Endobronchial Ultrasound Changed the World of Lung Cancer Patients: A 11-Year Institutional Experience

The Feasibility of Interventional Pulmonology Methods for Detecting the T790M Mutation after the First or Second-Generation EGFR-TKI Resistance of Non-Small Cell Lung Cancer

The development of third-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) targeting T790M-mutant non-small cell lung cancer (NSCLC) has raised the importance of re-biopsy after EGFR-TKI failure. This study aimed to investigate the feasibility of interventional pulmonology (IP) procedures as re-biopsy methods for identifying the T790M mutation in EGFR-TKI-resistant patients. One hundred and thirty-nine NSCLC patients who underwent IP procedures for re-biopsy as their initial investigation after EGFR-TKI treatment failure were enrolled in this study between January 2020 and August 2022. All patients underwent a first re-biopsy with IP methods, with a diagnostic yield of 81.2% and T790M mutation detection rate of 36%. Thirty patients underwent a second re-biopsy; IP methods were used for 17 (56.6%) patients and non-IP methods for 13 (43.4%) patients; the T790M mutation detection rate was 36.4%. Only six patients underwent a third re-biopsy; no T790M mutation was noted. The T790M mutation detection rate did not differ between IP and non-IP methods (33.6 % vs. 37.5%, p = 0.762). In 11 cases (7.5%), a re-biopsy revealed histologic transformation from lung adenocarcinoma. IP procedures, as first-line re-biopsy methods for NSCLC, are feasible and provide sufficient tissue for identification of the resistance mechanism and target gene T790M mutation.

Diagnostic value of the combined use of radial probe endobronchial ultrasound and transbronchial biopsy in lung cancer

BACKGROUND

Although the use of radial endobronchial ultrasound (R-EBUS) with a guide sheath has shown improved diagnostic capability in peripheral pulmonary lesions, its utility is still low due to variable performance. To overcome its limitation, we evaluated the feasibility and efficacy of R-EBUS combined with transbronchial biopsy (TBB) under fluoroscopic guidance.

METHODS

We retrospectively reviewed medical records of 74 patients with non-small cell lung cancer (NSCLC) who underwent R-EBUS combined with TBB or TBB alone as a diagnostic technique. Subjects were grouped according to the diagnostic modality used (R-EBUS combined with TBB vs. TBB alone). Each group was matched for age, sex, and location of the biopsy. The chi-square test and paired t-test were used to compare characteristics and identify factors that affected the diagnostic yield.

RESULTS

The mean age of the study cohort was 67.4 ± 12.8 years, with 21 (56.8%) men and 16 (43.2%) women in each group. The lesion size was significantly smaller in the R-EBUS group (23.6 vs. 33.9, P < 0.001). The diagnostic yield with the combined use of R-EBUS and TBB (27/37, 72.9%) was significantly higher than that with standard TBB alone (22/37, 59.4%). Lung lesions with a positive bronchus sign were associated with a higher diagnostic yield (odds ratio = 3.52 [1.17-10.62]; P = 0.025).

CONCLUSIONS

The combination of R-EBUS with TBB resulted in a higher diagnostic yield than either technique alone. Thus, the addition of R-EBUS biopsy would be helpful to improve the diagnostic yield of TBB.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: The combination of R-EBUS with TBB under fluoroscopic guidance improved the diagnostic yield of PPLs compared to TBB alone. A tissue diagnosis was more likely in pulmonary lesions with the air-bronchus sign.

WHAT THIS STUDY ADDS

The use of R-EBUS could help improve the low diagnostic yield of TBB under fluoroscopic guidance without increasing the incidence of complications.

Effect of Routine Clopidogrel Use on Bleeding Complications After Endobronchial Ultrasound-guided Fine Needle Aspiration

BACKGROUND

Endobronchial ultrasonography has proven to be highly sensitive and specific in the diagnoses of patients with mediastinal and hilar adenopathy. Many of these patients are on a combination of clopidogrel (a compound that inhibits adenosine diphosphate-induced platelet aggregation) and aspirin due to neurological and/or cardiac-related comorbidities, and stopping anticoagulation may place these patients at high risk for potential complications. Our group has previously showed that thoracentesis with an 8-french catheter is safe in patients receiving clopidogrel and aspirin with low risk of complications. In this manuscript, we report the outcomes of the largest prospective multicenter series of patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) while receiving clopidogrel.

