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Introduction
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is recommended as the first-line investigation in patients with non-small cell lung cancer requiring pathological mediastinal staging. 1-4 The expansion of EBUS services, which are primarily delivered by respiratory physicians, has been rapid across the UK. 5 However, marked variation exists in how frequently EBUS is used 6 and there is a lack of widespread performance reporting. The European Society of Thoracic Surgeons (ESTS) has defined a set of standards for preoperative nodal staging using EBUS-TBNA. 3 These standards mandate as a minimum: the visualisation of mediastinal lymph node (LN) stations 4R, 4L and 7, sampling of any LN measuring >5 mm and sampling of at least three N2/3 nodal stations per patient. Furthermore, The British Thoracic Society (BTS) Quality Standards for Bronchoscopy set a target of 88% for sensitivity in nodal staging with EBUS-TBNA. 7 Manchester Cancer is a large cancer network in the North West of England responsible for the diagnosis and treatment of over 2000 patients with lung cancer annually. This audit examined the performance of EBUS-guided mediastinal lung cancer staging before and after the adoption of ESTS minimum standards across this cancer network.
Materials and methods
Four independent centres were commissioned to deliver EBUS-TBNA for Manchester Cancer, centre 1 from 2010 and centres 2, 3 and 4 from 2012. Respiratory physicians performed all procedures, conscious sedation was used at all sites and only centre 4 had Rapid On Site Evaluation (ROSE). Quality standards for mediastinal staging were not initially defined. A standard database was installed at each site to collect procedure-related data prospectively. Staging procedure performance was audited before (1 January 2012 to 1 October 2013) and after (1 October 2013 to 1 October 2014) the introduction of ESTS minimum standards; purely diagnostic procedures were excluded. The location and number of all sampled LN stations was recorded in audit 1 (N1-3), but only N2/3 LNs in audit 2. Results of EBUS nodal staging, mediastinoscopy, intraoperative nodal sampling and 6 months of clinical-radiological follow-up were also recorded. EBUS-staging outcome was categorised...