Sensitivity of linear endobronchial ultrasonography and guided transbronchial needle aspiration for the identification of nodal metastasis in lung cancer staging

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.

Functions of Heparin Sodium Injection in the Prevention of Peripherally Inserted Central Catheter-Related Venous Thrombosis in NSCLC Patients during Postoperative Chemotherapy

Objective

This study intended to analyze hazardous factors of venous thrombosis by comparing the effect of different doses of heparin sodium injection on the incidence rate of peripherally inserted central catheter (PICC)-related venous thrombosis in non-small cell lung carcinoma (NSCLC) patients during postoperative chemotherapy.

Methods

425 NSCLC patients who received PICC catheterization in Cancer Hospital Chinese Academy of Medical Sciences, Shenzhen Hospital from July 2019 to July 2021 were collected. Based on their different pathological types, patients were given two different chemotherapy regimens: pemetrexed+cisplatin or paclitaxel+cisplatin. Patients were grouped according to the different doses of heparin sodium injection adopted. Control group (n = 140). Catheters were sealed with 10 mL saline only. Group I (n = 142). In addition to routine maintenance with normal saline, 2 mL of 10 IU/mL heparin sodium injection was sealed in the catheters under positive pressure every time after catheterization. Group II (n = 143). In addition to routine maintenance with normal saline, 5 mL of 10 IU/mL heparin sodium injection was sealed in the same manner as Group I. The baseline characteristics of the three groups of patients were compared by statistical means. Doppler ultrasonography was applied to check the venous thrombosis. The hazardous factors of venous thrombosis were analyzed through correlation analysis and binary logistic regression method.

Results

The incidence rates of thrombosis in the control group, Group I, and Group II were 20.00%, 7.04%, and 2.09%, respectively, with statistically significant differences (P < 0.01). Additionally, through the collinear correlation analysis of baseline characteristics, a significant correlation between the dosage of heparin sodium injection and the incidence of thrombosis was observed (P < 0.05), but there were no significant differences between other baseline data and the incidence of thrombosis (P > 0.05). Binary logistic regression analysis revealed that postoperative use of heparin sodium injection (Group I: OR = 0.312; P = 0.003; Group II: OR = 0.082, P < 0.001) was a protective factor for preventing thrombosis. In addition, the thromboprophylaxis effect of Group II was better than that of Group I. No serious adverse reactions were found in safety analysis.

Conclusion

Heparin sodium could significantly lower the incidence rate of PICC-related venous thrombosis in NSCLC patients during postoperative chemotherapy. Heparin sodium injection is safe enough to be promoted among PICC patients with a high risk of venous thrombosis.

Diagnostic utility of endobronchial ultrasound (EBUS) features in differentiating malignant and benign lymph nodes - A systematic review and meta-analysis

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.

Is it necessary to sample the contralateral nodal stations by EBUS-TBNA in patients with lung cancer and clinical N0 / N1 on PET-CT?

OBJECTIVES

Systematic mediastinal staging (sampling all visible nodes measuring ≥ 5 mm from N3 station to N1, regardless of PET/CT (positron emission tomography/computed tomography) by endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a decisive step in patients with non-small cell lung cancer (NSCLC). We analyzed the prevalence of N3 disease and the utility of systematic staging in the subgroup of patients who underwent EBUS-TBNA staging without showing mediastinal lesions on the PET/CT (N0/N1).

MATERIAL AND METHODS

We conducted a retrospective analysis of a prospectively collected database that included 174 patients with a final diagnosis of NSCLC, with N0/N1 disease on PET/CT who underwent a systematic EBUS-TBNA staging.

