Cytologic features and diagnostic value of PeriView FLEX transbronchial needle aspiration targeting pulmonary nodules

Can intraoperative improvement of radial endobronchial ultrasound imaging enhance the diagnostic yield in peripheral pulmonary lesions?

BACKGROUND

Data regarding the diagnostic efficacy of radial endobronchial ultrasound (R-EBUS) findings obtained via transbronchial needle aspiration (TBNA)/biopsy (TBB) with endobronchial ultrasonography with a guide sheath (EBUS-GS) for peripheral pulmonary lesions (PPLs) are lacking. We evaluated whether intraoperative probe repositioning improves R-EBUS imaging and affects diagnostic yield and safety of EBUS-guided sampling for PPLs.

METHODS

We retrospectively studied 363 patients with PPLs who underwent TBNA/TBB (83 lesions) or TBB (280 lesions) using EBUS-GS. Based on the R-EBUS findings before and after these procedures, patients were categorized into three groups: the improved R-EBUS image (n = 52), unimproved R-EBUS image (n = 69), and initial within-lesion groups (n = 242). The impact of improved R-EBUS findings on diagnostic yield and complications was assessed using multivariable logistic regression, adjusting for lesion size, lesion location, and the presence of a bronchus leading to the lesion on CT. A separate exploratory random-forest model with SHAP analysis was used to explore factors associated with successful repositioning in lesions not initially "within."

RESULTS

The diagnostic yield in the improved R-EBUS group was significantly higher than that in the unimproved R-EBUS group (76.9% vs. 46.4%, p = 0.001). The regression model revealed that the improvement in intraoperative R-EBUS findings was associated with a high diagnostic yield (odds ratio: 3.55, 95% confidence interval, 1.57-8.06, p = 0.002). Machine learning analysis indicated that inner lesion location and radiographic visibility were the most influential predictors of successful repositioning. The complication rates were similar across all groups (total complications: 5.8% vs. 4.3% vs. 6.2%, p = 0.943).

CONCLUSIONS

Improved R-EBUS findings during TBNA/TBB or TBB with EBUS-GS were associated with a high diagnostic yield without an increase in complications, even when the initial R-EBUS findings were inadequate. This suggests that repeated intraoperative probe repositioning can safely boost outcomes.

Transbronchial Needle Aspiration via Ultrathin Bronchoscope Improves Diagnostic Yield for Peripheral Lung Lesions: Randomized Sequencing Trial

BACKGROUND

Peripheral pulmonary lesions (PPLs) are frequently identified and require diagnostic sampling. Diagnostic yield of radial endobronchial ultrasound (rEBUS) guided bronchoscopic biopsies is suboptimal, despite ultrasound confirmation of navigation success. Pairing ultrathin bronchoscopy and peripheral transbronchial needle aspiration (pTBNA) may improve yield.

METHODS

We prospectively recruited consecutive patients undergoing Olympus MP190F ultrathin bronchoscopy with rEBUS-guided sampling of PPLs. Cases were randomized to pTBNA (Olympus Periview FLEX) either before or after the usual transbronchial forceps biopsy (TBLBx) and brush. Diagnostic yield from cytology or histopathology, clinical outcomes to a minimum 24 months follow-up and complications were recorded.

RESULTS

One hundred one sampled lesions were included (pTBNA first 61, pTBNA last 40). Overall diagnostic yield was 66.3%, with no significant difference between groups (64% vs. 70% P=0.528) or prespecified subgroups according to sampling order. Seventy lesions had an end diagnosis of malignancy, of which 50 were correctly diagnosed (71.4%). TBLBx (49/96, 49%) and pTBNA (48/101, 47.5%) had the highest individual positive yield. For 12 (11.9%) participants, pTBNA was the only positive sample. Lesions <20 mm and those with eccentric rEBUS image seemed to benefit most from this approach. Rapid on-site cytologic examination (ROSE) was associated with both positive procedural diagnosis (P=0.019) and pTBNA-positive samples (P=0.004). Pneumothorax occurred in 4% and moderate bleeding in 5%. Thirteen percent had an unplanned admission within 1 month of bronchoscopy.

