Diagnostic value of endobronchial and endoscopic ultrasound-guided fine needle aspiration for accessible lung cancer lesions after non-diagnostic conventional techniques: a prospective study

Retrospective application of WHO reporting system for lung cytopathology with assessment of risk of malignancy

INTRODUCTION

The recently introduced World Health Organization (WHO) Reporting System for Lung Cytopathology presents 5 diagnostic categories with corresponding risk of malignancy (ROM) and management protocols. This study uses the system to categorize our institutional respiratory tract cytology specimens, evaluating ROM and diagnostic accuracy for each category.

MATERIALS AND METHODS

In a retrospective analysis (May 2020 to August 2021), the following respiratory cytology specimens were classified based on the WHO categories: bronchoalveolar lavage (BAL), bronchial wash/bronchial brushings (BB/BW), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), fine-needle aspiration cytology (FNAC), sputum, biopsy imprint (BI), and endotracheal wash. Exclusions comprised pleural effusions and EBUS-TBNA from mediastinal and hilar lymph nodes. Correlation of cytologic and histopathologic diagnoses was performed to assess ROM collectively and individually.

RESULTS

A total of 1518 respiratory samples (BAL [968], BW/BB [380], EBUS-TBNA [42], FNAC [32], sputum [80], BI [11] and endotracheal wash [5]) of 1410 patients were screened, of which 522 cases (34.3%) had histopathologic correlation. One hundred forty-one cases (9.3%) were Insufficient/Inadequate/Non-Diagnostic (ND), 1221 (80.4%) were Benign (B), 3 (0.2%) were Atypical (A), 32 (2.1%) were Suspicious for malignancy (SM) and 121 (8.0%) were Malignant (M). The estimated ROM for each category was 49.2% for ND, 13.3% for B, 66.6% for A, 81.5% for SM and 92.7% for M. FNAC and EBUS-TBNA exhibited the highest sensitivity (100%) compared with BW/BB (66.3%). Specificity ranged from 96.8% to 100% across the samples, while diagnostic accuracy varied from 58.8% to 100%.

CONCLUSIONS

Application of the WHO reporting system enhances standardized terminology, aiding clinicians in informed decision-making and improving patient care through accurate risk assessment of malignancy.

Risk of malignancy assessment of the different cytologic categories in respiratory cytology samples according to the new guidelines of the Papanicolaou Society of Cytopathology

BACKGROUND

Cytology is extremely important for diagnosis of lung carcinoma and the Papanicolaou Society of Cytopathology (PSC) had proposed a new classification system for respiratory cytology for better communication between physicians and better patient management. The objective of this study is to analyze our samples in accordance with this classification and to evaluate the diagnostic accuracy of various cytologic techniques and to assess the risk of malignancy.

METHODS

Eight hundred and twenty respiratory cytology specimens (FNA, BAL, washing, brushing, sputum) collected between 2019 and 2022 were classified according to the PSC system and the risk of malignancy was assessed for each category using follow-up surgical samples. Sensitivity, specificity, and accuracy rates were determined based on a categorial approach, according to a similar study.

RESULTS

The data of 820 respiratory cytology specimens from 576 patients were analyzed. 2.6% of these were non-diagnostic, 64.1% were NM, 5% were AC, 0.4% were N-B-LG, 4% were SM and 23.9% were ML. The risk of malignancy for each diagnostic category were: 42.8% for non-diagnostic, 31.2% for NM, 43.9% for AC, 87.9% for SM, 94.3% for ML. Sensitivity and specificity was calculated using only the malignant cases considered as positive tests and was 45.57% and 97.34% respectively.

CONCLUSION

Our results correlated with the PSC system, and it was considered useful in clinical practice. However, more studies should be performed to evaluate the usefulness of this system. The ROMs of each category and the impact of different techniques should be further studied.

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration for diagnostic and staging purposes: a narrative review

Background and Objective

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is a feasible and well-tolerated modality that is increasingly used to diagnose intrathoracic lesions. This narrative review summarizes the current application of EUS-B-FNA for diagnosing lung cancer, thoracic sarcoidosis, and metastases from extrathoracic malignancies.

