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Moretti A, Kovacevic B, Vilmann P, Annema JT, Korevaar DA. Performance of EUS-FNA and EUS-B-FNA for the diagnosis of left adrenal glands metastases in patients with lung cancer: A systematic review and meta-analysis. Lung Cancer 2023; 186:107391. [PMID: 37827042 DOI: 10.1016/j.lungcan.2023.107391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/09/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES For diagnosing left adrenal gland metastasis in lung cancer, clinical guidelines recommend to perform EUS, but EUS-B (EUS using an EBUS-scope) is increasingly being used. We evaluated the diagnostic performance of both procedures. MATERIALS AND METHODS We did a systematic review (PROSPERO, CRD42023416205) and searched MEDLINE and EMBASE on 04-July-2023 for studies evaluating EUS and/or EUS-B in diagnosing left adrenal gland metastases in adults with (suspected) lung cancer. Outcomes were: (1) ability to visualize the left adrenal gland, (2) ability to sample (in those with successful visualization and in whom sampling was attempted), (3) ability to obtain adequate material (in those with successful sampling), (4) malignancy detection rate (in those with successful sampling), and (5) remaining risk of malignancy (in those with a negative EUS(-B)-FNA and undergoing a reference standard). We performed random-effects meta-analyses. RESULTS We included 19 studies (EUS: n = 11, EUS-B: n = 6, both: n = 2), covering 1712 patients. All studies had high (n = 18) or unclear (n = 1) risk of bias (QUADAS-2). Average ability to visualize the left adrenal gland was 0.94 (95 %CI 0.82-0.98; n = 7 studies). Average ability to sample was 1.00 (95 %CI 0.99-1.00; n = 9). Average ability to obtain adequate material was 0.96 (95 %CI 0.93-0.98; n = 18). Average malignancy detection rate was 0.42 (95 %CI 0.34-0.49; n = 18). Remaining risk of malignancy was 0.07 (95 %CI 0.04-0.12; n = 8). Ability to visualize was slightly higher for EUS (0.99; 95 %CI 0.90-1.00) than EUS-B (0.84; 95 %CI 0.70-0.92; p = 0.025), but the other performance characteristics were similar. No major complications were reported. CONCLUSION Both EUS and EUS-B have good performance and are safe for left adrenal gland analysis in patients with lung cancer, but the number of high-quality studies is limited and further well-constructed prospective studies are needed.
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Affiliation(s)
- Antonio Moretti
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands; Unit of Respiratory Diseases, Department of Medical and Surgical Sciences, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Bojan Kovacevic
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Jouke T Annema
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Daniël A Korevaar
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands.
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Vadala R, Mittal S, Nambirajan A, Hadda V, Mohan A, Guleria R, Madan K. Transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) for left adrenal gland (LAG) sampling: A report of three cases with a review of the literature. Lung India 2023; 40:550-554. [PMID: 37961966 PMCID: PMC10723211 DOI: 10.4103/lungindia.lungindia_381_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 11/15/2023] Open
Abstract
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard-of-care modality for evaluating mediastinal lymph nodes and masses. The EBUS bronchoscope may also be introduced through the oesophageal route to perform sampling of accessible lesions, a technique described as transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA). Because of the central oesophageal approach, EUS-B-FNA provides easy access to the left para-tracheal, subcarinal and para-oesophageal lymph nodes. In addition, the left adrenal gland (LAG) can also be imaged and sampled during the EUS-B-FNA procedure. In patients with suspected lung cancer, accurate staging is essential. Adrenal metastasis is relatively common and may often be a solitary metastatic site. We describe three cases where EUS-B-FNA was performed to safely sample the enlarged LAG in suspected lung cancer. We also review the literature on the performance characteristics of EUS-B-FNA for LAG aspiration.
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Affiliation(s)
- Rohit Vadala
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Aruna Nambirajan
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
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3
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Jeffus S, Quiroga EF, Hasan Z, Fedda F, Meena N, Bartter T. The yield and impact of pulmonologist-performed EUS-B-FNA of subdiaphragmatic lesions-an institutional experience. J Am Soc Cytopathol 2023; 12:362-367. [PMID: 37336683 DOI: 10.1016/j.jasc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/04/2023] [Accepted: 05/22/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Pulmonologists can biopsy structures below the diaphragm using the convex curvilinear ultrasound bronchoscope via the esophagus (EUS-B). The literature with respect to the value of EUS-B, rapid on-site evaluation, and final diagnostic yield for structures below the diaphragm is limited. We review our institutional experience. MATERIALS AND METHODS Our database was queried retrospectively for EUS-B fine needle aspirations (FNAs) from 2013 to 2021. All procedures involving EUS-B-FNA of subdiaphragmatic structures were selected for analysis. The following data elements were collected for each patient: age, gender, clinical indication, sample site, on-site adequacy (OSA), preliminary and final diagnoses, and sufficiency of cell block for ancillary studies. RESULTS A total of 75 subdiaphragmatic sites were biopsied in 74 patients. Of which, 87% of samples subjected to rapid on-site evaluation were deemed to contain adequate material (OSA+). There were no false-positive OSAs. Six cases remained nondiagnostic at the final diagnosis. The final diagnostic yield (with cell block) was 92% (69/75 cases). Cell block was sufficient for immunohistochemistry or special stains in all applicable cases (n = 36). Molecular testing was requested for 11 cases and successful in 10 (91%). Sampling of subdiaphragmatic sites changed the stage in 67% (38/57) of lung cancer patients. CONCLUSIONS Pulmonologists can perform EUS-B-FNA of subdiaphragmatic sites with high OSA and final diagnostic yield when assisted by cytopathologists. Strong correlations exist between OSA, cell block adequacy, and subsequent capacity to perform ancillary testing. EUS-B below the diaphragm can make an important contribution to the diagnosis of lung cancer, nonpulmonary malignancies, and other diseases.
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Affiliation(s)
- Susanne Jeffus
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | | | - Zeinab Hasan
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Faysal Fedda
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Nikhil Meena
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Thaddeus Bartter
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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4
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Biondini D, Tinè M, Semenzato U, Daverio M, Scalvenzi F, Bazzan E, Turato G, Damin M, Spagnolo P. Clinical Applications of Endobronchial Ultrasound (EBUS) Scope: Challenges and Opportunities. Diagnostics (Basel) 2023; 13:2565. [PMID: 37568927 PMCID: PMC10417616 DOI: 10.3390/diagnostics13152565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/20/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
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.
