Lung cancer diagnosis and staging with endobronchial ultrasound-guided transbronchial needle aspiration compared with conventional approaches: an open-label, pragmatic, randomised controlled trial

Abstract

Background: The diagnosis and staging of lung cancer is an important process that identifies treatment options and guides disease prognosis. We aimed to assess endobronchial ultrasound-guided transbronchial needle aspiration as an initial investigation technique for patients with suspected lung cancer.

Methods: In this open-label, multicentre, pragmatic, randomised controlled trial, we recruited patients who had undergone a CT scan and had suspected stage I to IIIA lung cancer, from six UK centres and randomly assigned them to either endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) or conventional diagnosis and staging (CDS), for further investigation and staging. If a target node could not be accessed by EBUS-TBNA, then endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) was allowed as an alternative procedure. Randomisation was stratified according to the presence of mediastinal lymph nodes measuring 1 cm or more in the short axis and by recruiting centre. We used a telephone randomisation method with permuted blocks of four generated by a computer. Because of the nature of the intervention, masking of participants and consenting investigators was not possible. The primary endpoint was the time-to-treatment decision after completion of the diagnostic and staging investigations and analysis was by intention-to-diagnose. This trial is registered with ClinicalTrials.gov, number NCT00652769.

Findings: Between June 10, 2008, and July 4, 2011, we randomly allocated 133 patients to treatment: 66 to EBUS-TBNA and 67 to CDS (one later withdrew consent). Two patients from the EBUS-TBNA group underwent EUS-FNA. The median time to treatment decision was shorter with EBUS-TBNA (14 days; 95% CI 14-15) than with CDS (29 days; 23-35) resulting in a hazard ratio of 1·98, (1·39-2·82, p<0·0001). One patient in each group had a pneumothorax from a CT-guided biopsy sample; the patient from the CDS group needed intercostal drainage and was admitted to hospital.

Interpretation: Transbronchial needle aspiration guided by endobronchial ultrasound should be considered as the initial investigation for patients with suspected lung cancer, because it reduces the time to treatment decision compared with conventional diagnosis and staging techniques.

Funding: UK Medical Research Council.

Figure 1

Trial profile EBUS-TBNA=endobronchial ultrasound-guided transbronchial needle aspiration. EUS-FNA=endoscopic ultrasound-guided fine needle aspiration. NSCLC=non-small-cell lung cancer.

Figure 2

Time to treatment decision in all patients (A) and in those with non-small-cell lung cancer (B) Kaplan-Meier plots for (A) all patients and (B) patients with non-small-cell lung cancer only undergoing CDS or EBUS-TBNA. CDS=conventional diagnosis and staging. NSCLC=non-small-cell lung cancer. EBUS-TBNA=endobronchial ultrasound-guided transbronchial needle aspiration. HR=hazard ratio.

Figure 3

Overall survival of patients with non-small-cell lung cancer Survival of patients with non-small-cell lung cancer undergoing CDS or EBUS-TBNA. NSCLC=non-small-cell lung cancer. CDS=conventional diagnosis and staging. EBUS-TBNA=endobronchial ultrasound-guided transbronchial needle aspiration. HR=hazard ratio.