Methods

A comprehensive and systematic online literature search via Medline/PubMed for the period January 2005 to December 2022 was conducted for articles published using the keywords "EUS-B-FNA", "endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)", "endoscopic ultrasound fine-needle aspiration (EUS-FNA)", "lung cancer", "staging", and "sarcoidosis".

Key Content and Findings

Recent data prove the efficacy and safety of EUS-B-FNA for providing complete lung cancer staging, when combined with EBUS-TBNA, and in the evaluation of para-esophageal lesions. EUS-B-FNA allows access to inferior mediastinal lymph nodes and para-esophageal masses that are not accessible by EBUS-TBNA. Additional advantages of using EUS-B-FNA include significantly lower doses of anesthetics and sedatives, a shorter procedural time, fewer incidents of oxygen desaturation due to a poor respiratory reserve, significantly less cough, and higher operator satisfaction. Moreover, this procedure can be performed sequentially in the same setting with EBUS-TBNA by one operator. Other benefits include a lower cost, a single setting, and scope use.

Conclusions

As EUS-B-FNA and EBUS-TBNA have complementary access to the mediastinum, the diagnostic yield of EUS-B-FNA combined with EBUS-TBNA is higher than that of endosonographic techniques alone in the diagnostic workup of intrathoracic lesions.

[The role of endoscopy in exploration of the mediastinum, indications and results]

Since 2005, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a standard pulmonological tool. The procedure is safe and well tolerated by patients, with minimal morbidity and almost no mortality. A previous review on the technique was published in 2012. However, over the last ten years, a number of new studies have been published on "benign" (sarcoidosis, tuberculosis…) as well as "malignant" diseases (lung cancer, metastases of extra-thoracic cancers, search for mutations and specific oncogenic markers…). These developments have led to expanded indications for EBUS-TBNA, with which it is indispensable to be familiar, in terms of "staging" as well as "diagnosis". In view of optimizing lymph node sampling, several publications have described and discussed EBUS exploration by means of newly available tools (biopsy forceps, larger needles…), and proposed interpretation of the images thereby produced. Given the ongoing evolution of linear EBUS, it seemed indispensable that information on this marvelous tool be updated. This review is aimed at summarizing the novel elements we have found the most important.

EUS-B-FNA Enhances the Diagnostic Yield of EBUS Bronchoscope for Intrathoracic Lesions

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.

Neuroendocrine Tumor Diagnosed Through Endoscopic Ultrasound-Guided Fine-Needle Biopsy of a Lung Mass

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is an excellent modality for tissue acquisition and has been shown to be superior to EUS-fine-needle aspiration in several studies. Although tissue sampling of lung nodules using EUS-fine-needle aspiration has been reported in the literature, the use of EUS-FNB for tissue acquisition of parenchymal lung mass has rarely been reported in the literature. Our report highlights that EUS-FNB is safe and effective for lung lesions that are near the esophageal wall.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Alternatives of histological material collection - When and how is histological confirmation by ultrasound (US), computer tomography (CT) or endosonography (EUS) useful?]

Histological classifications of tumorous lesions together with adequate staging are necessary for stage-appropriate and personalized therapies. The indications, technical possibilities, and limitations as well as potential complications of image-guided needle biopsy by ultrasound, computed tomography, and endosonography are described. Which procedure for which organ and which lesion?

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.

Transoesophageal endobronchial ultrasound-guided needle aspiration (EUS-B-NA) for poorly accessible thoracic lesions: a case series

Endobronchial ultrasound (EBUS) has long been a common diagnostic tool used in the diagnosis of pulmonary pathologies. In the last decade, increased interest has been shown in its usage via the oesophagus for sampling lesions inaccessible via the airways. We describe three cases in which we used this modality to biopsy lesions not visualised via conventional EBUS and which would be too risky to be attempted via a CT-guided biopsy with a high likelihood of complications. More focused education on using EBUS via the oesophagus for respiratory trainees could greatly improve overall clinical practice. It improves the diagnostic yield of lesions and prevents subsequent referral to gastrointestinal colleagues which may delay diagnosis especially during the COVID-19 pandemic as was the case in our patient cohort where services are already limited. EBUS, due to its smaller size, is less irritant to the upper airways and requires less sedation than endoscopic ultrasound (EUS) scopes. It is also shorter than an EUS scope improving manoeuvrability. Each of our cases resulted in early histological diagnosis and subsequent appropriate treatment.