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Affiliation(s)
- Davide Biondini
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Mariaenrica Tinè
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Umberto Semenzato
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Matteo Daverio
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Francesca Scalvenzi
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Erica Bazzan
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Graziella Turato
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Marco Damin
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Paolo Spagnolo
- Respiratory Disease Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
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5
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Zuccatosta L, Mei F, Bonifazi M, Gasparini S. Historical eye: from traditional to endobronchial ultrasound-guided needle aspiration and beyond. Curr Opin Pulm Med 2023; 29:3-10. [PMID: 36474461 DOI: 10.1097/mcp.0000000000000924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In the history of bronchoscopy, the advent of flexible transbronchial needle aspiration (TBNA) before and, subsequently, of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), have represented fundamental events, as they have significantly and definitively changed interventional pulmonology's role in diagnostic and therapeutic work-up of most of thoracic diseases.Purpose of this historical review is to retrace the main stages that have contributed to the development of these two techniques. RECENT FINDINGS TBNA allowed the bronchoscopists to overcome the barrier of the tracheobronchial wall and to obtain samples from hilar-mediastinal lesions. With this additional method, bronchoscopy has become an essential procedure for staging of lung cancer.The advent of echo-bronchoscopes, allowing to perform TBNA under direct ultrasound guidance in real time, further increased the diagnostic yield of this technique. Furthermore, the insertion of the echo-bronchoscope through the oesophagus allowed to extend the landscape of targets to sample, including also para-esophageal lesions, liver metastases, celiac nodes and left adrenal glands.EBUS-TBNA has shown its usefulness not only in the approach to mediastinal lesions, but also in other clinical conditions, such as lung nodules or masses adjacent to the tracheobronchial tree. SUMMARY Despite the obvious advantages of EBUS-TBNA, this technology is not yet available in many centres and countries worldwide. For this reason, TBNA remains a basic technique that must complete the technical background of bronchoscopists and it should not be forgotten.
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Affiliation(s)
- Lina Zuccatosta
- Pulmonary Diseases Unit, Azienda Ospedaliero-Universitaria 'Ospedali Riuniti'
| | - Federico Mei
- Pulmonary Diseases Unit, Azienda Ospedaliero-Universitaria 'Ospedali Riuniti'
- Department of Biomedical Science and Public Health, Polytechnic University of Marche Region, Ancona, Italy
| | - Martina Bonifazi
- Pulmonary Diseases Unit, Azienda Ospedaliero-Universitaria 'Ospedali Riuniti'
- Department of Biomedical Science and Public Health, Polytechnic University of Marche Region, Ancona, Italy
| | - Stefano Gasparini
- Pulmonary Diseases Unit, Azienda Ospedaliero-Universitaria 'Ospedali Riuniti'
- Department of Biomedical Science and Public Health, Polytechnic University of Marche Region, Ancona, Italy
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6
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EUS-B-FNA Enhances the Diagnostic Yield of EBUS Bronchoscope for Intrathoracic Lesions. Lung 2022; 200:643-648. [PMID: 36074142 DOI: 10.1007/s00408-022-00563-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/12/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Endobronchial ultrasound (EBUS) bronchoscopes have been used mainly through the airway for EBUS-guided transbronchial needle aspiration (EBUS-TBNA); however, they can also be used through the esophagus. The esophageal approach, endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA), has gradually become popular, as it can evaluate lesions that cannot be accessed through the airway. PURPOSE This study aimed to evaluate the value of adding EUS-B-FNA to EBUS-TBNA performed by pulmonologists for intrathoracic lesions in the clinical setting. METHODS Between March 2009 and March 2020, all patients who underwent EUS-B-FNA and EBUS-TBNA for diagnostic purposes were included and retrospectively analyzed at a single institution. RESULTS A total of 1794 procedures using an EBUS bronchoscope including, EBUS-TBNA, EUS-B-FNA, and the combination of EBUS-TBNA and EUS-B-FNA for evaluating intrathoracic lesions, were performed. We finally analyzed 276 patients who underwent EUS-B-FNA for diagnostic purposes. EUS-B-FNA provided diagnostic materials from only EBUS-TBNA-inaccessible lesions in 26 patients and in 18 patients whose conditions were inappropriate for bronchoscopy (e.g., respiratory failure, airway stenosis, etc.). EUS-B-FNA provided diagnostic results in four patients with non-diagnostic EBUS-TBNA results. EUS-B-FNA was preferable to EBUS-TBNA in 4.4% (48 of 1091) of patients; therefore, adding EUS-B-FNA to EBUS-TBNA increased the diagnostic yield from 72.6% (1043 of 1437) to 75.9% (1091 of 1437). CONCLUSION Pulmonologists are able to enhance diagnostic yields by acquiring the EUS-B-FNA technique.
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Endobronchial Therapies for Diagnosis, Staging, and Treatment of Lung Cancer. Surg Clin North Am 2022; 102:393-412. [DOI: 10.1016/j.suc.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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8
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Marshall T, Kalanjeri S, Almeida FA. Lung cancer staging, the established role of bronchoscopy. Curr Opin Pulm Med 2022; 28:17-30. [PMID: 34720099 DOI: 10.1097/mcp.0000000000000843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Lung cancer is the leading cause of cancer-related deaths worldwide. In the absence of distant metastases, accurate mediastinal nodal staging determines treatment approaches to achieve most favourable outcomes for patients. Mediastinal staging differentiates N0/N1 disease from N2/N3 in surgical candidates. Likewise, presence of nodal involvement in nonsurgical candidates who are being considered for stereotactic body radiation therapy is also critical. This review article seeks to discuss the current options available for mediastinal staging in nonsmall cell lung cancer (NSCLC), particularly the role of bronchoscopy. RECENT FINDINGS Although several techniques are available to stage the mediastinum, bronchoscopy with EBUS-TBNA with or without EUS-FNA appears to be superior in most clinical situations based on its ability to concomitantly diagnose and stage at once, safety, accessibility to the widest array of lymph node stations, cost and low risk of complications. However, training and experience are required to achieve consistent diagnostic accuracy with EBUS-TBNA. SUMMARY EBUS-TBNA with or without EUS-FNA is considered the modality of choice in the diagnosis and staging of NSCLC in both surgical and nonsurgical candidates.
