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Bordas-Martinez J, Vercher-Conejero JL, Rodriguez-González G, Notta PC, Martin Cabeza C, Cubero N, Lopez-Lisbona RM, Diez-Ferrer M, Tebé C, Santos S, Cortes-Romera M, Rosell A. Mediastinal staging lymph node probability map in non-small cell lung cancer. Respir Res 2025; 26:113. [PMID: 40128853 PMCID: PMC11934462 DOI: 10.1186/s12931-025-03121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 01/17/2025] [Indexed: 03/26/2025] Open
Abstract
BACKGROUND Mediastinal lymph node (LN) staging is routinely performed using PET/CT and EBUS-TBNA. Promising predictive algorithms for lymph nodes have been reported for each technique, both individually and in combination. This study aims to develop a predictive algorithm that combines EBUS, PET/CT and clinical data to provide a probability of malignancy. METHODS A retrospective study was conducted on consecutive patients with non-small cell lung carcinoma staged using PET/CT and EBUS-TBNA. Lymph nodes were identified by level (N1, N2, and N3) and anatomical region (AR) (subcarinal, paratracheal, and hilar). A Standardized Uptake Value (SUV) was determined for each sampled LN. The ultrasound features collected included diameter in the short axis (DSA), morphology, border, echogenicity and the presence of the vascular hilum. A robust logistic regression model was used to construct an algorithm to estimate the probability of malignancy of the lymph node. RESULTS A total of 116 patients with a mean age of 66, 93% of whom were men, were included. 358 lymph nodes were evaluated, 51% of which exhibited adenocarcinoma and 35% were squamous, while 14% were classified as non-small-cell lung carcinoma. The model estimated the probability of malignancy for each lymph node using age, DSA, SUVmax, and AR. The Area Under the ROC curve, was 0.89. A user-friendly application was also developed ( https://ubidi.shinyapps.io/lymma/ .) CONCLUSIONS: The integration of patient clinical characteristics, EBUS features, and PET/CT findings may generate a pre-sampling malignancy probability map for each lymph node. The model requires prospective and external validation.
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Affiliation(s)
- J Bordas-Martinez
- Pulmonology Department, Hospital General de Granollers, Barcelona, Catalonia, Spain
- Pulmonology Department, Bellvitge Universitary Hospital, UB, IDIBELL, CIBERES, Barcelona, Catalonia, Spain
| | - J L Vercher-Conejero
- Nuclear Medicine Department - PET-CT, ICS-IDI, UB, Bellvitge Universitary Hospital, IDIBELL, Barcelona, Catalonia, Spain
| | - G Rodriguez-González
- Pulmonology Department, Hospital General de Granollers, Barcelona, Catalonia, Spain
| | - P C Notta
- Nuclear Medicine Department - PET-CT, ICS-IDI, UB, Bellvitge Universitary Hospital, IDIBELL, Barcelona, Catalonia, Spain
| | - C Martin Cabeza
- Pulmonology Department, Hospital General de Granollers, Barcelona, Catalonia, Spain
| | - N Cubero
- Pulmonology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - R M Lopez-Lisbona
- Pulmonology Department, Bellvitge Universitary Hospital, UB, IDIBELL, CIBERES, Barcelona, Catalonia, Spain
| | - M Diez-Ferrer
- Pulmonology Department, Bellvitge Universitary Hospital, UB, IDIBELL, CIBERES, Barcelona, Catalonia, Spain
| | - C Tebé
- Biostatistics Unit, Germans Trias i Pujol University Hospital, IGTP, Barcelona, Catalonia, Spain
| | - S Santos
- Pulmonology Department, Bellvitge Universitary Hospital, UB, IDIBELL, CIBERES, Barcelona, Catalonia, Spain
| | - M Cortes-Romera
- Pulmonology Department, Hospital General de Granollers, Barcelona, Catalonia, Spain
| | - A Rosell
- Thorax Institute, Germans Trias i Pujol University Hospital, IGTP, UAB, Barcelona, Catalonia, Spain.
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Lin CK, Wu SH, Chua YW, Fan HJ, Cheng YC. TransEBUS: The interpretation of endobronchial ultrasound image using hybrid transformer for differentiating malignant and benign mediastinal lesions. J Formos Med Assoc 2025; 124:28-37. [PMID: 38702216 DOI: 10.1016/j.jfma.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 03/14/2024] [Accepted: 04/24/2024] [Indexed: 05/06/2024] Open
Abstract
The purpose of this study is to establish a deep learning automatic assistance diagnosis system for benign and malignant classification of mediastinal lesions in endobronchial ultrasound (EBUS) images. EBUS images are in the form of video and contain multiple imaging modes. Different imaging modes and different frames can reflect the different characteristics of lesions. Compared with previous studies, the proposed model can efficiently extract and integrate the spatiotemporal relationships between different modes and does not require manual selection of representative frames. In recent years, Vision Transformer has received much attention in the field of computer vision. Combined with convolutional neural networks, hybrid transformers can also perform well on small datasets. This study designed a novel deep learning architecture based on hybrid transformer called TransEBUS. By adding learnable parameters in the temporal dimension, TransEBUS was able to extract spatiotemporal features from insufficient data. In addition, we designed a two-stream module to integrate information from three different imaging modes of EBUS. Furthermore, we applied contrastive learning when training TransEBUS, enabling it to learn discriminative representation of benign and malignant mediastinal lesions. The results show that TransEBUS achieved a diagnostic accuracy of 82% and an area under the curve of 0.8812 in the test dataset, outperforming other methods. It also shows that several models can improve performance by incorporating two-stream module. Our proposed system has shown its potential to help physicians distinguishing benign and malignant mediastinal lesions, thereby ensuring the accuracy of EBUS examination.
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Affiliation(s)
- Ching-Kai Lin
- Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Department of Mechanical Engineering, College of Engineering, National Yang Ming Chiao Tung University, Hsin-Chu, Taiwan
| | - Shao-Hua Wu
- Department of Department of Mechanical Engineering, College of Engineering, National Yang Ming Chiao Tung University, Hsin-Chu, Taiwan.
| | - Yi-Wei Chua
- Department of Department of Mechanical Engineering, College of Engineering, National Yang Ming Chiao Tung University, Hsin-Chu, Taiwan
| | - Hung-Jen Fan
- Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Biomedical Park Hospital, Hsin-Chu County, 302, Taiwan
| | - Yun-Chien Cheng
- Department of Department of Mechanical Engineering, College of Engineering, National Yang Ming Chiao Tung University, Hsin-Chu, Taiwan.
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Leoncini F, Sotgiu G, Cancellieri A, Puci M, Cortese S, Livi V, Simonetti J, Paioli D, Magnini D, Cappuzzo F, Bria E, Trisolini R. Intrathoracic Lymph Node Microcalcifications are Associated With a High Prevalence of Malignancy and Anaplastic Lymphoma Kinase Rearrangement: The "Calce" Study. J Bronchology Interv Pulmonol 2024; 31:e0973. [PMID: 38946295 DOI: 10.1097/lbr.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 05/20/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Microcalcifications are acknowledged as a malignancy risk factor in multiple cancers. However, the prevalence and association of intrathoracic lymph node (ILN) calcifications with malignancy remain unexplored. METHODS In this cross-sectional study, we enrolled patients with known/suspected malignancy and an indication for endosonography for diagnosis or ILN staging. We assessed the prevalence and pattern of calcified ILNs and the prevalence of malignancy in ILNs with and without calcifications. In addition, we evaluated the genomic profile and PD-L1 expression in lung cancer patients, stratifying them based on the presence or absence of ILN calcifications. RESULTS A total of 571 ILNs were sampled in 352 patients. Calcifications were detected in 85 (24.1%) patients and in 94 (16.5%) ILNs, with microcalcifications (78/94, 83%) being the predominant type. Compared with ILNs without calcifications (214/477, 44.9%), the prevalence of malignancy was higher in ILNs with microcalcifications (73/78, 93.6%; P<0.0001) but not in those with macrocalcifications (7/16, 43.7%; P=0.93). In patients with lung cancer, the high prevalence of metastatic involvement in ILNs displaying microcalcifications was independent of lymph node size (< or >1 cm) and the clinical stage (advanced disease; cN2/N3 disease; cN0/N1 disease). The anaplastic lymphoma kinase (ALK) rearrangement was significantly more prevalent in patients with than in those without calcified ILNs (17.4% vs. 1.7%, P<0.001), and all of them exhibited microcalcifications. CONCLUSION ILN microcalcifications are common in patients undergoing endosonography for suspected malignancy, and they are associated with a high prevalence of metastatic involvement and ALK rearrangement.