Feasibility of combined optical coherence tomography and autofluorescence imaging for visualization of needle biopsy placement

SIGNIFICANCE

Diagnosis of suspicious lung nodules requires precise collection of relevant biopsies for histopathological analysis. Using optical coherence tomography and autofluorescence imaging (OCT-AFI) to improve diagnostic yield in parts of the lung inaccessible to larger imaging methods may allow for reducing complications related to the alternative of computed tomography-guided biopsy.

AIM

Feasibility of OCT-AFI combined with a commercially available lung biopsy needle was demonstrated for visualization of needle puncture sites in airways with diameters as small as 1.9 mm.

APPROACH

A miniaturized OCT-AFI imaging stylet was developed to be inserted through an 18G biopsy needle. We present design considerations and procedure development for image-guided biopsy. Ex vivo and in vivo porcine studies were performed to demonstrate the feasibility of the procedure and the device.

RESULTS

OCT-AFI scans were obtained ex vivo and in vivo. Discrimination of pullback site is clear.

CONCLUSIONS

Use of the device is shown to be feasible in vivo. Images obtained show the stylet is effective at providing structural information at the puncture site that can be used to assess the diagnostic potential of the sample prior to collection.

Patterns of diagnostic procedures for lung cancer pathology in the Middle East and North Africa

Background

Accurate pathological diagnosis is the first critical step in the management of lung cancer. This step is important to determine the histological subtype of the cancer and to identify any actionable targets. Our study aimed at evaluating the patterns of procedures used to obtain pathological diagnosis of lung cancer in the Middle East and North Africa (MENA) Region.

Methods

Data of consecutive patients with the diagnosis of non-small cell lung cancer (NSCLC) were collected from participating centers from different countries in the MENA Region. Methods of obtaining tissue diagnosis and workup were analyzed to determine the practice patterns of obtaining tissue diagnosis of lung cancer.

Results

A total of 566 patients were recruited from 10 centers in 5 countries including Saudi Arabia, United Arab Emirates (UAE), Qatar, Lebanon and Algeria. Majority of patients were males (78.1%) with a median age of 61 years (range, 22-89 years). Obtaining tissue diagnosis was successful in the first attempt in 72.3% of patients, while 16.4% and 6.3% of patients required 2^nd and 3^rd attempt, respectively. The success in first attempt was as follows: image guided biopsy (91%), surgical biopsy (88%), endobronchial biopsy (79%) and cytology (30%). The success in the second attempt was as follows; surgical biopsy (100%), image guided biopsy (95%), endobronchial biopsy (65%), cytology (25%).

Conclusions

More than quarter of the patients required repeated biopsy in the MENA Region. Image guided biopsy has the highest initial yield. Implementing clear process and multidisciplinary guidelines about the selection of diagnostic procedures is needed.

Reasons for prolonged time for diagnostic workup for stage I-II lung cancer and estimated effect of applying an optimized pathway for diagnostic procedures

BACKGROUND

Minimizing the time until start of cancer treatment is a political goal. In Norway, the target time for lung cancer is 42 days. The aim of this study was to identify reasons for delays and estimate the effect on the timelines when applying an optimal diagnostic pathway.

METHODS

Retrospective review of medical records of lung cancer patients, with stage I-II at baseline CT, receiving curative treatment (n = 100) at a regional cancer center in Norway.

RESULTS

Only 40% started treatment within 42 days. The most important delays were late referral to PET CT (n = 27) and exercise test (n = 16); repeated diagnostic procedures because bronchoscopy failed (n = 15); and need for further investigations after PET CT (n = 11). The time from referral to PET CT until the final report was 20.5 days in median. Applying current waiting time for PET CT (≤7 days), 48% would have started treatment within 42 days (p = 0.254). "Optimal pathway" was defined as 1) referral to PET CT and exercise test immediately after the CT scan and hospital visit, 2) tumor board discussion to decide diagnostic strategy and treatment, 3) referral to surgery or curative radiotherapy, 4) tissue sampling while waiting to start treatment. Applying the optimal pathway, current waiting time for PET CT and observed waiting times for the other procedures, 80% of patients could have started treatment within 42 days (p < 0.001), and the number of tissue sampling procedures could have been reduced from 112 to 92 (- 16%).