RESULTS

174 consecutive patients were included. Systematic EBUS-TBNA detected N2 mediastinal involvement in 21 (12 %) cases, and no cases of N3 disease were detected (neither hilar nor mediastinal). Of the remaining 153 patients N0/N1 EBUS-TBNA, 122 underwent lung resection that revealed 4 cases of N2 disease while 117 were confirmed to be N0/N1. Thirty-three patients with N0/1 disease after EBUS-TBNA did not undergo surgery and were excluded for the NPV calculation. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and overall accuracy of systematic EBUS was 84 %, 100 %, 96.7 %, 100 % and 97 % respectively.

CONCLUSION

Systematic EBUS-TBNA is a very accurate method for lymph node staging in patients with NSCLC without mediastinal involvement on PET/CT. Pending more studies, the absence of contralateral hilar nodal involvement in our series, questions the need for a contralateral hilar sampling in this subgroup of patients.

Concordance Between Rapid On-Site Evaluation and Final Cytologic Diagnosis in Patients Undergoing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Non-Small Cell Lung Cancer Staging

OBJECTIVES

In patients with lung cancer undergoing mediastinal staging through endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), decisions are based on rapid on-site evaluation (ROSE) findings. We aimed to analyze the concordance rate between ROSE diagnosis and final diagnosis.

METHODS

A prospective study was carried out in patients undergoing EBUS-TBNA for lung cancer staging. Diagnosis concordance was defined as cases where lymph nodes (LNs) presented the same diagnosis in ROSE and final diagnosis. Determinants of concordance were analyzed.

RESULTS

Sixty-four patients were included and 637 LNs sampled. ROSE diagnosis was concordant with final diagnosis in 612 (96.1%) LNs and nonconcordant in 25 (3.9%). Differences in the concordance rate were found between pathologists, ROSE diagnoses, presence of cell block, number of passes, and number of slides. The staging status was changed between ROSE and the final diagnosis in three (4.6%) patients.

CONCLUSIONS

ROSE diagnosis has a high concordance with the final diagnosis.

Evaluating the use of elastography in endobronchial ultrasound technique as a diagnostic approach for mesothorax lymphadenopathy

Introduction: Non-small cell lung cancer is still diagnosed at a late stage although we have new diagnostic equipment such the radial endobronchial ultrasound, convex probe endobronchial ultrasound, and electromagnetic navigation. The diagnostic techniques have been upgraded with rapid on-site evaluation (ROSE) and currently from 2014 real-time elastography is being evaluated as a ROSE technique.Areas covered: A thorough search was performed on PubMed and Scopus with the following key words: elastography, strain ratio, convex probe EBUS, endoscopic ultrasound (EUS), elastography. In the current mini review, we will focus on published data regarding elastography with the convex probe endobronchial ultrasound in two different systems and comment on this future ROSE technique. Elastography, strain ratio, and factors such as(I) margin (indistinct or distinct); (II) shape (oval or round); (III) short-axis size less or more than 1 cm; (IV) presence or absence of central hilar structure (CHS); (V) echogenicity (homogeneous or heterogeneous); and (VI) presence or absence of coagulation necrosis sign are presented in our review based on published literature.Expert opinion: Current data indicate that we can have up to 93% sensitivity and specificity of real-time elastography and strain ratio for the evaluation of benignancy and malignancy; however, sample biopsy is still necessary. For now, we can only reduce the number of punctures.

Comparison of specimen adequacy and diagnostic accuracy of a 25-gauge and 22-gauge needle in endobronchial ultrasound-guided transbronchial needle aspiration

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the preferred diagnostic modality for sampling mediastinal and hilar lymph nodes (LNs). The conventional needle used for sampling is either a 21-gauge (21G) or 22-gauge (22G). A 25-gauge (25G) needle has recently been introduced with little known regarding its efficacy.

Methods

A retrospective study was conducted on patients referred for EBUS-TBNA who had LNs sampled using a 25G or 22G needle. A propensity score matching analysis was performed. After matching the groups, each LN was assessed for adequacy and final diagnosis. Non-diagnostic and benign lymphoid specimens were compared with repeat biopsy findings or long-term clinical and radiological follow-up.