METHODS

Patients presenting to our institutions with mediastinal/hilar adenopathy, requiring EBUS-TBNA, and actively taking clopidogrel and aspirin were included in the study. If the medication could be held for 5 to 7 days before the procedure, the patient was excluded. EBUS-TBNA was performed by an interventional pulmonology faculty on a total of 42 patients. All patients received total intravenous anesthesia, and a total of 92 nodes were sampled. First, 3 passes were performed with a 22-G needle. If no complications were encountered, we followed with additional 3 passes with a 21 G. Rapid onsite evaluation was performed in all patients. Bleeding at the puncture site was considered significant if it required cold saline, topical sympathomimetic, or balloon tamponade for hemostasis. Bleeding was considered nonsignificant if no interventions were required to achieve hemostasis.

RESULTS

We were able to perform all procedures successfully using both the 21 and 22-G needles. One patient required 30 mL cold saline installation to accomplish hemostasis with the 21 and 22-G needles. Our yield was comparable with the current literature. No statistically significant complications occurred during the procedure. All patients were contacted within 24 hours, and none reported bloody sputum.

CONCLUSION

We suggest that EBUS-TBNA, using 22 and 21-G needles, is safe with high yields in patients with mediastinal/hilar adenopathy, actively taking clopidogrel and aspirin, and are at high risk for thrombotic complications if the medication is discontinued.

Latest technology in minimally invasive thoracic surgery

From the introduction of video-assisted thoracoscopic surgery (VATS) in the 1990s, to performing major lung resections using a uniportal VATS approach, technology has paved the way for the development of minimally invasive thoracic surgery. Natural orifice access to achieve a 'no port' approach, is also on the rise, with advancements in bronchoscopic techniques for diagnosis and therapy, as well as development of soft robotics to achieve desired flexibility, dexterity and stability in future platforms, which may involve in vivo deployment to bring the surgeon totally inside the body. Development of haptic feedback in robotic platforms to enhance the surgical experience is also a major goal, with vibrotactile and mechanical feedback generation, to replicate the traditional touch. In addition, the aid of technology in the form of procedural guidance mechanisms, like augmented reality, will further improve the safety and accuracy of future operations.

Radial probe endobronchial ultrasound using a guide sheath for peripheral lung lesions in beginners

Background

The diagnostic yields and safety profiles of transbronchial lung biopsy have not been evaluated in inexperienced physicians using the combined modality of radial probe endobronchial ultrasound and a guide sheath (EBUS-GS). This study assessed the utility and safety of EBUS-GS during the learning phase by referring to a database of performed EBUS-GS procedures.

Methods

From December 2015 to January 2017, all of the consecutive patients who underwent EBUS-GS were registered. During the study period, two physicians with no previous experience performed the procedure. To assess the diagnostic yields, learning curve, and safety profile of EBUS-GS performed by these inexperienced physicians, the first 100 consecutive EBUS-GS procedures were included in the evaluation.

Results

The overall diagnostic yield of EBUS-GS performed by two physicans in 200 patients with a peripheral lung lesion was 73.0%. Learning curve analyses showed that the diagnostic yields were stable, even when the procedure was performed by beginners. Complications related to EBUS-GS occurred in three patients (1.5%): pneumothorax developed in two patients (1%) and resolved spontaneously without chest tube drainage; another patient (0.5%) developed a pulmonary infection after EBUS-GS. There were no cases of pneumothorax requiring chest tube drainage, severe hemorrhage, respiratory failure, premature termination of the procedure, or procedure-related mortality.

Conclusions

EBUS-GS is a safe and stable procedure with an acceptable diagnostic yield, even when performed by physicians with no previous experience.

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0704-7) contains supplementary material, which is available to authorized users.

Endobronchial ultrasound - one year of experience in clinical practice

Background and aim

Endobronchial ultrasound (EBUS) is a recent minimally invasive, safe examination method for the mediastinum, with a good diagnostic precision.

This method makes possible real time examination with transbronchial fine needle aspiration, diagnostic transbronchial needle aspiration (TBNA) and staging of non-small pulmonary tumors, as well as diagnosis of mediastinal and hilar adenopathies of various causes.

Methods

We present the experience of the Bronchoscopy Department of the Pulmonology Clinic of Cluj-Napoca with EBUS-TBNA as a tool for the diagnosis and staging of tumors in contact with the bronchial wall and mediastinal and hilar adenopathies of unknown etiology. During the period August 2014 – January 2016 we examined 152 patients with no direct or indirect signs of lung tumor in traditional bronchoscopy. Rapid on site evaluation (ROSE) was available for all patients.

