Esophageal ultrasound (EUS) assessment of T4 status in NSCLC patients

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.

Endobronchial ultrasound for T4 staging in patients with resectable NSCLC

BACKGROUND

In lung cancer patients, accurate assessment of mediastinal and vascular tumor invasion (stage T4) is crucial for optimal treatment allocation and to prevent unnecessary thoracotomies. We assessed the diagnostic accuracy of linear endobronchial ultrasound (EBUS) for T4-status in patients with centrally located lung cancer.

METHODS

This is a retrospective study among consecutive patients who underwent EBUS for diagnosis and staging of lung cancer in four hospitals in The Netherlands (Amsterdam, Leiden), Italy (Bologna) and Poland (Zakopane) between 04-2012 and 04-2019. Patients were included if the primary tumor was detected by EBUS and subsequent surgical-pathological staging was performed, which served as the reference standard. T4-status was extracted from EBUS and pathology reports. Chest CT's were re-reviewed for T4-status.

RESULTS

104 patients with lung cancer in whom EBUS detected the primary tumour, and who underwent subsequent surgical-pathological staging were included. 36 patients (35 %) had T4-status, based on vascular (n = 17), mediastinal (n = 15), both vascular and mediastinal (n = 3), or oesophageal invasion (n = 1). For EBUS, sensitivity, specificity, PPV and NPV for T4-status were (n = 104): 63.9 % (95 %CI 46.2-79.2 %), 92.6 % (83.7-97.6 %), 82.1 % (65.6-91.7 %), and 82.9 % (75.7-88.2 %), respectively. For chest CT (n = 72): 61.5 % (95 %CI 40.6-79.8 %), 37.0 % (23.2-52.5 %), 35.6 % (27.5-44.6 %), and 63.0 % (47.9-75.9 %), respectively. When combining CT and EBUS with concordant T4 status (n = 33): 90.9 % (95 %CI 58.7-99.8 %), 77.3 % (54.6-92.20 %), 66.7 % (47.5-81.6 %), and 94.4 % (721-99.1%), respectively.

CONCLUSION

Both EBUS and CT alone are inaccurate for assessing T4-status as standalone test. However, combining a negative EBUS with a negative CT may rule out T4-status with high certainty.

A promising tool for T-staging of lung cancer: Is convex probe endobronchial ultrasound superior to computed tomography in detecting invasion of mediastinal and hilar vessels?

Background

In the present study, we aimed to compare performance of convex probe endobronchial ultrasound and computed tomography in detecting vascular invasion of mediastinal and hilar lesions.

Methods

Medical data of a total of 55 patients (47 males, 8 females; mean age 59.6±7.7 years; range, 29 to 76 years) who underwent convex probe endobronchial ultrasound for diagnosis and staging of lung cancer in a tertiary care hospital between May 2016 and December 2017 were retrospectively analyzed. The presence of vascular invasion was determined according to two main criteria: visualization of the tumor tissue within the vessel lumen and loss of vessel-tumor hyperechoic interface. All available contrast enhanced computed tomography images were retrospectively re-evaluated by a blinded radiologist. The intra-rater agreement between convex probe endobronchial ultrasound and computed tomography was analyzed. The sensitivity, specificity, positive and negative predictive values, and accuracy of both modalities were calculated.

Results

A total of 65 vessel-tumor interface areas of 55 patients were analyzed. Almost all mediastinal and hilar vascular structures including pulmonary arteries and veins, aorta, superior vena cava and its branches, and left atrium with pulmonary veno-atrial junctions could be easily assessed by convex probe endobronchial ultrasound. The intra-agreement of both modalities in detecting vascular invasion was k=0.268 (p=0.028). In nine patients with a surgical confirmation, the sensitivity, specificity, positive and negative predictive values, and accuracy values were 100%, 33.3%, 75.0%, 100%, and 77.7%, respectively for convex probe endobronchial ultrasound and 66.6%, 33.3%, 66.6%, 33.3%, and 55.5%, respectively for computed tomography.

Conclusion

Convex probe endobronchial ultrasound can be used to detect vascular invasion alone or in conjunction with contrast-enhanced computed tomography. Hence, a T₄ lesion would be better differentiated from T₃ in clinical staging of lung cancer.

Endoscopic Ultrasound with Bronchoscope-Guided Fine Needle Aspiration for the Diagnosis of Paraesophageally Located Lung Lesions

BACKGROUND

Diagnosing centrally located lung tumors without endobronchial abnormalities and not located near the major airways is a diagnostic challenge. Tumors near or adjacent to the esophagus can be aspirated and detected with esophageal ultrasound (EUS) using gastrointestinal endoscopes.

OBJECTIVE

To assess the feasibility and diagnostic yield of endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA) in paraesophageally located lung tumors and its added value to bronchoscopy and endobronchial ultrasound (EBUS).

METHODS

Retrospective, multicenter international study (from January 1, 2015 until January 1, 2018) of patients with suspected lung cancer, undergoing bronchoscopy, EBUS, and endoscopic ultrasound bronchoscopy (EUS-B) in one session by a single operator (pulmonologist), in whom the primary lung tumor was detected and aspirated by EUS-B. In the absence of malignancy following endoscopy, transthoracic ultrasound needle aspiration, clinical and radiological follow-up of at least 6 months was performed. The yield and sensitivity of EUS-B-FNA and its added value to bronchoscopy and EBUS was assessed.

RESULTS

58 patients were identified with the following diagnosis: non-small-cell lung cancer (n = 43), small-cell lung cancer (n = 6), mesothelioma (n = 2), metastasis (n = 1), nonmalignant (n = 6). The yield and sensitivity of EUS-B-FNA for detecting lung cancer was 90%. In 26 patients (45%), the intrapulmonary tumor was exclusively detected by EUS-B. Adding EUS-B to conventional bronchoscopy and EBUS increased the diagnostic yield for diagnosing lung cancer in para-esophageally located lung tumors from 51 to 91%. No EUS-B-related complications were observed.

CONCLUSION

EUS-B-FNA is a feasible and safe technique for diagnosing centrally located intrapulmonary tumors that are located near or adjacent to the esophagus. EUS-B should be considered in the same endoscopy session following nondiagnostic bronchoscopy and EBUS.