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Affiliation(s)
- Fausto Leoncini
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari
| | | | - Mariangela Puci
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari
| | - Stefania Cortese
- Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS
| | - Vanina Livi
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Jacopo Simonetti
- Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS
| | - Daniela Paioli
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Daniele Magnini
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Federico Cappuzzo
- Medical Oncology Division, IRCCS Regina Elena National Cancer Institute
| | - Emilio Bria
- Thoracic Oncology Division, Comprehensive Cancer Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rocco Trisolini
- Interventional Pulmonology Division, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
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Uzer F, Uzun R. Contribution of combined use of different ultrasound modes to evaluate mediastinal lymph nodes. Indian J Cancer 2024; 61:224-229. [PMID: 36861724 DOI: 10.4103/ijc.ijc_579_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 12/01/2021] [Indexed: 03/03/2023]
Abstract
BACKGROUND To determine the contribution to diagnostic rates of the evaluation of the sonographic characteristics of lymph nodes with EBUS together with vascularity. METHODS In the present study, patients who underwent the Endobronchial ultrasound (EBUS) procedure were evaluated retrospectively. Patients were classified as benign or malignant by using the sonographic features of EBUS. EBUS-Transbronchial Needle Aspiration (TBNA) confirmed histopathologically with lymph node dissection or in cases where no disease progression was observed clinically or radiologically in at least 6 months of follow-up. Malignant lymph node diagnosis was based on histological examination. RESULTS Evaluation was made of 165 patients comprising 122 (73.9%) males and 43 (26.1%) females with a mean age of 62.0 ± 10.7 years. Malignant disease was diagnosed in 89 (53.9%) cases and benign disease in 76 (46.1%) cases. The success level of the model was seen to be approximately 87%. The Nagelkerke R 2 value was calculated as 0.401. The probability of malignancy increased 3.86-fold (95% CI: 2.61-5.11) in lesions of diameter ≥20 mm compared to lesions <20 mm, 2.58-fold (95% CI: 1.48-3.68) in lesions not determined with central hilar structure (CHS) compared to those determined with CHS, 6.85-fold (95% CI: 4.67-9.03) in lymph nodes observed with necrosis compared to those without necrosis, and 1.51-fold (95% CI: 0.41-2.61) in lymph nodes with a vascular pattern (VP) score of 2-3 compared to those with a VP score of 0-1. CONCLUSION Visualization of coagulation necrosis with EBUS-B mode and the determination of VP 2-3 in power Doppler mode were seen to be the most important criteria of malignancy.
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Affiliation(s)
- Fatih Uzer
- Department of Respiratory Diseases, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Rusen Uzun
- Department of Respiratory Diseases, Health Sciences University, Antalya Education and Research Hospital, Antalya, Turkey
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Huang Z, Wang L, Chen J, Zhi X, Sun J. A risk-scoring model based on endobronchial ultrasound multimodal imaging for predicting metastatic lymph nodes in lung cancer patients. Endosc Ultrasound 2024; 13:107-114. [PMID: 38947743 PMCID: PMC11213589 DOI: 10.1097/eus.0000000000000051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Background and Objectives Endobronchial ultrasound (EBUS) imaging is a valuable tool for predicting lymph node (LN) metastasis in lung cancer patients. This study aimed to develop a risk-scoring model based on EBUS multimodal imaging (grayscale, Doppler mode, elastography) to predict LN metastasis in lung cancer patients. Patients and Methods This retrospective study analyzed 350 metastatic LNs in 314 patients with lung cancer and 124 reactive LNs in 96 patients with nonspecific inflammation. The sonographic findings were compared with the final pathology results and clinical follow-up. Univariate and multivariate logistic regression analyses were performed to evaluate the independent risk factors of metastatic LNs. According to the β coefficients of corresponding indicators in logistic regression analysis, a risk-scoring model was established. Receiver operating characteristic curve was applied to evaluate the predictive capability of model. Results Multivariate analysis showed that short axis >10 mm, distinct margin, absence of central hilar structure, presence of necrosis, nonhilar vascularity, and elastography score 4 to 5 were independent predictors of metastatic LNs. Both short axis and margin were scored 1 point, and the rest of independent predictors were scored 2 points. The combination of 3 EBUS modes had the highest area under the receiver operating characteristic and accuracy of 0.884 (95% confidence interval, 0.846-0.922) and 87.55%, respectively. The risk stratification was as follows: 0 to 2 points, malignancy rate of 11.11%, low suspicion; 3 to 10 points, malignancy rate of 86.77%, high suspicion. Conclusions The risk-scoring model based on EBUS multimodal imaging can effectively evaluate metastatic LNs in lung cancer patients to support clinical decision making.
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Affiliation(s)
- Zhihong Huang
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai 200030, China
| | - Lei Wang
- Department of Ultrasound, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
| | - Junxiang Chen
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai 200030, China
| | - Xinxin Zhi
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai 200030, China
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200030, China
- Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai 200030, China
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Ling B, Xie W, Zhong Y, Feng T, Huang Y, Ge L, Liu A. A Nomogram to Predict Benign/Malignant Mediastinal Lymph Nodes Based on EBUS Sonographic Features. Int J Clin Pract 2024; 2024:3711123. [PMID: 38454935 PMCID: PMC10919979 DOI: 10.1155/2024/3711123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/21/2023] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
Background Endobronchial ultrasound (EBUS) sonographic features help identify benign/malignant lymph nodes while conducting transbronchial needle aspiration (TBNA). This study aims to identify risk factors for malignancy based on EBUS sonographic features and to estimate the risk of malignancy in lymph nodes by constructing a nomogram. Methods 1082 lymph nodes from 625 patients were randomly enrolled in training (n = 760) and validation (n = 322) sets. The subgroup of EBUS-TBNA postoperative negative lymph nodes (n = 317) was randomly enrolled in a training (n = 224) set and a validation (n = 93) set. Logistic regression analysis was used to identify the EBUS features of malignant lymph nodes. A nomogram was formulated using the EBUS features in the training set and later validated in the validation set. Results Multivariate analysis revealed that long-axis, short-axis, echogenicity, fusion, and central hilar structure (CHS) were the independent predictors of malignant lymph nodes. Based on these risk factors, a nomogram was constructed. Both the training and validation sets of 5 EBUS features nomogram showed good discrimination, with area under the curve values of 0.880 (sensitivity = 0.829 and specificity = 0.807) and 0.905 (sensitivity = 0.819 and specificity = 0.857). Subgroup multivariate analysis revealed that long-axis, echogenicity, and CHS were the independent predictors of malignancy outcomes of EBUS-TBNA postoperative negative lymph nodes. Based on these risk factors, a nomogram was constructed. Both the training and validation sets of 3 EBUS features nomogram showed good discrimination, with the area under the curve values of 0.890 (sensitivity = 0.882 and specificity = 0.786) and 0.834 (sensitivity = 0.930 and specificity = 0.636). Conclusions Our novel scoring system based on two nomograms can be utilized to predict malignant lymph nodes.