Results

A total of 158 LNs were included. An adequate sample was obtained in 92.4% (73/79) in the 25G group and 92.4% (73/79) in the 22G group (P=1). The 25G group diagnosed benign lymphoid tissue in 82.3% (65/79), granuloma in 7.6% (6/79) and malignancy in 2.5% (2/79). Six lymph nodes in the 25G group were non-diagnostic (7.6%). The 22G group diagnosed benign lymphoid tissue in 83.5% (66/79), granuloma in 3.8% (3/79) and malignancy in 5.1% (4/79). Six lymph nodes in the 22G group were non-diagnostic (7.6%). The sensitivity, specificity, negative predictive value (NPV) and diagnostic accuracy in the 25G group was 88.9% (95% CI, 51.8-99.7%), 100% (95% CI, 92.1-100%), 97.8% (95% CI, 87.6-99.7%) and 98.2% (95% CI, 90.1-100%), respectively. The sensitivity, specificity, NPV and diagnostic accuracy in the 22G group was 77.8% (95% CI, 40-97.2%), 100% (95% CI, 86.8-100%), 92.9% (95% CI, 79.3-97.8%) and 94.3% (95% CI, 80.8-99.3%), respectively. The 25G and 22G group were comparable in diagnostic accuracy (P=0.7).

Conclusions

The 25G and 22G needle achieve comparable specimen adequacy and diagnostic accuracy in EBUS-TBNA.

Optimal Endobronchial Ultrasound Strain Elastography Assessment Strategy: An Explorative Study

BACKGROUND

In lung cancer staging, mediastinal lymph nodes are currently aspirated using endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) based on size and FDG-PET avidity. EBUS strain elastography (SE) is a new technique that may help predict the presence of malignancy. However, a standardized assessment strategy for EBUS-SE measurement is lacking.

OBJECTIVES

The aim of this study was to determine the optimal assessment strategy for investigating the predictive value of EBUS-SE in mediastinal lymph nodes.

METHODS

Two qualitative visual analogue scale strain scores and two semiquantitative strain elastography measurements (a strain histogram and strain ratio) were acquired in 120 lymph nodes of 63 patients with (suspected) lung cancer. The dataset was randomized into an 80% training dataset to determine cut-off values. Performance was consecutively tested on the remaining 20% and the overall dataset.

RESULTS

The semiquantitative mean histogram scoring strategy with a cut-off value of 78 (range 0-255) showed the best and most reproducible performance in prediction of malignancy with 93% overall sensitivity, 75% specificity, 69% positive predictive value, 95% negative predictive value, and 82% accuracy. Combining the EBUS-SE mean histogram scoring outcome with PET-CT information increased the post-test probability of disease in relevant clinical scenarios, having a positive test likelihood ratio of 4.16 (95% CI 2.98-8.13) and a negative test likelihood ratio of 0.14 (95% CI 0.04-2.81) in suspicious lymph nodes based on FDG-PET or CT imaging.

CONCLUSIONS

EBUS-SE can potentially help predict lymph node malignancy in patients with lung cancer. The best semiquantitative assessment method is the mean strain histogram technique.

Systematic Compared With Targeted Staging With Endobronchial Ultrasound in Patients With Lung Cancer

BACKGROUND

To evaluate the accuracy of systematic mediastinal staging by endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) (sampling of all visible nodes measuring ≥5 mm from stations N3 to N1 regardless of their positron emission tomography/computed tomography [PET/CT] features) and compare this staging approach with targeted EBUS-TBNA staging (sampling only 18F-fluorodeoxyglucose [FDG]-avid nodes) in patients with N2 non-small cell lung cancer on PET/CT.

METHODS

Retrospective study of 107 patients who underwent systematic EBUS-TBNA mediastinal staging. The results were compared with those of a hypothetical scenario where only FDG-avid nodes on PET/CT would be sampled.

