Core needle biopsy with endobronchial ultrasonography: single center experience with 100 cases

Endobronchial Ultrasound-guided Mediastinal Lymph Nodal Cryobiopsy in Patients With Nondiagnostic/Inadequate Rapid On-site Evaluation: A New Step in the Diagnostic Algorithm

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered the investigation of choice for sampling mediastinal nodes. A major drawback of EBUS-TBNA is its lower diagnostic yield for lymphoma and benign diseases. EBUS-guided mediastinal cryobiopsy (EBUS-MCB) is a novel technique that provides larger nodal biopsy samples, with an acceptable safety profile. In this study, we aimed to evaluate the diagnostic yield of EBUS-MCB in patients with an inconclusive rapid on-site evaluation (ROSE).

METHODS

This is a prospective study of patients who underwent EBUS-TBNA for undiagnosed mediastinal lymphadenopathy. Patients in whom ROSE did not yield a diagnosis (nondiagnostic ROSE) or ROSE revealed scanty atypical cells (inadequate ROSE) were subjected to EBUS-MCB. The diagnostic yield, adequacy, and complications of EBUS-MCB were analyzed.

RESULTS

Of the 196 patients undergoing EBUS-TBNA, 46 patients underwent EBUS-MCB. Thirty-two cases underwent EBUS-MCB for a nondiagnostic ROSE. EBUS-MCB confirmed the diagnosis in 19/32 (59.3%) cases. The additive diagnostic yield of EBUS-MCB over EBUS-TBNA was 43.7% (14/32 cases). In all 14 cases where EBUS-MCB was performed for an inadequate ROSE, the material obtained by EBUS-MCB was adequate for ancillary studies. The most common complication observed was a minor bleed in 13 cases.

CONCLUSION

EBUS-MCB has a diagnostic yield of 59.3% when performed in cases with a nondiagnostic EBUS-ROSE. The tissue obtained by EBUS-MCB is adequate for ancillary studies. We propose EBUS-MCB as an additional diagnostic step in cases with an inconclusive ROSE while performing EBUS-TBNA. Larger studies are, however, needed before EBUS-MCB can be incorporated in the diagnostic algorithm for the evaluation of mediastinal lesions.

Endobronchial ultrasound in diagnosing and staging of lung cancer by Acquire 22G TBNB versus regular 22G TBNA needles: A randomized clinical trial

OBJECTIVES

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has an important role in the diagnosis and staging of lung cancer. Evaluation of programmed death ligand 1 (PD-L1) expression and molecular profiling has become standard of care but cytological samples frequently contain insufficient tumor cells. The 22G Acquire needle with Franseen needle tip was developed to perform transbronchial needle biopsy (TBNB) with improved tissue specimens. This study evaluated if the 22G Acquire TBNB needle results in enhanced PD-L1 suitability rate compared to the regular Expect 22G TBNA needle.

METHODS

in this multi-center randomized clinical trial (Netherlands Trial Register NL7701), patients with suspected (N)SCLC and an indication for mediastinal/hilar staging or lung tumor diagnosis were recruited in five university and general hospitals in the Netherlands, Poland, Italy and Czech Republic. Patients were randomized (1:1) between the two needles. Two blinded reference pathologists evaluated the samples. The primary outcome was PD-L1 suitability rate in patients with a final diagnosis of lung cancer. In case no malignancy was diagnosed, the reference standard was surgical verification or 6 month follow-up.

RESULTS

154 patients were randomized (n = 76 Acquire TBNB; n = 78 Expect TBNA) of which 92.9% (n = 143) had a final malignant diagnosis. Suitability for PD-L1 analysis was 80.0% (n = 56/70; 95 %CI 0.68-0.94) with the Acquire needle and 76.7% (n = 56/73; 95 %CI 0.65-0.85) with the Expect needle (p = 0.633). Acquire TBNB needle specimens provided more frequent superior quality (65.3% (95 %CI 0.57-0.73) vs 49.4% (95 %CI 0.41-0.57, p = 0.005) and contained more tissue cores (72.0% (95 %CI 0.60-0.81) vs 41.0% (95 %CI 0.31-0.54, p < 0.01). There were no statistically significant differences in tissue adequacy, suitability for molecular analysis and sensitivity for malignancy and N2/N3 disease.