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Affiliation(s)
- Tanya Marshall
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Satish Kalanjeri
- Pulmonary and Critical Care Medicine, Harry S. Truman Memorial Veterans Hospital
- Pulmonary and Critical Care Medicine, University of Missouri School of Medicine, Columbia, Missouri
| | - Francisco Aecio Almeida
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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9
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Avasarala SK, Aravena C, Almeida FA. Convex probe endobronchial ultrasound: historical, contemporary, and cutting-edge applications. J Thorac Dis 2020; 12:1085-1099. [PMID: 32274177 PMCID: PMC7139045 DOI: 10.21037/jtd.2019.10.76] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The use of convex-probe endobronchial ultrasound (CP-EBUS) has revolutionized bronchoscopy. It has provided the option of a relatively safe, minimally invasive approach for the assessment of various intrathoracic diseases. In current practice, its most dramatic impact has been on the diagnosing and staging of lung cancer. It has served as an invaluable tool that has replaced mediastinoscopy in a variety of clinical scenarios. Many pulmonologists and thoracic surgeons consider CP-EBUS the most significant milestone in bronchoscopy after the development of the flexible bronchoscope itself. In this review, we summarize the historical aspects, current indications, technical approach, and future direction of CP-EBUS.
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Affiliation(s)
| | - Carlos Aravena
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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10
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Christiansen IS, Ahmad K, Bodtger U, Naur TMH, Sidhu JS, Nessar R, Salih GN, Høegholm A, Annema JT, Clementsen PF. EUS-B for suspected left adrenal metastasis in lung cancer. J Thorac Dis 2020; 12:258-263. [PMID: 32274092 PMCID: PMC7139040 DOI: 10.21037/jtd.2020.01.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Several studies have reported the efficacy of esophageal ultrasound-guided fine needle aspiration (EUS-FNA) for the detection of metastases in the left adrenal gland (LAG) in patients with lung cancer. Currently we have only limited evidence based on small studies on the usefulness of EUS-B [endobronchial ultrasound (EBUS) scope into the esophagus] to provide tissue proof of suspected LAG metastases. The objectives of this study are to investigate feasibility, safety and diagnostic yield of EUS-B-FNA in LAG analysis in patients with proven or suspected lung cancer. Methods In two Danish hospitals, a systematic search in the electronic database for patients who underwent EUS-B-FNA of the LAG for suspected or proven lung cancer was performed retrospectively between January 1st, 2015 and December 31st, 2017. Computed tomography (CT), positron emission tomography-CT, endoscopy, pathology and follow-up data were acquired. Results One hundred and thirty-five patients were included; the prevalence of biopsy proven LAG malignancy was 30% (40/135). A total of 87% (117/135) of EUS-B-FNA samples were adequate (i.e., containing adrenal or malignant cells). No complications were observed. Conclusions We present the largest cohort of patients ever reported showing that EUS-B-FNA of the LAG is a safe and feasible procedure and should therefore be used for staging purposes in patients with lung cancer and a suspicious LAG.
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Affiliation(s)
- Ida Skovgaard Christiansen
- Department of Internal Medicine, Unit of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark.,Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark
| | - Khaliq Ahmad
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark
| | - Uffe Bodtger
- Department of Internal Medicine, Unit of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark.,Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark.,Institute for Regional Health Research, University of Southern Denmark, Odense C, Denmark
| | - Therese Maria Henriette Naur
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Rafi Nessar
- Department of Internal Medicine, Unit of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Goran Nadir Salih
- Department of Internal Medicine, Unit of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Asbjørn Høegholm
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark
| | - Jouke Tabe Annema
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Paul Frost Clementsen
- Department of Internal Medicine, Unit of Respiratory Medicine, Zealand University Hospital, Roskilde, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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11
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Nessar R, Toennesen LL, Bodtger U, Christiansen IS, Clementsen PF. Endoscopic ultrasound-guided ascites aspiration in the hands of the chest physician using the EBUS endoscope in the oesophagus. Respir Med Case Rep 2020; 29:100998. [PMID: 31956479 PMCID: PMC6957818 DOI: 10.1016/j.rmcr.2020.100998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background The use of the endobronchial ultrasound (EBUS) scope in the oesophagus, the so-called EUS-B procedure, for the diagnosis and staging of lung cancer is quickly gaining ground. Case presentation We here present a case demonstrating that EUS-B guided aspiration of intraperitoneal fluid (ascites) is possible. This has never been described before. The procedure was performed with the use of a 22 G needle in a 71 years old woman suspected of lung cancer. No complications were seen. Conclusion We hereby demonstrate that EUS-B fine needle aspiration from ascites fluid is feasible and appears to be safe.
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Affiliation(s)
- Rafi Nessar
- Department of Internal Medicine, Zealand University Hospital, Roskilde, 4000, Roskilde, Denmark
| | - Louise L Toennesen
- Department of Internal Medicine, Zealand University Hospital, Roskilde, 4000, Roskilde, Denmark.,Department of Pulmonary Medicine, Bispebjerg University Hospital, 2400, Copenhagen, Denmark
| | - Uffe Bodtger
- Department of Internal Medicine, Zealand University Hospital, Roskilde, 4000, Roskilde, Denmark.,Department of Respiratory Medicine, Naestved Hospital, 4700, Naestved, Denmark.,Institute for Regional Health Research, University of Southern Denmark, 5000, Odense, Denmark
| | | | - Paul Frost Clementsen
- Department of Internal Medicine, Zealand University Hospital, Roskilde, 4000, Roskilde, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, 2100, Copenhagen, University of Copenhagen and the Capital Region of Denmark, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
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12
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Sapalidis K, Romanidis K, Oikonomou P, Zarogoulidis P, Katsaounis A, Amaniti A, Michalopoulos N, Koulouris C, Tsakiridis K, Giannakidis D, Kesisoglou I, Ioannidis A, Nikolaos-Katsios I, Vagionas A, Hohenforst-Schmidt W, Huang H, Bai C, Goganau AM, Kosmidis C. Convex endobronchial ultrasound: same coin, two faces. Challenging biopsy and staging for non-small-cell lung cancer. Lung Cancer Manag 2020; 8:LMT20. [PMID: 31983928 PMCID: PMC6978727 DOI: 10.2217/lmt-2019-0008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Lung cancer is still diagnosed at a late stage due to lack of early disease symptoms. Despite the development of new diagnostic endoscopic tools, such as radial/convex endobronchial ultrasounds (EBUS) and electromagnetic navigation, most patients are still diagnosed at advanced stage disease. Most of the patients refer to their doctor only if they cough blood or their cough changes character. There are challenging cases in the diagnosis and staging of a patient, such as the one that we will present. We present a case of lung cancer that was diagnosed through a biopsy from the main lesion, with access from the esophagus, through transbronchial needle aspiration with EBUS, under general anesthesia and intubation. Staging with transbronchial needle aspiration with EBUS was also performed at the same session.