RESULTS

Systematic EBUS-TBNA sampling demonstrated N3 disease in 3 patients, N2 disease in 60 (42 single-station or N2a, 18 multiple-station or N2b) and N0/N1 disease in 44. Of these 44, 7 underwent mediastinoscopy, which did not show mediastinal disease; 6 of the 7 proceeded to lung resection, which also showed no mediastinal disease. Thirty-four N0/N1 patients after EBUS-TBNA underwent lung resection directly: N0/N1 was found in 30 and N2 in 4 (1 N2b with a PET/CT showing N2a disease, 3 N2a). Sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy of systematic EBUS-TBNA were 94%, 100%, 90%, 100% and 96%, respectively. Compared with targeted EBUS-TBNA, systematic EBUS-TBNA sampling provided additional important clinical information in 14 cases (13%): 3 N3 cases would have passed unnoticed, and 11 N2b cases would have been staged as N2a.

CONCLUSIONS

In clinical practice, systematic sampling of the mediastinum by EBUS-TBNA, regardless of PET/CT features, is to be recommended over targeted sampling.

Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report

BACKGROUND

Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians.

METHODS

Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion.

RESULTS

Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement.

CONCLUSIONS

Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure.

Initial experience with real-time elastography using an ultrasound bronchoscope for the evaluation of mediastinal lymph nodes

Real-time elastography performed during endoscopic ultrasonography is a relatively new method for characterizing tissue stiffness, and has been used successfully as a predictor of malignancy in mediastinal lymph nodes. This case report describes our practical experience with this technique using an ultrasound bronchoscope to examine mediastinal lymph nodes. We present a case of sectorial endobronchial ultrasound and the first published case of endoscopic ultrasound elastography using ultrasound bronchoscope in two patients with non-small cell lung carcinoma. Qualitative tissue color pattern was obtained in both cases and correlated with pathological evaluation. The initial feasibility results are promising and suggest that ultrasound bronchoscopy techniques, such as guided nodal staging, merit additional studies. It may be important to categorize the risk of malignancy to facilitate sampling decisions.

Linear EBUS in staging non-small cell lung cancer and diagnosing benign diseases

As an evolving technique, linear endobronchial ultrasound is becoming the first choice and standard of care not only to diagnose the malignant and benign mediastinal lesions but also to stage non-small cell lung cancer. Lung cancer is the leading cause of cancer-related mortality in both men and women. The disease causes more death compared with colorectal, breast, and prostate cancers combined in the United States. Staging of lung cancer determines the prognosis. The type of lung cancer has changed in the past few decades. The frequency of adenocarcinoma has increased, whereas squamous cell carcinoma now is less frequent. Determining the cell type and its molecular characteristics allow targeted treatments in adenocarcinoma. The diagnosis of indeterminate mediastinal lymph nodes or masses and staging lung cancer might be challenging. This article will review the principles and clinical utility of endobronchial ultrasound in mediastinal lesions.

Intra- and interobserver agreement among bronchial endosonographers for the description of intrathoracic lymph nodes

Several sonographic features observed by endobronchial ultrasonography have been suggested to be useful to predict malignancy in mediastinal lymph nodes. To evaluate agreement to describe sonographic features, 28 video images were evaluated twice by eight expert bronchoscopists. The observers reviewed each case for the presence of coagulation necrosis sign (CNS), central hilar structure (CHS), heterogeneity, distinct margin, round shape, size >1 cm and malignancy. Intraobserver agreement was almost perfect for size (κ = 0.826), substantial for CNS (κ = 0.721) and shape (κ = 0.615), and moderate for CHS (κ = 0.565), heterogeneity (κ = 0.441) and margin (κ = 0.407). Interobserver agreement was substantial for size (κ = 0.641), moderate for shape (κ = 0.445), and fair for CNS (κ = 0.340) and margin (κ = 0.274). In conclusion, inter- and intraobserver agreement of the endosonographic features for mediastinal or hilar lymph nodes is good for shape or size but not good enough for the other ultrasonographic features.

