EUS-FNA as the initial diagnostic modality in centrally located primary lung cancers

EUS-guided transesophageal fine-needle biopsy sampling of lung masses: diagnostic performance and safety

BACKGROUND AND AIMS

Pulmonary masses are a diagnostic challenge in the field of EUS tissue acquisition, especially through transesophageal EUS-guided fine-needle biopsy sampling (EUS-FNB). Our study evaluated the feasibility, diagnostic performance, and safety of EUS-FNB of pulmonary lesions.

METHODS

Fifty-three patients were enrolled in a prospective registry. All EUS procedures were performed by experienced endosonographers. Outcomes were specimen adequacy, diagnostic accuracy, diagnostic sensibility, diagnostic specificity, and safety.

RESULTS

The mean patient age was 70 ± 10.4 years, and 71.7% were men. The mean lesion size was 52.4 ± 23.3 mm, and patients mostly had a single lesion (86.8%). Most patients had an advanced stage at diagnosis (stage IV, 41.82%), and the most common lung cancer was non-small cell lung carcinoma (69.4%). The diagnostic adequacy rate was 92.86%, and diagnostic accuracy was 87.5%. Adverse events were reported in 3 procedures.

CONCLUSIONS

Transesophageal EUS-FNB is a feasible and safe diagnostic method of tissue sampling for lung masses reachable by EUS.

Endoscopic Diagnosis of Extra-Luminal Cancers

The last 2 decades have seen an emergence of endoscopic technologies and techniques allowing for minimally invasive modalities for assessing and sampling lesions outside of the gastrointestinal lumen, including the chest, abdomen, and pelvis. Incorporating these new endoscopic approaches has revolutionized the diagnosis and staging of extra-luminal malignancies and has enabled more accessible and safer tissue acquisition.

Transesophageal endoscopic ultrasound in the diagnosis of the lung masses: a multicenter experience with fine-needle aspiration and fine-needle biopsy needles

BACKGROUND AND AIM

Intraparenchymal lung masses inaccessible through bronchoscopy or endobronchial ultrasound guidance pose a diagnostic challenge. Furthermore, some fragile or hypoxic patients may be poor candidates for transbronchial approaches. Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) offers a potential diagnostic approach to lung cancers adjacent to the esophagus. We aimed to evaluate the feasibility, accuracy, and safety of trans-esophageal EUS-FNA/FNB for tissue sampling of pulmonary nodules.

METHODS

We retrospectively analyzed data from patients with pulmonary lesions who underwent EUS-FNA/FNB between March 2015 and August 2021 at eight Italian endoscopic referral centers.

RESULTS

A total of 47 patients (36 male; mean age 64.47 ± 9.05 years) were included (22 EUS-FNAs and 25 EUS-FNBs). Overall diagnostic accuracy rate was 88.9% (76.3-96.2%). The sensitivity and diagnostic accuracy were superior for EUS FNB sampling versus EUS-FNA (100% vs. 78.73%); P = 0.05, and (100% vs. 78.57%); P = 0.05, respectively. Additionally, sample adequacy was superior for EUS-FNB sampling versus EUS-FNA (100% vs. 78.5%); P = 0.05. Multivariate logistic regression analysis for diagnostic accuracy showed nodule size at the cutoff of 15 mm (OR 2.29, 1.04-5.5, P = 0.05) and use of FNB needle (OR 4.33, 1.05-6.31, P = 0.05) as significant predictors of higher diagnostic accuracy. There were no procedure-related adverse events.

CONCLUSION

This study highlights the efficacy and safety of EUS-FNA/FNB as a minimally invasive procedure for diagnosing and staging peri-esophageal parenchymal lung lesions. The diagnostic yield of EUS-FNB was superior to EUS-FNA.

Characterization of Lung Tumors that the Pulmonologist can Biopsy from the Esophagus with Endosonography (EUS-B-FNA)

BACKGROUND

According to guidelines, it is possible to biopsy lung tumors "immediately adjacent to the esophagus" with EUS-B-FNA. However, it is unknown what "immediately adjacent" exactly means.

OBJECTIVE

to investigate the possibility of achieving EUS-B-FNA biopsies from a lung tumor depending on the distance from the esophagus and to establish the maximal allowable distance between the tumor and the esophagus.