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Affiliation(s)
- Konstantinos Sapalidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Romanidis
- Second Department of Surgery, University Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Panagoula Oikonomou
- Second Department of Surgery, University Hospital of Alexandroupolis, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Paul Zarogoulidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.,Pulmonary Department, Creta InterClinic Private Hospital, Iraklio, Crete, Greece
| | - Athanasios Katsaounis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aikaterini Amaniti
- Anesthesiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Michalopoulos
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charilaos Koulouris
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kosmas Tsakiridis
- Thoracic Surgery Department, Interbalkan European Medical Center, Thessaloniki, Greece
| | - Dimitrios Giannakidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Isaak Kesisoglou
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Ioannidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Iason Nikolaos-Katsios
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Wolfgang Hohenforst-Schmidt
- Sana Clinic Group Franken, Department of Cardiology/Pulmonology/Intensive Care/Nephrology, 'Hof' Clinics, University of Erlangen, Hof, Germany
| | - Haidong Huang
- The Diagnostic & Therapeutic Center of Respiratory Diseases, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Chong Bai
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandru Marian Goganau
- General Surgery Clinic 1, University of Medicine andPharmacy of Craiova, Craiova County Emergency Hospital, Craiova, Romania
| | - Christoforos Kosmidis
- 3rd Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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13
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Alıcı İO, Aydoğdu Z. EUS-B-FNA for Left Adrenal Lesions in Non-Small Cell Lung Cancer Patients: Report of Cases and Literature Review. Turk Thorac J 2019; 21:209-212. [PMID: 32584239 DOI: 10.5152/turkthoracj.2019.190109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/18/2019] [Indexed: 11/22/2022]
Abstract
The left adrenal gland (LAG) is a common metastatic site in patients with non-small-cell lung cancer. In practice, staging mainly relies on radiologic studies and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Recently, a new technique using convex probe-endobronchial ultrasound (CP-EBUS) scope through the esophagus (EUS-B) has been introduced. A complete mediastinal staging and a reach for upper-abdominal structures in a single session naturally attract attention. However, scientific data are not sufficient to clearly judge the role of this technique in the cytological diagnosis of left adrenal lesions. Therefore, we present cases in which our patients have undergone EUS-B for LAG lesions to increase the data in the literature with regard to accessibility, diagnostic performance, and rate of complications.
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Affiliation(s)
- İbrahim Onur Alıcı
- Department of Pulmonary Medicine, Dr. Suat Seren Training and Research Hospital for Pulmonary Diseases and Thoracic Surgery, İzmir, Turkey
| | - Zekiye Aydoğdu
- Department of Pathology, Dr. Suat Seren Training and Research Hospital for Pulmonary Diseases and Thoracic Surgery, İzmir, Turkey
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14
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Soo CI, Kho SS, Ng BH, Tie ST. Endobronchial and endoscopic ultrasound: it only takes an echobronchoscope to tango. Respirol Case Rep 2019; 7:e00482. [PMID: 31467678 PMCID: PMC6711354 DOI: 10.1002/rcr2.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/01/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022] Open
Abstract
Endobronchial ultrasound (EBUS) is indispensable when it comes to evaluation of mediastinal lesion and staging of lung cancer. The incorporation of endoscopic ultrasound using an echobronchoscope (EUS-B) further extends this capability to the paraoesophageal and subdiaphragmatic structures. When combined, EBUS with EUS-B increases the diagnostic yield. Both procedures can be done in a single session and by a single operator; this translates into an overall reduction in the healthcare cost.
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Affiliation(s)
- Chun Ian Soo
- Pulmonology Unit, Department of Internal MedicineNational University of Malaysia (UKM) Medical CentreKuala LumpurMalaysia
| | - Sze Shyang Kho
- Division of Respiratory Medicine, Department of Internal MedicineSarawak General Hospital, Ministry of HealthKuchingSarawakMalaysia
| | - Boon Hau Ng
- Pulmonology Unit, Department of Internal MedicineNational University of Malaysia (UKM) Medical CentreKuala LumpurMalaysia
| | - Siew Teck Tie
- Division of Respiratory Medicine, Department of Internal MedicineSarawak General Hospital, Ministry of HealthKuchingSarawakMalaysia
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15
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Darwiche K, Becker J, Winantea J, Karpf-Wissel R, Funke F, Stenzel E, Hautzel H, Hager T, Eisenmann S. Integration of Bronchoscopic Transesophageal Ultrasound Examination of the Left Adrenal Gland into Routine Lung Cancer Staging Workup: A Prospective Trial. Respiration 2019; 99:43-49. [PMID: 31618731 DOI: 10.1159/000503396] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/16/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound (EBUS) with transbronchial needle aspiration increases the diagnostic yield of lung cancer staging. The left adrenal gland (LAG) is a common site for lung cancer metastasis. The modality of transesophageal examination with an EBUS bronchoscope (EUS-B) routinely for LAG has not been assessed. OBJECTIVE The aim of this study was to prospectively assess if evaluation and tissue sampling of the LAG could routinely be implemented in an EBUS procedure. METHODS Patients referred for EBUS between March and August 2017 had assessment of the LAG via EUS-B. Fine-needle aspiration (FNA) was performed in cases with a suspicious LAG. The detection rate, procedure time, and learning curve of four experienced EBUS-bronchoscopists was assessed, plus the diagnostic accuracy and complication rate of FNA. RESULTS In total, 313 consecutive patients were included. The overall LAG detection rate was 87.5%. After the initial learning curve, the detection rate for all four bronchoscopists was >93%. The detection rate did not correlate with any patient characteristics. EUS-B-FNA revealed nine LAG metastases, with a sensitivity, specificity, and accuracy of 75%, 100%, and 99%, respectively. The mean EUS-B operation time was 194.4 s, with 594.8 s for FNA. There were no FNA-associated complications. CONCLUSIONS Evaluation of the LAG with EUS-B could routinely be included in an EBUS procedure if necessary. A high detection rate can be achieved after an initial learning period. FNA of the LAG was feasible and safe. EUS-B of the LAG could be integrated into the usual EBUS/EUS-B procedure in lung cancer staging workup.
