Endobronchial ultrasound-guided transbronchial biopsy with or without a guide sheath for peripheral pulmonary malignancy

Randomised trial of assessing diagnostic yield in transbronchial biopsy with a guide sheath

Objectives

Radial probe endobronchial ultrasound (rEBUS)-guided transbronchial biopsy (TBB) with a guide sheath (GS) is widely used to diagnose peripheral lung lesions (PPLs), but there is no consensus on whether it increases the diagnostic yield. We conducted this prospective study to compare the diagnostic yield of the GS method to the conventional method without a GS.

Methods

From November 2019 to March 2023, patients with PPLs were recruited and randomly assigned to rEBUS-TBB with a GS (GS group) or without a GS (conventional group). The histopathology, cytology and microbiology yield rates, as well as procedure time and post-procedure adverse events, of the two groups were compared.

Results

A total of 102 patients were enrolled (54 in the GS group and 48 in the conventional group). The pathology yield showed no statistical difference between the two groups (75.9% versus 68.8%, p=0.418), while the yield rates of brushing cytology (64.3% versus 42.9%, p=0.030) and washing cytology (41.5% versus 20.0%, p=0.0443) were higher in the GS group. Meanwhile, the yield from GS washing culture was lower than the bronchial washing culture yield (0% versus 57.1%, p=0.017). The bleeding risk was also lower in the GS group (9.3% versus 20.8%, p=0.049).

Conclusion

The pathology yield of rEBUS TBB with a GS did not significantly differ from the conventional method. However, a GS could improve the cytology yield rate and reduce the risk of bleeding. To enhance the microbiology yield, additional bronchial washing should be utilised.

Does the guide sheath outperform the non-guide sheath method in endobronchial ultrasound-guided biopsy of peripheral pulmonary lesions?-a meta-analysis

Background

Endobronchial ultrasound (EBUS)-guided transbronchial biopsy with or without a guide sheath (EBUS-GS or EBUS-nGS) is commonly utilized for the diagnosis of peripheral pulmonary lesions (PPLs). The primary objective of this meta-analysis is to assess the diagnostic yield, surgical time, and safety of EBUS-GS and EBUS-nGS in patients presenting with PPLs, providing valuable insights for clinical decision-making.

Methods

We conducted a systematic search of four databases (PubMed, Embase, Web of Science, Cochrane Library) up to January 2024. Two researchers independently screened the retrieved articles, extracted the data, assessed the quality of the studies, and conducted statistical analysis through Review Manager 5.4 and STATA 14.0. Subgroup analysis was used to explore potential sources of heterogeneity. Publication bias was assessed through funnel plot tests. Sensitivity analyses were also performed to evaluate the robustness of the combined results.

Results

The meta-analysis included data from nine studies comprising 2,898 patients. No publication bias was detected. There was no difference in the overall diagnostic rate of EBUS-GS and EBUS-nGS for PPLs [odds ratio (OR): 0.83, 95% confidence interval (CI): 0.64-1.08, Z-score (Z) =1.37, P=0.17]. Conversely, in cases utilizing a bronchoscope with an outer diameter of 3.0 mm (OR: 0.58, 95% CI: 0.40-0.84, Z=2.86, P=0.004), a 1.7-mm bronchoscope channel (OR: 0.70, 95% CI: 0.51-0.96, Z=2.21, P=0.03), or lesions ≤30 mm in size, or lesions situated in the lower lobe of the lung (OR: 0.59, 95% CI: 0.38-0.91, Z=2.36, P=0.02), the diagnostic rate was higher in the EBUS-nGS group. However, the EBUS-GS group demonstrated a tremendous advantage in terms of safety (OR: 0.64, 95% CI: 0.44-0.93, Z=2.33, P=0.02).

Conclusions

EBUS-GS and EBUS-nGS showed no significant difference in the overall diagnostic rate for PPLs. When using a bronchoscope with an outer diameter of 3.0 mm or a channel diameter of 1.7 mm, or when lesions are ≤30 mm or located in the lower lobe of the lung, EBUS-nGS demonstrated a higher diagnostic rate, and EBUS-nGS demonstrated a higher diagnostic rate. However, EBUS-GS exhibited more tremendous advantages in terms of safety.

Advanced Bronchoscopic Diagnostic Techniques in Lung Cancer

The increasing incidence of incidental pulmonary nodules necessitates effective biopsy techniques for accurate diagnosis and treatment planning. This paper reviews the widely used advanced bronchoscopic techniques, such as radial endobronchial ultrasound-guided transbronchial lung biopsy, electromagnetic navigation bronchoscopy, and the cutting-edge robotic-assisted bronchoscopy. In addition, the cryobiopsy technique, which can enhance diagnostic yield by combination with conventional biopsy tools, is described for application to peripheral pulmonary lesions and mediastinal lesions, respectively.

