Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging

A prospective, open-label, randomized clinical trial to evaluate the efficacy and safety of remimazolam in patients undergoing EBUS-TBNA: REST trial design

BACKGROUND

Remimazolam is safe and effective for moderate sedation during flexible bronchoscopy, but its safety and efficacy during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) remains undetermined. The REST trial (NCT06275594) will be a prospective randomized study of remimazolam in patients undergoing EBUS-TBNA with conscious sedation. The primary aim is to evaluate whether remimazolam is safe and effective for moderate sedation during EBUS-TBNA compared to real-world midazolam and on-label midazolam.

METHODS

The REST trial will recruit 330 patients from four university hospitals with mediastinal lesions suspected of being lung cancer who are eligible for EBUS-TBNA under moderate sedation. The participants will be randomized into groups using remimazolam, real-world midazolam, and on-label midazolam (US prescribing information dosage) to perform EBUS-TBNA for procedural sedation. The primary endpoint will be procedural success using composite measures.

DISCUSSION

The REST trial will prospectively evaluate the efficacy and safety of remimazolam during EBUS-TBNA under moderate sedation. It will provide information for optimizing sedation modalities and contribute to practical benefits in patients undergoing EBUS-TBNA.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT06275594). Prospectively registered on 15 February 2024.

Impact of rapid on-site evaluation in expediting the fast investigative lung cancer pathway

OBJECTIVE

EBUS-TBNA is a method of acquiring tissue samples from intrathoracic lymph nodes and central intrathoracic tumours in patients suspected of having lung cancer. Rapid on-site evaluation (ROSE) denotes assessing tissue samples during EBUS (or bronchoscopy), providing instant feedback on sample adequacy and provisional cytomorphological diagnosis. Sector multidisciplinary team (MDT) discussion can then make informed treatment decisions, with confirmatory immunohistochemistry being finalised before provision of final treatment. Currently, impact of ROSE on length of time patients spend on the lung cancer diagnostic pathway remains unclear.

METHODS

We retrospectively evaluated the impact of ROSE on the length of time between patients' EBUS/bronchoscopy procedures and discussion at sector MDT, referred to as time to treatment decision (TTD), at our institution. Additionally, we assessed impact of ROSE on number of passes (number of times nodes/masses were sampled) per procedure.

RESULTS

The mean TTD was 77.9% shorter (p = 0.001) with ROSE present than when absent. Patients who received ROSE spend 34.3% less time (p = 0.028) on lung cancer diagnostic pathway overall. There was a significant reduction in number of passes in non-malignant nodes with ROSE present (2.23) than when absent (3.14) (p < 0.001). With ROSE present there was a significantly greater number of passes at malignant sites (5.07) than non-malignant sites (2.23) (p < 0.001).

CONCLUSIONS

These findings support conclusions made in our institution's previous study, that utilisation of ROSE reduces TTD. ROSE also allows safe advancement through nodes with low suspicion of malignant involvement, focusing time on sampling nodes/masses of greater suspicion.

Transbronchial needle aspiration combined with cryobiopsy in the diagnosis of mediastinal diseases: a multicentre, open-label, randomised trial

BACKGROUND

Transbronchial mediastinal cryobiopsy is a novel sampling technique for mediastinal disease. Despite the possibility of lung cancer misdiagnosis, the improved diagnostic yield of this approach for non-lung-cancer lesions compared with standard endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) highlights its diagnostic potential as a complementary technique to conventional biopsy. We aimed to evaluate the safety profile and added value of the combined use of transbronchial mediastinal cryobiopsy and standard EBUS-TBNA for the diagnosis of mediastinal diseases.

METHODS

We conducted an open-label, randomised trial at three hospital sites in Europe and Asia. Eligible patients were aged 15 years or older, with at least one mediastinal lesion of 1 cm or longer in the short axis that required diagnostic bronchoscopy. Participants were randomly assigned (1:1) using a block randomisation scheme generated by a computer (block size of four participants based on a random table from an independent statistician) to the combined use of EBUS-TBNA and transbronchial mediastinal cryobiopsy (combined group) or EBUS-TBNA alone (control group). Because of the nature of the intervention, neither participants nor investigators were masked to group assignment. The coprimary outcomes were differences in procedure-related complications and diagnostic yield (defined as the proportion of participants for whom mediastinal biopsy led to a definitive diagnosis), assessed in the full analysis set, including all the patients who met the eligibility criteria and had a biopsy. A fully paired, intraindividual diagnostic analysis in participants who had both needle aspiration and mediastinal cryobiopsy was conducted, in addition to interindividual comparisons. This trial is now complete and is registered with ClinicalTrials.gov, NCT04572984.

FINDINGS

Between Oct 12, 2020, and Sept 9, 2021, 297 consecutive patients were assessed for eligibility and 271 were enrolled and randomly assigned to the combined group (n=136) or the control group (n=135). The addition of cryobiopsy to standard sampling significantly increased the overall diagnostic yield for mediastinal lesions, as shown by both interindividual (126 [93%] of 136 participants in the combined group vs 109 [81%] of 135 in the control group; risk ratio [RR] 1·15 [95% CI 1·04-1·26]; p=0·0039) and intraindividual (126 [94%] of 134 vs 110 [82%] of 134; RR 1·15 [95% CI 1·05-1·25]; p=0·0026) analyses. In subgroup analyses in the intraindividual population, diagnostic yields were similar for mediastinal metastasis (68 [99%] of 69 participants in the combined group vs 68 [99%] of 69 in the control group; RR 1·00 [95% CI 0·96-1·04]; p=1·00), whereas the combined approach was more sensitive than standard needle aspiration in benign disorders (45 [94%] of 48 vs 32 [67%] of 48; RR 1·41 [95% CI 1·14-1·74]; p=0·0009). The combined approach also resulted in an improved suitability of tissue samples for molecular and immunological analyses of non-small-cell lung cancer. The incidence of adverse events related to the biopsy procedure did not differ between trial groups, as grade 3-4 airway bleeding occurred in three (2%) patients in the combined group and two (1%) in the control group (RR 0·67 [95% CI 0·11-3·96]; p=1·00). There were no severe complications causing death or disability.

INTERPRETATION

The addition of mediastinal cryobiopsy to standard EBUS-TBNA resulted in a significant improvement in diagnostic yield for mediastinal lesions, with a good safety profile. These data suggest that this combined approach is a valid first-line diagnostic tool for mediastinal diseases.

FUNDING

National Natural Science Foundation of China.

Integral mediastinal staging in patients with NON-SMALL cell lung cancer and risk factors for occult N2 disease

BACKGROUND

In patients with non-small cell lung cancer (NSCLC), the presence of abnormal hiliar lymph nodes (clinical N1; cN1), central tumor location and/or tumor size (diameter >3 cm) increases the risk of occult mediastinal metastasis (OMM). This study investigates prospectively the diagnostic value of an integral mediastinal staging (IMS) strategy that combines EndoBronchial Ultrasound-TransBronchial Needle Aspiration (EBUS-TBNA) and Video-Assisted Mediastinoscopy (VAM) in patients with NSCLC at risk of OMM.

METHODS

Patients with NSCLC and radiologically normal mediastinum assessed non-invasively by positron emission tomography and computed tomography of the chest (PET-CT), and OMM risk factors (cN1, central tumor and/or >3 cm) underwent EBUS-TBNA followed by VAM if the former was negative. Those with negative IMS underwent resection surgery of the tumor.

RESULTS

EBUS-TBNA identified OMM in 2 out of the 49 patients evaluated (4%) and VAM in 1 of the 47 patients with negative EBUS (2%). Two patients with a negative IMS had OMM at surgery. Overall, the prevalence of OMM was 10%. EBUS-TBNA has a sensitivity of 40%, a negative predictive value (NPV) of 93.6%, and negative likelihood ratio of 0.60 (95%CI:0.30-1.16). The risk of not diagnosing OMM after EBUS was 6% and after IMS was 4.4%.

CONCLUSION

Integral mediastinal staging in patients with NSCLC and clinical risk factors for OMM, does not seem to provide added diagnostic value to that of EBUS-TBNA, except perhaps in patients with cN1 disease who deserve further research.