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Affiliation(s)
- Bingchao Ling
- Department of Endoscopy, Guangxi Medical University Cancer Hospital, Nanning 530021, China
| | - Weishun Xie
- Department of Endoscopy, Guangxi Medical University Cancer Hospital, Nanning 530021, China
| | - Yi Zhong
- Department of Endoscopy, Guangxi Medical University Cancer Hospital, Nanning 530021, China
| | - Taowen Feng
- Department of Endoscopy, Guangxi Medical University Cancer Hospital, Nanning 530021, China
| | - Yueli Huang
- Department of Endoscopy, Guangxi Medical University Cancer Hospital, Nanning 530021, China
| | - Lianying Ge
- Department of Endoscopy, Guangxi Medical University Cancer Hospital, Nanning 530021, China
| | - Aiqun Liu
- Department of Endoscopy, Guangxi Medical University Cancer Hospital, Nanning 530021, China
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Polanco D, Pinilla L, Gracia-Lavedan E, Gatius S, Zuil M, Pardina M, Gómez S, Barbé F. Performance of endobronchial ultrasound transbronchial needle aspiration as the first nodal staging procedure for the determination of programmed death ligand-1 expression in non-small cell lung cancer patients. J Cancer Res Clin Oncol 2023; 149:12459-12468. [PMID: 37450028 DOI: 10.1007/s00432-023-05039-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The determination of the programmed death ligand-1 (PD-L1) expression is part of the diagnostic algorithm for advanced non-small cell lung cancer (NSCLC) patients. We aimed to analyze the diagnostic performance of EBUS-TBNA performed as first-choice nodal staging procedure for the determination of PD-L1 expression in NSCLC patients. METHODS Longitudinal-prospective study including NSCLC patients diagnosed between January 2018 and October 2019, for whom a primary tumor biopsy sample and an EBUS-TBNA cytological malignant sample were available. Samples with fewer than 100 malignant cells were considered inadequate. PDL-1 IHC 22C3 pharmDx antibody was used. The percentage of tumor cells expressing PD-L1, setting 1% and 50% as cutoff points, was collected. The weighted kappa coefficient was used to assess the concordance of PD-L1 expression. The PD-L1 expression was compared in precision terms. RESULTS From a total of 43 patients, 53 pairs of samples were obtained, of which 23 (43.4%) were adequate and included for analysis. The weighted kappa coefficient for PD-L1 expression was 0.41 (95% CI 0.15-0.68) and 0.56 (95% CI 0.23-0.9) for cutoff values ≥ 1% and ≥ 50%, respectively. In advanced stages, the weighted kappa coefficient was 0.6 (95% CI 0.3-0.9) and 1 (95% CI 1-1) for PD-L1 expression cutoff values ≥ 1% and ≥ 50%, respectively. EBUS-TBNA showed a sensitivity, specificity, positive predictive value, and negative predictive value of 1 to detect PDL-1 expression ≥ 50% in advanced stages. CONCLUSION EBUS-TBNA performed as first nodal staging procedure in advanced NSCLC patients provides reliable specimens for the detection of PD-L1 expression ≥ 50% and could guide immunotherapy.
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Affiliation(s)
- Dinora Polanco
- Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, Biomedical Research Institute of Lleida (IRB Lleida), Lleida, Spain
| | - Lucía Pinilla
- Group of Precision Medicine in Chronic Diseases, University Hospital Arnau de Vilanova and Santa Maria, Biomedical Research Institute of Lleida (IRB Lleida), Lleida, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Esther Gracia-Lavedan
- Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, Biomedical Research Institute of Lleida (IRB Lleida), Lleida, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Sonia Gatius
- Pathology Department, University Hospital Arnau de Vilanova, Lleida, Spain
| | - María Zuil
- Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, Biomedical Research Institute of Lleida (IRB Lleida), Lleida, Spain
| | - Marina Pardina
- Radiology Department, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Silvia Gómez
- Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, Biomedical Research Institute of Lleida (IRB Lleida), Lleida, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Ferrán Barbé
- Group of Translational Research in Respiratory Medicine, University Hospital Arnau de Vilanova and Santa Maria, Biomedical Research Institute of Lleida (IRB Lleida), Lleida, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
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8
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Mohan A, Madan K, Hadda V, Mittal S, Suri T, Shekh I, Guleria R, Khader A, Chhajed P, Christopher DJ, Swarnakar R, for the “EBUS Guidelines Working Group” Working group Members (in alphabetical order by surname), Agarwal R, Aggarwal AN, Aggarwal S, Agrawal G, Ayub II, Bai M, Baldwa B, Chauhan A, Chawla R, Chopra M, Choudhry D, Dhar R, Dhooria S, Garg R, Goel A, Goel M, Goyal R, Gupta N, Manjunath BG, Iyer H, Jain D, Khan A, Kumar R, Koul PA, Lall A, Arunachalam M, Madan NK, Mehta R, Loganathan N, Nath A, Nangia V, Nene A, Patel D, Pattabhiraman VR, Raja A, Rajesh B, Rangarajan A, Rathi V, Sehgal IS, Shankar SH, Sindhwani G, Singh PK, Srinivasan A, Talwar D, Thangakunam B, Tiwari P, Tyagi R, Chandra NV, Sharada V, Vadala R, Venkatnarayan K. Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations. Lung India 2023; 40:368-400. [PMID: 37417095 PMCID: PMC10401980 DOI: 10.4103/lungindia.lungindia_510_22] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/30/2022] [Accepted: 01/31/2023] [Indexed: 07/08/2023] Open
Abstract
Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.
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Affiliation(s)
- Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tejas Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Irfan Shekh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abdul Khader
- Institute of Pulmonology, Allergy and Asthma Research, Calicut, India
| | | | | | | | | | - Ritesh Agarwal
- Department of Pulmonary Medicine, PGIMER, Chandigarh, India
| | | | - Shubham Aggarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gyanendra Agrawal
- Department of Internal Medicine, Respiratory and Critical Care Medicine, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Irfan Ismail Ayub
- Department of Pulmonology, Sri Ramachandra, Medical Centre, Chennai, India
| | - Muniza Bai
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bhvya Baldwa
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Chauhan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Chawla
- Department of Pulmonary Medicine, Jaipur Golden Hospital, Delhi, India
| | - Manu Chopra
- Department of Medicine, Command Hospital Eastern Command Kolkata, India
| | - Dhruva Choudhry
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | - Raja Dhar
- Department of Pulmonology, Calcutta Medical Research Institute, Kolkata, India
| | | | - Rakesh Garg
- Department of Onco-Anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Goel
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Goel
- Department of Pulmonology, Fortis, Gurugram, India
| | - Rajiv Goyal
- Department of Respiratory Medicine, Rajiv Gandhi Cancer Institute, Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - BG Manjunath
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | - Hariharan Iyer
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajmal Khan
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, India
| | - Raj Kumar
- Director, Vallabhbhai Patel Chest Institute, Delhi, India
| | - Parvaiz A. Koul
- Director, Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ajay Lall
- Department of Pulmonary Medicine, Max Hospital, Saket, Delhi, India
| | - M. Arunachalam
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neha K. Madan
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ravindra Mehta
- Department of Pulmonary and Critical Care Medicine, Apollo Hospitals, Bengaluru, India
| | - N Loganathan
- Department of Pulmonary Medicine, Sri Ramakrishna Hospital, Coimbatore, India
| | - Alok Nath
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, India
| | - Vivek Nangia
- Department of Pulmonology and Respiratory Medicine, Max Super Speciality Hospital Saket, New Delhi, India
| | - Amita Nene
- Bombay Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Arun Raja
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Benin Rajesh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Amith Rangarajan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vidushi Rathi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sujay H. Shankar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Girish Sindhwani
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Pawan K. Singh
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | | | | | | | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Tyagi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naren V. Chandra
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - V. Sharada
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Vadala
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kavitha Venkatnarayan
- Department of Pulmonary Medicine, St. John’s National Academy of Health Sciences, Bengaluru, India
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9
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Guler N, Tertemiz KC, Gurel D. A valuable endobronchial ultrasound scoring system predicting malignant lymph nodes. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:358-366. [PMID: 37664768 PMCID: PMC10472475 DOI: 10.5606/tgkdc.dergisi.2023.23568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/20/2022] [Indexed: 09/05/2023]
Abstract
Background This study aims to determine the sonographic criteria of lymph nodes to predict malignancy with endobronchial ultrasound. Methods A total of 1,987 lymph nodes of 967 patients (666 males, 301 females; mean age: 62.1±11.9 years; range, 21 to 90 years) between May 2016 and July 2020 were retrospectively analyzed. The endobronchial ultrasound images of lymph nodes were evaluated according to the following criteria: size (short axis >1 cm), shape (round or oval), margin (distinct or indistinct), coagulation necrosis sign (present or absent), central hilar structure (present or absent) and echogenicity (homogeneous or heterogeneous). A scoring system was developed for predicting malignancy. Results A total of 765 (38.5%) of the lymph nodes were malignant. In the univariate analysis, size >1 cm, round shape, distinct margin, absence of central hilar structure, presence of coagulation necrosis sign, and heterogeneity were significant predictors of malignancy (p<0.001 for all). In the multivariate analysis, the main independent predictors were heterogeneity and presence of coagulation necrosis sign (odds ratio=5.9, 95% confidence interval: 4.2-8.2 vs. odds ratio=3.1 95% confidence interval: 2.2-4.5, respectively). A cut-off value for endobronchial ultrasound score of ≥4 increased the malignancy risk 30 times with a sensitivity of 84.7%, and specificity of 84.5%. Conclusion Our study results show that endobronchial ultrasound scoring system with six criteria has a high sensitivity and specificity for predicting malignant lymph nodes.
