Endobronchial ultrasound transbronchial needle aspiration in mediastinal and hilar lymphadenopathies

Efficacy and safety of EBUS-TBNA under conscious sedation with meperidine and midazolam

Background

According to the guidelines, endobronchial ultrasound guided transbronchial needle aspiration (EBUS‐TBNA) is the technique of choice for the diagnosis of mediastinal involvement in lung cancer; it is also useful for other mediastinal malignancies and benign pathology. Nevertheless, there is still discussion about whether to perform it under general anesthesia or under conscious sedation.

Methods

We retrospectively analyzed the data of all patients who underwent EBUS‐TBNA under conscious sedation with up to 1 mg/kg of meperidine and up to 0.15 mg/kg of midazolam in the Interventional Pulmonology Unit of the Azienda USL‐IRCCS Santa Maria Nuova of Reggio Emilia during 2 consecutive years. Demographic data, indication for the procedure, duration, number of lymph node sampled, number of passes per station, diagnostic yield, drugs dosage, questionnaire score, and complications were collected.

Results

A total of 302 patients underwent EBUS‐TBNA, and 68% of the patients were males and the mean age was 65 ± 13 years old. The average duration of procedures was 24.4 minutes and the mean dosage of drugs was 4.32 ± 1.52 mg for midazolam and 50.86 ± 13.71 mg for meperidine. The mean number of lymph nodes sampled per patient was 1.75 ± 0.82, and each patient received an average of 4.71 ± 1.78 passes. A total of 90.7% of patients completed the procedures, 85% had adequate samples, and 94.4% of patients declared with Likert's questionnaire that they strongly agree to repeat the test if necessary.

Conclusion

EBUS‐TBNA performed under conscious sedation with meperidine and midazolam is feasible and well‐tolerated and has a similar diagnostic yield of that reported in literature.

Ultrasound techniques in the evaluation of the mediastinum, part I: endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS) and transcutaneous mediastinal ultrasound (TMUS), introduction into ultrasound techniques

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography (EUS and EBUS) should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [EBUS combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [EUS fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all mediastinal lymph nodes can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review, in two integrative parts, is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part I is dealing with an introduction into ultrasound techniques, mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques and part II with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

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.

Improved efficacy of endobronchial ultrasound-guided fine-needle aspiration biopsy in comparison to endobronchial ultrasound-guided miniforceps biopsy

OBJECTIVE

Endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) cytology and EBUS-miniforceps biopsy (MFB) have emerged as less invasive tools for evaluating mediastinal lymph nodes and pulmonary lesions. The aim of this study is to compare the diagnostic yields of EBUS-FNA cytology to EBUS-MFB.

STUDY DESIGN

A retrospective cohort study was performed by reviewing the database at our institution between December 12, 2010, and August 10, 2012. A total of 476 consecutive cases were identified. Of these, 227 patients had concurrent FNA and MFB taken during the procedure. The results and diagnostic yields of both techniques are calculated.

RESULTS

Of the 476 cases, the mean age was 62 ± 14 years with 53% being males. In 453 of the total cases, the less invasive FNA technique alone produced enough diagnostic cytology material negating the need for concurrent MFB. Of these FNA cases, 280 were diagnosed as malignant neoplasms. The diagnostic yield of EBUS-FNA cytology was comparable to EBUS-MFB (95% FNA and 94% MFB). There were discordant diagnoses between cytology and histology in 19 of the 227 (∼8.4%) cases.

CONCLUSIONS

EBUS-FNA cytology is a more efficacious diagnostic modality compared to EBUS-MFB.