CONCLUSION

Adding pTBNA to conventional sampling through an ultrathin bronchoscope guided by rEBUS, improved diagnostic yield (11.9% additional diagnoses). The sampling sequence did not affect the yield of pTBNA.

Diagnostic Value and Safety of Addition of Transbronchial Needle Aspiration to Transbronchial Biopsy Through Endobronchial Ultrasonography Using a Guide Sheath Under Virtual Bronchoscopic Navigation for the Diagnosis of Peripheral Pulmonary Lesions

BACKGROUND

The diagnostic yield of peripheral pulmonary lesions (PPLs) through endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) under virtual bronchoscopic navigation is unsatisfactory because radial EBUS probe is not always located within the lesion. Transbronchial needle aspiration with a guide sheath (GS-TBNA) has the potential to overcome the lower diagnostic yield by improving the relationship between the probe and the lesion and enabling repeated sampling while maintaining the location of a GS near the lesion. However, there are few data regarding the diagnostic yield and safety for diagnosing PPLs in this procedure.

METHODS

We retrospectively analyzed consecutive 363 lesions (83 lesions underwent GS-TBNA/EBUS-GS TBB and 280 lesions underwent EBUS-GS TBB) at our institution between April 1, 2019 and March 31, 2022. We investigated the diagnostic efficacy and complications of GS-TBNA/EBUS-GS TBB and compared them with those of EBUS-GS TBB.

RESULTS

The lesion size, distance from the hilum, presence of bronchus leading to the lesion, and EBUS images during the examination differed significantly between the two procedures. Logistic regression analysis adjusted for these 4 covariates revealed that GS-TBNA/EBUS-GS TBB was a significant factor affecting the diagnostic success of PPLs compared with EBUS-GS TBB (odds ratio=2.43, 95% CI=1.16-5.07, P=0.018). Neither procedure differed significantly in terms of complications (6.0% vs. 5.7%, P>0.999).

CONCLUSION

GS-TBNA performed in addition to EBUS-GS TBB might be a promising sampling method for improving the diagnostic yield for PPLs without increasing the incidence of complications.

Clinical outcomes of transbronchial cryobiopsy using a 1.1-mm diameter cryoprobe for peripheral lung lesions - A prospective pilot study

OBJECTIVES

Transbronchial cryobiopsy (TBCB) is a novel technique for the diagnosis of peripheral lung lesions (PLLs). We aim to evaluate the clinical outcomes of TBCB using a new 1.1-mm diameter cryoprobe for the diagnosis of PLLs.

MATERIALS AND METHODS

We performed a prospective observational pilot study on the diagnosis of PLLs (diameter ≤30 mm) by TBCB, using a 1.1-mm diameter cryoprobe with radial endobronchial ultrasound (RP-EBUS), virtual bronchoscopic navigation and fluoroscopy from December 2021 to July 2022. Primary outcome was the pathological diagnostic yield of TBCB, and secondary outcome was adverse event.

RESULTS

A total of 50 patients were enrolled (mean lesion size, 21 mm). TBCB was performed in 49 patients up to three times except for the one with "invisible" finding on RP-EBUS. The overall diagnostic yield of TBCB was 90% (45/50). There was no difference in the diagnostic yield between size (20 mm vs. 20-30 mm; 88% [22/25] vs. 92% [23/25]; P = 1.000), RP-EBUS findings (concentric vs. others; 97% [28/29] vs. 81% [17/21]; P = 0.148), and acute angle location (apical segment of both upper lobes vs. others; 92% [12/13] vs. 89% [33/37]; P = 1.000). The cumulative diagnostic yields of the first, second, and third TBCB were 82% (41/50), 88% (44/50), and 90% (45/50), respectively. Mild bleeding was developed in 56% (28/50), and moderate bleeding was found in 26% (13/50).

CONCLUSION

TBCB using a 1.1-mm diameter cryoprobe is an effective, reasonable method for the diagnosis of PLLs regardless of its size, RP-EBUS finding, and anatomical location without serious complication.

TRIAL REGISTRATION

Clinical Trials.Gov (NCT05046093).