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Affiliation(s)
- Kaid Darwiche
- Division of Interventional Pneumology, Department of Pulmonary Medicine, Ruhrlandklinik, University Medicine Essen, Essen, Germany,
| | - Jonathan Becker
- Division of Interventional Pneumology, Department of Pulmonary Medicine, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Jane Winantea
- Division of Interventional Pneumology, Department of Pulmonary Medicine, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Ruediger Karpf-Wissel
- Division of Interventional Pneumology, Department of Pulmonary Medicine, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Faustina Funke
- Division of Interventional Pneumology, Department of Pulmonary Medicine, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Elena Stenzel
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Hubertus Hautzel
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas Hager
- Institute of Pathology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Stephan Eisenmann
- Division of Interventional Pneumology, Department of Pulmonary Medicine, Ruhrlandklinik, University Medicine Essen, Essen, Germany.,Department of Pneumology, University Hospital of Martin Luther University, Halle (Saale), Germany
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16
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Christiansen IS, Bodtger U, Naur TMH, Ahmad K, Singh Sidhu J, Nessar R, Salih GN, Høegholm A, Annema JT, Clementsen PF. EUS-B-FNA for Diagnosing Liver and Celiac Metastases in Lung Cancer Patients. Respiration 2019; 98:428-433. [PMID: 31563907 DOI: 10.1159/000501834] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 06/30/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In patients with suspected or proven lung cancer, assessment of regional nodal and distant metastases is key before treatment planning. By introducing the endobronchial ultrasound (EBUS)-guided scope into the esophagus and stomach (EUS-B), liver lesions and celiac nodes can be visualized. To date, the utility of EUS-B in diagnosing liver lesions and retroperitoneal lymph nodes is unknown. OBJECTIVES To assess the feasibility, safety, and diagnostic yield of sampling of liver lesions and retroperitoneal nodes by EUS-B fine-needle aspiration (FNA) in a lung cancer staging setting. METHOD Consecutive patients suspected of lung cancer in 2 Danish centers between 1 January 2015 and 31 December 2017 were included retrospectively when a lesion in the liver or a retroperitoneal lymph node was visualized and biopsied with EUS-B-FNA. RESULTS 23 left liver lobe lesions and 19 retroperitoneal lymph nodes were sampled by EUS-B-FNA. Sensitivity and diagnostic yield of sampled liver lesions were 86 and 83%, respectively. In 19/23 patients, there was a cytopathological diagnosis of malignancy. Sensitivity and diagnostic yield from retroperitoneal lymph node samples were 83 and 63%, respectively. In 10/19 patients, the diagnosis was malignancy. No complications were observed. CONCLUSION EUS-B-FNA enables safe sampling of left liver lobe lesions and retroperitoneal lymph nodes. EUS-B should be considered as a minimally invasive technique to provide tissue proof of distant metastases lung cancer patients.
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Affiliation(s)
- Ida Skovgaard Christiansen
- Unit of Respiratory Medicine, Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark.,Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark
| | - Uffe Bodtger
- Unit of Respiratory Medicine, Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark.,Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark.,Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Therese Maria Henriette Naur
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Copenhagen, Denmark
| | - Khaliq Ahmad
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark
| | | | - Rafi Nessar
- Unit of Respiratory Medicine, Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Goran Nadir Salih
- Unit of Respiratory Medicine, Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Asbjørn Høegholm
- Department of Respiratory Medicine, Næstved Hospital, Næstved, Denmark
| | - Jouke Tabe Annema
- Department of Respiratory Medicine, AMC, Amsterdam University Medical Centers, Amsterdam, The Netherlands,
| | - Paul Frost Clementsen
- Unit of Respiratory Medicine, Department of Internal Medicine, Zealand University Hospital, Roskilde, Denmark.,Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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17
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Muthu V, Sehgal IS, Dhooria S, Prasad KT, Gupta N, Aggarwal AN, Agarwal R. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Techniques and Challenges. J Cytol 2019; 36:65-70. [PMID: 30745744 PMCID: PMC6343395 DOI: 10.4103/joc.joc_171_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Intrathoracic lymphadenopathy is a common problem encountered in clinical practice and is caused by a wide variety of diseases. Traditionally, the mediastinal lymph nodes were sampled using conventional transbronchial needle aspiration (TBNA), or surgical methods such as mediastinoscopy, and thoracotomy (open or video-assisted thoracoscopy). However, surgical modalities including mediastinoscopy are invasive, expensive, and not universally available. Moreover, they are associated with considerable morbidity and mortality. Conventional TBNA although minimally invasive has a low diagnostic yield. In the last decade, endobronchial ultrasound-guided TBNA (EBUS-TBNA) has emerged as the diagnostic procedure of choice in evaluating undiagnosed intrathoracic lymphadenopathy. EBUS-TBNA is also currently the preferred modality in the mediastinal staging of lung cancer. The procedure is minimally invasive, safe, and can be performed as a day-care procedure. In the era of personalized medicine in lung cancer, optimizing the procedure, sample collection, and processing are crucial, as more tissue is required for performing a wide array of molecular tests. Despite its widespread use and acceptance, the diagnostic sensitivity of EBUS-TBNA is still low. To maximize the yield, cytologists and physicians should be aware of the technical details of the procedure. Herein, we discuss the technique of performing EBUS-TBNA, its indications, contraindications, and the processing of the samples at our bronchoscopy suite. We also highlight the challenges faced by the cytologists and clinicians while processing EBUS aspirates.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy T. Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nalini Gupta
- Department of Cytology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N. Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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18
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Dietrich CF, Arcidiacono PG, Braden B, Burmeister S, Carrara S, Cui X, Leo MD, Dong Y, Fusaroli P, Gottschalk U, Healey AJ, Hocke M, Hollerbach S, Garcia JI, Ignee A, Jürgensen C, Kahaleh M, Kitano M, Kunda R, Larghi A, Möller K, Napoleon B, Oppong KW, Petrone MC, Saftoiu A, Puri R, Sahai AV, Santo E, Sharma M, Soweid A, Sun S, Bun Teoh AY, Vilmann P, Seifert H, Jenssen C. What should be known prior to performing EUS exams? (Part II). Endosc Ultrasound 2019; 8:360-369. [PMID: 31571619 PMCID: PMC6927139 DOI: 10.4103/eus.eus_57_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In “What should be known prior to performing EUS exams, Part I,” the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?