CONCLUSION

Changing the sequence of investigations would significantly reduce the time until start of treatment in curative lung cancer patients at our hospital and reduce the resources needed.

A pragmatic application of endobronchial ultrasound-guided transbronchial needle aspiration: a single institution experience

Background

Endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is minimally invasive technique used for diagnosis and/or staging of benign and malignant pulmonary and non-pulmonary disease. Previous studies have established the utility of EBUS-TBNA in narrowly defined indications and populations. In this pragmatic ‘real world’ study we have analysed the use of EBUS-TBNA for a variety of clinical presentations and its clinical application in conjunction with other invasive investigations.

Methods

All EBUS-TBNA procedures performed at Sir Charles Gardiner Hospital in 2012–2014 were reviewed retrospectively, using relevant hospital databases.

Results

A total of 327 patients underwent 337 EBUS-TBNA procedures. EBUS-TBNA procedures were used to diagnose a wide spectrum of benign and malignant conditions. The main application was in the diagnosis and staging of malignant conditions (70.6%), and in the diagnosis of benign conditions such as sarcoidosis 40 (12.2%), and silicoanthracosis 17 (5.2%). EBUS-TBNA was sufficient to diagnose and stage the disease as a single stand-alone invasive procedure in 191 (59.2%) patients. EBUS-TBNA was the final invasive procedure undertaken in 283 (87.6%) patients. Only 13.3% of non small cell lung cancer (NSCLC) patients who had EBUS-TBNA as a first investigation required multiple procedures compared to 51.1% of all NSCLC patients undergoing EBUS-TBNA. Overall sensitivity, specificity, NPV and diagnostic accuracy for EBUS-TBNA were 89.7, 100, 85.1 and 89.9%, respectively and three minor complications (0.9%) occurred as a result of the procedure.

Conclusions

EBUS-TBNA was undertaken for a wide variety of clinical conditions. Good diagnostic accuracy and safety profiles were demonstrated for the procedure, supporting its application as a first line investigation in the diagnosis and/or staging of a range of malignant and benign conditions. Our study was unique in its documentation of the use of EBUS-TBNA in a real-world setting in conjunction with other invasive modalities. EBUS-TBNA was utilised as a stand alone invasive procedure in more than half of the patients. Importantly, in NSCLC, when EBUS-TBNA was performed as primary diagnostic and staging investigation, less patients underwent subsequent invasive procedures.

Needle-based Optical Coherence Tomography to Guide Transbronchial Lymph Node Biopsy

BACKGROUND

Transbronchial needle aspiration (TBNA), often used to sample lymph nodes for lung cancer staging, is subject to sampling error even when performed with endobronchial ultrasound. Optical coherence tomography (OCT) is a high-resolution imaging modality that rapidly generates helical cross-sectional images. We aim to determine if needle-based OCT can provide microstructural information in lymph nodes that may be used to guide TBNA, and improve sampling error.

METHODS

We performed ex vivo needle-based OCT on thoracic lymph nodes from patients with and without known lung cancer. OCT imaging features were compared against matched histology.

RESULTS

OCT imaging was performed in 26 thoracic lymph nodes, including 6 lymph nodes containing metastatic carcinoma. OCT visualized lymphoid follicles, adipose tissue, pigment-laden histiocytes, and blood vessels. OCT features of metastatic carcinoma were distinct from benign lymph nodes, with microarchitectural features that reflected the morphology of the carcinoma subtype. OCT was also able to distinguish lymph node from adjacent airway wall.

CONCLUSIONS

Our results demonstrate that OCT provides critical microstructural information that may be useful to guide TBNA lymph node sampling, as a complement to endobronchial ultrasound. In vivo studies are needed to further evaluate the clinical utility of OCT in thoracic lymph node assessment.