METHODS

In a prospective observational study, we included patients with a lung tumor located maximum 6 cm from the esophagus and indication of EUS-B-FNA from the tumor. The tumors were of different sizes. In a plot presenting the tumor size-distance relationship in cases with (biopsy) versus without (non-biopsy) successful EUS-B-FNA, a separation line representing the threshold between the groups were identified and a biopsy-index equation established. The maximal tumor-size corrected distance (TSCD) was calculated using the residuals to the separation line.

RESULTS

In total, 70 patients were included. EUS-B-FNA from the lung tumor was possible in 46 patients. All tumors with a distance from the esophagus below 19 mm could be biopsied. The maximal allowable esophagus-tumor distance depended on tumor size. From the separation line, a biopsy-index equation was established with the sensitivity of 93.5%, a specificity of 100%, and total accuracy of 95.7%. The TSCD was 31 mm (sensitivity: 95.7%, specificity 75.0%, and accuracy: 88.6%).

CONCLUSION

We established a biopsy-index equation to predict the achievability of a lung tumor using EUS-B-FNA depending on distance to esophagus and tumor size. A general maximal TSCD was 31 mm.

Exhaustive Review on Lung Cancers: Novel Technologies

BACKGROUND

Lung cancers or (Bronchogenic-Carcinomas) are the disease in certain parts of the lungs in which irresistible multiplication of abnormal cells leads to the inception of a tumor. Lung cancers consisting of two substantial forms based on the microscopic appearance of tumor cells are: Non-Small-Cell-Lung-Cancer (NSCLC) (80 to 85%) and Small-Cell-Lung-Cancer (SCLC) (15 to 20%).

DISCUSSION

Lung cancers are existing luxuriantly across the globe and the most prominent cause of death in advanced countries (USA & UK). There are many causes of lung cancers in which the utmost imperative aspect is the cigarette smoking. During the early stage, there is no perspicuous sign/symptoms but later many symptoms emerge in the infected individual such as insomnia, headache, pain, loss of appetite, fatigue, coughing etc. Lung cancers can be diagnosed in many ways, such as history, physical examination, chest X-rays and biopsy. However, after the diagnosis and confirmation of lung carcinoma, various treatment approaches are existing for curing of cancer in different stages such as surgery, radiation therapy, chemotherapy, and immune therapy. Currently, novel techniques merged that revealed advancements in detection and curing of lung cancer in which mainly includes: microarray analysis, gene expression profiling.

CONCLUSION

Consequently, the purpose of the current analysis is to specify and epitomize the novel literature pertaining to the development of cancerous cells in different parts of the lung, various preeminent approaches of prevention, efficient diagnostic procedure, and treatments along with novel technologies for inhibition of cancerous cell growth in advance stages.

Transesophageal approach to lung, adrenal biopsy and fiducial placement using endoscopic ultrasonography (EUS): An interventional pulmonology experience. Initial experience of the UCSF-FRETOC (fresno tracheobronchial & oesophageal center) study group

BACKGROUND

Routine lung cancer surveillance has resulted in early detection of pulmonary nodules and masses. Combined endobronchial ultrasound (EBUS) and trans-esophageal endoscopic ultrasound (EUS) are approved methods for sampling lymph nodes or masses. Furthermore, EUS allows for adrenal sampling as part of staging, and can assist with fiducial placement for stereotactic body radiation therapy (SBRT).

OBJECTIVES

Promote use of EUS by interventional pulmonologists in the United States when diagnosing and staging lung cancer or when placing fiducials.

METHODS

All patients undergoing EUS and/or EBUS were serially entered into a prospectively maintained database. Only patients undergoing EUS guided lung and/or adrenal biopsy and/or fiducial placement were selected for analysis. All patients underwent a post-procedure chest radiograph and were followed outpatient.

RESULTS

20 of 39 patients underwent sampling of a suspicious lung mass. An adequate sample was obtained in 19 of 20 patients. In all 19 patients a definitive diagnosis was achieved (95%). In all 13 patients who underwent adrenal sampling, presence or absence of metastasis was conclusively established. 6 patients successfully underwent fiducial placement. In all 39 patients, no major procedure related complications were noted for a period of 30 days. One patient had a small pneumothorax that resolved spontaneously.