Efficient procedure planning for comprehensive lymph node staging bronchoscopy

Purpose: For a patient at risk of having lung cancer, accurate disease staging is vital as it dictates disease prognosis and treatment. Accurate staging requires a comprehensive sampling of lymph nodes within the chest via bronchoscopy. Unfortunately, physicians are generally unable to plan and perform sufficiently comprehensive procedures to ensure accurate disease staging. We propose a method for planning comprehensive lymph node staging procedures. Approach: Drawing on a patient's chest CT scan, the method derives a multi-destination tour for efficient navigation to a set of lymph nodes. We formulate the planning task as a traveling salesman problem. To solve the problem, we apply the concept of ant colony optimization (ACO) to derive an efficient airway tour connecting the target nodes. The method has three main steps: (1) CT preprocessing, to define important chest anatomy; (2) graph and staging zone construction, to set up the necessary data structures and clinical constraints; and (3) tour computation, to derive the staging plan. The plan conforms to the world standard International Association for the Study of Lung Cancer (IASLC) lymph node map and recommended clinical staging guidelines. Results: Tests with a patient database indicate that the method derives optimal or near-optimal tours in under a few seconds, regardless of the number of target lymph nodes (mean tour length = 1.4% longer than the optimum). A brute force optimal search, on the other hand, generally cannot reach a solution in under 10 min. for patients exhibiting > 16 nodes, and other methods provide poor solutions. We also demonstrate the method's utility in an image-guided bronchoscopy system. Conclusions: The method provides an efficient computational approach for planning a comprehensive lymph node staging bronchoscopy. In addition, the method shows promise for driving an image-guided bronchoscopy system or robotics-assisted bronchoscopy system tailored to lymph node staging.

Steffen2 R. EBUS-TBNA versus mediastinoscopy for mediastinal staging of lung cancer: a cost-minimization analysis

Objective:

To assess cost differences between EBUS-TBNA and mediastinoscopy for mediastinal staging of non-small cell lung cancer (NSCLC).

Methods:

This was an economic evaluation study with a cost-minimization analysis. We used a decision analysis software program to construct a decision tree model to compare the downstream costs of mediastinoscopy, EBUS-TBNA without surgical confirmation of negative results, and EBUS-TBNA with surgical confirmation of negative results for the mediastinal staging of NSCLC. The study was conducted from the perspective of the Brazilian public health care system. Only direct medical costs were considered. Results are shown in Brazilian currency (Real; R$) and in International Dollars (I$).

Results:

For the base-case analysis, initial evaluation with EBUS-TBNA without surgical confirmation of negative results was found to be the least costly strategy (R$1,254/I$2,961) in comparison with mediastinoscopy (R$3,255/I$7,688) and EBUS-TBNA with surgical confirmation of negative results (R$3,688/I$8,711). The sensitivity analyses also showed that EBUS-TBNA without surgical confirmation of negative results was the least costly strategy. Mediastinoscopy would become the least costly strategy if the costs for hospital supplies for EBUS-TBNA increased by more than 300%. EBUS-TBNA with surgical confirmation of negative results, in comparison with mediastinoscopy, will be less costly if the prevalence of mediastinal lymph node metastasis is ≥ 38%.

Conclusions:

This study has demonstrated that EBUS-TBNA is the least costly strategy for invasive mediastinal staging of NSCLC in the Brazilian public health care system.

Multimodal Registration for Image-Guided EBUS Bronchoscopy

The state-of-the-art procedure for examining the lymph nodes in a lung cancer patient involves using an endobronchial ultrasound (EBUS) bronchoscope. The EBUS bronchoscope integrates two modalities into one device: (1) videobronchoscopy, which gives video images of the airway walls; and (2) convex-probe EBUS, which gives 2D fan-shaped views of extraluminal structures situated outside the airways. During the procedure, the physician first employs videobronchoscopy to navigate the device through the airways. Next, upon reaching a given node’s approximate vicinity, the physician probes the airway walls using EBUS to localize the node. Due to the fact that lymph nodes lie beyond the airways, EBUS is essential for confirming a node’s location. Unfortunately, it is well-documented that EBUS is difficult to use. In addition, while new image-guided bronchoscopy systems provide effective guidance for videobronchoscopic navigation, they offer no assistance for guiding EBUS localization. We propose a method for registering a patient’s chest CT scan to live surgical EBUS views, thereby facilitating accurate image-guided EBUS bronchoscopy. The method entails an optimization process that registers CT-based virtual EBUS views to live EBUS probe views. Results using lung cancer patient data show that the method correctly registered 28/28 (100%) lymph nodes scanned by EBUS, with a mean registration time of 3.4 s. In addition, the mean position and direction errors of registered sites were 2.2 mm and 11.8∘, respectively. In addition, sensitivity studies show the method’s robustness to parameter variations. Lastly, we demonstrate the method’s use in an image-guided system designed for guiding both phases of EBUS bronchoscopy.

High SUVmax Is an Independent Predictor of Higher Diagnostic Accuracy of ROSE in EBUS-TBNA for Patients with NSCLC

Introduction: This study aimed to verify the predictors of the diagnostic accuracy of rapid on-site evaluation (ROSE) in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) among patients with non-small cell lung cancer (NSCLC). Methods: We retrospectively reviewed consecutive patients with NSCLC who underwent EBUS-TBNA for staging or diagnosis at our hospital from June 2016 to June 2018. The patients were divided into two groups—those with a correct diagnosis and an incorrect diagnosis after ROSE. Kaplan−Meier plots and log-rank tests were used to estimate outcomes. Results: A total of 84 patients underwent EBUS-TBNA for staging and diagnosis. Sixty patients with demonstrated malignant mediastinal lymph nodes were enrolled. In the univariate analysis, lymph nodes < 1.5 cm (HR = 3.667, p = 0.031) and a SUVmax > 5 (HR = 41, p = 0.001) were statistically significant for diagnostic accuracy of ROSE. In the multivariate Cox regression analysis, only a SUVmax > 5 (HR = 20.258, p = 0.016) was statistically significant. Conclusions: A SUVmax > 5 is an independent predictor of higher diagnostic accuracy of ROSE in EBUS-TBNA in patients with NSCLC with malignant mediastinal lymph nodes. Therefore, ROSE in patients with a SUVmax < 5 might not be reliable and requires further prudent assessment (more shots or repeated biopsies at mediastinal LNs) in clinical practice.

Predicting malignant pleural effusion during diagnostic pleuroscopy with biopsy: A prospective multicentre study

BACKGROUND AND OBJECTIVE

Pleuroscopy with pleural biopsy has a high sensitivity for malignant pleural effusion (MPE). Because MPEs tend to recur, concurrent diagnosis and treatment of MPE during pleuroscopy is desired. However, proceeding directly to treatment at the time of pleuroscopy requires confidence in the on-site diagnosis. The study's primary objective was to create a predictive model to estimate the probability of MPE during pleuroscopy.

METHODS

A prospective observational multicentre cohort study of consecutive patients undergoing pleuroscopy was conducted. We used a logistic regression model to evaluate the probability of MPE with relation to visual assessment, rapid on-site evaluation (ROSE) of touch preparation and presence of pleural nodules/masses on computed tomography (CT). To assess the model's prediction accuracy, a bootstrapped training/testing approach was utilized to estimate the cross-validated area under the receiver operating characteristic curve.

RESULTS

Of the 201 patients included in the study, 103 had MPE. Logistic regression showed that higher level of malignancy on visual assessment is associated with higher odds of MPE (OR = 34.68, 95% CI = 9.17-131.14, p < 0.001). The logistic regression also showed that higher level of malignancy on ROSE of touch preparation is associated with higher odds of MPE (OR = 11.63, 95% CI = 3.85-35.16, p < 0.001). Presence of pleural nodules/masses on CT is associated with higher odds of MPE (OR = 6.61, 95% CI = 1.97-22.1, p = 0.002). A multivariable logistic regression model of final pathologic status with relation to visual assessment, ROSE of touch preparation and presence of pleural nodules/masses on CT had a cross-validated AUC of 0.94 (95% CI = 0.91-0.97).

CONCLUSION

A prediction model using visual assessment, ROSE of touch preparation and CT scan findings demonstrated excellent predictive accuracy for MPE. Further validation studies are needed to confirm our findings.

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.