Combined Endosonography Reduces Time to Diagnose Pulmonary Coccidioidomycosis

Coccidioidomycosis causes significant morbidity in endemic areas. In the absence of sensitive diagnostic serologic testing, clinicians have increasingly relied on lung and lymph node biopsies for diagnosis. Recently, endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been shown to be an excellent sampling method for the diagnosis and staging of lung cancers, especially when combined with endoscopic ultrasound guided fine needle aspiration (EUS-FNA). We present 13 consecutive cases where EBUS-TBNA and/or EUS-FNA of pulmonary lymph nodes were performed as part of the workup for pulmonary coccidioidomycosis. EBUS-TBNA+EUS-FNA led to diagnosis in all nine cases in which they were performed concurrently, and in the remaining 4 in which either was performed individually. BAL was performed in all cases with positive results in 5 (38%). The mean time to diagnose by EBUS/EUS (1.6 d) was significantly shorter than by bronchoalveolar lavage (6.3 d) (P=0.003). The findings indicate that combined EBUS-TBNA+EUS-FNA for lymph node biopsy facilitates early and accurate diagnosis of pulmonary coccidioidomycosis.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Initial report of transesophageal EUS-guided intraparenchymal lung mass core biopsy: Findings and outcomes in two cases

EUS is most commonly used to evaluate and sample lesions of the abdomen but has only been used on rare occasions to evaluate and sample lung lesions. Prior reported cases of EUS sampling of lung lesions were performed by fine-needle aspiration. We present what is believed to be the first reported cases of EUS-guided core biopsy of intraparenchymal lung lesions through two separate case reports. Both patients had the upper lobe lesions not amenable to bronchoscopy or endobronchial ultrasound, and both patients underwent core biopsy without adverse event. This report of two cases shows that EUS-guided core biopsy of intraparenchymal lung lesions is technically possible and may not necessarily result in adverse events such as hemorrhage, pneumothorax, or infection.

Trans-esophageal endobronchial ultrasound-guided needle aspiration (EUS-B-NA): A road map for the chest physician

The endobronchial ultrasound (EBUS) scope has been increasingly used in the gastrointestinal tract (EUS-B). Scientific data proves its efficacy and safety to provide a complete lung cancer staging, when combined with EBUS-TBNA, and in the diagnosis of para-esophageal lesions. There are multiple barriers to start performing EUS-B but probably the most important ones are related to knowledge and training, so new operators should follow a structured training curriculum. This review aims to reflect the best current knowledge regarding EUS-B and provide a road map to assist those who are incorporating the technique into their clinical practice.

Regional differences in use of endoscopic ultrasonography in Ontario: a population-based retrospective cohort study

BACKGROUND

Endoscopic ultrasonography is a safe and accurate modality for evaluating and managing hepatobiliary and gastrointestinal conditions (malignant and nonmalignant); its use is increasing. The aim of this study was to describe regional trends in the use of endoscopic ultrasonography in Ontario.

METHODS

We conducted a population-based retrospective cohort study using health administrative databases. We identified all patients who underwent an endoscopic ultrasound procedure in Ontario from 2003 to 2011 using physician billing data. Patient, physician and institution characteristics were examined. The primary outcome was use of endoscopic ultrasonography.

RESULTS

We identified 9076 endoscopic ultrasound procedures performed in 8001 patients (3858 women [48.2%]; median patient age at first procedure 59 years). A total of 3066 procedures (33.8%) involved fine-needle aspiration. Use of endoscopic ultrasonography increased 17-fold over the study period. In 2011, people living in the health region with the highest rate of use of endoscopic ultrasonography were more than 4 times more likely to undergo the procedure than people living in the health region with the lowest rate of use (standardized rate 61.6 v. 12.9 per 100 000). About 7 in 10 endoscopic ultrasound procedures were performed in an academic institution or regional cancer centre. All 17 endoscopists performing endoscopic ultrasonography during the study period practised in urban areas.

INTERPRETATION

Although the use of endoscopic ultrasonography increased over time in Ontario, there were marked regional differences in use. Provincial needs- and evidence-based initiatives may be needed to narrow the regional gaps in provision of endoscopic ultrasound services in the province.

