arcs to specify which events will have been observed at the time each decision is made; 4) ensure that missing arcs reflect intentional assertions about conditional independence and the timing of observations; and 5) ensure that there are no cycles in the influence diagram. They then build an influence diagram for the problem of staging non-small-cell lung cancer as an illustration. Influence diagrams offer several strengths for structuring medical decisions. They represent graphically and compactly the probabilistic relationships between parameters in the model. Influence diagrams also allow the model to be structured in a fashion that eases the necessary probability assessments, regardless of whether the assessments are based on available evidence or on expert judgment. Influence diagrams provide an important complement to decision trees, especially for representing probabilistic relationships among variables in a decision model.

[Role of ultrasound-guided endoscopy in the evaluation of mediastinal lesions]. / Papel de la ultrasonografía endoscópica en la evaluación del mediastino.

The evaluation of the mediastinum is still a challenge. In most cases, a pathologic study is mandatory for therapeutic decision-making. In this setting, endoscopic ultrasonography (EUS) without and with fine needle aspiration (FNA) is currently considered as a very useful and safe non-invasive technique since it overcomes most problems raising from standard radiologic techniques at the time of obtaining histologic confirmation. Moreover, it avoids the surgical approach for diagnosis in a significant number of patients. Thus, performance characteristics (sensitivity, specificity and accuracy) of EUS FNA in the diagnosis of mediastinal lymph nodes of unknown origin are higher than 90%. The place of EUS FNA in the staging of lung cancer is not well established yet, but available data suggest that it can play a major role in patients with negative transbronchial biopsy or even in the initial evaluation regardless of CT results. Finally, recent studies also suggest that EUS FNA is the most cost-effective non-surgical technique for the study of the mediastinum.

[Diagnostic invasive procedures in the diagnosis of primary lung cancer. Diagnostic value and complications]. / Diagnostiske invasive undersøgelser ved primaer lungecancer. Diagnostisk voerdi og komplikationer.

The invasive procedures used in the diagnosis of primary lung cancer are reviewed based on the literature. The choice of method should be related to its diagnostic accuracy, complications and cost. The chest x-ray provides the background for the further choice of diagnostic method. In central tumors, bronchoscopy meets the requirements and in peripheral lesions percutaneous transthoracic needle biopsy fulfils the conditions. In some centres, mediastinoscopy is preferred in all cases preoperatively, while others only perform this examination if a CT-scan shows mediastinal lymph nodes larger than 1 cm in diameter. If the latter procedure is followed, 10-30% of the patients will have lymph node metastases. Thoracoscopy is used when a pleural effusion remains undiagnosed after pleuracentesis. A considerable amount of patients will be shown to have pleural neoplastic spread even though cytological examination of the pleural fluid did not demonstrate malignant cells. The complication rates in all methods are low.

Endobronchial ultrasonography versus mediastinoscopy: a single-institution cost analysis and waste comparison.

BACKGROUND: Mediastinoscopy (MED) and endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) have similar accuracy for mediastinal lymph node sampling (MLNS). The threatened financial and environmental sustainability of our health care system mandate that surgeons consider cost and environmental impact in clinical decision making of similarly effective procedures. We performed a cost and waste comparison of MED versus EBUS-TBNA for MLNS to raise awareness of the financial and environmental implications of our practices. METHODS: We conducted a retrospective review of outpatients who underwent MLNS under general anesthesia in the OR with MED or EBUS-TBNA (September 2007 to December 2009). We analyzed direct costs based on hospital charges, calculated expected payment using a decision support model, and profit margins (modeled expected payment-direct costs). Our waste comparison was measured in kilograms of solid waste per case. RESULTS: We performed MLNS in 148 patients (89 EBUS-TBNA, 39 MED, 20 EBUS + MED). Direct costs were lower for MED ($2,356) compared with EBUS-TBNA ($2,503), whereas expected payment was greater (MED, $3,449; EBUS-TBNA, $3,249), resulting in a profit margin that was $347 greater for MED. The amount of solid waste for each MED was 1.8 kg versus 0.5 kg for EBUS-TBNA. CONCLUSIONS: MED costs less than EBUS-TBNA in the OR setting but generates 3.6 times the amount of EBUS-TBNA waste. The cost of EBUS-TBNA may improve by performance in the endoscopy suite, and surgical pack revision could reduce the amount of MED solid waste. This comparison sets the stage for sophistication of our clinical decision making, taking into consideration the major threats to our health care system.