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Affiliation(s)
- Christoph F Dietrich
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Neubrandenburg; Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Paolo Giorgio Arcidiacono
- Pancreatico/Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Rozzano, Milan, Italy
| | - Barbara Braden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford OX3 9DU, England
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Silvia Carrara
- Humanitas Clinical and Research Center- IRCCS- Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Milan, Italy
| | - Xinwu Cui
- Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Milena Di Leo
- Humanitas Clinical and Research Center- IRCCS- Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Milan, Italy
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna/Imola Hospital, Imola, Italy
| | - Uwe Gottschalk
- Medical Department, Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany
| | - Andrew J Healey
- General and HPB Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Hocke
- Medical Department, Helios Klinikum Meiningen, Meiningen, Germany
| | - Stephan Hollerbach
- Department of Gastroenterology, Allgemeines Krankenhaus Celle, Celle, Germany
| | - Julio Iglesias Garcia
- Department of Gastroenterology and Hepatology, Health Research Institute of Santiago de Compostela, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - André Ignee
- Medical Department 2, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Neubrandenburg, Germany
| | | | - Michel Kahaleh
- Department of Gastroenterology, The State University of New Jersey, New Jersey, USA
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark; Department of Surgery and Department of Advanced Interventional Endoscopy, University Hospital Brussels, Brussels, Belgium, France
| | - Alberto Larghi
- Digestive Endoscopy Unit, IRCCS Foundation University Hospital, Policlinico A. Gemelli, Rome, Italy
| | - Kathleen Möller
- Medical Department I/Gastroenterology, SANA Hospital Lichtenberg, Berlin, Germany
| | - Bertrand Napoleon
- Digestive Endoscopy Unit, Hopital Privé J Mermoz Ramsay Générale de Santé, Lyon, France
| | - Kofi W Oppong
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne, England
| | - Maria Chiara Petrone
- Pancreatico/Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Rozzano, Milan, Italy
| | - Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Rajesh Puri
- Interventional Gastroenterology, Institute of Digestive and Hepatobiliary Sciences, Medanta the Medicity, Gurugram, Haryana, India
| | - Anand V Sahai
- Center Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Erwin Santo
- Department of Gastroenterology and Liver Diseases, Tel Aviv, Sourasky Medical Center, Tel Aviv, Israel
| | - Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India
| | - Assaad Soweid
- Division of Gastroenterology, Endosonography and Advanced Therapeutic Endoscopy, The American University of Beirut, Medical Center, Beirut, Lebanon
| | - Siyu Sun
- Endoscopy Center, ShengJing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Division of Upper Gastrointestinal and Metabolic Surgery, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Peter Vilmann
- Department of Surgery, GastroUnit, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - Hans Seifert
- Department of Gastroenterology, Klinikum Oldenburg, Oldenburg, Germany
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany
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19
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Tamburrini M, Gothi D, Barbetta C, Del Conte A, Sulfaro S, Zuccon U. Esophageal ultrasound with ultrasound bronchoscope (EUS-B) guided left adrenal biopsy: Case report with review of literature. Respir Med Case Rep 2018; 26:154-156. [PMID: 30603608 PMCID: PMC6310773 DOI: 10.1016/j.rmcr.2018.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/18/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022] Open
Abstract
A 45-year old man, chronic smoker with a pancoast tumor due to squamous cell carcinoma has been described. The initial diagnosis of lung carcinoma was based on a scant tissue so the exact cell typing was not possible. The initial treatment consisted of platinum based chemotherapy and radiotherapy. He developed a left adrenal lesion on treatment. There was a possibility of metachronous primary. Also, a large tissue sample was required for tumor markers. The lung mass was difficult to access and was static on treatment. A left adrenal biopsy was considered to be more appropriate. A novel approach for left adrenal lesion with esophageal ultrasound using ultrasound bronchoscope (EUS-B) was successfully performed. This article is aimed at describing the use of EUS-B for transdiaphragmatic structures.
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Affiliation(s)
- Mario Tamburrini
- Department of Pulmonary Medicine, Santa Maria degli Angeli di Pordenone, Italy
| | - Dipti Gothi
- Department of Pulmonary Medicine, ESI-PGIMSR, Delhi, India
| | - Carlo Barbetta
- Department of Pulmonary Medicine, Santa Maria degli Angeli di Pordenone, Italy
| | | | - Sandro Sulfaro
- Department of Pathology, Santa Maria degli Angeli di Pordenone, Italy
| | - Umberto Zuccon
- Department of Pulmonary Medicine, Santa Maria degli Angeli di Pordenone, Italy
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20
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Dong Q, Fu L, Zhao Y, Du Y, Li Q, Qiu X, Wang E. Rab11a promotes proliferation and invasion through regulation of YAP in non-small cell lung cancer. Oncotarget 2018; 8:27800-27811. [PMID: 28468127 PMCID: PMC5438609 DOI: 10.18632/oncotarget.15359] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/09/2017] [Indexed: 12/25/2022] Open
Abstract
Rab11a, an evolutionarily conserved Rab GTPases, plays important roles in intracellular transport and has been implicated in cancer progression. However, its role in human non-small cell lung cancer (NSCLC) has not been explored yet. In this study, we discovered that Rab11a protein was upregulated in 57/122 NSCLC tissues. Rab11a overexpression associated with advanced TNM stage, positive nodal status and poor patient prognosis. Rab11a overexpression promoted proliferation, colony formation, invasion and migration with upregulation of cyclin D1, cyclin E, and downregulation of p27 in NSCLC cell lines. Nude mice xenograft demonstrated that Rab11a promoted in vivo cancer growth. Importantly, we found that Rab11a induced YAP protein and inhibited Hippo signaling. Depletion of YAP abolished the effects of Rab11a on cell cycle proteins and cell proliferation. Furthermore, immunoprecipitation showed that Rab11a interacted with YAP in lung cancer cells. In conclusion, the present study suggestes that Rab11a serves as an important oncoprotein and a regulator of YAP in NSCLC.