Results

Our study is a retrospective study of 152 EBUS-TBNA examinations. The average age of our patients was 54.43 years and 64% came from urban and 36% from rural background. EBUS-TBNA brought the final histological confirmation (tumors, sarcoidosis, limphoma) in 82.8% of the cases. A tumor confirmation was obtained in 95% of the patients who were suspected of having tumor.

For a better understanding of the importance of this method in the daily clinical practice we present a case of peripheral pulmonary neoplasm with mediastinal and hilar adenopathies, where the contribution of EBUS-TBNA to a rapid diagnosis was essential.

Conclusion

By the introduction of this method in our country one year ago, we can diagnose patients with lung and mediastinal tumors, which cannot be diagnosed by traditional bronchoscopy. This brings a valuable contribution to the improvement of lung cancer staging and diagnostic.

Severe Chronic Obstructive Pulmonary Disease Is Not Associated With Complications After Navigational Bronchoscopy Procedures

BACKGROUND

Electromagnetic navigational bronchoscopy (ENB) is a commonly used technique to obtain biopsies of peripheral pulmonary lesions. Little is known about risk factors for complications with this procedure. The aim of this study was to assess the complication rate associated with ENB and the relationship of complications to patient- and procedure-related factors.

METHODS

Consecutive ENB procedures at an academic medical center between May 11, 2011, and September 11, 2015, were reviewed retrospectively. Preoperative characteristics, including pulmonary function, procedure characteristics, and the occurrence of complications, were recorded.

RESULTS

In all, 361 procedures were performed on 341 patients. Complications occurred in 30 of 361 (8.3%), the most common of which was pneumothorax (27, 7.5%). Complications were not related to age, sex, American Society of Anesthesiologists grade, or pulmonary function test result. Patients with complications had longer procedure times (50 versus 73 minutes, p = 0.03), and had more interventional modalities used (2.4 versus 3.2, p = 0.001). Multiple logistic regression demonstrated that bronchoalveolar lavage was significantly associated with complications (odds ratio 6.40; 95% confidence interval: 1.68 to 24.3, p = 0.006).

CONCLUSIONS

Electromagnetic navigational bronchoscopy is safe, and the rate of complications is not elevated among patients with poor lung function. Bronchoalveolar lavage performed during ENB was associated with elevated risk of complications and should be studied further.

Utility of endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing non-specific inflammatory intrathorcacic lymphadenitis

BACKGROUND AND OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a minimally invasive technique for diagnosing intrathoracic malignancies and some benignancies; however, there are no data available on the utility of EBUS-TBNA for the diagnosis of non-specific inflammatory intrathoracic lymphadenitis.

METHODS

A prospective analysis was performed from 104 patients with enlarged lymphadenopathy suspected of non-specific lymphadenitis referred for EBUS-TBNA between October 2009 and March 2012. Rapid on-site cytological evaluation was not adopted. Microbiological tests were carried out in all patients. Patients were excluded from the study if there was other diagnosis being defined.

RESULTS

One hundred ninety-one lesions were aspirated in 94 patients with enlarged mediastinal/hilar lymph nodes within reach of EBUS-TBNA, which were diagnosed as non-specific intrathorcacic lymphadenitis by pathology and clinical follow-up. According to EBUS-TBNA pathologies, 94 patients were categorized into four kinds: (i) inflammatory cell infiltrates and/or noncaseating necrosis in 38 cases; (ii) granuloma formed by epithelioid cells and/or fiber hyperplasia in 13 cases; (iii) lymph node tissue/lymphocyte without obvious abnormal lesions in 41 cases; (iv) inadequate sample in 2 cases. Bacterial and/or fungal smears and cultures were carried out in all 94 patients (100%), with pathogens being found in 4 (4.3%) cases. All patients (100%) underwent acid-fast staining and culture for mycobacterium tuberculosis to exclude tuberculosis. No procedure-related complication was observed.

CONCLUSIONS

EBUS-TBNA can provide pathological and microbiological evidences for diagnosing non-specific inflammatory intrathoracic lymphadenopathy, and it is a safe and effective first-line investigation for ruling out malignancies and other benign diseases.