CONCLUSIONS

EUS can be safely performed by a trained interventional pulmonologist for the diagnosis of lung, adrenal masses and placement of fiducials. We think that interventional pulmonologists in the United States involved in lung cancer staging should receive training in EUS techniques.

Esophageal Endosonography for the Diagnosis of Intrapulmonary Tumors: A Systematic Review and Meta-Analysis

BACKGROUND

Biopsy-based diagnosis in patients with paraesophageal intrapulmonary tumors suspected of lung cancer is crucial for adequate treatment planning.

OBJECTIVE

To evaluate the performance of transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in the diagnosis of intrapulmonary tumors located near or adjacent to the esophagus.

METHODS

We performed a systematic review (PROSPERO, CRD42016033737) and searched MEDLINE, Embase, BIOSIS Previews, and Web of Science on September 22, 2016, without date or language restrictions. We included studies that evaluated the yield and/or sensitivity of EUS-FNA for diagnosing intrapulmonary tumors. Yield was defined as the number of patients in whom EUS-FNA made a biopsy-proven diagnosis (malignant or nonmalignant) relative to the total number of patients on whom EUS-FNA was performed. Sensitivity was defined as the number of patients in whom EUS-FNA made a biopsy-proven diagnosis of malignancy relative to the total number of patients in whom the tumor was found to be malignant. We performed a random-effects meta-analysis.

RESULTS

Of 3,320 search results, 11 studies were included. Ten had a high risk of bias. The total number of patients was 313; the proportion of patients with malignancy ranged from 87 to 100% across these studies. The average yield was 0.90 (95% CI 0.82-0.95) and the average sensitivity was 0.92 (0.83-0.96). In the subgroup of prospective studies (n = 3), the average yield was 0.80 (0.56-0.93) and the average sensitivity was 0.83 (0.58-0.95). EUS-FNA-induced complications were reported for 5/256 patients (2.0%) for whom this information was available.

CONCLUSIONS

Although the number of high-quality studies is limited, these findings suggest that EUS-FNA is safe and has a high yield for diagnosing intrapulmonary tumors.

Endoscopic ultrasound in the diagnosis and staging of lung cancer

We reviewed the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound guided fine needle aspiration (EUS-FNA) in the pretherapeutic assessment of patients with proven or suspected lung cancer. EUS-FNA and EBUS-TBNA have been shown to have a good diagnostic accuracy in the diagnosis and staging of lung cancer. In the future, these techniques in combination with positron emission tomography/computed tomographic may replace surgical staging in patients with suspected and proven lung cancer, but until then surgical staging remains the gold standard for adequate preoperative evaluation.

Role of EUS-FNA in Recurrent Lung Cancer: Maximum Results with Minimum (minimally invasive) Effort

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an excellent method for primary lung cancer staging. We describe a 66-year-old male who underwent EUS-FNA for the diagnosis of recurrent lung cancer. Two years after initial radiation therapy followed by complete remission, routine follow-up imaging study revealed a mass in the right hilum. Trans-esophageal EUS revealed a 1.3-cm mass and the result of EUS-FNA was consistent with non-small lung cancer. EUS-FNA can play an important role in diagnosis of recurrent lung cancer as well as primary staging avoiding the more invasive diagnostic technique.

Complication rate of endosonography (endobronchial and endoscopic ultrasound): a systematic review

BACKGROUND

Endosonography [endoscopic ultrasound (EUS)-guided fine needle aspiration and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration] is increasingly used for lung cancer staging and the assessment of sarcoidosis. Serious adverse events (SAE) have been reported in case reports, but the true incidence of complications is yet unknown.

OBJECTIVES

To assess the rate of SAE related to endosonography and to investigate associated risk factors.

MATERIALS AND METHODS

PubMed, EMBASE and Cochrane libraries were searched for eligible references up to April 2012 and these included studies reporting on linear EUS or EBUS for the analysis of mediastinal/hilar nodal or central intrapulmonary lesions. Case series describing complications were excluded. Reported complications were classified into SAE or minor adverse events (AE).