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Affiliation(s)
- Nurcan Guler
- Department of Respiratory Diseases, Dokuz Eylül University Faculty of Medicine, Izmir, Türkiye
| | - Kemal Can Tertemiz
- Department of Respiratory Diseases, Dokuz Eylül University Faculty of Medicine, Izmir, Türkiye
| | - Duygu Gurel
- Department of Pathology, Dokuz Eylül University Faculty of Medicine, Izmir, Türkiye
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10
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Yan Y, Wang Z, Yan W, Li S, Wu Q. Endobronchial ultrasound-guided transbronchial needle aspiration in patients with previously treated malignancies: diagnostic performance and predictive value. BMC Pulm Med 2022; 22:470. [PMID: 36494658 PMCID: PMC9733028 DOI: 10.1186/s12890-022-02266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration is a minimally invasive and effective sampling approach for patients with mediastinal or hilar lymphadenopathy. Increased recognition of the ultrasonographic features revealed the value of its images in predicting mediastinal lymph node malignancy. However, its diagnostic validity and the predictive value of its ultrasonographic features have not been demonstrated well in patients after systemic anti-tumor therapy. This study aimed to evaluate the efficiency of endobronchial ultrasound-guided transbronchial needle aspiration in patients with suspicious lymph nodes after anti-tumor therapy. METHODS We retrospectively reviewed cases of endobronchial ultrasound-guided transbronchial needle aspiration performed between January 2019 and August 2021 at a single tertiary hospital center. Patients with suspected mediastinal or hilar lymph nodes within 5 years of systemic anti-tumor therapy were enrolled. Final diagnoses were determined by pathologic diagnoses of samples from transbronchial needle aspiration, surgery, or follow-up for at least 6 months. Ultrasonographic features were analyzed to assess the predictive value of malignant lymph nodes after treatment. RESULTS Overall, 168 lymph nodes of 138 patients were analyzed. Among 110 (65.5%) malignant lymph nodes, 75 originated from lung cancers; the other 35 were from other malignancies. No complications related to endobronchial ultrasound-guided transbronchial needle aspiration were observed. Of 58 negative results of transbronchial needle aspiration, 51 were proven to be true negatives; 7 were false. The overall sensitivity and the negative predictive value were 94.02% and 87.93%, respectively. Univariate and multivariate analysis revealed the absence of central hilar structure and short axis > 10 mm as independent predictive factors for malignancy. CONCLUSIONS Endobronchial ultrasound-guided transbronchial needle aspiration performs satisfactorily in diagnosing mediastinal and hilar lymphadenopathy even after anti-tumor treatment.
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Affiliation(s)
- Yan Yan
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Endoscopy, Peking University Cancer Hospital & Institute, Beijing, China
| | - Zhilong Wang
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing, China
| | - Wanpu Yan
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Thoracic Surgery, Peking University Cancer Hospital & Institute, Beijing, China
| | - Shijie Li
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Endoscopy, Peking University Cancer Hospital & Institute, Beijing, China
| | - Qi Wu
- grid.412474.00000 0001 0027 0586Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Endoscopy, Peking University Cancer Hospital & Institute, Beijing, China
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11
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Crown-Cut Endobronchial Ultrasound Guided Transbronchial Aspiration Needle: First Real-World Experiences. J Clin Med 2021; 11:jcm11010163. [PMID: 35011904 PMCID: PMC8745307 DOI: 10.3390/jcm11010163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 12/18/2022] Open
Abstract
Advancements in personalized medicine have increased the demand for quantity and preservation of tissue architecture of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples. These demands may be addressed by the SonoTip TopGain® needle, which has a 3-point crown-cut design that contrasts with the standard single bevel design of the ViziShot 2®. The objective was to compare the SonoTip TopGain® and ViziShot 2® needles by considering biopsy sample characteristics, diagnostic accuracy, and patient safety. The primary endpoint of the study was the number of high-power fields (HPFs) in the center of the formalin-fixed paraffin-embedded cell block per sample. The lymph node with the highest probability for malignant infiltration based on size and sonographic appearance was chosen as the target lymph node for 20 patients. The same lymph node in each patient was sampled using both the ViziShot 2® and SonoTip TopGain® needles. The samples were measured, sliced, and analyzed by a pathologist. Sixteen patients were biopsied with both needles. Four patients could not be biopsied with the SonoTip TopGain® needle since it could not penetrate cartilage or be repositioned to bypass cartilage. HPFs and sample dimensions were significantly greater in the patients where sampling with the SonoTip TopGain® needle was possible (p = 0.007 and p = 0.005, respectively). Diagnostic accuracy and safety profiles were comparable. Significantly more material can be sampled using the SonoTip TopGain® needle when cartilage penetration can be avoided. This improves the yield for molecular workup in the era of personalized medicine.
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12
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Oezkan F, Eisenmann S, Darwiche K, Gassa A, Carbone DP, Merritt RE, Kneuertz PJ. Linear Endobronchial Ultrasound in the Era of Personalized Lung Cancer Diagnostics-A Technical Review. J Clin Med 2021; 10:jcm10235646. [PMID: 34884348 PMCID: PMC8658311 DOI: 10.3390/jcm10235646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/21/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Abstract
Major advances in molecular profiling for available targeted treatments and immunotherapy for lung cancer have significantly increased the complexity of tissue-based diagnostics. Endobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNA) are commonly performed for diagnostic biopsies and lymph node staging. EBUS-TBNA has increasingly become one of the main sources of tumor cells for molecular analyses. As a result, there is a growing need for high quality EBUS-TBNA samples with adequate cellularity. This has increased the technical demands of the procedure and has created additional challenges, many of which are not addressed in the current EBUS guidelines. This review provides an overview of current evidence on the technical aspects of EBUS-TBNA in light of comprehensive sample processing for personalized lung cancer management. These include sonographic lymph node characterization, optimal needle choice, suction biopsy technique, and the role of rapid on-site evaluation. Attention to these technical details will be important to maximize the throughput of EBUS-TBNA biopsies for molecular testing.
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Affiliation(s)
- Filiz Oezkan
- Comprehensive Cancer Center, Division of Medical Oncology, The Ohio State University, Columbus, OH 43210, USA;
- Department of Pulmonary Medicine, Section of Interventional Pneumology, Ruhrlandklinik-University Hospital Essen, University of Duisburg-Essen, 45239 Essen, Germany;
- Fifth Department of Internal Medicine, Faculty of University Heidelberg, University Medicine Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
- German Cancer Research Center, A420 Research Group, 69120 Heidelberg, Germany
- Correspondence:
| | - Stephan Eisenmann
- Department of Pneumology, University Hospital of Martin Luther University, 06108 Halle, Germany;
| | - Kaid Darwiche
- Department of Pulmonary Medicine, Section of Interventional Pneumology, Ruhrlandklinik-University Hospital Essen, University of Duisburg-Essen, 45239 Essen, Germany;
| | - Asmae Gassa
- Heart Center, Department of Cardiothoracic Surgery, Faculty of Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany;
| | - David P. Carbone
- Comprehensive Cancer Center, Division of Medical Oncology, The Ohio State University, Columbus, OH 43210, USA;
| | - Robert E. Merritt
- Comprehensive Cancer Center, Division of Thoracic Surgery, Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (R.E.M.); (P.J.K.)
| | - Peter J. Kneuertz
- Comprehensive Cancer Center, Division of Thoracic Surgery, Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (R.E.M.); (P.J.K.)