Radial Endobronchial Ultrasound-guided Transbronchial Cryobiopsy versus Forceps Biopsy for the Diagnosis of Solitary Pulmonary Nodules: A Prospective Randomised Trial

Background

Improvements in pulmonary diagnostic imaging and the development of lung cancer screening are increasing the prevalence of Solitary pulmonary nodules (SPNs). Fluoroscopically guided radial endobronchial ultrasound (EBUS) with transbronchial forceps biopsy (TB-FB) has been the conventional diagnostic method. Transbronchial cryobiopsy (TB-CB) is an alternative biopsy method. We sought to compare transbronchial cryobiopsy to transbronchial forceps biopsy for the diagnosis of SPNs.

Methods

A prospective, single-centre, randomised controlled trial was conducted at the Royal Adelaide Hospital (RAH). Patients with SPNs were randomised to either 5 transbronchial forceps biopsies or one transbronchial cryobiopsy. Complete blinding of investigators and participants was not possible, as transbronchial cryobiopsy required general anaesthesia. The primary outcome was diagnostic yield with secondary outcomes of specimen size, diagnostic yield for subsets challenging to access with forceps and safety.

Results

The overall diagnostic yield for the 28 enrolled subjects was 76.8%(22/28). The diagnostic yield was 91.7% (11/12 patients) for transbronchial cryobiopsy and 68.8% (11/16 patients) for forceps biopsy (p=0.14). Median biopsy sizes were consistently larger for the cryobiopsy arm at 7.0mm compared to 2.5mm(p<0.0001). An eccentric EBUS image signalling the probe was adjacent to the nodule occurred in 4/28 cases, and TB-CB confirmed a diagnosis in 3/3 randomised to this arm. There were no major complications with either technique.

Conclusion

Transbronchial cryobiopsy under the guidance of fluoroscopy and radial EBUS facilitates larger biopsy specimens without a significant increase in major complications. Further research is required to confirm the effect on diagnostic yield; however, our study supports a role for TB-CB in the diagnosis of SPNs and small, nodule-adjacent biopsies.

Clinical Trial Registration Number

Reference number of R20160213(HREC/16/RAH/37).

Endobronchial ultrasound-guided transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis

The diagnosis of peripheral pulmonary lesions (PPLs) remains a challenge for physicians. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been applied in the diagnosis of PPLs, but its diagnostic rate varies widely. The systematic review and meta-analysis was conducted to figure out the accuracy and safety of EBUS-TBNA in the diagnosis of PPLs. We searched the PubMed and Embase databases for relevant studies published from January 1, 2000 to December 30, 2021 and used PICO (Participants, Intervention, Comparison, and Outcome) to worked out the diagnostic rate of EBUS-TBNA in PPLs. Two reviewers independently performed the data extraction and assessed study quality. Statistical analysis was carried out via R software. In 7 studies of totally 510 patients of PPLs, the overall EBUS-TBNA diagnosis yield is 0.75 (95% CI 0.67-0.84) by the random effect model. EBUS-TBNA showed a higher accuracy of 0.64 (95% CI 0.53-0.74) compared to 0.46 (95% CI 0.19-0.72) of endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) when EBUS probe is adjacent to lesions. In the case of malignant lesions, the diagnostic rate of EBUS-TBNA is 0.79 (95% CI 0.72-0.88). Combined EBUS-TBNA with conventional bronchoscopy procedures showed the highest diagnostic yield (0.83 (95% CI 0.79-0.87)). Collectively, EBUS-TBNA should be performed firstly in patients with PPLs suspected to lung cancer especially when the EBUS probe was adjacent to the lesions. No serious procedure-related complications were observed.

Inheritance and innovation of the diagnosis of peripheral pulmonary lesions

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.

Radial-EBUS and virtual bronchoscopy planner for peripheral lung cancer diagnosis: How it became the first-line endoscopic procedure

Background

Various advanced bronchoscopy methods have been developed to reach peripheral lung lesions (PLL). In a large cohort, we aimed to assess a standardized procedure of first‐line radial‐endobronchial ultrasound (r‐EBUS) and virtual bronchoscopy planner for the diagnosis of peripheral lung cancer.

Methods

This retrospective, single center study included patients who had r‐EBUS‐guided bronchoscopy for the diagnosis of a PLL between 2008 and 2019. Cases without a final diagnosis of cancer or follow‐up were excluded.