Crown-Cut Endobronchial Ultrasound Guided Transbronchial Aspiration Needle: First Real-World Experiences

Advancements in personalized medicine have increased the demand for quantity and preservation of tissue architecture of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples. These demands may be addressed by the SonoTip TopGain^® needle, which has a 3-point crown-cut design that contrasts with the standard single bevel design of the ViziShot 2^®. The objective was to compare the SonoTip TopGain^® and ViziShot 2^® needles by considering biopsy sample characteristics, diagnostic accuracy, and patient safety. The primary endpoint of the study was the number of high-power fields (HPFs) in the center of the formalin-fixed paraffin-embedded cell block per sample. The lymph node with the highest probability for malignant infiltration based on size and sonographic appearance was chosen as the target lymph node for 20 patients. The same lymph node in each patient was sampled using both the ViziShot 2^® and SonoTip TopGain^® needles. The samples were measured, sliced, and analyzed by a pathologist. Sixteen patients were biopsied with both needles. Four patients could not be biopsied with the SonoTip TopGain^® needle since it could not penetrate cartilage or be repositioned to bypass cartilage. HPFs and sample dimensions were significantly greater in the patients where sampling with the SonoTip TopGain^® needle was possible (p = 0.007 and p = 0.005, respectively). Diagnostic accuracy and safety profiles were comparable. Significantly more material can be sampled using the SonoTip TopGain^® needle when cartilage penetration can be avoided. This improves the yield for molecular workup in the era of personalized medicine.

Linear Endobronchial Ultrasound in the Era of Personalized Lung Cancer Diagnostics-A Technical Review

Major advances in molecular profiling for available targeted treatments and immunotherapy for lung cancer have significantly increased the complexity of tissue-based diagnostics. Endobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNA) are commonly performed for diagnostic biopsies and lymph node staging. EBUS-TBNA has increasingly become one of the main sources of tumor cells for molecular analyses. As a result, there is a growing need for high quality EBUS-TBNA samples with adequate cellularity. This has increased the technical demands of the procedure and has created additional challenges, many of which are not addressed in the current EBUS guidelines. This review provides an overview of current evidence on the technical aspects of EBUS-TBNA in light of comprehensive sample processing for personalized lung cancer management. These include sonographic lymph node characterization, optimal needle choice, suction biopsy technique, and the role of rapid on-site evaluation. Attention to these technical details will be important to maximize the throughput of EBUS-TBNA biopsies for molecular testing.

Image-guided EBUS bronchoscopy system for lung-cancer staging

The staging of the central-chest lymph nodes is a major step in the management of lung-cancer patients. For this purpose, the physician uses a device that integrates videobronchoscopy and an endobronchial ultrasound (EBUS) probe. To biopsy a lymph node, the physician first uses videobronchoscopy to navigate through the airways and then invokes EBUS to localize and biopsy the node. Unfortunately, this process proves difficult for many physicians, with the choice of biopsy site found by trial and error. We present a complete image-guided EBUS bronchoscopy system tailored to lymph-node staging. The system accepts a patient’s 3D chest CT scan, an optional PET scan, and the EBUS bronchoscope’s video sources as inputs. System workflow follows two phases: (1) procedure planning and (2) image-guided EBUS bronchoscopy. Procedure planning derives airway guidance routes that facilitate optimal EBUS scanning and nodal biopsy. During the live procedure, the system’s graphical display suggests a series of device maneuvers to perform and provides multimodal visual cues for locating suitable biopsy sites. To this end, the system exploits data fusion to drive a multimodal virtual bronchoscope and other visualization tools that lead the physician through the process of device navigation and localization. A retrospective lung-cancer patient study and follow-on prospective patient study, performed within the standard clinical workflow, demonstrate the system’s feasibility and functionality. For the prospective study, 60/60 selected lymph nodes (100%) were correctly localized using the system, and 30/33 biopsied nodes (91%) gave adequate tissue samples. Also, the mean procedure time including all user interactions was 6 min 43 s All of these measures improve upon benchmarks reported for other state-of-the-art systems and current practice. Overall, the system enabled safe, efficient EBUS-based localization and biopsy of lymph nodes.

Comparing diagnostic sensitivity of different needle sizes for lymph nodes suspected of lung cancer in endobronchial ultrasound transbronchial needle aspiration: Systematic review and meta-analysis

BACKGROUND

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a safe and minimally invasive procedure for evaluating hilar and mediastinal lymph nodes. The reported sensitivity and specificity of EBUS-TBNA are 95% and 97%, respectively. A comparison of diagnostic sensitivity for lymph nodes suspected of lung cancer according to needle size in EBUS-TBNA is needed.

OBJECTIVES

To compare the diagnostic sensitivity of the 19-G, 21-G, 22-G and 25-G needles for lymph nodes suspected of non-small cell lung cancer (NSCLC) using EBUS-TBNA.

METHODS

A literature search from PubMed, EMBASE, LILACS, DOAJ and CENTRAL through October 2020 was performed by two reviewers. The extracted data were evaluated using STATA® and Open Meta Analyst software for meta-analysis with a binary method model to compare sensitivity, specificity and summary receiver operating characteristic curve for each needle size.

RESULTS

Fourteen studies including 1296 participants were considered for the analysis. The overall sensitivity of EBUS-TBNA was 88.2% (95% CI 84%, 91%) and 93% (95% CI 88%, 95%) for the 19-G needle, 87.6% (95% CI 79.6%, 92.8%) for the 21-G needle and 85% (95% CI 80%, 88%) for the 22-G needle. The overall sensitivity of EBUS-TBNA for diagnosing NSCLC was 88.3% (95% CI, 81%, 93%) and 92.9% (95% CI, 85%, 97%) for the 19-G needle, 89.4% (95% CI 79.4%, 94.8%) for the 21-G needle and 82.1% (95% CI 66%, 91%) for the 22-G needle.

CONCLUSION

The 19-G, 21-G and 22-G needles present a similarly high diagnostic sensitivity in EBUS-TBNA. The 19-G needle provided better sample adequacy for molecular and immunohistochemical testing, improving diagnostic yield in this subgroup.

Utility and Safety of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Diagnosis of Isolated Mediastinal Masses

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a valuable tool for diagnosing pulmonary disease due to its efficiency and safety. We retrospectively analyzed patients with mediastinal masses who underwent diagnostic EBUS-TBNA at Shanghai Chest Hospital, and evaluated the clinical accuracy of EBUS-TBNA in the diagnosis mediastinal masses.

Method

From 2009 and 2014, patients who received EBUS-TBNA to diagnose a isolated mediastinal mass were enrolled. Clinical follow-up was performed to ascertain the patient’s final diagnosis.

Results

Forty-six patients were enrolled in this study. Thirty-seven were diagnosed with an oncologic disease, 3 were diagnosed with a mediastinal infection, and 2 were found to have a mediastinal goiter. The overall sensitivity, specificity, positive predictive value, negative predictive value, diagnostic yield was 63.6%, 100%, 100%, 42.9%, and 71.4%, respectively.

Conclusion

EBUS-TBNA is a safe and effective means of diagnosing mediastinal masses.

Comparison of technical success and safety of transbronchial versus percutaneous CT-guided fiducial placement for SBRT of lung tumors

OBJECTIVE

To evaluate the technical success and safety of transbronchial (bronchoscopic) fiducial placement compared to percutaneous CT-guided fiducial placement for stereotactic body radiotherapy (SBRT) of lung tumors.

MATERIALS AND METHODS

This IRB-approved, HIPAA-compliant retrospective study was performed at a single tertiary institution. Consecutive patients undergoing lung fiducial placement for purposes of guiding SBRT (CyberKnife®, Accuray, Inc.) between September 2005 to January 2013 were included in the study. Fiducial seeds were placed percutaneously with CT guidance or transbronchially with bronchoscopic guidance. We compared procedure-related complications (pneumothorax, chest tube placement), technical success (defined as implantation enabling adequate treatment planning with CT simulation) and migration rate. The need for repeat procedures and their mode was noted. Statistical analysis was performed using Fisher exact and Chi square probability tests.