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13
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Luthra K, Singh J. Evaluation of 18FDG PET-CT-positive mediastinal-hilar lymph nodes in extrathoracic malignancies by EBUS-TBNA; correlation of SUVmax, and short-axis diameter with the final diagnosis. Indian J Cancer 2021; 0:327235. [PMID: 35017370 DOI: 10.4103/ijc.ijc_687_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Intrathoracic lymph node metastasis from extrathoracic neoplasms are rare. Primary malignancies that metastasize to mediastinal-hilar lymph nodes are head and neck , carcinoma breast ,and genitourinary. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)/endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently the preferred modality for mediastinal lymph node sampling. METHODS Fifty seven patients with extrathoracic malignancies with maximum standardized uptake value (SUVmax) of mediastinal-hilar lymph nodes greater than or equal to 2.5 were taken up for EBUS-TBNA. The histo-cytopathological results obtained from EBUS-TBNA were compared with SUVmax value and short-axis diameter of a lymph node as noted on EBUS. RESULTS Out of 74 sampled nodes, 49 (66.2%) were benign and 25 (33.8%) were malignant. The SUVmax range of benign nodes was 2.8-13 as compared to 3-18 of malignant nodes. The size range of malignant and benign nodes were 8-35 mm and 8-30 mm, respectively. The mean size of abnormal nodes (metastatic + granulomatous) was 17.5 (8-35 mm) and the mean SUVmax was 9.1 (3.4-18), and it was a statistically significant difference when compared to reactive (normal) nodes. At SUVmax cut-off 7.5, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were 78.5%, 81.2%, 84.6%, and 74.2%, respectively for detecting abnormal nodes. At 13 mm size cut-off, sensitivity, specificity, PPV, NPV were 75.5%, 65%, 75%, and 72%, respectively, for detecting abnormal nodes. CONCLUSION The majority of mediastinal-hilar nodes with increased metabolic activity are benign in nature. Size and SUVmax are poor predictors of metastasis in tuberculosis endemic region. There should be a restrictive attitude toward invasive diagnostic testing for mediastinal-hilar nodes in extrathoracic malignancies.
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Affiliation(s)
- Kunal Luthra
- Department of Chest and Respiratory Medicine, Delhi State Cancer Institute, Delhi, India
| | - Jyoti Singh
- Department of Chest and Respiratory Medicine, Delhi State Cancer Institute, Delhi, India
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14
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Zhi X, Chen J, Wang L, Xie F, Zheng X, Li Y, Sun J. Endobronchial Ultrasound Multimodal Imaging for the Diagnosis of Intrathoracic Lymph Nodes. Respiration 2021; 100:898-908. [PMID: 34077944 DOI: 10.1159/000515664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound (EBUS) imaging is valuable in diagnosing intrathoracic lymph nodes (LNs), but there has been little analysis of multimodal imaging. This study aimed to comprehensively compare the diagnostic performance of single and multimodal combinations of EBUS imaging in differentiating benign and malignant intrathoracic LNs. METHODS Subjects from July 2018 to June 2019 were consecutively enrolled in the model group and July 2019 to August 2019 in the validation group. Sonographic features of three EBUS modes were analysed in the model group for the identification of malignant LNs from benign LNs. The validation group was used to verify the diagnostic efficiency of single and multimodal diagnostic methods built in the model group. RESULTS 373 LNs (215 malignant and 158 benign) from 335 subjects and 138 LNs (79 malignant and 59 benign) from 116 subjects were analysed in the model and validation groups, respectively. For single mode, elastography had the best diagnostic value, followed by grayscale and Doppler. The corresponding accuracies in the validation group were 83.3%, 76.8%, and 71.0%, respectively. Grayscale with elastography had the best diagnostic efficiency of multimodal methods. When at least two of the three features (absence of central hilar structure, heterogeneity, and qualitative elastography score 4-5) were positive, the sensitivity, specificity, and accuracy in the validation group were 88.6%, 78.0%, and 84.1%, respectively. CONCLUSIONS In both model and validation groups, elastography performed the best in single EBUS modes, as well as grayscale combined with elastography in multimodal imaging. Elastography alone or combined with grayscale are feasible to help predict intrathoracic benign and malignant LNs.
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Affiliation(s)
- Xinxin Zhi
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Junxiang Chen
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Lei Wang
- Department of Ultrasound, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Xiaoxuan Zheng
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Ying Li
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
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15
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Li J, Zhi X, Chen J, Wang L, Xu M, Dai W, Sun J, Xiong H. Deep learning with convex probe endobronchial ultrasound multimodal imaging: A validated tool for automated intrathoracic lymph nodes diagnosis. Endosc Ultrasound 2021; 10:361-371. [PMID: 33565422 PMCID: PMC8544010 DOI: 10.4103/eus-d-20-00207] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives: Along with the rapid improvement of imaging technology, convex probe endobronchial ultrasound (CP-EBUS) sonographic features play an increasingly important role in the diagnosis of intrathoracic lymph nodes (LNs). Conventional qualitative and quantitative methods for EBUS multimodal imaging are time-consuming and rely heavily on the experience of endoscopists. With the development of deep-learning (DL) models, there is great promise in the diagnostic field of medical imaging. Materials and Methods: We developed DL models to retrospectively analyze CP-EBUS images of 294 LNs from 267 patients collected between July 2018 and May 2019. The DL models were trained on 245 LNs to differentiate benign and malignant LNs using both unimodal and multimodal CP-EBUS images and independently evaluated on the remaining 49 LNs to validate their diagnostic efficiency. The human comparator group consisting of three experts and three trainees reviewed the same test set as the DL models. Results: The multimodal DL framework achieves an accuracy of 88.57% (95% confidence interval [CI] [86.91%–90.24%]) and area under the curve (AUC) of 0.9547 (95% CI [0.9451–0.9643]) using the three modes of CP-EBUS imaging in comparison to the accuracy of 80.82% (95% CI [77.42%–84.21%]) and AUC of 0.8696 (95% CI [0.8369–0.9023]) by experts. Statistical comparison of their average receiver operating curves shows a statistically significant difference (P < 0.001). Moreover, the multimodal DL framework is more consistent than experts (kappa values 0.7605 vs. 0.5800). Conclusions: The DL models based on CP-EBUS imaging demonstrated an accurate automated tool for diagnosis of the intrathoracic LNs with higher diagnostic efficiency and consistency compared with experts.
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Affiliation(s)
- Jin Li
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Xinxin Zhi
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Junxiang Chen
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Lei Wang
- Department of Ultrasound, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mingxing Xu
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Wenrui Dai
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Hongkai Xiong
- School of Electronic Information and Electrical Engineering, Shanghai Jiao Tong University, Shanghai, China
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16
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Zhi X, Chen J, Xie F, Sun J, Herth FJF. Diagnostic value of endobronchial ultrasound image features: A specialized review. Endosc Ultrasound 2021; 10:3-18. [PMID: 32719201 PMCID: PMC7980684 DOI: 10.4103/eus.eus_43_20] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) technology is important in the diagnosis of intrathoracic benign and malignant lymph nodes (LNs). With the development of EBUS imaging technology, its role in noninvasive diagnosis, as a supplement to pathology diagnosis, has been given increasing attention in recent years. Many studies have explored qualitative and quantitative methods for the three EBUS modes, as well as a variety of multimodal analysis methods, to find the optimal method for the noninvasive diagnosis using EBUS for LNs. Here, we review and comment on the research methods and predictive diagnostic value, discuss the existing problems, and look ahead to the future application of EBUS imaging.