Cost-Effectiveness of a Bronchial Genomic Classifier for the Diagnostic Evaluation of Lung Cancer

INTRODUCTION

The use of a bronchial genomic classifier has been shown to improve the diagnostic accuracy of bronchoscopy for suspected lung cancer by identifying patients who may be more suitable for radiographic surveillance as opposed to invasive procedures. Our objective was to assess the cost-effectiveness of bronchoscopy plus a genomic classifier versus bronchoscopy alone in the diagnostic work-up of patients at intermediate risk for lung cancer.

METHODS

A decision-analytic Markov model was developed to project the costs and effects of two competing strategies by using test performance from the Airway Epithelial Gene Expression in the Diagnosis of Lung Cancer-1 and Airway Epithelial Gene Expression in the Diagnosis of Lung Cancer-2 studies. The diagnostic accuracy of noninvasive and invasive follow-up, as well as associated adverse event rates, were derived from published literature. Procedure costs were based on claims data and 2016 inpatient and outpatient reimbursement amounts. The model projected the number of invasive follow-up procedures, 2-year costs and quality-adjusted life-years (QALYs) by strategy, and resulting incremental cost-effectiveness ratio discounted at 3% per annum.

RESULTS

Use of the genomic classifier reduced invasive procedures by 28% at 1 month and 18% at 2 years, respectively. Total costs and QALY gain were similar with classifier use ($27,221 versus $27,183 and 1.512 versus 1.509, respectively), resulting in an incremental cost-effectiveness ratio of $15,052 per QALY.

CONCLUSIONS

Our analysis suggests that the use of a genomic classifier is associated with meaningful reductions in invasive procedures at about equal costs and is therefore a high-value strategy in the diagnostic work-up of patients at intermediate risk of lung cancer.

Outcomes of research biopsies in clinical trials of EGFR mutation-positive non-small cell lung cancer patients pretreated with EGFR-tyrosine kinase inhibitors

BACKGROUND/PURPOSE

Research biopsies (RBs) are crucial for developing novel molecular targeted agents. However, the safety and diagnostic yields of RBs have not been investigated in EGFR mutation-positive non-small cell lung cancer (NSCLC) patients pretreated with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs).

METHODS

We searched the medical records of NSCLC patients who participated in lung cancer clinical trials and underwent mandatory RBs between 2012 and 2014 at our institution. Only patients with EGFR mutation-positive NSCLC pretreated with at least 1 EGFR-TKI were enrolled.

RESULTS

Of 140 enrolled patients, 73 (52.1%) and 59 (42.1%) had exon 19 deletions and exon 21 L858R mutation, respectively. Before RBs, 108 (77.1%), 83 (59.3%), and 36 (25.7%) patients had been treated with gefitinib, erlotinib, and afatinib, respectively. Computed tomography-guided percutaneous core needle biopsy was the most frequently used modality among 181 RBs performed (50.8%), followed by ultrasonography-guided (32.0%) and endoscopic RBs (16.0%). The most common RB sites were the lung (69.6%), pleura (8.8%), and liver (6.1%). Pathologic examinations revealed malignant cells in most RB specimens (72.9%). Complications due to RBs included pneumothorax (11.6%), bleeding (6.1%), and infection (1.1%). Only 1 patient required chest tube placement for pneumothorax, and 2 patients underwent endotracheal intubation because of bleeding.

CONCLUSION

RBs in this patient population were generally safe. Pneumothorax was the most frequent complication; bleeding, while infrequent, increased the risk of severe events. The diagnostic yields and complications of any particular modality should therefore be discussed with prospective clinical trial participants.

Thoracic Ultrasound: Technique, Applications, and Interpretation

Thoracic ultrasound is used at the bedside in emergency and critical care settings. Advantages of ultrasound include rapid real-time, low-cost, diagnostic information that can direct patient care without the use of ionizing radiation. We describe methods on how to perform lung ultrasound, with the intent to educate the radiologist who might otherwise be relatively unfamiliar with thoracic sonography. We describe and depict the normal sonographic appearance of lung anatomy. We also show the sonographic appearance of a wide range of lung and pleural pathologies such as pneumonia, pneumothorax, as well as lung and pleural masses. We review various lines and signs described in the literature, such as A-lines, B-lines, the stratosphere sign, and the bat-wing sign. Finally, we correlate our findings with chest x-ray and computerized tomography to emphasize the anatomy.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Minimally Invasive Methods for Staging in Lung Cancer: Systematic Review and Meta-Analysis