RESULTS

Two hundred and forty-four patients with lung tumors and 272 fiducial seed placements were included in the study. Two hundred and twenty-one of the 272 (81.2%) fiducial markers were placed percutaneously and 51/272 (18.8%) were placed transbronchially. Pneumothorax was seen in 73/221 (33%) of percutaneously-placed fiducials and in 4/51 (7.8%) of transbronchial placements (p<0.001). No significant difference was seen in the rate of chest tube placement between the two groups: 20/221 (9%) of percutaneously placed fiducials and 2/51 (3.9%) of transbronchially placed fiducials (p=0.39). Fifteen of the 51 (29%) of fiducial placements with transbronchial approach were unsuccessful, as discovered at radiotherapy planning session, and required a repeat procedure. Nine of the 15 (60%) of repeat procedures were performed percutaneously, 5/15 (33%) were placed during repeat bronchoscopy, and 1/15 (7%) was placed at transesophageal endoscopic ultrasound. No repeat fiducial placements were required for patients who had the fiducials placed percutaneously (p<0.001), with a technical success rate of 100%.

CONCLUSION

Transbronchial fiducial marker placement has a significantly higher rate of failed seed placements requiring repeat procedures in comparison to percutaneous placement. Complication rate of pneumothorax requiring chest drain placement is similar between the two approaches.

Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal lesions: a randomised trial

BACKGROUND

Guidelines recommend endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as an initial investigation technique for mediastinal nodal staging in lung cancer. However, EBUS-TBNA can be limited by the inadequacy of intact tissues, which might restrict its diagnostic yield in mediastinal lesions of certain etiologies. We have previously shown that EBUS-guided transbronchial mediastinal cryobiopsy can provide intact samples with greater volume.

METHODS

This randomised study determined the diagnostic yield and safety of transbronchial mediastinal cryobiopsy monitored by endosonography for the diagnosis of mediastinal lesions. Patients with mediastinal lesion of 1 cm or more in the short axis were recruited. Following identification of the mediastinal lesion by linear EBUS, fine-needle aspiration and cryobiopsy were sequently performed in a randomised order. Primary endpoints were diagnostic yield defined as the percentage of patients for whom mediastinal biopsy provided a definite diagnosis, and procedure-related adverse events.

RESULTS

One hundred and ninety-seven patients were enrolled and randomly allocated. The overall diagnostic yield was 79.9% and 91.8% for TBNA and transbronchial mediastinal cryobiopsy, respectively (p=0.001). Diagnostic yields were similar for metastatic lymphadenopathy (94.1% versus 95.6%, p=0.58), while cryobiopsy was more sensitive than TBNA in uncommon tumors (91.7% versus 25.0%, p=0.001) and benign disorders (80.9% versus 53.2%, p=0.004). No significant differences in diagnostic yield were detected between TBNA first and cryobiopsy first groups. We observed 2 cases of pneumothorax and 1 case of pneumomediastinum.

CONCLUSIONS

Transbronchial cryobiopsy performed under EBUS guidance is a safe and useful approach that offers diagnostic histological samples of mediastinal lesions.

Mediastinal lymphadenopathy: a practical approach

Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.

Predicting Lymph Node Metastasis in Non-small Cell Lung Cancer: Prospective External and Temporal Validation of the HAL and HOMER Models

BACKGROUND

Two models, the Help with the Assessment of Adenopathy in Lung cancer (HAL) and Help with Oncologic Mediastinal Evaluation for Radiation (HOMER), were recently developed to estimate the probability of nodal disease in patients with non-small cell lung cancer (NSCLC) as determined by endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). The objective of this study was to prospectively externally validate both models at multiple centers.

RESEARCH QUESTION

Are the HAL and HOMER models valid across multiple centers?

STUDY DESIGN AND METHODS

This multicenter prospective observational cohort study enrolled consecutive patients with PET-CT clinical-radiographic stages T1-3, N0-3, M0 NSCLC undergoing EBUS-TBNA staging. HOMER was used to predict the probability of N0 vs N1 vs N2 or N3 (N2|3) disease, and HAL was used to predict the probability of N2|3 (vs N0 or N1) disease. Model discrimination was assessed using the area under the receiver operating characteristics curve (ROC-AUC), and calibration was assessed using the Brier score, calibration plots, and the Hosmer-Lemeshow test.

RESULTS

Thirteen centers enrolled 1,799 patients. HAL and HOMER demonstrated good discrimination: HAL ROC-AUC = 0.873 (95%CI, 0.856-0.891) and HOMER ROC-AUC = 0.837 (95%CI, 0.814-0.859) for predicting N1 disease or higher (N1|2|3) and 0.876 (95%CI, 0.855-0.897) for predicting N2|3 disease. Brier scores were 0.117 and 0.349, respectively. Calibration plots demonstrated good calibration for both models. For HAL, the difference between forecast and observed probability of N2|3 disease was +0.012; for HOMER, the difference for N1|2|3 was -0.018 and for N2|3 was +0.002. The Hosmer-Lemeshow test was significant for both models (P = .034 and .002), indicating a small but statistically significant calibration error.

INTERPRETATION

HAL and HOMER demonstrated good discrimination and calibration in multiple centers. Although calibration error was present, the magnitude of the error is small, such that the models are informative.

Predictors of mediastinal staging and usefulness of pet in patients with stage IIIA (N2) or IIIB (N3) lung cancer

OBJECTIVE

To analyze which factors predict mediastinal N2/N3 lymph node staging and diagnostic accuracy of PET and CT to determine it.

PATIENTS AND METHODS

We analyzed data collected prospectively in a database that included patients with non-small cell lung cancer (NSCLC) who underwent EBUS-TBNA. Prior to EBUS-TBNA, CT and PET were used to define the radiographic N stage and lymph nodes with short axis ≥ 1 cm by CT or with ratio between maximum standardized uptake value (maxSUV), by PET, of lymph node and primary tumor greater than 0.56, were considered pathological. Definitive lymph node staging was established through EBUS-TBNA, mediastinoscopy or surgical lymph node dissection.

RESULTS

One hundred and thirty four patients were included, in 88 of whom (65.6%), definitive lymph node staging was N2 or N3. Primary tumor of central location, lymph node size, maxSUV of lymph node and radiographic N stage by CT or PET were associated with N2/N3 in univariate analysis, but in logistic regression model it was only independently related with N stage by CT or PET. Negative predictive value and positive predictive value of CT were 0.81 and 0.74, respectively, and for PET 0.78 and 0.68.

CONCLUSION

In NSCLC, in locoregional disease radiographic staging by CT or PET predict the existence of N2/N3 mediastinal disease, but negative and positive predictive values of both imaging techniques are not adequate, so EBUS-TBNA samples should be taken in all lymph nodes with a diameter greater than 5 mm, regardless of PET findings.

Is Biopsy of Contralateral Hilar N3 Lymph Nodes With Negative PET-CT Scan Findings Necessary When Performing Endobronchial Ultrasound Staging?

BACKGROUND

Systematic endobronchial ultrasound (EBUS)-guided lung cancer staging starts with hilar N3 nodes, proceeding sequentially to mediastinal N3, N2, and N1 nodes, with sampling of all enlarged nodes (size, ≥ 5 mm) by EBUS. However, procedure time is limited by patient comfort when moderate sedation is used. It is unclear if EBUS staging should start with hilar N3 nodes or whether starting with mediastinal N3 nodes suffices. Knowing the probability of hilar N3 nodes with PET-CT scan negative findings harboring occult metastasis can inform this decision.

RESEARCH QUESTION

What proportion of patients with hilar N3 nodes showing negative PET-CT scan findings have malignancy by EBUS?

STUDY DESIGN AND METHODS

This retrospective observational, single-center cohort study included consecutive patients with clinical-radiographic T1-3, N0-3, M0 non-small cell lung cancer undergoing systematic EBUS staging with biopsy of hilar N3 nodes with negative PET-CT scan findings. The primary outcome was the proportion of patients with malignant hilar N3 nodes showing negative PET-CT scan findings. Based on expert opinion, a threshold probability of malignancy of less than 5% was considered sufficient to skip hilar N3 nodes. We used the binomial exact test to compare the observed proportion vs threshold probability of 5%.

RESULTS

Of 1,737 consecutive patients undergoing EBUS staging, 1,567 showed negative PET-CT scan findings of the hilar N3 nodes. These nodes were enlarged by EBUS and were sampled in 739 patients. Malignancy was found in the hilar N3 nodes of 5 of 739 patients (0.68%; 95% CI, 0.22%-1.57%). The proportion was significantly less than the threshold probability (P < .001). Patients with positive PET scan results of the mediastinal N3 nodes were at higher risk of having occult hilar N3 nodal metastasis (P = .003), found in 3 of 46 patients (6.5%; 95% CI, 1.4%-17.9%) with positive PET scan results of the mediastinal N3 nodes.