Contribution of cell blocks obtained through endobronchial ultrasound-guided transbronchial needle aspiration to the diagnosis of lung cancer

Background

Conventional smears of samples obtained by endobronchial ultrasound with real-time transbronchial needle aspiration (EBUS-TBNA) have proven useful in lung cancer staging, but the value of additional information from cell-block processing of EBUS-TBNA samples has only been marginally investigated. This study focussed on the contribution of cell block analysis to the diagnostic yield in lung cancer.

Methods

Patients referred for lung cancer diagnosis and/or staging by means of EBUS-TBNA were enrolled, the adequacy of the obtained samples for preparing cell blocks was assessed, and the additional pathologic or genetic information provided from cell block analysis was examined.

Results

In 270 lung cancer patients referred for EBUS-TBNA (mean age, 63.3 SD 10.4 years) 697 aspirations were performed. Cell blocks could be obtained from 334 aspirates (47.9%) and contained diagnostic material in 262 (37.6%) aspirates, providing information that was additional to conventional smears in 50 of the 189 samples with smears that were non-diagnostic, corresponding 21 of these blocks to malignant nodes, and allowing lung cancer subtyping of 4 samples. Overall, cell blocks improved the pathologic diagnosis attained with conventional smears in 54 of the 697 samples obtained with EBUS-TBNA (7.7%). Cell blocks obtained during EBUS-TBNA also made epithelial growth factor receptor mutation analysis possible in 39 of the 64 patients with TBNA samples showing metastatic adenocarcinoma (60.1%). Overall, cell blocks provided clinically significant information for 83 of the 270 patients participating in the study (30.7%).

Conclusions

Cell-block preparation from EBUS-TBNA samples is a simple way to provide additional information in lung cancer diagnosis. Analysis of cell blocks increases the diagnostic yield of the procedure by nearly seven per cent and allows for genetic analysis in a sixty per cent of the patients with metastatic adenocarcinoma.

Representativeness of nodal sampling with endobronchial ultrasonography in non-small-cell lung cancer staging

The objective of our study was to determine the procedure-related requirements of mediastinal node sampling with endobronchial ultrasonography with real-time transbronchial needle aspiration (EBUS-TBNA) that would provide negative predictive value (NPV) for the identification of stage III disease in non-small-cell lung cancer (NSCLC) high enough to consider the technique equivalent to cervical mediastinoscopy. Representative EBUS-TBNA was defined as a sampling procedure obtaining satisfactory samples from normal nodes in regions 4R, 4L and 7 or diagnosing malignancy in mediastinal nodes. NPV was estimated using the results of postsurgical staging in patients who underwent surgery as a reference. Two-hundred ninety-six patients staged with EBUS-TBNA were included. Representative samples from regions 4R, 4L and 7 showing nonmalignant cytology were obtained from 98 patients (33.1%) and EBUS-TBNA detected N2/N3 disease in 150 (50.7%). Accordingly, an EBUS-TBNA procedure accomplishing the representativeness criteria required for sampling was attained in 248 of the participating patients (83.8%). The NPV of the procedure in this setting was 93.6%, with false-negative results only found in 5 patients, four of them with nodal metastasis out of the reach of EBUS-TBNA (regions 5, 8 and 9). In conclusion, representative sampling of regions 4R, 4L and 7 is achieved in more than 80% of patients staged using EBUS-TBNA, and in the procedures that attain this requirement a NPV >90% for mediastinal malignancy is reached, a figure equivalent to cervical mediastinoscopy.

Endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal staging tool for lung cancer but also a diagnostic tool for mediastinal lesions near the airway. After a brief historic rationale, this article reviews the indications for EBUS-TBNA, provides an overview of practical, training and financial issues; reviews the evidence comparing the mediastinal staging tools and briefly discusses potential future applications. EBUS-TBNA is most commonly used for staging non-small cell lung cancer (NSCLC), but is also used for diagnosis of unexplained mediastinal lymphadenopathy of other causes. For staging before radical treatment, many centres still perform mediastinoscopy and this should be done to confirm negative EBUS-TBNA results in this setting and when the pre-test clinical probability of lung cancer is high. EBUS-TBNA may be used in the future for staging when the mediastinal nodes are normal according to radiological staging and also in re-staging. EBUS-TBNA can be learned with appropriate training and mentorship; it offers numerous advantages over mediastinoscopy; and it is less invasive and can reduce costs by avoiding unnecessary mediastinoscopies in many cases.

[Application of real time endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging]

线性经支气管超声引导针吸活检（endobronchial ultrasound-guided transbronchial needle aspiration, EBUSTBNA）是新引进的技术，它是实时超声下可视淋巴结的针吸活检。尽管有研究显示，其为肺癌纵隔分期的有效方 法，但全世界多数机构并未应用该技术。本报道旨在分享我们应用EBUS-TBNA的经验，并对相关文献做一简要概 述。我们对有关该技术的已有文献进行综述，并特别介绍了我们应用该技术方面的经验。 EBUS-TBNA用以探查肺 癌患者的转移性纵隔淋巴结和/或肺门淋巴结是有效且安全的。在其它病理状态下，其亦为有效的诊断方法。

[Endobronchial ultrasound-guided tranbronchial needle aspiration (EBUS-TBNA) in the diagnosis and staging of lung cancer]

经支气管超声引导针吸活检（endobronchial ultrasound guided tranbronchial needle aspiration, EBUS-TBNA）支气管镜具有一置入的微型超声探头，以便实现实时的TBNA活检。在肺癌中，EBUS-TBNA的敏感性为88%-90%，特异性为100%。受试者工作特征曲线下面积低于0.99时，测试效果良好。其诊断率显著优于传统盲法TBNA。然而，其假阴性率仍然很高，大约为20%。因此，阴性针吸结果需经纵隔镜检查、外科取样或临床随访证实。新辅助化疗后纵隔的再分期并不十分乐观，据报道，EBUS-TBNA的敏感性仅为76%，阴性预测值仅为20%。该方法亦已被成功用于获取气管旁及支气管周围区域原发肿瘤的活检标本，敏感性为82%-94%。EBUS-TBNA的优势在于其可在门诊中实施，患者仅需中度镇静，且无需电离辐射消毒。尽管在多数研究机构中EBUS-TBNA目前仍仅用于肿大淋巴结的靶向取样，但也有可能实现影像学检查正常的纵隔的完全分期。因此，如果设备及专家条件具备，EBUS-TBNA可作为肺癌诊断及有创分期的一线方案之一。

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and staging of lung cancer

The endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) bronchoscope has a built-in miniaturized ultrasound probe that facilitates real-time TBNA biopsies. The sensitivity of EBUS-TBNA in lung cancer is 88% to 90% and specificity is 100%. The test performance is excellent with an area under the summary receiver operating characteristics curve of 0.99. This diagnostic yield clearly exceeds that of conventional blind TBNA. However, the false negative rate remains high, about 20%. Therefore, negative aspirates need to be confirmed with mediastinoscopy, surgical sampling or clinical follow up. Restaging the mediastinum after neoadjuvant chemotherapy has had less success with a reported EBUS-TBNA sensitivity of only 76% and a negative predictive value of 20%. The procedure has also been used to successfully obtain biopsy specimens in primary tumors located in the paratracheal and peribronchial region with a sensitivity of 82 to 94%. The benefit of EBUS-TBNA is that it can be performed under moderate sedation in an outpatient setting without ionizing radiation. Although the current practice in most institutions remains targeted sampling of enlarged lymph nodes, complete staging of a radiologically normal mediastinum is also possible. Therefore, EBUS-TBNA can be considered one of the first-line modalities for the diagnosis and invasive staging of lung cancer if the equipment and expertise are available.