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Affiliation(s)
- Xinxin Zhi
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai; Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Junxiang Chen
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai; Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Fangfang Xie
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai; Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai; Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai; Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Felix J F Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
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17
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Zhi X, Wang L, Chen J, Zheng X, Li Y, Sun J. Scoring model of convex probe endobronchial ultrasound multimodal imaging in differentiating benign and malignant lung lesions. J Thorac Dis 2020; 12:7645-7655. [PMID: 33447457 PMCID: PMC7797845 DOI: 10.21037/jtd-2020-abpd-005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Convex probe endobronchial ultrasound images can reflect the morphology, blood flow status and stiffness of the lesions. Endobronchial ultrasound multimodal imaging has great value for the diagnosis of intrathoracic lymph nodes. This study aimed to analyze the application of endobronchial ultrasound multimodal imaging on lung lesions. Methods Patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration in Shanghai Chest Hospital from July 2018 to December 2019 were retrospectively enrolled. Nine grayscale features (long and short axes, margin, shape, lobulation sign, echogenicity, necrosis, liquefaction, calcification, and air-bronchogram), blood flow volume and elastography five-score method were analyzed to explore the best diagnostic method. The gold standard for diagnosing lesions depends on the histological and cytopathological findings of endobronchial ultrasound-guided transbronchial needle aspiration, transthoracic biopsy, resected sample of lesions, microbiological examination or clinical follow-up of at least 6 months. Results Endobronchial ultrasound multimodal imaging of 97 malignant lung lesions and 19 benign lung lesions from 116 patients were analyzed. There were statistically significant differences in distinct margin, presence of lobulation sign, presence of necrosis, and elastography grading score 4–5 between malignant and benign lung lesions, among which presence of lobulation sign and elastography grading score 4–5 were independent predictors. A diagnostic scoring model was then constructed based on the above four features, and when two or more features were present, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for malignant lung lesions prediction were 92.78%, 57.89%, 91.84%, 61.11% and 87.07%, respectively. Conclusions The combination of endobronchial ultrasound grayscale and elastography has potential value for malignant and benign lung lesions differentiation. The diagnostic scoring model established in this study needs further validation to guide the malignant and benign diagnosis of lung lesions.
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Affiliation(s)
- Xinxin Zhi
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Lei Wang
- Department of Ultrasound, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Junxiang Chen
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Xiaoxuan Zheng
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Ying Li
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
| | - Jiayuan Sun
- Department of Respiratory Endoscopy, Shanghai Jiao Tong University, Shanghai, China.,Department of Respiratory and Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Engineering Research Center of Respiratory Endoscopy, Shanghai, China
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18
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Yamamichi T, Kakihana M, Nitta Y, Hamanaka W, Kajiwara N, Ohira T, Ikeda N. F-18 fluorodeoxyglucose uptake in lymph nodes and sonographic features on endobronchial ultrasonography predict lymph node metastasis in lung cancer patients. J Thorac Dis 2020; 12:5420-5429. [PMID: 33209375 PMCID: PMC7656352 DOI: 10.21037/jtd-20-1888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Sonographic findings of lymph nodes on endobronchial ultrasonography (EBUS) images have been reported to be useful to predict lymph node metastasis (LNM) in lung cancer patients. F-18 fluorodeoxyglucose (FDG) uptake in lymph nodes was also found to be useful. In this study, we aimed to clarify whether a combination of sonographic features and maximum standardized uptake values of lymph nodes (LN-SUVmax) is useful for predicting LNM in lung cancer patients. Methods From January 2014 to December 2019, a total of 147 lymph nodes from 104 patients with lung cancer, who underwent preoperative EBUS and FDG-positron emission tomography (PET)/computed tomography (CT) followed by surgery were retrospectively assesses. The characteristics of the patients, LN-SUVmax, and sonographic findings of lymph nodes were reviewed. Predictive factors associated with LNM were identified using the logistic regression model. Results The average size of the lymph nodes was 8.55 (range, 3–22) mm and the average LN-SUVmax was 5.36 (range, 1.79–31.19). The prevalence of nodal metastasis was 26/147 (17.4%), including 22 in mediastinal lymph nodes and 4 in hilar lymph nodes. Multivariate analysis demonstrated four independent predictive factors for LNM; size, round or oval shape, absence of a central hilar structure, and LN-SUVmax. The optimal cutoff value for lymph node size and LN-SUVmax were 10 mm and 6.00, respectively. By combinating of the two modalities, we obtained the results with sensitivity of 76.9%, specificity of 95.1% and accuracy of 93.2%. Conclusions A combination of sonographic findings and LN-SUVmax showed a higher diagnostic rate of LNM than either modality alone in lung cancer patients.
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Affiliation(s)
| | | | - Yasuyuki Nitta
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Wakako Hamanaka
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | | | - Tatsuo Ohira
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Norihiko Ikeda
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
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Criner GJ, Eberhardt R, Fernandez-Bussy S, Gompelmann D, Maldonado F, Patel N, Shah PL, Slebos DJ, Valipour A, Wahidi MM, Weir M, Herth FJ. Interventional Bronchoscopy. Am J Respir Crit Care Med 2020; 202:29-50. [PMID: 32023078 DOI: 10.1164/rccm.201907-1292so] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.
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Affiliation(s)
- Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Ralf Eberhardt
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | | | - Daniela Gompelmann
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Fabien Maldonado
- Department of Medicine and Department of Thoracic Surgery, Vanderbilt University, Nashville, Tennessee
| | - Neal Patel
- Division of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida
| | - Pallav L Shah
- Respiratory Medicine at the Royal Brompton Hospital and National Heart & Lung Institute, Imperial College, London, United Kingdom
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Krankenhaus Nord, Vienna, Austria; and
| | - Momen M Wahidi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mark Weir
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Felix J Herth
- Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
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20
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Agrawal S, Goel AD, Gupta N, Lohiya A, Gonuguntla HK. Diagnostic utility of endobronchial ultrasound (EBUS) features in differentiating malignant and benign lymph nodes - A systematic review and meta-analysis. Respir Med 2020; 171:106097. [PMID: 32805534 DOI: 10.1016/j.rmed.2020.106097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/15/2020] [Accepted: 07/26/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND EBUS is being widely used today for echolocation of lymph nodes for FNAC. We present a systematic review and meta-analysis to assess the diagnostic accuracy of EBUS characteristics of lymph nodes in diagnosing malignancy. METHODS A systematic search of published literature was undertaken using databases like PubMed, Web of Science, Cochrane, Google Scholar and Researchgate. Those studies reporting any endobronchial ultrasonography features of malignant lymph nodes like size, margins, echogenicity, shape, central hilar structure (CHS), coagulation necrosis sign (CNS) or color power doppler index (CPDI) were included for review. Random effects model was used to calculate pooled sensitivity, specificity, positive and negative likelihood ratios (LR), and diagnostic odds ratio (DOR). The review protocol was registered with the International prospective register of systematic reviews (PROSPERO registration no. CRD42019117716). RESULTS 992 articles were retrieved of which 542 articles were evaluated in detail and finally 29 articles met the inclusion criteria. All EBUS features except CPDI showed a statistically significant area under the SROC curve. CNS showed highest area under the SROC curve [0.81 (SE: 0.09)] with maximum pooled specificity [0.93, 95%CI: 0.92-0.94], maximum pooled LR+ [5.12, 95%CI: 2.56-10.2] and DOR [9.23, 95%CI 3.85-22.15]. Maximum sensitivity was seen for CHS 0.91 [95%CI: 0.90-0.92]. CONCLUSION EBUS features have the potential to help in more precise location of a malignant lymph node thereby helping in increasing the diagnostic yield. However, high diagnostic accuracy of various EBUS features can currently only be said to supplement tissue diagnosis.
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Affiliation(s)
- Sumita Agrawal
- Department of Pulmonary and Critical Care Medicine, Medipulse Hospital, Jodhpur, India
| | - Akhil Dhanesh Goel
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India.
| | - Nitesh Gupta
- Department of Pulmonary and Critical Care Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - Ayush Lohiya
- Department of Preventive Oncology, Super Speciality Cancer Institute & Hospital, Lucknow, India
| | - Hari Kishan Gonuguntla
- Lead - Division of Interventional Pulmonology, Yashoda Superspeciality Hospitals, Hyderabad, India
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21
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Abedini A, Razavi F, Mehravaran H, Toutkaboni MP, Kashefizadeh A, Emami H, Kazempour-Dizaji M, Farahani M, Kiani A. Identification of Sonographic Features for Predicting Benign Versus Malignant Mediastinal or Hilar Lymph Nodes Using Endobronchial Ultrasound. Oman Med J 2020; 35:e112. [PMID: 32405434 PMCID: PMC7199125 DOI: 10.5001/omj.2020.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/21/2019] [Indexed: 12/25/2022] Open
Abstract
Objectives In countries with a high prevalence of tuberculosis, such as Iran, the differentiation of malignant from non-malignant tumors is crucial. We attempted to find a reliable model in determining malignant nodes by investigating the sonographic characteristics of lymph nodes (LNs). Methods In this prospective study, the morphologic characteristics of LNs, including size, shape, vascular pattern, echogenicity, margin, coagulation necrosis sign, calcification, and central hilar structure, which had been obtained during endobronchial ultrasound-guided transbronchial needle aspiration, were compared with the final pathology results. Results We examined 253 LNs from 93 patients. Round shape, non-hilar vascular pattern, heterogeneous echogenicity, hyperechogenicity, distinct margin, and the existence of necrosis signs were significantly higher in malignant nodes. On the other hand, the existence of calcification, as well as the presence of central hilar structure, were highly suggestive of benign nodes (p < 0.050). Multivariate logistic regression revealed that size > 1 cm, heterogeneous echogenicity, hyperechogenicity, the existence of necrosis signs, and the lack of central hilar structure are independent predictive factors for malignancy. The accuracy of each of the aforementioned characteristics are 42.3%, 71.5%, 71.9%, 73.5%, and 65.6%, respectively. Of 74 malignant LNs, 100% had at least one of these independent factors. Conclusions The morphological features of LNs based on endobronchial ultrasound-guided transbronchial needle aspiration can play a role in predicting malignancy.