INTERPRETATION

When using moderate sedation, because time is limited, it is reasonable to start with the mediastinal N3 nodes if the hilar and mediastinal N3 nodes show negative PET scan results. Patients with positive PET scan findings of the mediastinal N3 nodes probably should undergo hilar N3 node sampling.

Endobronchial ultrasound-guided transbronchial needle aspiration versus mediastinoscopy for mediastinal staging of lung cancer: A systematic review of economic evaluation studies

Introduction

The emergence of endobronchial ultrasound (EBUS) changed the approach to staging lung cancer. As a new method being incorporated, the use of EBUS may lead to a shift in clinical and costs outcomes.

Objective

The aim of this systematic review is to gather information to better understand the economic impact of implementing EBUS.

Methods

This review is reported according to the PRISMA statement and registered on PROSPERO (CRD42019107901). Search keywords were elaborated considering descriptors of terms related to the disease (lung cancer / mediastinal staging of lung cancer) and the technologies of interest (EBUS and mediastinoscopy) combined with a specific economic filter. The literature search was performed in MEDLINE, EMBASE, LILACS, Cochrane Library of Trials, Web of Science, Scopus and National Health System Economic Evaluation Database (NHS EED) of the Center for Reviews and Dissemination (CRD). Screening, selection of articles, data extraction and quality assessment were carried out by two reviewers.

Results

Seven hundred and seventy publications were identified through the database searches. Eight articles were included in this review. All publications are full economic evaluation studies, one cost-effectiveness, three cost-utility, and four cost-minimization analyses. The costs of strategies using EBUS-TBNA were lower than the ones using mediastinoscopy in all studies analyzed. Two of the best quality scored studies demonstrate that the mediastinoscopy strategy is dominated by the EBUS-TBNA strategy.

Conclusion

Information gathered in the eight studies of this systematic review suggest that EBUS is cost-effective compared to mediastinoscopy for mediastinal staging of lung cancer.

Endobronchial ultrasound-guided transbronchial needle aspiration can improve the diagnostic accuracy of positron emission tomography/computed tomography in hilar and/or mediastinal lymphadenopathy

Context

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and positron emission tomography/computed tomography (PET/CT) are the two most extensively used methods for the diagnosis and staging of lung cancer.

Aims

The present study was designed to compare the diagnostic performance of EBUS-TBNA with that of PET/CT in patients with hilar and/or mediastinal lymphadenopathy.

Settings and Design

We compared the accuracy of EBUS-TBNA with that of PET/CT in the diagnosis of hilar and/or mediastinal lymphadenopathy and evaluated the diagnostic utility of EBUS-TBNA in patients with PET/CT false-positive and false-negative findings.

Methods

This study retrospectively analyzed 85 patients with hilar and/or mediastinal lymphadenopathy who underwent EBUS-TBNA and PET/CT between January 2014 and December 2017. The accuracy of EBUS-TBNA histopathology and cytopathology was evaluated and compared with PET/CT scan findings.

Results

The diagnostic accuracy of EBUS-TBNA combined with PET/CT was significantly higher than that of the single diagnostic method (P < 0.001). Among PET/CT-negative lymph nodes, 4 of 9 (44.4%) malignant lymph nodes were identified by EBUS-TBNA. Among PET/CT-positive lymph nodes, 43 of 47 (91.5%) benign lymph nodes were diagnosed by EBUS-TBNA.

Conclusions

EBUS-TBNA combined with PET/CT could effectively reduce false-positive and false-negative rates in the diagnosis of hilar and mediastinal lymphadenopathy, which might provide accurate staging, determine optimum therapeutic strategy and improve survival in patients with lung cancer.

An International Survey of Mediastinal Staging Practices amongst Interventional Bronchoscopists

INTRODUCTION

In potentially curable non-small-cell lung cancer, different practice guidelines recommend invasive me-diastinal staging in tumors larger than 3 cm, central, or hy-permetabolic N1 lymph nodes. There is no consensus concerning the use of an endosonographic procedure or a mediastinoscopy in the first line in patients with a radiologically normal mediastinum, while in case of a mediastinal involvement, the latest European guidelines recommend the combination of endobronchial ultrasound (EBUS) and endoscopic ultrasound/endoscopic ultrasound with EBUS endoscope (EUS/EUS-B), using a systematic endosonographic procedure. This international survey was conducted to describe current medical practices in endoscopic mediastinal staging amongst interventional bronchoscopists.

METHODS

A survey was developed and sent to all members of different interventional pulmonology societies, with the purpose to describe who, when and how an endoscopic mediastinal staging was performed.

RESULTS

One hundred and fifty-three bronchoscopists responded to the survey. Most of them practiced in Europe (n = 84, 55%) and North America (n = 52, 34%). In the first line, EBUS alone was the most widely used endoscopic procedure for mediastinal staging. Half of the responders performed a systematic endoscopic staging procedure, including a systematic examination of all accessible nodal stations and a sampling of all lymph nodes >5 mm in the short axis at each station. A higher proportion of bronchoscopists who have completed a dedicated fellowship program performed systematic endoscopic mediastinal staging. Few endoscopists routinely perform combined EBUS/EUS(-B) for mediastinal staging and use the combination only in selected cases.

CONCLUSION

There are several areas of divergence between published guidelines and current practices reported by interventional bronchoscopists. EBUS alone is the most widely used endoscopic procedure for mediastinal staging in lung cancer, and a combined endoscopic approach is frequently omitted by the responders. A fellowship program appears to be associated with a higher rate of systematic endoscopic staging procedures.

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.

Risk factors for pulmonary infection after diagnostic bronchoscopy in patients with lung cancer

Pulmonary infection is a relatively rare but serious complication of flexible bronchoscopy. The aim of this study was to identify the risk factors for pulmonary infectious complications after diagnostic bronchoscopy in patients with lung cancer. We retrospectively analyzed the medical records of 636 patients who underwent bronchoscopic biopsy for lung cancer diagnosis between April 2011 and March 2016. We compared patients' characteristics, chest computed tomography and bronchoscopic findings, undertaken procedures, and final diagnoses between patients who developed the complication and those who did not. Pulmonary infection after the diagnostic bronchoscopy occurred in 19 patients (3.0%) and included pneumonia in 16 patients and lung abscess in 3. Patients with larger lesions, presence of endobronchial lesions, histology of small cell lung cancer, and advanced disease stage tended to develop pulmonary infectious complications more often. Our multivariate analysis revealed that a larger lesion size and the presence of endobronchial lesions were independently associated with post-bronchoscopy pulmonary infection. Although we found no mortality associated with the infections, two patients were left with significant performance status deterioration after the pulmonary infection and received no anticancer treatment. In conclusion, endobronchial lesions and a larger lesion size are independent risk factors for the incidence of infections following bronchoscopic biopsy in patients with lung cancer.

Displaced Cartilage Within Lymph Node Parenchyma Is a Novel Biopsy Site Change in Resected Mediastinal Lymph Nodes Following EBUS-TBNA

Biopsy site changes in mediastinal lymph nodes (LNs) attributable to prior endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have not been studied in a systematic manner. Twenty-four contributors from 14 institutions in 5 countries collaborated via social media (Twitter) to retrospectively review consecutive cases of resected mediastinal LNs from patients with prior EBUS-TBNA. Resected LNs were reexamined by submitting pathologists for changes attributable to EBUS-TBNA. Patients who received neoadjuvant therapy were excluded. Cases with suspected biopsy site changes underwent central review by 5 pathologists. A total of 297 mediastinal LN resection specimens from 297 patients (183 male/114 female, mean age: 65 y, range: 23 to 87) were reviewed. Biopsy site changes were most common in station 7 (10 cases) followed by 11R, 4R, and 10R, and were found in 34/297 (11.4%) cases, including displacement of tiny cartilage fragments into LN parenchyma in 26, intranodal or perinodal scars in 7, and hemosiderin in 1. Cartilage fragments ranged from 0.26 to 1.03 mm in length and 0.18 to 0.62 mm in width. The mean interval between EBUS-TBNA and LN resection was 38 days (range: 10 to 112) in cases with biopsy site changes. A control group of 40 cases without prior EBUS-TBNA, including 193 mediastinal LN stations, showed no evidence of biopsy site changes. Biopsy site changes are identified in a subset of resected mediastinal LNs previously sampled by EBUS-TBNA. The location of the abnormalities, temporal association with prior EBUS-TBNA, and the absence of such findings in cases without prior EBUS-TBNA support the contention that they are caused by EBUS-TBNA.