Introduction. Endobronchial ultrasound (EBUS) is a procedure that provides access to the mediastinal staging; however, EBUS cannot be used to stage all of the nodes in the mediastinum. In these cases, endoscopic ultrasound (EUS) is used for complete staging. Objective. To provide a synthesis of the evidence on the diagnostic performance of EBUS + EUS in patients undergoing mediastinal staging. Methods. Systematic review and meta-analysis to evaluate the diagnostic yield of EBUS + EUS compared with surgical staging. Two researchers performed the literature search, quality assessments, data extractions, and analyses. We produced a meta-analysis including sensitivity, specificity, and likelihood ratio analysis. Results. Twelve primary studies (1515 patients) were included; two were randomized controlled trials (RCTs) and ten were prospective trials. The pooled sensitivity for combined EBUS + EUS was 87% (CI 84-89%) and the specificity was 99% (CI 98-100%). For EBUS + EUS performed with a single bronchoscope group, the sensitivity improved to 88% (CI 83.1-91.4%) and specificity improved to 100% (CI 99-100%). Conclusion. EBUS + EUS is a highly accurate and safe procedure. The combined procedure should be considered in selected patients with lymphadenopathy noted at stations that are not traditionally accessible with conventional EBUS.

Ultrasound techniques in the evaluation of the mediastinum, part 2: mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques, clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node (MLN) staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [endobronchial ultrasound combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [endoscopic ultrasound fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all MLNs can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review in two integrative parts is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part 1 deals with an introduction into ultrasound techniques, MLN anatomy and diagnostic reach of ultrasound techniques and part 2 with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

Ten Years of Linear Endobronchial Ultrasound: Evidence of Efficacy, Safety and Cost-effectiveness

Real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is one of the major landmarks in the history of bronchoscopy. In the 10 years since it was introduced, a vast body of literature on the procedure and its results support the use of this technique in the study of various mediastinal and pulmonary lesions. This article is a comprehensive, systematic review of all the available scientific evidence on the more general indications for this technique. Results of specific studies on efficacy, safety and cost-effectiveness available to date are examined. The analysis shows that EBUS-TBNA is a safe, cost-effective technique with a high grade of evidence that is a valuable tool in the diagnosis and mediastinal staging of patients with suspected or confirmed lung cancer. However, more studies are needed to guide decision-making in the case of a negative result. Evidence on the role of EBUS-TBNA in the diagnosis of sarcoidosis and extrathoracic malignancies is also high, but much lower when used in the study of tuberculosis, lymphoma and for the re-staging of lung cancer after neoadjuvant chemotherapy. Nevertheless, due to its good safety record and lack of invasiveness compared to surgical techniques, the grade of evidence for recommending EBUS-TBNA as the initial diagnostic test in patients with these diseases is very high in most cases.

Utility of endobronchial ultrasound-guided-fine-needle aspiration and additional value of cell block in the diagnosis of mediastinal granulomatous lymphadenopathy

Background:

Endobronchial ultrasound-guided transbronchial fine-needle aspiration is a minimally invasive technique for diagnosis of mediastinal lesions. Although most studies have reported the utility of EBUS-FNA in malignancy, its use has been extended to the benign conditions as well.

Objective:

To evaluate the diagnostic yield and cytologic accuracy of endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-FNA) in cases of clinically and radiologically suspected granulomatous diseases.

Patients and Method:

From May 2010 to April 2015, 43 of 115 patients who underwent EBUS-FNA at one center for radiologically and clinically suspicious granulomatous lesions, and with no definite histological diagnosis, were included in this retrospective study.

Results:

When the histological diagnosis was taken as the gold standard, the sensitivity of EBUS-FNA was 85% and specificity was 100% with the positive predictive value of 100. The combined diagnostic sensitivity of EBUS-FNA and transbronchial lung biopsy was 100%. In 4 cases, cell block provided an exclusive morphological diagnosis of sarcoidosis which was noncontributory by EBUS-FNA.