Results

Between 2008 and 2019, 2735 patients had a r‐EBUS procedure, among whom 1627 had a final diagnosis of cancer and were included in the present study. Over the 12‐year study period, r‐EBUS became the first‐line endoscopic procedure to assess PLL (25% as first‐line bronchoscopy in 2008 vs. 92% in 2019). The frequency of the bronchus sign decreased from 2009 to 2019 (100% to 80%; p = 0.001), whereas US visualization of the lesion remained stable (88%). The median number of biopsies increased from two (2008 to 2014) to four (2015 to 2019) (p < 0.0001), with the same diagnostic efficiency (74% total and 80% when a bronchus sign was present). Of the 651 adenocarcinomas, molecular analysis was possible in 86%. PD‐L1 expression analysis was possible in 81% of cases. During the study period, the lifetime of the radial probe increased from 57 procedures to 77 procedures/probe.

Conclusion

Because r‐EBUS and VB planner is easy to perform under local anesthesia, inexpensive and efficient it can be used as a first‐line procedure to assess peripheral lung cancer.

Novel Robotic-Assisted Cryobiopsy for Peripheral Pulmonary Lesions

PURPOSE

Tissue acquisition in lung cancer is vital for multiple reasons. Primary reasons reported for molecular testing failure in lung cancer biopsy specimens include insufficient amount of tumor cells provided and inadequate tissue quality. Robotic bronchoscopy is a new tool enabling peripheral pulmonary lesion sampling; however, diagnostic yield remains imperfect possibly due to the location of nodules adjacent to or outside of the airway. The 1.1-mm cryoprobe is a novel diagnostic tool and accesses tissue in a 360-degree manner, thus potentially sampling eccentric/adjacent lesions. This study examines the diagnostic yield of the cryoprobe compared to standard needle aspiration and forceps biopsy. It additionally evaluates yield for molecular markers in cases of lung cancer.

METHODS

This is a retrospective analysis of 112 patients with 120 peripheral pulmonary lesions biopsied via robotic bronchoscopy using needle aspirate, forceps, and cryobiopsy.

RESULTS

The overall diagnostic yield was 90%. Nearly 18% of diagnoses were made exclusively from the cryobiopsy sample. Molecular analysis was adequate on all cryobiopsy samples sent. Digital imaging software confirmed an increase in quantity and quality of samples taken via cryobiopsy compared to needle aspirate and traditional forceps biopsy.

CONCLUSION

Using the 1.1-mm cryoprobe to biopsy PPN combined with the Ion robotic bronchoscopy system is safe, feasible, and provides more diagnostic tissue than needle aspirates or traditional forceps biopsies. The combination of cryobiopsy with robotic-assisted bronchoscopy increased diagnostic yield, likely due to its 360-degree tissue acquisition which is beneficial when targeting extraluminal lesions adjacent to the airway.

Endobronchial Ultrasonography with a Guide Sheath Transbronchial Biopsy for Diagnosing Peripheral Pulmonary Lesions within or near Fibrotic Lesions in Patients with Interstitial Lung Disease

Simple Summary

Lung cancer often occurs around fibrotic lesions in patients with interstitial lung disease (ILD). In patients with ILD, several methods are available for diagnosing peripheral pulmonary lesions (PPLs), such as bronchoscopy with radial endobronchial ultrasound (R-EBUS), transthoracic needle biopsy, and surgical lung biopsy. As well as previous reports, in patients with ILD, bronchoscopy with R-EBUS might be an option as the primary procedure for diagnosing PPLs with fewer complications. However, the utility and safety of bronchoscopy with R-EBUS for PPLs in patients with ILD remain unknown. In this study, we assessed the efficacy and complications as the initial diagnostic procedure of bronchoscopy with R-EBUS according to the proximity of PPLs to fibrotic lesions. Our study might make a contribution to physicians who treat PPLs in patients with underlying ILD.