Small cell lung cancer: Recent changes in clinical presentation and prognosis

BACKGROUND

Small cell lung cancer (SCLC) is a leading cause of death all over the world. Diagnostic and therapeutic arsenals have improved in recent years, but we are unsure as to whether these advances have been transferred to clinical practice. The aim of this study was to evaluate differences in SCLC diagnostic processes and short-term survival rates between two recent cohorts.

METHODS

A prospective, observational study was conducted with patients diagnosed with SCLC (either at extensive or limited stages) in the 2011-2016 period. Patients were divided into two cohorts (2011-2013 and 2014-2016) and followed up for 1 year after diagnosis.

RESULTS

Around 713 patients with lung cancer were selected, 134 of whom had SCLC (74 patients in the 2011-2013 cohort and 60 in the 2014-2016 cohort). We observed a chronological increase in the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) and positron emission tomography-computed tomography (PET-CT) between the cohorts. Overall, short-term survival was similar between the two groups and improved survival was associated with age and limited stage.

CONCLUSIONS

Changes in diagnostic process in SCLC have been observed towards a more precise stadification. Although short-term survival has not changed for SCLC, it is unclear that the real benefit of PET-CT and EBUS-TBNA is far from correct disease staging.

Diagnostic value of rapid on-site evaluation during endobronchial ultrasound with a guide sheath for peripheral pulmonary lesions

OBJECTIVE

To evaluate the applied value of rapid on-site evaluation during endobronchial ultrasound (EBUS) with a guide sheath for peripheral pulmonary lesions (PPLs).

METHODS

Consecutive patients who underwent EBUS with a guide sheath for PPLs at our hospital from December 2015 to June 2017 in this retrospective study. The samples obtained from each operation were made rapid on-site evaluation at the same time. The results of rapid on-site evaluation were compared with the pathological diagnosis.

RESULTS

A total of 127 PPLs in 124 patients were included in the study. 70 lesions were malignancy in the final pathological diagnosis. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of rapid on-site evaluation for malignancy during EBUS with a guide sheath for PPLs was 88.6%, 98.2%, 98.4%, 87.5% and 92.9%, respectively.

CONCLUSIONS

Rapid on-site evaluation during EBUS with a guide sheath has a high diagnostic value for malignant PPLs.

Endobronchial ultrasound-guided transbronchial needle aspiration versus mediastinoscopy for mediastinal staging of lung cancer: A protocol for a systematic review of economic evaluation studies

BACKGROUND

Lung cancer is a major health problem, with estimates of 1.6 million tumor-related deaths annually worldwide. The emergence of endobronchial ultrasound (EBUS), a minimally invasive procedure capable of providing valuable information for primary tumor diagnosis and mediastinal staging, significantly changed the approach of pulmonary cancer, becoming part of the routine mediastinal evaluation of lung cancer in developed countries. Some economic evaluation studies published in the last 10 years have already analyzed the incorporation of the EBUS technique in different health systems. The aim of this systematic review is to synthesize the relevant information brought by these studies to better understand the economic effect of the implementation of this staging tool.

METHODS

The systematic review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Eletronic databases (Medline, Lilacs, Embase, Cochrane Library of Trials, Web of Science, Scopus, National Health System Economic Evaluation Database) will be searched for full economic analyses regarding the use of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) compared to the surgical technique of mediastinoscopy for the mediastinal staging of lung cancer. Two authors will perform the selection of studies, data extraction, and the assessment of risk of bias. Occasionally, a senior reviewer will participate, if necessary, on study selection or data extraction.

RESULTS

Results will be published in a peer-reviewed journal.

CONCLUSION

This review may influence a more cost-effective mediastinal staging approach for patients with lung cancer around the world and help health decision makers decide whether the EBUS-TBNA technique should be incorporated into their health systems and how to do it efficiently.

PROTOCOL REGISTRY

PROSPERO 42019107901.

Interventional Pulmonology: A Focused Review for Primary Care Physicians

Interventional pulmonology (IP) has evolved in recent decades, and recent advances have greatly expanded the services offered by IP physicians. IP is best defined as the use of advanced techniques for the evaluation and treatment of benign and malignant pulmonary disorders. The field has further advanced with the recent establishment of a board certification via the American Association of Bronchology and Interventional Pulmonology and the release in 2017 of accreditation standards for specialized fellowship training. This article provides a broad overview of the field to serve as a resource for primary care physicians.

Systematic and combined endosonographic staging of lung cancer (SCORE study)

Guidelines recommend endosonography for mediastinal nodal staging in patients with resectable nonsmall cell lung cancer (NSCLC). We hypothesise that a systematic endobronchial ultrasound (EBUS) evaluation combined with an oesophageal investigation using the same EBUS bronchoscope (EUS-B) improves mediastinal nodal staging versus the current practice of targeted positron emission tomography (PET)-computed tomography (CT)-guided EBUS staging alone.A prospective, multicentre, international study (NCT02014324) was conducted in consecutive patients with (suspected) resectable NSCLC. After PET-CT, patients underwent systematic EBUS and EUS-B. Node(s) suspicious on CT, PET, EBUS and/or EUS-B imaging and station 4R, 4L and 7 (short axis ≥8 mm) were sampled. For patients without N2/N3 disease determined on endosonography, surgical-pathological staging was the reference standard.229 patients were included in this study. The prevalence of N2/N3 disease was 103 out of 229 patients (45%). A PET-CT-guided targeted approach by EBUS identified 75 patients with N2/N3 disease (sensitivity 73%, 95% CI 63-81%; negative predictive value (NPV) 81%, 95% CI 74-87%). Four additional patients with N2/N3 disease were found by systematic EBUS (sensitivity 77%, 95% CI 67-84%; NPV 84%, 95% CI 76-89%) and five more by EUS-B (84 patients total; sensitivity 82%, 95% CI 72-88%; NPV 87%, 95% CI 80-91%). Additional clinical relevant staging information was obtained in 23 out of 229 patients (10%).Systematic EBUS followed by EUS-B increased sensitivity for the detection of N2/N3 disease by 9% compared to PET-CT-targeted EBUS alone.

18F-fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of clinically node-negative non-small cell lung cancer

One in four non-small cell lung cancer (NSCLC) patients are diagnosed at an early-stage. Following the results of the National Lung Screening Trial that demonstrated a survival benefit for low-dose computed tomography screening in high-risk patients, the incidence of early-stage NSCLC is expected to increase. Use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography during initial diagnosis of these early-stage lesions has been increasing. Traditionally, positron emission tomography/computed tomography scans have been utilized for mediastinal nodal staging and to rule out distant metastases in suspected early-stage NSCLC. In clinically node-negative NSCLC, the use of sublobar resection and selective lymph node dissection has been increasing as a therapeutic option. The higher rate of locoregional recurrences after limited resection and the significant incidence of occult lymph node metastases underscores the need to further stratify clinically node-negative NSCLC in order to select patients for limited resection versus lobectomy with complete mediastinal lymph node dissection. In this report, we review the published data, and discuss the significance and potential role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography evaluation for clinically node-negative NSCLC. Consequently, the literature review demonstrates that maximum standardized uptake value is a predictive factor for occult nodal metastasis with an accuracy of 55-77%. In addition, maximum standardized uptake value is a predictor for worse overall, as well as disease-free, survival.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Use for Subclassification and Genotyping of Lung Non-Small-Cell Carcinoma

OBJECTIVES

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the primary method for the diagnosis and staging of lung cancer. The purpose of this study was to assess the yield of EBUS-TBNA in the subtyping and genotyping of lung adenocarcinoma.

METHODS

Sixty-nine patients at Indiana University Hospital and Sidney and Lois Eskenazi Hospital with possible or confirmed lung adenocarcinoma underwent EBUS-TBNA using a 21-gauge Olympus needle without suction. Samples were sent for molecular testing after rapid onsite specimen evaluation. A total of 6 to 10 passes were placed in a cell block.