Conclusion:

Our study supports the use of EBUS-FNA, by virtue of being a safe, minimally invasive, and an outpatient procedure, in the diagnosis of granulomatous mediastinal lymphadenopathy, thereby obviating more invasive testing in a significant number of patients. Also, cell block provides additional data in the diagnosis in these benign mediastinal diseases.

Endoscopic ultrasound and/or endobronchial ultrasound-guided needle biopsy of central intraparenchymal lung lesions not adjacent to airways or esophagus

Background and Objectives:

It is usually challenging to diagnose intraparenchymal pulmonary nodules and masses that are not adjacent to central airways or esophagus. We evaluated the diagnostic accuracy and safety of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) and/or endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) for these lesions.

Materials and Methods:

We performed an Internal Review Board-approved retrospective analysis of all patients who underwent EBUS, EUS, or both for the diagnosis of centrally located pulmonary nodules and masses between November 2008 and July 2013. We report results as median values with ranges.

Results:

We identified 16 consecutive patients who underwent EBUS-TBNA and/or EUS-FNA of pulmonary nodules and masses not adjacent to airways or esophagus. We performed EBUS-FNA in 10 patients, EUS-FNA in five patients, and both EBUS-FNA and EUS-FNA in one patient. Median lung lesion size was 22.5 mm (11-45 mm) and median distance from airway or esophagus was 19 mm (5-30 mm). We obtained a tissue diagnosis in 15 patients (93.8%). There were no procedure-related complications.

Conclusion:

We conclude that EBUS-TBNA and/or EUS-FNA are accurate and safe for the diagnosis of intraparenchymal pulmonary lesions that are not adjacent to central airways or esophagus.

Endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer diagnosis and staging

Lung cancer is one of the most prevalent types of cancer in the world. A complete diagnosis of lung cancer involves tissue acquisition for pathological subtype, molecular diagnosis and accurate staging of the disease to guide appropriate therapy. Real-time endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is minimally invasive and relatively safe procedure, which can be done on an outpatient basis under moderate sedation. EBUS-TBNA has been shown to be a safe modality to obtain tissue for diagnosis, staging and molecular profiling in lung cancer. EBUS-TBNA stands out in comparison with other modalities for tissue acquisition in lung cancer. EBUS-TBNA performed with the patient under moderate sedation yields sufficient tissue for sequential molecular analysis in most patients. In this review, we describe the role of EBUS-TBNA in various aspects of diagnosis and staging of lung cancer in the present era along with its future aspects.

The use of convex probe endobronchial ultrasound-guided transbronchial needle aspiration in a pediatric population: a multicenter study

INTRODUCTION

The presence of intrathoracic lymphadenopathy and mediastinal masses in the pediatric population often presents a diagnostic challenge. With limited minimally invasive methodologies to obtain a diagnosis, invasive sampling via mediastinoscopy or thoracotomy is often pursued. Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, outpatient procedure that has demonstrated significant success in the adult population in the evaluation of such abnormalities. Within the pediatric literature there is limited data regarding the use of EBUS-TBNA. We report the first multicenter review of a pediatric population undergoing EBUS-TBNA procedures identifying the feasibility, safety, utility, and outcomes of this procedure.

METHODS

All patients of 18 years of age or younger undergoing EBUS-TBNA at six major academic medical centers from the years 2007 through 2013 were reviewed. Data regarding procedural performance, outcomes, and complications were recorded.

RESULTS

A total of 21 patients meeting the inclusion criteria were identified in six centers. The mean age of the cohort was 13.7 (±4.1) years. EBUS-TBNA provided adequate sampling in 20/21 (95%) of the cases with diagnostic material obtained in 10 (48%) cases. Eight patients (38%) underwent additional surgical procedures to confirm or obtain diagnostic tissue. Within our cohort, 13 patients (62%) were able to avoid invasive surgical biopsy procedures. No procedural or anesthesia related complications were identified.

CONCLUSION

We report the first multicenter study to date confirming the feasibility and utility of EBUS-TBNA in the pediatric population. Due to the low overall procedural risk of EBUS-TBNA, it should be considered as a potential first line diagnostic option for children presenting with mediastinal or hilar abnormalities but further prospective studies are needed.