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Affiliation(s)
- Qianze Dong
- Department of Pathology, First Affiliated Hospital and College of Basic Medical Science, China Medical University, Shenyang, China
| | - Lin Fu
- Department of Pathology, First Affiliated Hospital and College of Basic Medical Science, China Medical University, Shenyang, China
| | - Yue Zhao
- Department of Pathology, First Affiliated Hospital and College of Basic Medical Science, China Medical University, Shenyang, China
| | - Yaming Du
- Department of Cardiovascular Thoracic Surgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Qingchang Li
- Department of Pathology, First Affiliated Hospital and College of Basic Medical Science, China Medical University, Shenyang, China
| | - Xueshan Qiu
- Department of Pathology, First Affiliated Hospital and College of Basic Medical Science, China Medical University, Shenyang, China
| | - Enhua Wang
- Department of Pathology, First Affiliated Hospital and College of Basic Medical Science, China Medical University, Shenyang, China
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21
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Wimaleswaran H, Farmer MW, Irving LB, Jennings BR, Steinfort DP. Pulmonologist-performed transoesophageal sampling for lung cancer staging using an endobronchial ultrasound video-bronchoscope: an Australian experience. Intern Med J 2017; 47:205-210. [PMID: 27860078 DOI: 10.1111/imj.13330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/16/2016] [Accepted: 11/03/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transoesophageal endobronchial ultrasound (EBUS) video-bronchoscope insertion provides pulmonologists access to conduct endoscopic fine-needle aspiration (EUS-B-FNA) of mediastinal lymph node (LN) lesions and also assist in lung cancer staging by sampling left adrenal gland (LAG) lesions. Limited literature has described additional diagnostic value whilst maintaining patient safety. To elicit whether combining endoscopic transoesophageal fine-needle aspiration using convex probe bronchoscope (EUS-B-FNA) and EBUS bronchoscopy enhances the diagnostic yield of mediastinal nodal staging in lung cancer, whilst maintaining safety. METHODS All eligible patients with paraoesophageal lesions on thoracic computed tomography (CT) underwent pulmonologist-performed EUS-B-FNA at two tertiary centres and were included in this prospective observational cohort study. RESULTS EUS-B-FNA sampling was performed at 69 mediastinal LN lesion sites, including 17 sites inaccessible to bronchoscopic sampling. Four LAG lesions were sampled via EUS-B-FNA. There were no complications. EBUS-TBNA was augmented by EUS-B-FNA because of accessibility of sampling lesions otherwise unamenable bronchoscopically, thereby increasing diagnostic utility. Diagnostic sensitivity of EUS-B-FNA for malignancy in mediastinal LN lesions was 88% (51 of 58). For mediastinal LN lesions not amenable to EBUS-TBNA, the sensitivity for diagnosis of malignancy via EUS-B-FNA was 88% (15 of 17). Diagnostic sensitivity of EUS-B-FNA for malignancy in LAG lesions was 50% (2 of 4). CONCLUSION EUS-B-FNA is a precise and safe approach in the evaluation and staging of lung cancer when performed by a pulmonologist. It complements and increases the diagnostic utility of EBUS-TBNA by further coverage of mediastinal LN stations and access to LAG lesions.
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Affiliation(s)
- Hari Wimaleswaran
- Deparment of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael W Farmer
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Louis B Irving
- Deparment of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Barton R Jennings
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Daniel P Steinfort
- Deparment of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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22
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Liu L, Zhou XM, Yang FF, Miao Y, Yin Y, Hu XJ, Hou G, Wang QY, Kang J. TRIM22 confers poor prognosis and promotes epithelial-mesenchymal transition through regulation of AKT/GSK3β/β-catenin signaling in non-small cell lung cancer. Oncotarget 2017; 8:62069-62080. [PMID: 28977927 PMCID: PMC5617487 DOI: 10.18632/oncotarget.18911] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 05/23/2017] [Indexed: 01/21/2023] Open
Abstract
Expression pattern and biological roles of TRIM22 remains unknown in most human cancers. The present study aims to discover its clinical significance and function in human non-small cell lung cancer (NSCLC). Immunohistochemistry was used to examine TRIM22 expression in 126 cases of NSCLC specimens. TRIM22 protein was upregulated in 70/126 (55.6%) non-small cell lung cancer tissues compared with normal lung tissue. TRIM22 overexpression was associated with advanced TNM stage, positive nodal metastasis and poor prognosis. Plasmid and siRNA transfection were performed in lung cancer cell lines. TRIM22 overexpression promoted proliferation, colony formation and invasion in A549 cells. While its depletion exhibited the opposite effects in H1299 cell line. TRIM22 overexpression promoted cell cycle progression through regulation of cyclin D1, cyclin E and p27. TRIM22 also changed the expression of epithelial to mesenchymal transition (EMT) markers including E-cadherin N-cadherin, Vimentin and Snail. Furthermore, TRIM22 activated PI3K/AKT/GSK3β/β-catenin oncogenic signaling pathways. Treatment with PI3K inhibitor LY294002 and β-catenin siRNA blocked the effects of TRIM22 on EMT in TRIM22-overexpressing cells. In conclusion,TRIM22 serves as an important oncoprotein and a promoter of cell proliferation and invasion through AKT/ GSK3β/β-catenin induced EMT in NSCLC.
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Affiliation(s)
- Li Liu
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Xiao-Ming Zhou
- Department of Respiratory Medicine, The Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Fang-Fei Yang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Yuan Miao
- Department of Pathology, The First Hospital and College of Basic Medical Sciences, China Medical University, Shenyang 110001, China
| | - Yan Yin
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Xue-Jun Hu
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Gang Hou
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Qiu-Yue Wang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Jian Kang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang 110001, China
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23
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Marchand C, Medford AR. Relationship between endobronchial ultrasound-guided (EBUS)-transbronchial needle aspiration utility and computed tomography staging, node size at EBUS, and positron emission tomography scan node standard uptake values: A retrospective analysis. Thorac Cancer 2017; 8:285-290. [PMID: 28436173 PMCID: PMC5494455 DOI: 10.1111/1759-7714.12438] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) diagnoses and stages mediastinal lymph node pathology. This retrospective study determined the relationship between EBUS-TBNA utility and non-small cell lung cancer (NSCLC) stage, lymph node size, and positron emission tomography (PET) standard uptake values (SUV), and the utility of neck ultrasound in bulky mediastinal disease. METHODS Data of 284 consecutive patients who had undergone EBUS-TBNA was collected. Two hundred patients had suspected NSCLC, with 148 confirmed NSCLC cases. The diagnostic utility of EBUS-TBNA was determined according to NSCLC stage, EBUS lymph node size, PET SUV, use in distal metastases, and mutation testing. The utility of neck ultrasound for N3 disease was calculated in patients with bulky mediastinal disease. RESULTS EBUS-TBNA was well tolerated with 97% sensitivity in distant metastatic disease, avoiding the need for distal metastases biopsy in 81% of cases. It had equivalent diagnostic accuracy in all NSCLC stages and in lymph nodes <10 mm, <20 mm or >20 mm (sensitivity >92% in all cases), with no mutation testing failures. EBUS-TBNA had 33% sensitivity in PET indolent (SUV < 4) nodes and 79% sensitivity in PET active nodes (SUV > 4). EBUS-TBNA diagnosed 12 cases of lymphoma without flow cytometry. CONCLUSIONS The use of EBUS-TBNA meant that distant metastatic biopsy was avoided in 81% of cases, performing well irrespective of cancer stage, node size, and facilitating mutation testing. Neck ultrasound failed to detect N3 disease in patients with bulky mediastinal disease. EBUS-TBNA had a sensitivity of 33% for metastases in PET negative nodes, highlighting PET limitations.