RESULTS

Sixty-nine samples from patients with non-small-cell lung cancer were sent for molecular testing for epidermal growth factor receptor. Results were obtained in all of the patients. Mutations were found in three patients (4.3%). Fifty-eight samples were sent for V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog (100% yield), 10 of which had mutations (17.2%). Fifty-one samples were sent for proto-oncogene tyrosine-protein kinase ROS testing (1 [7.8%] mutant). Tissue samples were inadequate in three patients (94.1% yield). Sixty-three samples were sent for anaplastic lymphoma receptor tyrosine kinase testing (3 [4.8%] mutant, 6 [9.5%] inadequate, 90.5% yield).

CONCLUSIONS

EBUS-TBNA with a 21-gauge needle is appropriate for the analysis of multiple mutations and the genotyping of lung adenocarcinoma.

First Evaluation of the Next-Generation Endobronchial Ultrasound System in Preclinical Models

BACKGROUND

The next-generation convex probe endobronchial ultrasound (CP-EBUS) was developed to improve the ease of operation and the acquisition of EBUS skills for new trainees. The aim of this study was to evaluate the changes in the prototype next-generation CP-EBUS compared with the current CP-EBUS.

METHODS

The prototype next-generation CP-EBUS, with a decreased forward oblique view, more flexible angulation range, smaller ultrasound probe, and sharper needle angle, was compared with the current CP-EBUS. The operability, which was evaluated by using a 5-level Likert-type scale, and safety were evaluated in 2 live pigs, a cadaveric lung, and 10 ex vivo human lungs by 9 bronchoscopists. The time required to access the upper lobe bronchus and the time required to detect prespecified lymph node stations by 7 novice bronchoscopists with both CP-EBUS were compared with assess the operability difference for new trainees.

RESULTS

In all evaluated models, operability (eg, maneuverability, endoscopic visibility, bronchial trees selectivity, insertability to the upper airway) was scored 5 (significantly improved). All trainee bronchoscopists were able to access the upper lobe bronchi and detect each lymph node except 4R significantly faster than with the current CP-EBUS without any airway damage.

CONCLUSIONS

The next-generation CP-EBUS has improved operability, which resulted in better access to each lobar bronchus and more prompt detection of mediastinal or hilar lymph nodes. These improvements may allow more precise lymph node staging and diagnosis, as well as improve EBUS procedural skill acquisition, once introduced to clinical practice.

Determining factors of endobronchial ultrasound-guided transbronchial needle aspiration specimens for lung cancer subtyping and molecular testing

Objective:

This study is to explore the determining factors for testing epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) fusion after subtyping by immunohistochemistry (IHC) using samples obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Materials and Methods:

Patients suspected with advanced lung cancer were performed EBUS-TBNA without rapid on-site evaluation(ROSE) from January 2015 to March 2016 in Shanghai Chest Hospital. All samples diagnosed as lung cancer by histopathology underwent IHC to identify subtypes. EGFR mutation and ALK fusion were tested in adenocarcinoma and non-small-cell lung cancer-not otherwise specified (NSCLC-NOS) using remnant tissue samples.

Results:

A total of 453 patients were diagnosed with lung cancer, including 44.15% (200/453) with adenocarcinoma and 11.04% (50/453) with NSCLC-NOS. With the average passes of 3.41 ± 0.68, samples obtained from EBUS-TBNA were adequate for performing EGFR mutation and ALK fusion gene analysis in 80.4% (201/250) of specimens after routine IHC. On univariate analysis, successful molecular testing was associated with passes per lesion (P = 3.80E-05), long-axis diameters (P = 6.00E-06) and short-axis diameters (P = 4.77E-04), and pathology subtypes of lesions (P = 3.00E-03). Multivariate logistic regression revealed that passes per lesion (P = 1.00E-03), long-axis diameters (P = 3.50E-02), and pathology subtypes (P = 8.00E-03) were independent risk factors associated with successful molecular testing.

Conclusions:

With at least three passes of per lesion, EBUS-TBNA is an efficient method to provide adequate samples for testing of EGFR mutation and ALK gene arrangement following routine histopathology and IHC subtyping. Determining factors associated with successful pathology subtyping and molecular testing using samples obtained by EBUS-TBNA are passes of per lesion, long-axis diameter, and pathology subtypes. During the process of EBUS-TBNA, selecting larger lymph nodes and the puncturing at least 3 passes per lesion may result in higher success rate in lung cancer subtyping and molecular testing.

Use of an Additional 19-G EBUS-TBNA Needle Increases the Diagnostic Yield of EBUS-TBNA

BACKGROUND

Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has an excellent diagnostic yield, there remain cases where the diagnosis is not obtained. We hypothesized that additional sampling with a 19-G EBUS-TBNA needle may increase diagnostic yield in a subset of cases where additional tissue sampling was required.

METHODS

Indications for use of the 19-G needle following 22-G sampling with rapid on-site cytologic examination were: (1) diagnostic uncertainty of the on-site cytopathologist (eg, nondiagnostic, probable lymphoma, etc.), (2) non-small cell lung cancer with probable need for molecular genetic and/or PD-L1 testing, or (3) need for a larger tissue sample for consideration of inclusion in a research protocol.

RESULTS

A 19-G EBUS-TBNA needle was utilized following standard sampling with a 22-G needle in 48 patients (50 sites) during the same procedure. Although the diagnostic yield between the needles was equivalent, the concordance rate was only 83%. The 19-G determined a diagnosis in 4 additional patients (8%) and provided additional histopathologic information in 6 other cases (12%). Conversely, in 3 cases (6%) diagnostic information was provided only by the 22-G needle. Compared with 22-G EBUS-TBNA alone, sampling with both the 22- and 19-G EBUS needles resulted in an increase in diagnostic yield from 92% to 99% (P=0.045) and a number needed to sample of 13 patients to provide one additional diagnosis. There were no significant complications.

CONCLUSION

In select cases where additional tissue may be needed, sampling with a 19-G EBUS needle following standard aspiration with a 22-G needle results in an increase in diagnostic yield.

Diagnostic Yield and Safety of Bronchoscopist-directed Moderate Sedation With a Bolus Dose Administration of Propofol During Endobronchial Ultrasound Bronchoscopy

BACKGROUND

The propofol use for moderate sedation (MS) during endobronchial ultrasound (EBUS) bronchoscopy is primarily restricted for use by an anesthesiologist because of safety concerns. The goals of this study were to demonstrate the safety and the diagnostic yield of the use of propofol by bronchoscopists and trained endoscopy nurses during EBUS bronchoscopy without intubation.

METHODS

We tested a bolus propofol administration protocol targeting MS for EBUS bronchoscopy. A fixed initial dose of 40 mg of propofol along with a fixed 50 mcg fentanyl dose were administered. Sedation assessment was performed every 2 minutes, and repeated bolus doses of propofol were given to maintain MS under the direction of the bronchoscopist.

RESULTS

A total of 122 subjects underwent EBUS bronchoscopy with a goal of MS from August 2015 to April 2017. In total, 110 subjects who underwent convex EBUS bronchoscopy under MS with propofol were included in the analysis. Median procedure duration was 57 minutes (range, 15 to 97 min). Deep sedation and agitation-related delay were occurred in 14 and 21 subjects, respectively. Hemodynamic instability and hypoxemia occurred in 23 subjects. However, there was no need for vasopressors or artificial airway placement. Median of total propofol dose per case was 560 mg. Diagnostic yield for malignancy and granuloma was 68%, and a median of 4 lymph node stations were sampled per subject. All specimens with adenocarcinoma were sufficient for genetic marker analysis. There were no major sedation-related complications.

CONCLUSION

A bolus administration of propofol during EBUS bronchoscopy provided excellent adequacy of sedation and well tolerance safety profile.

Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pulmonary cytology including indications for bronchial brushings, washings, and endobronchial ultrasound guided transbronchial fine-needle aspiration (EBUS-TBNA), technical recommendations for cytological sampling, recommended terminology and classification schemes, recommendations for ancillary testing and recommendations for post-cytological management and follow-up. All recommendations are based on the expertise of the authors, an extensive literature review and feedback from presentations at national and international conferences. This document selectively presents the results of these discussions. The present document summarizes recommendations regarding techniques used to obtain cytological and small histologic specimens from the lung and mediastinal lymph nodes including rapid on-site evaluation (ROSE), and the triage of specimens for immunocytochemical and molecular studies.