CONCLUSION

The 22G Acquire TBNB needle procured improved quality tissue specimens compared to the Expect TBNA needle but this did not result in an improved the suitability rate for PD-L1 analysis.

Clinical Applications of Endobronchial Ultrasound (EBUS) Scope: Challenges and Opportunities

Endobronchial Ultrasound (EBUS) has been widely used to stage lung tumors and to diagnose mediastinal diseases. In the last decade, this procedure has evolved in several technical aspects, with new tools available to optimize tissue sampling and to increase its diagnostic yield, like elastography, different types of needles and, most recently, miniforceps and cryobiopsy. Accordingly, the indications for the use of the EBUS scope into the airways to perform the Endobronchial Ultrasound-TransBronchial Needle Aspiration (EBUS-TBNA) has also extended beyond the endobronchial and thoracic boundaries to sample lesions from the liver, left adrenal gland and retroperitoneal lymph nodes via the gastroesophageal tract, performing the Endoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In this review, we summarize and critically discuss the main indication for the use of the EBUS scope, even the more uncommon, to underline its utility and versatility in clinical practice.

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.

Endobronchial ultrasound bronchoscopy Franseen fine needle biopsy tool versus standard fine needle aspiration needle: Impact on diagnosis and tissue adequacy

BACKGROUND

The Franseen fine needle biopsy tool (Acquire®, Boston Scientific, Boston, MA) may provide better quality specimens than current endobronchial ultrasound-transbronchial needle aspiration (EBUS-TNBA) needles. We performed a comparative retrospective study evaluating the diagnostic yield of the Franseen fine needle biopsy (FNB) versus standard fine needle aspiration (FNA) for benign lymphadenopathy and tissue acquisition for next generation sequencing (NGS) in non-small cell carcinoma (NSCLC).

METHODS

All EBUS-TBNA procedures performed between January 1st, 2019 to January 1st^, 2020 where both the FNB needle and the FNA needle were used were analyzed. All demographic, procedural, and diagnostic data were recorded. The median tumor surface area, tumor cellularity and adequacy for NGS was evaluated for NSCLC specimens.

RESULTS

A total of 69 target lesions in 66 patients were biopsied with both the FNB and FNA needles. The mean (SD) size of target biopsied was 1.8 cm (0.8); The most common stations were 7 (54%) and 4R (26%). The mean (SD) needle passes were 6 (2.2) and 4 (1.8) with FNA and FNB needles, respectively (p < 0.0001). Benign lymphadenopathy was diagnosed with FNA needle in 46% and in 82% with FNB (p < 0.0001). NGS tissue adequacy was 47% with FNA needle versus 76% with FNB (p = 0.02). Median tumor surface area and tumor cellularity were greater with FNB needle than FNA needle (80 mm² versus 9 mm², p = 0.002, and 81% versus 45%, p = 0.0004).

CONCLUSION

The FNB needle demonstrated higher diagnostic yield in benign lymphadenopathy and higher quality for NGS than standard FNA needle.

Comparison of a 22G Crown-Cut Needle with a Conventional 22G Needle with EBUS Guidance in Diagnosis of Sarcoidosis

INTRODUCTION

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a standard procedure in cases of enlarged mediastinal lymph nodes. Recently, new tools were developed aiming to improve the diagnostic yield. A novel crown-cut needle is considered to obtain tissue cores which can be beneficial for the evaluation by the pathologist. This study aimed to compare the novel 22G crown-cut needle with a conventional 22G needle with EBUS guidance in the diagnosis of sarcoidosis.

METHODS

We designed a single-center prospective randomized clinical trial between March 2020 and January 2021 with 30 patients with mediastinal lymphadenopathy and suspected sarcoidosis.