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Affiliation(s)
- Clare Marchand
- North Bristol Lung CentreNorth Bristol NHS Trust, Southmead HospitalBristolUK
| | - Andrew R.L. Medford
- North Bristol Lung CentreNorth Bristol NHS Trust, Southmead HospitalBristolUK
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Sanz-Santos J, Serra P, Andreo F, Torky M, Centeno C, Morán T, Carcereny E, Fernández E, García-Reina S, Ruiz-Manzano J. Transbronchial and transesophageal fine-needle aspiration using a single ultrasound bronchoscope in the diagnosis of locoregional recurrence of surgically-treated lung cancer. BMC Pulm Med 2017; 17:46. [PMID: 28241873 PMCID: PMC5330131 DOI: 10.1186/s12890-017-0388-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/22/2017] [Indexed: 12/18/2022] Open
Abstract
Background The present study sought to evaluate the usefulness of EBUS-TBNA in the diagnosis of locoregional recurrence of lung cancer in a cohort of lung cancer patients who were previously treated surgically, and describe our initial experience of EUS-B-FNA in this clinical scenario. Methods We retrospectively studied the clinical records of all patients with a previous surgically-treated lung cancer who were referred to our bronchoscopy unit after suspicion of locoregional recurrence. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy of EBUS-TBNA for the diagnosis of locoregional recurrence were evaluated. Results Seventy-three patients were included. EBUS-TBNA confirmed malignancy in 40 patients: 34 confirmed to have locoregional recurrence, six had metachronous tumours. Of the 33 patients with non-malignant EBUS-TBNA; 2 had specific non-malignant diseases, 26 underwent radiological follow up and 5 patients underwent surgery. Of the 26 patients who had radiological follow up; 18 remained stable, three presented thoracic radiological progression and 5 presented extrathoracic progression. Of the 5 patients who underwent surgery; 3 had metachronous tumours, one confirmed to be a true negative and one presented nodal invasion. Seven patients underwent EUS-B-FNA, four of them confirmed to have recurrence. The sensitivity, specificity, NPV, PPV and overall accuracy of EBUS-TBNA for the diagnosis of locoregional recurrence were 80.9, 100, 69.2, 100 and 86.6% respectively. Conclusions EBUS-TBNA is an accurate procedure for the diagnosis of locoregional recurrence of surgically-treated lung cancer. EUS-B-FNA combined with EBUS-TBNA broads the diagnostic yield of EBUS-TBNA alone.
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Affiliation(s)
- José Sanz-Santos
- Pulmonology Department, Hospital Germans Trias i Pujol, Carretera de Canyet S/N. 08916, Badalona, Barcelona, Spain.
| | - Pere Serra
- Pulmonology Department, Hospital Germans Trias i Pujol, Carretera de Canyet S/N. 08916, Badalona, Barcelona, Spain.,Department de Medicina. Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Felipe Andreo
- Pulmonology Department, Hospital Germans Trias i Pujol, Carretera de Canyet S/N. 08916, Badalona, Barcelona, Spain
| | - Mohamed Torky
- Pulmonology Department, Hospital Germans Trias i Pujol, Carretera de Canyet S/N. 08916, Badalona, Barcelona, Spain
| | - Carmen Centeno
- Pulmonology Department, Hospital Germans Trias i Pujol, Carretera de Canyet S/N. 08916, Badalona, Barcelona, Spain
| | - Teresa Morán
- Catalan Institute of Oncology, Badalona, Barcelona, Spain
| | - Enric Carcereny
- Thoracic Surgery Department, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Esther Fernández
- Thoracic Surgery Department, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Samuel García-Reina
- Thoracic Surgery Department, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Juan Ruiz-Manzano
- Pulmonology Department, Hospital Germans Trias i Pujol, Carretera de Canyet S/N. 08916, Badalona, Barcelona, Spain
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Abstract
INTRODUCTION In patients with lung cancer, left adrenal glands (LAG) suspected for distant metastases (M1b) based on imaging require further evaluation for a definitive diagnosis. Tissue acquisition is regularly performed using conventional EUS-FNA. The aim of this study was to investigate the success rate of endoscopic ultrasound guided fine-needle aspiration using the EBUS scope (EUS-B-FNA) for LAG analysis. METHODS This is a prospective multicenter study in consecutive patients with (suspected) lung cancer and suspected mediastinal and LAG metastases. Following complete mediastinal staging using the EBUS scope (EBUS+EUS-B), the LAG was evaluated and sampled by both EUS-B (experimental procedure) and conventional EUS (current standard of care). RESULTS The success rate for LAG analysis (visualized, sampled and adequate tissue obtained) was 89% (39/44; 95% CI 76-95%) for EUS-B-FNA, and 93% (41/44; 95%CI 82-98%) for EUS-FNA. In the absence of metastases at EUS-B and/or EUS, surgical verification of the LAG or 6 months clinical and radiological follow-up was obtained, but missing for 5 patients. The prevalence of LAG metastases was 54% (21/39). In patients in whom LAG was seen and sampled, sensitivity for LAG metastases was at least 87% (95%CI 65-97%) for EUS-B, and at least 83% (95%CI 62-95%) for conventional EUS. CONCLUSION LAG analysis by EUS-B shows a similar high success rate in comparison to conventional EUS. IMPLICATION Both a mediastinal nodal and LAG evaluation can be adequately performed with just an EBUS scope and single endoscopist. This staging strategy is likely to reduce patient-burden and costs.
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Fally M, Nessar R, Behrendt N, Clementsen PF. Endoscopic Ultrasound-Guided Liver Biopsy in the Hands of a Chest Physician. Respiration 2016; 92:53-5. [PMID: 27287428 DOI: 10.1159/000446924] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/09/2016] [Indexed: 11/19/2022] Open
Abstract
Liver biopsy using transesophageal bronchoscopic ultrasound-guided fine needle aspiration (EUS-B-FNA) has never been described before and biopsies of infradiaphragmatic lesions using this technique are not considered to be standard. A patient suspected for primary lung cancer with multiple lesions in the liver was referred to our department. We conducted bronchoscopy and endobronchial ultrasound-guided (EBUS) biopsy from several enlarged mediastinal lymph nodes. Thereafter, we conducted EUS-B-FNA from a lesion in the left liver lobe. Pathology showed that the liver lesion represented a metastasis from a pulmonary adenocarcinoma. Bronchoscopy and EBUS samples were not able to establish diagnosis. We hereby demonstrated that a diagnostic EUS-B-FNA from a liver metastasis in a patient with lung cancer is possible. This underlines that chest physicians should not forget the esophagus when staging lung cancer.
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Affiliation(s)
- Markus Fally
- Department of Internal Medicine, Zealand University Hospital Roskilde, Roskilde, Denmark
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