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Affiliation(s)
- Atefeh Abedini
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Razavi
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Mehravaran
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mihan Pourabdollah Toutkaboni
- Pediatric Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Kashefizadeh
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Habib Emami
- Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Kazempour-Dizaji
- Mycobacteriology Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Farahani
- Departemant of Interventional Pulmonology, Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences,Tehran, Iran
| | - Arda Kiani
- Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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22
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Performance of Endobronchial Ultrasound Elastography in the Differentiation of Malignant and Benign Mediastinal Lymph Nodes. J Bronchology Interv Pulmonol 2019; 26:193-198. [DOI: 10.1097/lbr.0000000000000551] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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23
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Shah PL. Sonic biopsy: A new tool for the assessment of peripheral pulmonary lesions. Respirology 2019; 24:933-934. [PMID: 31095802 DOI: 10.1111/resp.13581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart & Lung Institute, Imperial College, London, UK
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24
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Wolters C, Darwiche K, Franzen D, Hager T, Bode-Lesnievska B, Kneuertz PJ, He K, Koenig M, Freitag L, Wei L, Eisenmann S, Taube C, Weinreich G, Oezkan F. A Prospective, Randomized Trial for the Comparison of 19-G and 22-G Endobronchial Ultrasound-Guided Transbronchial Aspiration Needles; Introducing a Novel End Point of Sample Weight Corrected for Blood Content. Clin Lung Cancer 2019; 20:e265-e273. [PMID: 30914312 DOI: 10.1016/j.cllc.2019.02.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/01/2019] [Accepted: 02/21/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND The use of 22- or 21-gauge (G) endobronchial ultrasound (EBUS) needles are recommended for lung cancer diagnosis and staging. Performance of detailed molecular workup and programmed death ligand 1 (PD-L1) staining in lung cancer patients increases the demand for tissue. The aim of this prospective, randomized two-center trial was to compare 19-G and 22-G EBUS needles regarding tissue quality, diagnostic yield, feasibility, safety, performance, and blood content. PATIENTS AND METHODS Patients with a computed tomography scan indicative of lung cancer with mediastinal or hilar lymph node metastases were prospectively enrolled and randomized for the use of either a 19-G or a 22-G EBUS needle. A blood content score from 0 to 2 was applied. Samples were weighed, tumor cells were counted per slide, and complications and final diagnoses were documented. RESULTS We enrolled 107 patients (53 [49.5%] in the 19-G group/54 [50.5%] in the 22-G group) and samples were weighed immediately after performing EBUS. Samples obtained with a 19-G needle contained significantly more tissue (P = .0119). Non-small-cell lung cancer-infiltrated EBUS samples contained significantly more tumor cells when sampled with a 19-G needle (P = .0312). The diagnostic yield was equally adequate in both groups. Four moderate EBUS-related bleedings occurred (2 per group), hemostasis was rapidly achieved in all cases. Further complications did not occur. CONCLUSION Endobronchial ultrasound-guided transbronchial needle aspirations with a 19-G needle contain significantly more tissue and tumor cells per slide with a safety profile similar to 22-G needles. Further research is needed to investigate the relevance of this finding in terms of molecular analyses and PD-L1 staining.
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Affiliation(s)
- Celina Wolters
- Department of Interventional Pneumology, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Kaid Darwiche
- Department of Interventional Pneumology, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Daniel Franzen
- Interventional Lung Center, Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Hager
- Institute of Pathology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Beata Bode-Lesnievska
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Peter J Kneuertz
- The Arthur G. James Thoracic Cancer Center, The Ohio State University, Columbus, OH
| | - Kai He
- The Arthur G. James Thoracic Cancer Center, The Ohio State University, Columbus, OH
| | - Michael Koenig
- The Arthur G. James Thoracic Cancer Center, The Ohio State University, Columbus, OH
| | - Lutz Freitag
- Department of Interventional Pneumology, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Lai Wei
- Center for Biostatistics, The Ohio State University, Columbus, OH
| | - Stephan Eisenmann
- Department of Interventional Pneumology, University Medicine Essen - Ruhrlandklinik, Essen, Germany; Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Christian Taube
- Department of Pulmonary Medicine, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Gerhard Weinreich
- Department of Pulmonary Medicine, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Filiz Oezkan
- Department of Interventional Pneumology, University Medicine Essen - Ruhrlandklinik, Essen, Germany; The Arthur G. James Thoracic Cancer Center, The Ohio State University, Columbus, OH.
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25
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Takasaki Y, Irisawa A, Shibukawa G, Sato A, Abe Y, Yamabe A, Arakawa N, Maki T, Yoshida Y, Igarashi R, Yamamoto S, Ikeda T. New endoscopic ultrasonography criteria for malignant lymphadenopathy based on inter-rater agreement. PLoS One 2019; 14:e0212427. [PMID: 30794598 PMCID: PMC6386303 DOI: 10.1371/journal.pone.0212427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 02/02/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS Various studies have been previously conducted on the diagnosis of lymphadenopathy as benign or malignant, but the results vary. These studies did not describe the inter-rater agreement on the EUS features of lymphadenopathy. In this study, we evaluate the inter-rater agreement on EUS features and propose EUS diagnostic norms for lymphadenopathy based on inter-rater agreement. METHOD A total of 68 lymph nodes subjected to EUS-fine needle aspiration (FNA) were reviewed by five endoscopic experts. The EUS features evaluated lymph node size, shape, border, margin, echogenicity, homogeneity, and the hilum of the lymph node. Inter-rater agreement (multi-rater kappa statics) was performed. We established new criteria using results with a high degree of inter-rater agreement from EUS features and compared them with the former criteria. RESULT There was a moderate agreement on shape, kappa (K) = 0.44 (95% confidence interval [CI]: 0.34-0.54), and fair agreement on echogenicity, homogeneity, border, and hilum of the lymph node, K (95% CI) = 0.33 (0.17-0.38), 0.34 (0.26-0.35), 0.22 (0.21-0.31), and 0.22 (0.11-0.26), respectively. This resulted in the establishment of new EUS diagnostic criteria using shape, long axis > 20 mm and short axis > 10 mm. New criteria were superior to old criteria (area under the curve 0.82 vs 0.52, P < 0.001). CONCLUSION EUS diagnostic criteria for lymphadenopathy based on inter-rater agreement were more accurate than old criteria. This result will be useful for the diagnosis of lymphadenopathy.