Endobronchial Ultrasound: Clinical Uses and Professional Reimbursements

Endobronchial ultrasonography (EBUS) has become an invaluable tool in the diagnosis of patients with a variety of thoracic abnormalities. The majority of EBUS procedures are used to diagnose and stage mediastinal and hilar abnormalities, as well as peripheral pulmonary targets, with a probe-based technology. Nearly 1,000 articles have been written about its use and utility. New Current Procedural Terminology (CPT) codes have been introduced in 2016 to better capture the work and clinical use associated with the various types of EBUS procedures. The existing 31620 code has been deleted and replaced by three new codes: 31652, 31653, and 31654. These new codes have been through the valuation process, and the new rule for reimbursement has been active since January 1, 2016 with National Correct Coding Initiative correction as of April 1, 2016. The impact of these new codes will result in a net reduction in professional and technical reimbursement. This article describes the current use of EBUS and explains the current codes and professional reimbursement.

Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: combination of radial probe endobronchial ultrasound and rapid on-site evaluation

BACKGROUND

Rapid on-site evaluation (ROSE) of cytologic specimens is a useful ancillary technique in needle aspiration procedures of pulmonary/mediastinal lesions, but few reports had been carried out to confirm the utility in the diagnosis of peripheral pulmonary lesions (PPLs) by radial probe endobronchial ultrasound (R-EBUS).

METHODS

To evaluate the impact of ROSE on the diagnostic yield of R-EBUS for PPLs, we retrospectively analyzed the diagnostic yields of transbronchial biopsy (TBB) or brushing using R-EBUS for patients with PPLs in a tertiary university hospital from December 2012 to December 2014.

RESULTS

A total of 815 patients with PPLs were included. A definite diagnosis was made by R-EBUS-guided TBB or brushing for 627 patients (76.9%). A total of 279 patients (34.2%) were examined by a ROSE technique. The combination of R-EBUS guided TBB or brushing with ROSE raised the diagnostic yield in the diagnosis of PPLs, especially difficult cases: right apical and left apical-posterior segment locations, small PPLs <3 cm without bronchus signs on computed tomography (CT) scan, PPLs with pleural effusions, and the position of probe is not within.

CONCLUSIONS

ROSE can improve the PPLs diagnostic yield when using R-EBUS guided TBB or brushing.

The role of the team physician in school athletics

Background

Convenient approaches for accurate biopsy are extremely important to the diagnosis of lung cancer. We aimed to systematically review the clinical updates and development trends of approaches for biopsy, i.e., CT-guided PTNB (Percutaneous Transthoracic Needle Biopsy), ENB (Electromagnetic Navigation Bronchoscopy), EBUS-TBNA (Endobroncheal Ultrasonography-Transbronchial Needle Aspiration), mediastinoscopy and CTC (Circulating Tumor Cell).

Methods

Medline and manual searches were performed. We identified the relevant studies, assessed study eligibility, evaluated methodological quality, and summarized diagnostic yields and complications regarding CT-guided PTNB (22 citations), ENB(31 citations), EBUS-TBNA(66 citations), Mediastinoscopy(15 citations) and CTC (19 citations), respectively.

Results

The overall sensitivity and specificity of CT-guided PTNB were reported to be 92.52% ± 3.14% and 97.98% ± 3.28%, respectively. The top two complications of CT-guided PTNB was pneumothorax (946/4170:22.69%) and hemorrhage (138/1949:7.08%). The detection rate of lung cancer by ENB increased gradually to 79.79% ± 15.34% with pneumothorax as the top one complication (86/1648:5.2%). Detection rate of EBUS-TBNA was 86.06% ± 9.70% with the top three complications, i.e., hemorrhage (53/8662:0.61%), pneumothorax (46/12432:0.37%) and infection (34/11250:0.30%). The detection rate of mediastinoscopy gradually increased to 92.77% ± 3.99% with .hoarseness as the refractory complication (4/2137:0.19%). Sensitivity and specificity of CTCs detection by using PCR (Polymerase Chain Reaction) were reported to be 78.81% ± 14.72% and 90.88% ± 0.53%, respectively.

Conclusion

The biopsy approaches should be chosen considering a variety of location and situation of lesions. CT-guided PTNB is effective to reach lung parenchyma, however, diagnostic accuracy and incidence of complications may be impacted by lesion size or needle path length. ENB has an advantage for biopsy of smaller and deeper lesions in lung parenchyma. ENB plus EBUS imaging can further improve the detection rate of lesion in lung parenchyma. EBUS-TBNA is relatively safer and mediastinoscopy provides more tissue acquisition and better diagnostic yield of 4R and 7th lymph node. CTC detection can be considered for adjuvant diagnosis.