RESULTS

190 studies met the inclusion criteria. Information on follow-up was missing in half of the studies. In 16,181 patients, 23 SAE (0.14%) and 35 AE (0.22%) were reported. No mortality was observed. SAE were more frequent in patients investigated with EUS (0.30%) than in those investigated with EBUS (0.05%). Infectious SAE were most prevalent (0.07%) and predominantly occurred in patients with cystic lesions and sarcoidosis. In lung cancer patients, complications were rare.

DISCUSSION

Endosonography for intrathoracic nodal assessment seems safe for lung cancer patients and mortality has not been reported. For cystic lesions and sarcoidosis, there may be a small, but nonnegligible risk of infectious complications. The true incidence of SAE might be higher as accurate documentation of complications is missing in most studies.

Diagnostic yield and safety of endoscopic ultrasound guided fine needle aspiration of central mediastinal lung masses

Background and Aims. EUS-FNA is an accurate and safe technique to biopsy mediastinal lymph nodes. However, there are few data pertaining to the role of EUS-FNA to biopsy central lung masses. The aim of the study was to assess the diagnostic yield and safety of EUS-FNA of indeterminate central mediastinal lung masses. Methods.

DESIGN

Retrospective review of a prospectively maintained database; noncomparative.

SETTING

Tertiary referral center. From 10/2004 to 12/2010, all patients with a lung mass located within proximity to the esophagus were referred for EUS-FNA.

MAIN OUTCOME MEASUREMENT

EUS-FNA diagnostic accuracy and safety. Results. 73 consecutive patients were included. EUS allowed detection in 62 (85%) patients with lack of visualization prohibiting FNA in 11 patients. Among sampled lesions, one patient (1/62 = 1.6%) had a benign lung mass (hamartoma), while the remaining 61 patients (61/62 = 98.4%) had a malignant mass (primary lung cancer: 55/61 = 90%; lung metastasis: 6/61 = 10%). The sensitivity, specificity, and accuracy of EUS-FNA were 96.7%, 100%, and 96.7%, respectively. The sensitivity was 80.8% when considering nonvisualized masses. One patient developed a pneumothorax (1/62 = 1.6%). Conclusions. EUS-FNA appears to be an accurate and safe technique for tissue diagnosis of central mediastinal lung masses.

Transoesophageal needle aspiration using a convex probe ultrasonic bronchoscope

BACKGROUND AND OBJECTIVE

Although endoscopic ultrasound-guided fine needle aspiration can be helpful when combined with bronchoscopic procedures, endoscopic ultrasound-guided fine needle aspiration is not available as a conjunctive procedure with bronchoscopy at many institutions. This study evaluated the feasibility and the additional role of transoesophageal fine needle aspiration using a convex probe ultrasonic bronchoscope (EUS-B-FNA).

METHODS

We analysed 84 patients who underwent EUS-B-FNA between Oct 2007 and May 2008. Bronchoscopy and/or endobronchial ultrasound-guided transbronchial needle aspiration was performed on 83 patients prior to EUS-B-FNA.

RESULTS

EUS-B-FNA was performed on 89 lesions (1.7 aspirations/lesion) including three lung masses and 86 lymph nodes (nodal stations 1, 3P, 4L, 5, 7, 8, 9 and 10L) without complication. Sample adequacy was 95.4% for each aspiration and 100% for each lesion. Of the 89 lesions, 39 malignant lesions were confirmed by EUS-B-FNA. EUS-B-FNA provided additional diagnostic gain to bronchoscopic procedures in 16 patients (19.0%): 3 lung cancers were upstaged, 11 lung cancers were pathologically confirmed, and 2 patients were diagnosed with mediastinal metastasis from an extrathoracic malignancy. This gain was obtained by the sampling of inaccessible (n = 4) or difficult lesions by endobronchial ultrasound-guided transbronchial needle aspiration (n = 2) or when bronchoscopy was difficult due to dyspnoea, cough, brain metastasis or other conditions (n = 10).

CONCLUSIONS

EUS-B-FNA is a technically feasible and safe procedure, which may be an alternative to endoscopic ultrasound-guided fine needle aspiration as a procedure that complements bronchoscopy. Additional diagnostic yield can be obtained by combining EUS-B-FNA with bronchoscopic procedures.