Abstract

In patients with interstitial lung disease (ILD), the most frequent locations of lung cancer are within or near fibrotic lesions. However, the diagnostic yield for peripheral pulmonary lesions (PPLs) within or near fibrotic lesions using endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) may be unsatisfactory compared to that for PPLs distant from fibrotic lesions because of the difficulty in reaching the lesions. Our objectives were to evaluate the yield for PPLs using EBUS-GS TBB according to the proximity of PPLs to fibrotic lesions and to determine factors affecting the yield for PPLs. We retrospectively investigated 323 consecutive lesions using EBUS-GS TBB between 1 November 2014 and 31 December 2016. We identified PPLs with ILD in such lesions. PPLs with ILD were divided into PPLs within or near fibrotic lesions which met the criterion of PPLs, and of fibrotic lesions overlapping each other (PPLs-FL) and those distant from fibrotic lesions, which met the criterion of PPLs and the area of fibrotic lesion not overlapping each other (PPLs-NFL). Of the 323 lesions, 55 were included (31 PPLs-FL and 24 PPLs-NFL). The diagnostic yield for PPLs-FL was significantly lower than for PPLs-NFL (45.2% vs. 83.3%, p = 0.004). Multivariate analysis revealed that PPLs-NFL (odds ratio (OR) = 7.509) and a probe position within the lesion (OR = 4.172) were significant factors affecting diagnostic yield. Lesion’s positional relation to fibrotic lesions and the probe position were important factors affecting the successful diagnosis via EBUS-GS TBB in these patients.

Transbronchial needle aspiration with endobronchial ultrasonography and ultrathin bronchoscopy for peripheral pulmonary lesions

BACKGROUND

Although the efficacy of lung cancer treatment has improved, it is dependent on a reliable diagnosis via bronchoscopy. Transbronchial biopsy using ultrathin bronchoscopy can help detect small peripheral pulmonary lesions (PPLs), with a high diagnostic yield. However, the diagnosis rate using forceps biopsy when the radial endobronchial ultrasonography (rEBUS) probe is adjacent to a lesion tends to be low. Transbronchial needle aspiration (TBNA) may improve the diagnostic yield from adjacent lesions. Recently, PeriView FLEX, a new TBNA needle that can be inserted into ultrathin bronchoscopes, has become available. We examined whether TBNA with PeriView FLEX and forceps biopsy improved adjacent lesion diagnosis when using ultrathin bronchoscopes.

METHODS

We retrospectively examined 51 consecutive patients who underwent TBNA and forceps biopsy using ultrathin bronchoscopes under rEBUS for small PPLs at the Hakodate Goryoukaku Hospital between November 2019 and August 2020. The histological diagnosis rate using TBNA and forceps biopsy, TBNA alone, or forceps biopsy alone was compared between cases where the rEBUS probe was "Within" and "Adjacent To" the lesions.

RESULTS

The diagnosis rate using TBNA and forceps biopsy was 86.3% (95.7% vs. 78.6%; p = 0.08) for all lesions (Within cases vs. Adjacent To cases). The corresponding rate using TBNA alone was 68.6% (69.6% vs. 67.9%; p = 0.57), and that using forceps biopsy alone was 72.5% (91.3% vs. 57.1%; p = 0.0067).

CONCLUSIONS

Forceps biopsy with TBNA during ultrathin bronchoscopy for small PPLs improved the diagnostic yield when lesions were adjacent to the rEBUS probe.

Diagnosis of unexposed tumours using endobronchial ultrasonography with a guide sheath and a thin transbronchial needle

Transbronchial diagnosis of unexposed lung tumours is challenging in clinical practice. Although modified transbronchial needle aspiration (TBNA) is used for this purpose, the diagnostic yield is unsatisfactory. In such cases, conventional endobronchial ultrasonography with a guide sheath and transbronchial biopsy (TBB) is also ineffective. We found TBB was feasible by placing a guide sheath with a thin transbronchial needle into the tumours. We report two cases of unexposed tumours diagnosed successfully with this technique. Case 1 presents a typical carcinoid in the peripheral lung. Case 2 presents a squamous cell carcinoma at the third bifurcation of the right lung. TBB samples obtained this way were larger than TBNA samples. Moreover, multiple TBBs were possible once the guide sheath was inserted intratumourally. In the modern era of precision medicine, larger amounts of tissues are required for multiple downstream analyses. This novel technique will make a significant contribution towards diagnosing unexposed lung tumours.