Endobronchial and Endoscopic Ultrasound-Guided Transvascular Biopsy of Mediastinal, Hilar, and Lung Lesions

Endobronchial Ultrasound Access to Pulmonary Vasculature in Thoracic Malignancy

Endobronchial ultrasound (EBUS) has evolved beyond conventional applications in mediastinal staging and central pulmonary tumor diagnosis. It encompasses the assessment of pulmonary vasculature in patients with thoracic malignancies. EBUS can visualize major vessels and allow assessment of pulmonary embolism, differential diagnosis of endovascular lesions, and T staging. Additionally, EBUS-guided transvascular needle aspiration (TVNA) has proven valuable for sampling lesions behind vessels and diagnosing conditions such as pulmonary artery sarcoma and tumor embolism, with low complication rates reported. The PubMed and SCOPUS databases were searched up to November 2024 for articles in the English language reporting the use of EBUS for pulmonary vasculature assessment. References were also searched for relevant articles. The integration of EBUS with other modalities enhances staging and diagnostic capabilities in thoracic malignancies. Despite promising findings, limitations include suboptimal image quality and challenges in extensively assessing all the vasculature. Safety concerns, particularly with transvascular biopsy, remain minimal with expert handling, although further studies are needed to assess specific risks like hematogenous tumor seeding. EBUS continues to evolve, suggesting its potential to become the cornerstone in advanced thoracic diagnostics and treatment planning. This review systematically explores the feasibility, safety, and diagnostic utility of EBUS in pulmonary vasculature assessment, highlighting its potential as an indispensable tool in thoracic diagnostics and treatment planning.

Assessment of effectiveness and safety of thrombolytic therapy to pulmonary emboli by endobronchial ultrasound-guided transbronchial needle injection

Objective

Endobronchial ultrasound-guided transbronchial needle injection (EBUS-TBNI) may effectively treat acute pulmonary embolisms (PEs). Here, we assessed the effectiveness of clot dissolution and safety of tissue plasminogen activator (t-PA) injection using EBUS-TBNI in a 1-week survival study of a porcine PE model.

Methods

Six pigs with bilateral PEs were used: 3 for t-PA injection using EBUS-TBNI (TBNI group) and 3 for systemic administration of t-PA (systemic group). Once bilateral PEs were created, each 25 mg of t-PA injection using EBUS-TBNI for bilateral PEs (a total of 50 mg t-PA) and 100 mg of t-PA systemic administration was performed on day 1. Hemodynamic parameters, blood tests, and contrast-enhanced computed tomography scans were carried out at several time points. On day 7, pigs were humanely killed to evaluate the residual clot volume in the pulmonary arteries.

Results

The average of percent change of residual clot volumes was significantly lower in the TBNI group than in the systemic group (%: systemic group 36.6 ± 22.6 vs TBNI group 9.6 ± 6.1, P < .01) on day 3. Considering the elapsed time, the average decrease of clot volume per hour at pre-t-PA to post t-PA was significantly greater in the TBNI group than in the systemic group (mm3/hour: systemic 68.1 ± 68.1 vs TBNI 256.8 ± 148.1, P < .05). No hemorrhage was observed intracranially, intrathoracically, or intraperitoneally on any contrast-enhanced computed tomography images.

Conclusions

This study revealed that t-PA injection using EBUS-TBNI is an effective and safe way to dissolve clots.

Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations

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.

Efficacy and safety of endosonography-guided transvascular needle aspiration of thoracic and abdominal lesions: A systematic review and meta-analysis

BACKGROUND

The diagnosis of intrathoracic and abdominal masses is challenging when lesions are located behind major vessels. Endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS)-guided transvascular needle aspiration (TVNA) provides a potentially useful diagnostic tool for such lesions. Data with respect to the safety and outcome of E-TVNA are scarce. Hence, this meta-analysis was conducted to assess the critical role of E-TVNA for diagnosis of various lesions.

METHODS AND MATERIAL

A meta-analysis was performed by pooling the data from studies obtained from comprehensive search of Medline, Embase, and Scopus from January 2000 to September 2022. The outcomes analyzed included sample adequacy, diagnostic accuracy and adverse events including bleeding.

RESULTS

A total of 17 studies (n = 411) were included in the final analysis. The pooled rate of sample adequacy was 91.5% [95% confidence interval (CI): 86.8-96.2], while the pooled rate of diagnostic accuracy was 85.0% (95% CI: 78.9-91.2). The pooled rate of bleeding with E-TVNA was 1.4% (95% CI 0.0-3.1%). All the episodes of bleeding were mild and resolved without any further intervention. There was no significant heterogeneity with respect to various outcomes and results were comparable on sensitivity analysis.