[Detection of lymph node involvement and surgical treatment of pulmonary neoplastic processes. Current state of diagnostic and therapeutic procedures]

An analysis is made of different publications associated with the surgical staging and treatment of primary and metastasic pulmonary neoplastic processes. A suitable treatment program is essential to determine lymph node involvement in patients with bronchogenic carcinoma. The indication and sequence of the procedure to use (CT-PET, transbronchial puncture, videomediastinoscopic ultrasound guided transbronchial needle aspiration) is evaluated in accordance to the sensitivity, specificity and positive and negative predictive value of the different methods. Another interesting challenge is to define the criteria for indicating a sublobar resection in certain tumours and patients. Different factors, age, lung function, tumour location and type of sublobar resection, are analysed. Levels of evidence and recommendations of the procedure are also considered. Surgical resection is an accepted therapeutic option in the treatment of colorectal cancer lung metastases. Its indication is based on acceptable survival rates and knowledge of the impact of various factors (interval free of disease, number of metastases, presence of liver metastasis, presence of lymph node involvement, or increased pre-operative levels of carcinoembryonic antigen), is analysed in detail.

Endobronchial ultrasound guided transbronchial needle aspiration

Staging for non-small cell lung cancer (NSCLC) requires accurate assessment of the mediastinal lymph nodes which determines treatment and outcome. As radiological staging is limited by its specificity and sensitivity, it is necessary to sample the mediastinal nodes. Traditionally, mediastinoscopy has been used for evaluation of the mediastinum especially when radical treatment is contemplated, although conventional transbronchial needle aspiration (TBNA) has also been used in other situations for staging and diagnostic purposes. Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) offers a minimally invasive alternative to mediastinoscopy with additional access to the hilar nodes, a better safety profile, and it removes the costs and hazards of theatre time and general anaesthesia with comparable sensitivity, although the negative predictive value of mediastinoscopy (and sample size) is greater. EBUS-TBNA also obtains larger samples than conventional TBNA, has superior performance and theoretically is safer, allowing real-time sampling under direct vision. It can also have predictive value both in sonographic appearance of the nodes and histological characteristics. EBUS-TBNA is therefore indicated for NSCLC staging, diagnosis of lung cancer when there is no endobronchial lesion, and diagnosis of both benign (especially tuberculosis and sarcoidosis) and malignant mediastinal lesions. The procedure is different than for flexible bronchoscopy, takes longer, and requires more training. EBUS-TBNA is more expensive than conventional TBNA but can save costs by reducing the number of more costly mediastinoscopies. Revenue based tariff systems have been slow to reflect the innovation of techniques such as EBUS-TBNA. In the future, endobronchial ultrasound may have applications in airways disease and pulmonary vascular disease.

Integrated Positron-Emission Tomography for Nodal Staging in Lung Cancer

As lymph node metastasis is the most important factor determining the surgical outcome of lung cancer, we evaluated the accuracy and clinical usefulness of functional imaging with integrated positron-emission tomography and computed tomography in nodal staging of non-small-cell lung cancer. Between October 2003 and August 2004, 43 newly diagnosed patients underwent curative surgical resection or mediastinoscopic nodal biopsy after chest computed tomography as well as whole-body functional imaging for clinical staging. Based on histopathologic findings in the lymph nodes, we compared the diagnostic usefulness of computed tomography and functional imaging. Twenty-two patients were N0 stage, 6 were N1, 11 were N2, and 4 were N3. Although functional imaging seemed to be superior for evaluation of N2 nodes, there were no significant differences in the sensitivity, specificity, positive-predictive value, negative-predictive value, or accuracy. The situation was similar for N1 nodes, and there were no significant differences except for the false-negative rate. High false-positive and negative-rates for N2 lymph nodes suggest that functional imaging should not replace mediastinoscopy.