Changes in non-small cell lung cancer diagnosis, molecular testing and prognosis 2011-2016

Background

Non-small cell lung cancer (NSCLC) is a leading cause of death all over the world. Diagnostic and therapeutic arsenals have improved in recent years, but we are unsure as to whether these advances have been transferred to clinical practice. The aim of this study was to evaluate differences in NSCLC diagnostic processes and short-term survival rates between two recent cohorts.

Methods

A prospective, observational study was conducted with patients diagnosed with NSCLC in the period of 2011-2016. Patients were divided into two cohorts (2011-2013 and 2014-2016), and monitored for up to 1 year after diagnosis.

Results

A total of 713 patients with lung cancer were selected, 500 of whom had NSCLC (222 patients in the 2011-2013 cohort, and 278 in the 2014-2016 cohort). We observed a chronological increase in the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) and ultrasound-guided transthoracic puncture (US-TTP) between the cohorts. Overall short-term survival was similar between the two groups, both for locally and for advanced disease. Treatment with tyrosine kinase inhibitors (TKI) was the only therapeutic factor associated with an improved likelihood of survival.

Conclusions

Changes in diagnostic process in NSCLC have been observed towards a more precise stratification. Although short-term survival has not changed for advanced NSCLC, some of the newer therapeutic options are associated with increased survival in real-world scenarios.

Needle wash solution cultures following EBUS-TBNA with or without endobronchial intubation

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield in lesions adjacent to the airways. However, complications associated with EBUS-TBNA, such as mediastinitis, have recently been reported. Oral bacteria contamination in punctured lymph nodes can cause severe infections. In the current study, we investigated whether endobronchial intubation using EBUS-TBNA can prevent oral bacterial contamination of punctured lymph nodes.

METHODS

We retrospectively evaluated 80 patients (102 lymph nodes) who had undergone EBUS-TBNA and divided them two groups: Group A comprised 60 patients who had undergone EBUS-TBNA with endobronchial intubation and Group B consisted of 20 patients who had undergone EBUS-TBNA without endobronchial intubation. The patients' medical records were examined and the two groups were compared using the unpaired Student's t-test.

RESULTS

EBUS-TBNA needle wash cultures were positive in only two Group A cases (3.3%), but in all 20 Group B cases (100%) (P < 0.05). Except for one case of Mycobacterium tuberculosis, all bacterial isolates yielded typical oropharyngeal commensal flora. Fever (≥ 38.0 °C) was observed in six Group A cases (10%) and two Group B cases (10%; P = 0.526). This was treated by cooling, a single administration of non-steroidal anti-inflammatory drugs, and/or antibiotic therapy. Fever was not associated with any clinical features, including malignancy in punctured lesions, number of punctures, echo features, simultaneous peripheral biopsy, additional oral prophylactic antibiotics, or positive needle wash cultures.

CONCLUSIONS

Endobronchial intubation may prevent contamination by oropharyngeal commensal bacteria.

Endobronchial Ultrasound Transbronchial Needle Aspiration in Thoracic Diseases: Much More than Mediastinal Staging

Background and Objective

EBUS-TBNA has revolutionized the diagnostic approach to thoracic diseases from a surgical to minimally invasive procedure. In non small-cell lung cancer (NCSLC) patients, EBUS-TBNA is able to dictate the consecutive therapy both for early and advanced stages, providing pathological diagnosis, mediastinal staging, and even adequate specimens for molecular analysis. This study reports on the ability of EBUS-TBNA to make different diagnoses and dictates the consecutive therapy in a large cohort of patients presenting different thoracic diseases.

Methods

All procedures performed from January 2012 to September 2016 were reviewed. Five groups of patients were created according to the main indications for the procedure. Group 1: lung cancer staging; Group 2: pathological diagnosis in advanced stage lung cancer; Group 3: lymphadenopathy in previous malignancies; Group 4: pulmonary lesions; Group 5: unknown origin lymphadenopathy. In each group, the diagnostic yield of the procedure was analysed. Non malignant diagnosis at EBUS-TBNA was confirmed by a surgical procedure or clinical and radiological follow-up.

Results

1891 patients were included in the analysis. Sensitivity, negative predictive value, and diagnostic accuracy in each group were 90.7%, 79.4%, and 93.1% in Group 1; 98.5%, 50%, and 98.5% in Group 2; 92.4%, 85.1%, and 94.7% in Group 3; 90.9%, 51.0%, and 91.7% in Group 4; and 25%, 83.3%, and 84.2% in Group 5. Overall sensitivity, negative predictive value, and accuracy were 91.7%, 78.5%, and 93.6%, respectively.

Conclusions

EBUS-TBNA is the best approach for invasive mediastinal investigation, confirming its strategic role and high accuracy in thoracic oncology.

Utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration in patients with mediastinal and hilar lymphadenopathy: Western region experience

AIMS

The aim of the study was to evaluate the clinical utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with mediastinal and hilar lymphadenopathy and to explicitly describe the utility of this procedure in patient's outcome.

METHODS

A retrospective review and analysis was conducted on 52 patients with mediastinal or hilar lymphadenopathy who underwent EBUS-TBNA from June 2012 to June 2016. All the patients were evaluated by computed tomography (CT) chest with contrast before EBUS examination. Enlarged mediastinal or hilar lymph node was defined as >1 cm short axis on the enhanced CT.

RESULTS

Among the 52 patients studied, 57.7% were presented with mediastinal or hilar lymphadenopathy for diagnosis and 42.3% presented with suspected mediastinal malignancy. Paratracheal stations were the most common site for puncture in 33 lymph nodes (43%). The best diagnostic yield was obtained from subcarinal stations and the lowest yield from the hilar stations. Surgical biopsies confirmed lymphoma in six patients, tuberculosis (TB) in three, sarcoidosis in two and one had metastatic adenocarcinoma of unknown primary. The sensitivity, specificity, positive predictive value, and negative predictive value of EBUS-TBNA for diagnosis of mediastinal and hilar lymph node abnormalities were 78.6%, 100%, 100%, and 80%, respectively. The diagnostic yield of EBUS-TBNA in malignant and benign conditions was 79.0%.

CONCLUSIONS

EBUS-TBNA is a safe and efficacious procedure which can be performed using conscious sedation with high yields. It can be used for the staging of malignancies as well as for the diagnosis of inflammatory and infectious conditions such as sarcoidosis and TB.

Combined pleuroscopy and endobronchial ultrasound for diagnosis and staging of suspected lung cancer

The standard approach to staging of lung cancer in patients with pleural effusion (clinical M1a) is thoracentesis followed by pleural biopsies if the cytologic analysis is negative. If pleural biopsy findings are negative, endobronchial ultrasound-guided transbronchial needle aspiration is used to complete the staging process and, in some cases, obtain diagnosis. In this case series we report 7 patients in which a combined procedure was performed for staging of known or suspected lung cancer. We found that the combined approach was both feasible and safe in this case series.

Molecular testing on endobronchial ultrasound (EBUS) fine needle aspirates (FNA): Impact of triage

BACKGROUND

Endobronchial ultrasound (EBUS)-guided fine needle aspiration (FNA) is performed to diagnose and stage lung cancer. Multiple studies have described the value of Rapid On-Site Evaluation (ROSE), but often the emphasis is upon diagnosis than adequacy for molecular testing (MT). The aim was to identify variable(s), especially cytology-related, that can improve MT.

METHODS

A search for EBUS-FNAs with ROSE was conducted for lung adenocarcinomas or when this diagnosis could not be excluded. All such cases underwent reflex MT on cell blocks. The impact of cytology-related variables [i.e., number of pass(es), dedicated pass(es) directly into media, cytotechnologist (CT), laboratory technician (LT) and triage with 1 or >1 cytologist] was evaluated. The latter category was divided into Group A [ROSE, triage and slide preparation by cytopathologist (CP) and CT at start of the procedure] and Group B (ROSE only by CT or by CT/CP after start of procedure; triage and slide preparation by CT or clinical staff). The impact of all these variables on MT was assessed.

RESULTS

A total of 100 cases were identified, and 79 had sufficient tissue for MT. Of all variables evaluated, MT was positively affected by performing a direct dedicated pass (P = 0.013) and ROSE by Group A (P = 0.033).

CONCLUSIONS

ROSE with appropriate triage, including performing a dedicated pass and proper slide preparation, improves MT, and this is enhanced by having >1 cytologist at the start of the procedure. In the era of personalized medicine, "adequate" should denote sufficient tissue for diagnosis and MT.