CONCLUSIONS

E-TVNA offers a safe and accurate diagnostic modality for the diagnosis of mediastinal and abdominal lesions located on the other side of major vessels. Selection of potential candidates and close periprocedural observation are essential to improve the outcome.

Efficacy and safety of endosonography‐guided transvascular needle aspiration of thoracic and abdominal lesions: A systematic review and meta‐analysis

Background

The diagnosis of intrathoracic and abdominal masses is challenging when lesions are located behind major vessels. Endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS)‐guided transvascular needle aspiration (TVNA) provides a potentially useful diagnostic tool for such lesions. Data with respect to the safety and outcome of E‐TVNA are scarce. Hence, this meta‐analysis was conducted to assess the critical role of E‐TVNA for diagnosis of various lesions.

Methods and Material

A meta‐analysis was performed by pooling the data from studies obtained from comprehensive search of Medline, Embase, and Scopus from January 2000 to September 2022. The outcomes analyzed included sample adequacy, diagnostic accuracy and adverse events including bleeding.

Results

A total of 17 studies (n = 411) were included in the final analysis. The pooled rate of sample adequacy was 91.5% [95% confidence interval (CI): 86.8–96.2], while the pooled rate of diagnostic accuracy was 85.0% (95% CI: 78.9–91.2). The pooled rate of bleeding with E‐TVNA was 1.4% (95% CI 0.0–3.1%). All the episodes of bleeding were mild and resolved without any further intervention. There was no significant heterogeneity with respect to various outcomes and results were comparable on sensitivity analysis.

Conclusions

E‐TVNA offers a safe and accurate diagnostic modality for the diagnosis of mediastinal and abdominal lesions located on the other side of major vessels. Selection of potential candidates and close periprocedural observation are essential to improve the outcome.

Interventional Pulmonology and Esophagus: Combined Endobronchial Ultrasound and Endoscopic Ultrasound for Mediastinal Staging

Endoscopic ultrasound (EUS) techniques in addition to endobronchial ultrasound (EBUS) can lead to diagnosis and complete accurate staging of the mediastinum in a single session. This allows for decreased health care costs, less delay in diagnosis and treatment, reduced patient discomfort, and decreased morbidity compared with invasive surgical staging techniques. In comparison to conventional mediastinoscopy, the cost-effectiveness and reduced complication profile of the endoscopic approach has made this a superior initial step in the staging and diagnosis of lung cancer. Moreover, compared with EBUS alone, combined EUS and EBUS has significantly increased yield, as well as diagnostic sensitivity making a combined approach preferable as the emerging gold-standard technique for initial minimally invasive mediastinal staging. We discuss the advantage of using EUS in combination with EBUS and highlight techniques, lymph node landmarks, utility in staging and restaging of the mediastinum, roles in diagnosing mediastinal infections and granulomatous lesions, and future directions in endosonography.

Endoscopic ultrasound-guided transvascular needle biopsy of thoracic and abdominal lesions: a multicenter experience

Background and study aims  Traditionally in the case of a vascular interposition, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been contraindicated. A transvascular route (TV) is feasible and probably a safe alternative approach in selected patients, but data are scarce. The primary aim of this study was to analyze the diagnostic yield and safety of EUS-TV-FNA in thoracic and abdominal lesions. Secondary aims included evaluation of the clinical impact and technical aspects. Patients and methods  A retrospective multicenter study was conducted with inclusion of all consecutive patients that underwent EUS-TV-FNA from July 2007 to January 2020. Feasibility, cytopathology, procedure details, and safety were evaluated. Univariate analysis was performed to identify variables associated with incidents, cytopathological diagnosis, and clinical impact. Results  Data were collected from a total of 49 cases and 50 EUS-TV-FNAs. The aorta (n = 19) and portal system (n = 17) were the most frequently punctured. The most frequent lesions were mediastinal lymph nodes (n = 13) and pancreatic tumors (n = 11). The diagnostic yield was 86 %, and there were nondiagnostic samples in seven cases. Overall sensitivity, specificity, and accuracy were 88 % (95 %CI,0.74-0.96), 100 % (95 %CI,0.59-1), and 90 % (95 %CI,0.78-0.96), respectively. Only three incidents were detected: two mural hematomas and a self-limited bleeding of gastroduodenal artery. In most patients, there was a significant impact on clinical management (88 %). Arterial vessel and ASA-III had a trend with incidents (both, P  < 0.08). Rapid on-site evlauation was found to be an independent predictor for obtaining a conclusive sample (OR 6.2; 95 %CI, 1.06-36.73, P  < 0.04). Conclusions  EUS-TV-FNA is feasible, seems to be safe, and can be recommended when no other targets are available, and the information obtained would impact on the clinical plan.