Endobronchial ultrasound with a guide sheath during bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

Radial probe endobronchial ultrasound (rEBUS) improves the diagnostic yield of peripheral pulmonary lesions (PPLs). A notable methodological limitation of rEBUS is that it does not provide real-time images during transbronchial biopsy (TBB) procedures. To overcome this limitation, a guide sheath (GS) method was developed.

AREAS COVERED

This review covers the procedures and complications of rEBUS-guided TBB with a GS (EGS method). We also present the data from key randomized controlled trials (RCTs) of the EGS method and summarize the usefulness of combining the EGS method with various techniques. Finally, we discuss in which situations EGS should be used.

EXPERT OPINION

A large RCT showed that the diagnostic yield of the EGS method for PPLs was significantly higher than that of rEBUS-guided TBB without a GS (non-GS method). However, since the EGS and non-GS methods each have their own advantages and disadvantages, they should be considered complementary and used flexibly in different cases. In some cases, a combination of the two may be an option. The appropriate combination of EGS with various techniques may enhance the diagnostic yield of PPLs and help prevent complications. The choice should be based on the location and texture of the target lesion, as well as operator skill, resource availability, safety, and accuracy.

Endobronchial ultrasound-guided transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis

The diagnosis of peripheral pulmonary lesions (PPLs) remains a challenge for physicians. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been applied in the diagnosis of PPLs, but its diagnostic rate varies widely. The systematic review and meta-analysis was conducted to figure out the accuracy and safety of EBUS-TBNA in the diagnosis of PPLs. We searched the PubMed and Embase databases for relevant studies published from January 1, 2000 to December 30, 2021 and used PICO (Participants, Intervention, Comparison, and Outcome) to worked out the diagnostic rate of EBUS-TBNA in PPLs. Two reviewers independently performed the data extraction and assessed study quality. Statistical analysis was carried out via R software. In 7 studies of totally 510 patients of PPLs, the overall EBUS-TBNA diagnosis yield is 0.75 (95% CI 0.67-0.84) by the random effect model. EBUS-TBNA showed a higher accuracy of 0.64 (95% CI 0.53-0.74) compared to 0.46 (95% CI 0.19-0.72) of endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) when EBUS probe is adjacent to lesions. In the case of malignant lesions, the diagnostic rate of EBUS-TBNA is 0.79 (95% CI 0.72-0.88). Combined EBUS-TBNA with conventional bronchoscopy procedures showed the highest diagnostic yield (0.83 (95% CI 0.79-0.87)). Collectively, EBUS-TBNA should be performed firstly in patients with PPLs suspected to lung cancer especially when the EBUS probe was adjacent to the lesions. No serious procedure-related complications were observed.

Inheritance and innovation of the diagnosis of peripheral pulmonary lesions

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.

Factors related to the diagnosis of lung cancer by transbronchial biopsy with endobronchial ultrasonography and a guide sheath

BACKGROUND

Transbronchial biopsy (TBB) with endobronchial ultrasonography and a guide sheath (EBUS-GS) is an effective examination tool for the diagnosis of lung cancer. Factors related to making the diagnosis are still not fully understood.

METHODS

A total of 367 patients who underwent EBUS-GS and were diagnosed with lung cancer in Saga University Hospital were investigated retrospectively. Clinical characteristics were compared between 244 patients who were diagnosed with lung cancer and 123 patients who were not diagnosed by TBB with EBUS-GS but were diagnosed by other examinations.

RESULTS

Size of target lesion, rate of patients with target lesion size ≥20 mm, presence of the bronchus sign, and detection by EBUS imaging were significantly associated with making the diagnosis (all p < 0.01). In patients whose lesion was detected by EBUS imaging, patients with positive findings within the lesion were significantly more often diagnosed by TBB with EBUS-GS than those with positive findings adjacent to the lesion (p < 0.01). The odds ratio (OR) of patients whose lesion was detected by EBUS imaging (OR [95% confidence interval] 14.5 [8.0-26.4]) tended to be higher compared to the ORs of size of lesion ≥20 mm (3.9 [2.2-6.8]) and the bronchus sign (7.5 [4.6-12.2]).

CONCLUSION

Targeted lesion diameter ≥20 mm, bronchus sign, and detection by EBUS imaging, especially within the lesion, are important factors for the diagnosis of lung cancer by TBB with EBUS-GS.