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Affiliation(s)
- Yusuke Takasaki
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
| | - Goro Shibukawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Ai Sato
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Yoko Abe
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan
| | - Akane Yamabe
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Noriyuki Arakawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan
| | - Takumi Maki
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Yoshitsugu Yoshida
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Ryo Igarashi
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Shogo Yamamoto
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
| | - Tsunehiko Ikeda
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan
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26
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Chen YF, Mao XW, Zhang YJ, Zhang CY, Yu YF, Qin E, Chen X, Shen JX. Endobronchial Ultrasound Elastography Differentiates Intrathoracic Lymph Nodes: A Meta-Analysis. Ann Thorac Surg 2018; 106:1251-1257. [DOI: 10.1016/j.athoracsur.2018.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/27/2018] [Accepted: 04/02/2018] [Indexed: 12/27/2022]
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Lin CK, Yu KL, Chang LY, Fan HJ, Wen YF, Ho CC. Differentiating malignant and benign lymph nodes using endobronchial ultrasound elastography. J Formos Med Assoc 2018; 118:436-443. [PMID: 30007831 DOI: 10.1016/j.jfma.2018.06.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/19/2018] [Accepted: 06/26/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/PURPOSE Endobronchial ultrasound (EBUS) elastography is a new technique that provides information on tissue compressibility during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The purposes of this study were to evaluate the utility of EBUS elastography in differentiating malignant and benign mediastinal lymph nodes (LNs) and to explore the factors that influence its accuracy. METHODS A retrospective chart review of patients who underwent EBUS-TBNA from October 2016 to July 2017 was performed. EBUS with conventional B-mode features and elastographic patterns were compared with the final pathology results or clinical follow-up. We used the following EBUS elastographic patterns for classification: type 1, predominantly non-blue (green, yellow and red); type 2, part blue, part non-blue; type 3, predominantly blue. The potential impacts of the characteristics of LNs, the underlying lung diseases and obtaining fibrotic components from EBUS-TBNA specimens were evaluated relative to the accuracy of EBUS elastography. RESULTS A total of 206 LNs from 94 patients were retrospectively evaluated. In classifying type 1 as 'benign' and type 3 as 'malignant,' the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy rate were 90.6, 82.6, 71.6, 94.7 and 85.2%, respectively. The EBUS elastographic patterns had higher diagnostic yields and negative predictive values than conventional B-mode features. Logistic regression analysis revealed that central necrosis was a factor that influenced the accuracy of elastography in malignant LNs. The fibrotic component within benign LNs could cause an incorrect elastographic pattern. CONCLUSION EBUS elastography is a valuable tool in discriminating benign and malignant mediastinal LNs.
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Affiliation(s)
- Ching-Kai Lin
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, HsinChu, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Lun Yu
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, HsinChu, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Lih-Yu Chang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, HsinChu, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Jen Fan
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, HsinChu, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Chutung Branch, Chutung, Taiwan
| | - Yueh-Feng Wen
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, HsinChu, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Chi Ho
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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28
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Marchand C, Medford AR. Relationship between endobronchial ultrasound-guided (EBUS)-transbronchial needle aspiration utility and computed tomography staging, node size at EBUS, and positron emission tomography scan node standard uptake values: A retrospective analysis. Thorac Cancer 2017; 8:285-290. [PMID: 28436173 PMCID: PMC5494455 DOI: 10.1111/1759-7714.12438] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) diagnoses and stages mediastinal lymph node pathology. This retrospective study determined the relationship between EBUS-TBNA utility and non-small cell lung cancer (NSCLC) stage, lymph node size, and positron emission tomography (PET) standard uptake values (SUV), and the utility of neck ultrasound in bulky mediastinal disease. METHODS Data of 284 consecutive patients who had undergone EBUS-TBNA was collected. Two hundred patients had suspected NSCLC, with 148 confirmed NSCLC cases. The diagnostic utility of EBUS-TBNA was determined according to NSCLC stage, EBUS lymph node size, PET SUV, use in distal metastases, and mutation testing. The utility of neck ultrasound for N3 disease was calculated in patients with bulky mediastinal disease. RESULTS EBUS-TBNA was well tolerated with 97% sensitivity in distant metastatic disease, avoiding the need for distal metastases biopsy in 81% of cases. It had equivalent diagnostic accuracy in all NSCLC stages and in lymph nodes <10 mm, <20 mm or >20 mm (sensitivity >92% in all cases), with no mutation testing failures. EBUS-TBNA had 33% sensitivity in PET indolent (SUV < 4) nodes and 79% sensitivity in PET active nodes (SUV > 4). EBUS-TBNA diagnosed 12 cases of lymphoma without flow cytometry. CONCLUSIONS The use of EBUS-TBNA meant that distant metastatic biopsy was avoided in 81% of cases, performing well irrespective of cancer stage, node size, and facilitating mutation testing. Neck ultrasound failed to detect N3 disease in patients with bulky mediastinal disease. EBUS-TBNA had a sensitivity of 33% for metastases in PET negative nodes, highlighting PET limitations.
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Affiliation(s)
- Clare Marchand
- North Bristol Lung CentreNorth Bristol NHS Trust, Southmead HospitalBristolUK
| | - Andrew R.L. Medford
- North Bristol Lung CentreNorth Bristol NHS Trust, Southmead HospitalBristolUK
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29
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Korrungruang P, Boonsarngsuk V. Diagnostic value of endobronchial ultrasound elastography for the differentiation of benign and malignant intrathoracic lymph nodes. Respirology 2017; 22:972-977. [PMID: 28102963 DOI: 10.1111/resp.12979] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/25/2016] [Accepted: 10/27/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Endobronchial ultrasound (EBUS) findings can be used for benign/malignant differentiation of lymph nodes (LNs). Recently, EBUS elastography has been introduced as a complementary modality in the evaluation of intrathoracic lymphadenopathy. We evaluated the ability of EBUS elastography to differentiate between benign and malignant LNs. METHODS A prospective study was conducted on patients sent for evaluation of intrathoracic lymphadenopathy. LNs were classified qualitatively according to elastographic colour pattern: type 1, predominantly non-blue; type 2, partly blue, partly non-blue and type 3, predominantly blue. Quantitative elastography of LNs was measured by the strain ratio (SR). Qualitative and quantitative elastographies were compared for the final diagnosis of LNs. RESULTS There were 120 LNs from 72 patients who underwent EBUS elastography. The final diagnosis included 96 malignant and 24 benign LNs. All of the 16 type 1 LNs proved to be benign diseases, while 95 of the 101 type 3 LNs were finally diagnosed as malignancies. Three LNs classified as type 2 proved to be two benign and one malignant. Malignant LNs presented a higher median SR than benign LNs (73.50 vs 1.29, P = 0.001). An SR of >2.5 and non-type 1 elastographic pattern achieved similar diagnostic performance in benign/malignant differentiation (sensitivity, 100% vs 100%; specificity, 70.8% vs 66.7%; positive predictive value, 93.2% vs 92.3%; negative predictive value, 100% vs 100%). CONCLUSION EBUS elastography is a promising diagnostic modality for the differentiation of benign and malignant LNs during EBUS-guided transbronchial needle aspiration (TBNA). Qualitative and quantitative EBUS elastographies provide similar diagnostic performance.
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Affiliation(s)
- Potjanee Korrungruang
- Division of Pulmonary Medicine, Department of Medicine, Rajavithi Hospital, Rangsit University, Bangkok, Thailand
| | - Viboon Boonsarngsuk
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Nasir BS, Yasufuku K, Liberman M. When Should Negative Endobronchial Ultrasonography Findings be Confirmed by a More Invasive Procedure? Ann Surg Oncol 2017; 25:68-75. [PMID: 28074327 DOI: 10.1245/s10434-016-5674-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Indexed: 12/25/2022]
Abstract
The treatment of non-small cell lung cancer is largely dependent on accurate staging in order to determine appropriate therapy. Despite advances in imaging, such as computed tomography and positron emission tomography, invasive mediastinal staging is frequently needed to rule out mediastinal involvement prior to curative-intent stereotactic ablative radiotherapy or surgical resection. Surgical mediastinal staging with mediastinoscopy, or anterior mediastinotomy, were traditionally considered the gold standard for invasive mediastinal staging. Endobronchial and endoscopic ultrasound have emerged as modern techniques that are being used as first-line options instead of surgical staging. As experience is gained with these newer techniques, the need for confirmatory surgical staging continues to diminish. This article addresses the situations in which negative results should be confirmed by a more invasive procedure.
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Affiliation(s)
- Basil S Nasir
- Division of Thoracic Surgery, Vancouver General Hospital, Vancouver, BC, Canada.
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Moishe Liberman
- Department of Thoracic Surgery, University of Montreal, Montreal, QC, Canada
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Invited Commentary. Ann Thorac Surg 2015; 100:1209-10. [PMID: 26434429 DOI: 10.1016/j.athoracsur.2015.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 05/01/2015] [Accepted: 05/04/2015] [Indexed: 11/24/2022]
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