Intimal angiosarcoma of the thoracic aorta diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration: a case report

Background

Primary malignant tumors of the aorta are extremely rare. They are frequently located in the abdominal aorta, followed by the thoracic aorta. Sarcomas are the most common histological type. These tumors originate from the middle or intimal layer, the latter being the most common. Symptoms and radiological findings are generally nonspecific. Since their growth is endovascular, embolic phenomena can occur leading to occlusive signs and symptoms.

Case presentation

We describe the case of a 75-year-old Hispanic man, a former tobacco smoker, with a history of pain and epigastric tenderness, dysphagia, and weight loss of approximately 6 kg. A thorax computed tomography scan showed a mass within the posterior mediastinum with poorly defined borders and heterogeneous density, located between thoracic vertebra 5–8, with a size of 78 × 53 × 76 mm, with left main bronchus compression. Endobronchial ultrasound-guided transbronchial needle aspiration was performed; it found an extrinsic posterior compression of the left main bronchus with no endobronchial injury. An intimal angiosarcoma of the thoracic aorta was diagnosed.

Conclusion

Tumors of the aorta are rare and difficult to diagnose; they are a challenge during the diagnosis, since they usually require open surgical procedures. Endobronchial ultrasound-guided transbronchial needle aspiration associated with rapid on-site examination offered, in this case, the possibility of a successful diagnosis, avoiding major procedures. This is the first case reported in the literature of an intimal angiosarcoma of the thoracic aorta diagnosed using endobronchial ultrasound-guided transbronchial needle aspiration.

Thrombolysis of Pulmonary Emboli via Endobronchial Ultrasound-Guided Transbronchial Needle Injection

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle injection (EBUS-TBNI) is a novel technique for treating peribronchial targets. The aim of this study was to evaluate preliminary feasibility of thrombolysis of pulmonary emboli via EBUS-TBNI.

METHODS

Yorkshire pigs (30-48 kg) were anesthetized and mechanically ventilated. Pre-formed autologous clots were injected sequentially into bilateral lower pulmonary arteries in bilateral models (PE1 and PE2, respectively) or into 1 side in unilateral models using a 21-gauge EBUS-TBNA needle under EBUS guidance. In the bilateral model, 2 hours after clot injection either 25 mL of tissue-plasminogen activator (t-PA; 1mg/mL) or distilled water were administered into each embolus via 25-gauge EBUS-TBNA needle. In the unilateral model, 25 mg t-PA was administered intravenously. Hemodynamic parameters were monitored continuously, and clot dissolved volume was evaluated by EBUS 30 minutes post-treatment administration.

RESULTS

All clots (6.1 ± 1.7 mL) were successfully injected as documented by EBUS Doppler imaging. Clot injection in the bilateral model (n = 6) increased pulmonary arterial pressure (mm Hg: Baseline 19.2 ± 5.9 vs PE1: 26.7 ± 9.1, P = .005 vs PE2 29.9 ± 7.1, P = .0007). After t-PA TBNI in the bilateral model (n = 6), pulmonary arterial pressure at 30 minutes post-injection showed improvement (mm Hg: PE2 29.9 ± 7.1 vs post-t-PA 24.4 ± 3.9, P = .0283). Treatment with t-PA TBNI demonstrated superior clot dissolution at 30 minutes post-treatment (dissolved mm³: t-PA TBNI 625.4 ± 156.6 vs t-PA intravenously: 181.6 ± 94.3, P = .0003 vs distilled water TBNI 42.5 ± 33.0, P < .0001). There were no complications.

CONCLUSIONS

EBUS-guided transbronchial thrombolysis may be a feasible approach for treating central pulmonary emboli.

Endoscopic ultrasonography guided transgastric trans-portal system fine needle aspiration for diagnosing pancreatic head and uncinate process malignancy

Background

Endoscopic ultrasonography guided fine needle aspiration (EUS-FNA) is a well-established technique for diagnosing pancreatic malignancy. In general, tissue of pancreatic head and uncinate process lesions is obtained via a transduodenal approach. However, this tissue-acquisition modality is not applicable in cases of pyloric obstruction and duodenal bulb ulceration. The aim of this study is to determine the feasibility and safety of a novel EUS-guided transgastric trans-portal system FNA in the diagnosis of pancreatic head and uncinate process cancer.

Methods

This study retrospectively analyzed 26 consecutive inpatient patients who had undergone EUS-FNA for highly suspected malignancy of pancreatic head or uncinate process between December 2013 and December 2018. EUS-guided transgastric trans-portal vein (trans-PV, n=2) or trans-superior mesenteric vein (trans-SMV, n=24) FNA was performed in the patients under conscious sedation. Feasibility, diagnostic yield and complication rates of the technique were evaluated.