RESULTS

24 patients (mean age 49.5 vs 54.1, mean FVC 73.7% vs 86.7%, mean DLCO 72.4% vs 72.5% for crown-cut needle vs conventional needle, respectively) were diagnosed with sarcoidosis. In the remaining six patients, sarcoidosis was reasonably excluded. The diagnostic yield for sarcoidosis was 77% with the crown-cut needle vs. 82% with the conventional needle (p > 0.05). In patients with histopathologic hallmarks typical of sarcoidosis (n = 19), the crown-cut needle was superior in detecting granulomas (8.3 vs 3.8 per cytoblock, p < 0.05) and histiocytes (502 vs 186 per cytoblock, p < 0.05). Four of seven bronchoscopists experienced difficulties passing through the bronchial wall with the crown-cut needle and one episode of bleeding occurred in this group which made interventions necessary.

CONCLUSIONS

Despite equivalence in diagnostic accuracy, the crown-cut needle was superior to the conventional needle in detecting granulomas and histiocytes. This indicates greater potential for obtaining higher quality sample material with the crown-cut needle in cases of granulomatous inflammation.

Airway stenosis complicated by endobronchial ultrasound-guided tissue acquisition: A case report

Endobronchial ultrasound (EBUS)‐guided tissue acquisition (TA) performed by transbronchial needle aspiration (TBNA) is the main diagnostic procedure in mediastinal and hilar lymph node (LN) biopsy. EBUS‐guided intranodal forceps biopsy (EBUS‐IFB) and EBUS‐guided cryobiopsy can achieve higher diagnostic yield of lymphomas, uncommon tumors, and benign diseases. However, these techniques require the creation of a tract to insert biopsy devices, which may result in critical complications. Here, we report a rare case of airway stenosis (AS) that occurred after EBUS‐TA for mediastinal LN biopsy. An 80‐year‐old man had multiple pulmonary nodules and an enlarged mediastinal LN. EBUS‐TBNA and EBUS‐IFB were performed for histological diagnosis. Cutaneous adnexal carcinoma (CAC) was diagnosed. The patient underwent chemotherapy. Four months later, he was hospitalized for AS due to a tracheal tumor with dyspnea. Chest computed tomography and bronchoscopy revealed that the tracheal tumor was caused by invasion from the biopsied LN into the tracheal lumen by tract seeding (TS) caused by EBUS‐TA. Cryotherapy was performed. The tracheal tumor was pathologically consistent with CAC and is currently under control with radiotherapy. TS‐associated EBUS‐TA is rare but may increase in frequency with aggressive tissue sampling techniques. Bronchoscopists should perform EBUS‐TA with awareness of the potentially serious complications.

Role of EBUS-TBNA in Non-Neoplastic Mediastinal Lymphadenopathy: Review of Literature

Mediastinal lymphadenopathy is a condition in which one or more mediastinal lymph nodes are enlarged for malignant or benign causes, generally more than 10 mm. For a long time, the only way to approach the mediastinum was surgery, while in last decades endoscopic techniques gained their role in neoplastic diseases. At the present time, EBUS is the technique of choice for studying the mediastinum in the suspicion of cancer, while there are not strong indications in guidelines for the study of benign mediastinal lymphadenopathy. We reviewed the literature, looking for evidence of the role of EBUS in the diagnostics of non-neoplastic mediastinal lymphadenopathy, with special regard for granulomatous disease, both infectious and non-infectious. EBUS is a reliable alternative to surgery in non-neoplastic mediastinal lymphadenopathy, even if more evidence is needed for granulomatous diseases other than tuberculosis and sarcoidosis.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): Technical Updates and Pathological Yield

Since the endobronchial ultrasound bronchoscope was introduced to clinical practice, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become the procedure of choice to sample hilar and mediastinal adenopathy. Multiple studies have been conducted in the last two decades to look at the different technical aspects of the procedure and their effects on the final cytopathological yield. In addition, newer modes of ultrasound scanning and newer tools with the potential to optimize the selection and sampling of the target lymph node have been introduced. These have the potential to reduce the number of passes, reduce the procedure time, and increase the diagnostic yield, especially in rare tumors and benign diseases. Herein, we review the latest updates related to the technical aspects of EBUS-TBNA and their effects on the final cytopathological yield in malignant and benign diseases.