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Introduction Mediastinal lymphadenopathy in patients with an extrathoracic malignancy is a common clinical scenario. Invasive sampling of intrathoracic lymph nodes may be performed by mediastinoscopy or endoscopic ultrasound-guided fine needle aspiration. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an alternative to mediastinoscopy and endoscopic ultrasound in patients with lung cancer and sarcoidosis. The utility of EBUS-TBNA in patients with extrathoracic malignancy was evaluated. Methods Consecutive patients who were suspected to have intrathoracic lymph node metastases from an extrathoracic malignancy underwent EBUS-TBNA. When EBUS-TBNA did not provide a specific diagnosis, patients underwent mediastinoscopy or clinical follow-up of at least 6 months duration. Results One hundred sixty-one patients meeting the inclusion criteria underwent EBUS-TBNA in five UK centers over a 3-year period. EBUS-TBNA diagnosed mediastinal or hilar metastases in 71 (44%) patients, new lung cancer in 20 (12%) patients, and sarcoidosis in 14 (9%) patients. The sensitivity, negative predictive value for malignancy, and overall accuracy for EBUS-TBNA were 87%, 73% and 88%, respectively. One hundred ten (68%) patients in the study had a final diagnosis of malignant intrathoracic lymphadenopathy. Conclusion Because of the high prevalence of alternative diagnoses, pathological evaluation is important in patients with extrathoracic malignancy and suspected mediastinal or hilar lymph node metastases. EBUS-TBNA is a safe and sensitive technique and may be considered a first-line investigation in these patients.

Most large hospitals in the United Kingdom will see 100 to 150 new cases of lung cancer a year, mostly as new outpatient referals, but as much as 30% of patients are admitted through the emergency department to be cared for by a variety of disciplines. So, it is a significant load, for a disease for which the median survival is 8 to 9 months,it needs prompt and expert attention. Before the National Cancer Plan in 1997, there was no system of prioritization for suspected cancer referrals, and for those patients admitted, much depended on the specialty in charge as to what might happen and at what pace (let alone whether a respiratory refferal was made!). The British government has made cancer care a priority, basically because British 5-year survival figures were considered inferior to those of other comparable European and western countries for several cancer types and because there was inadequate order in the organization of day-to-day cancer care.As discussed in the commentary by Devbhandari et al. in this issue oft The Journal, the expectation is for patients suspected to have lung cancer to be seen within 14 days of a refferal, diagonsed and staged with a decision for intial treatment within 62 days of initial referral. In addition to forming regional cancer centre, each with several units (district general hospitals), the development of weekly multidisciplinary team(MDT) meetings and provision of clinical coordinators to run these meetings, follow patients and speed up,tests the setting has been laid for improvement.