Results

Specimens obtained by EUS-guided transgastric trans-portal system FNA were adequate for cytological evaluation in all 26 patients. Cytological diagnosis of adenocarcinoma was established in 22 patients, while the remaining 4 patients were negative. The diagnostic accuracy, sensitivity and specificity were 92.3%, 91.7% and 100% respectively. No immediate or delayed procedure-related complications were observed.

Conclusions

EUS-guided transgastric trans-portal system FNA is a feasible and probably safe method for diagnosing pancreatic head and uncinate process malignancy. Careful selection of the potential candidates and close periprocedural observation are mandatory.

Combined Endosonographic Mediastinal Lymph Node Staging in Positron Emission Tomography and Computed Tomography Node-Negative Non-Small-Cell Lung Cancer in High-Risk Patients

Positron emission tomography (PET) with computed tomography (CT) is routinely utilized to investigate lymph node (LN) metastases in non-small-cell lung cancer. However, it is less sensitive in normal-sized LNs. This study was performed in order to define the prevalence of mediastinal LN metastases discovered on combined endosonography by endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration in patients with a radiologically normal mediastinum. This study consists of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database. Patients were identified from a cohort between January 2009 and December 2014. One hundred and sixty-one patients with biopsy-proven, non-small-cell lung cancer were identified in whom both the preendosonography CT and PET-CT were negative for mediastinal LN metastases. Combined endosonography (EBUS + EUS-FNA) was performed in all patients. Z test was used for statistical analysis. A P value of <0.05 was considered statistically significant. A total of 161 consecutive patients were included. Patients were staged if they had central tumor, tumor size >3 cm, N1 lymph node involvement on PET-CT/CT, or if there was low SUV (<2.5) in the primary tumor. A total of 416 lymph nodes were biopsied in the 161 patients using combined endosonography; 147 with EBUS and 269 with EUS. Mean and median number of lymph nodes biopsied per patient using combined EBUS/EUS was 2.5 and 3, respectively (mean and median EBUS: 0.91 and 2.5; mean and median EUS 1.6 and 3). Endosonographic staging upstaged 13% of patients with radiologically normal lymph nodes in the mediastinum, hilum, lobar, and sublobar regions (confidence interval 8.22-19.20). Twenty-one out of 161 patients (13%) with radiologically normal mediastinum were positive on combined EBUS/EUS staging. Out of 21 patients upstaged on endosonography, 15 (71%) had tumor size >3 cm. Six (28%) had occult N1 disease. Thirteen (61%) had occult N2 disease and 2 (9%) had adrenal involvement. None of the upstaged patients had N1 LN involvement on PET-CT or CT scan. Combined endosonographic lymph node staging should be considered in the pretreatment staging of high-risk patients with non-small-cell lung cancer in the presence of radiologically normal mediastinal lymph nodes due to the significant rate of radiologically occult lymph node metastases.

Esophageal ultrasound with ultrasound bronchoscope (EUS-B) guided transvascular needle aspiration (TVNA)

We have described a 67-year-old man, diagnosed to have adenocarcinoma of lung by transvascular approach with esophageal ultrasound using ultrasound bronchoscope (EUS-B). To the best of our knowledge this is the first case where EUS-B has been used for transvascular fine needle aspiration cytology to diagnose lung carcinoma.

Defining expanded areas in EBUS sampling: EBUS guided trans- and intra-pulmonary artery needle aspiration, with review of transvascular EBUS

BACKGROUND

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) has revolutionized the diagnostic approach to mediastinal diseases. Lesions located lateral to the pulmonary artery (trans-PA, Station 5), or in the lumen of the PA (intra-PA) are in the 'blind-spot' of EBUS.

OBJECTIVES

We describe a case series where EBUS guided trans-pulmonary or intra-pulmonary aspiration (EBUS-TIPNA) was used for diagnosis.

METHODS

Retrospective analysis of 10 patients who had EBUS-TIPNA over 3 years in 2 centres. The inclusion criteria included patients with station 5 lesions, or intrapulmonary artery lesions, where no other option was possible.

RESULTS

The study included 4 males and 6 females, mean age 52 years, with 7 trans-PA and 3 intra-PA lesions. Adequacy was seen in 10/10, and a definitive diagnosis was made in 9/10 patients. There were no procedure-related complications.

CONCLUSION

EBUS-TIPNA can be done as a safe and successful procedure and adds to the armamentarium of Convex Probe-EBUS (CP-EBUS), in carefully selected patients.