Factors Related to Diagnostic Yield of Transbronchial Biopsy Using Endobronchial Ultrasonography With a Guide Sheath in Small Peripheral Pulmonary Lesions

Ultrathin bronchoscopy versus conventional bronchoscopy in the diagnosis of peripheral pulmonary lesions: a systematic review and meta-analysis

BACKGROUND

Ultrathin bronchoscopy (UTB) is commonly used to diagnose peripheral pulmonary lesions due to its small diameter. However, there is no consensus on its comparison with conventional bronchoscopy (CB) combined with various guiding modalities.

METHODS

A comprehensive literature search was performed to identify studies comparing UTB and CB, extracting data on diagnostic yield, operating time, complications, pathological diagnoses, and lesion size. Protocol registration: identifier CRD42024554649. PRISMA guidelines were followed.

RESULTS

This meta-analysis included 11 studies with 2,640 patients. UTB demonstrated a significantly higher diagnostic yield (70.5% vs. 57.6%, p = 0.005), particularly with rEBUS and fluoroscopy (p = 0.02). UTB had a higher complication rate, but the difference was not significant (p = 0.37). It also had a shorter operative time than CB-GS (p = 0.007). UTB showed a significant advantage in diagnosing malignant tumors, especially adenocarcinoma and metastatic cancer (p = 0.02, p = 0.03). Both techniques were comparable in diagnosing benign conditions, but UTB outperformed CB in all lesion size categories (p < 0.01).

CONCLUSIONS

UTB's smaller diameter likely provides a diagnostic advantage over CB and CB-GS by enabling deeper and more accurate access to peripheral lung regions.

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.

Improving Cancer Probability Estimation in Nondiagnostic Bronchoscopies: A Meta-Analysis

BACKGROUND

In patients with peripheral pulmonary lesions (PPLs), nondiagnostic bronchoscopy results are not uncommon. The conventional approach to estimate the probability of cancer (pCA) after bronchoscopy relies on dichotomous test assumptions, using prevalence, sensitivity, and specificity to determine negative predictive value. However, bronchoscopy is a multidisease test, raising concerns about the accuracy of dichotomous methods.

RESEARCH QUESTION

By how much does calculating pCA using a dichotomous approach (pCAdichotomous) underestimate the true pCA when applied to multidisease tests like bronchoscopy for the diagnosis of PPL?

METHODS

In this meta-analysis of cohort studies involving radial endobronchial ultrasound for PPL, Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed, constructing 2 × 2 contingency tables for calculating pCAdichotomous. For the multidisease test approach, 3 × 3 contingency tables for calculating probability of malignancy for a test that can have different categories of results and can diagnose multiple diseases (pCAmultidisease) using the likelihood ratio (LR) method for nondiagnostic results (LR(T0)) was used. Observed malignancy rates in patients with nondiagnostic results were compared with pCAdichotomous and pCAmultidisease.

RESULTS

In 46 studies (7,506 patients), malignancy was the underlying diagnosis in 76% of cases, another specific disease in 13% of cases, and nonspecific fibrosis or scar in 10% of cases. The percentage of patients with nondiagnostic results who had malignancy matched pCAmultidisease across all studies. In contrast, pCAdichotomous consistently underestimated cancer risk (median difference, 0.12; interquartile range, 0.06-0.23), particularly in studies with a higher prevalence of nonmalignant disease. The pooled LR(T0) was 0.46 (95% CI, 0.40-0.52; I2 = 76%; P < .001) and correlated with the prevalence of nonmalignant diseases (P = .001).

INTERPRETATION

Conventional dichotomous methods for estimating pCA after nondiagnostic bronchoscopies underestimate the likelihood of malignancy. Physicians should opt for the multidisease test approach when interpreting bronchoscopy results.

Ultrathin Bronchoscopy Without Virtual Navigation for Diagnosis of Peripheral Lung Lesions

BACKGROUND

The increasing incidence of encountering lung nodules necessitates an ongoing search for improved diagnostic procedures. Various bronchoscopic technologies have been introduced or are in development, but further studies are needed to define a method that fits best in clinical practice and health care systems.

RESEARCH QUESTION

How do basic bronchoscopic tools including a combination of thin (outer diameter 4.2 mm) and ultrathin bronchoscopes (outer diameter 3.0 mm), radial endobronchial ultrasound (rEBUS) and fluoroscopy perform in peripheral pulmonary lesion diagnosis?

STUDY DESIGN AND METHODS

This is a retrospective review of the performance of peripheral bronchoscopy using thin and ultrathin bronchoscopy with rEBUS and 2D fluoroscopy without a navigational system for evaluating peripheral lung lesions in a single academic medical center from 11/2015 to 1/2021. We used a strict definition for diagnostic yield and assessed the impact of different variables on diagnostic yield, specifically after employment of the ultrathin bronchoscope. Logistic regression models were employed to assess the independent associations of the most impactful variables.

RESULTS

A total of 322 patients were included in this study. The median of the long axis diameter was 2.2 cm and the median distance of the center of the lesion from the visceral pleural surface was 1.9 cm. Overall diagnostic yield was 81.3% after employment of the ultrathin bronchoscope, with more detection of concentric rEBUS views (93% vs. 78%, p < 0.001). Sensitivity for detecting malignancy also increased from 60.5% to 74.7% (p = 0.033) after incorporating the ultrathin scope into practice, while bronchus sign and peripheral location of the lesion were not found to affect diagnostic yield. Concentric rEBUS view, solid appearance, upper/middle lobe location and larger size of the nodules were found to be independent predictors of successful achievement of diagnosis at bronchoscopy.

INTERPRETATION

This study demonstrates a high diagnostic yield of biopsy of lung lesions achieved by utilization of thin and ultrathin bronchoscopes. Direct visualization of small peripheral airways with simultaneous rEBUS confirmation increased localization rate of small lesions in a conventional bronchoscopy setting without virtual navigational planning.

Value of ultrathin bronchoscope in improving the endobronchial ultrasound localization rate and diagnosing peripheral pulmonary nodules by cryobiopsy

BACKGROUND

A 3.0-mm ultrathin bronchoscope (UTB) with a 1.7-mm working channel provides better accessibility to peripheral bronchi. A 4.0-mm thin bronchoscope with a larger 2.0-mm working channel facilitates the use of a guide sheath (GS), ensuring repeated sampling from the same location. The 1.1-mm ultrathin cryoprobe has a smaller diameter, overcoming the limitation of the size of biopsy instruments used with UTB. In this study, we compared the endobronchial ultrasound localization rate and diagnostic yield of peripheral lung lesions by cryobiopsy using UTB and thin bronchoscopy combined with GS.

METHODS

We retrospectively evaluated 133 patients with peripheral pulmonary lesions with a diameter less than 30 mm who underwent bronchoscopy with either thin bronchoscope or UTB from May 2019 to May 2023. A 3.0-mm UTB combined with rEBUS was used in the UTB group, whereas a 4.0-mm thin bronchoscope combined with rEBUS and GS was used for the thin bronchoscope group. A 1.1-mm ultrathin cryoprobe was used for cryobiopsy in the two groups.

RESULTS

Among the 133 patients, peripheral pulmonary nodules in 85 subjects were visualized using r-EBUS. The ultrasound localization rate was significantly higher in the UTB group than in the thin bronchoscope group (96.0% vs. 44.6%, respectively; P < 0.001). The diagnostic yield of cryobiopsy specimens from the UTB group was significantly higher compared to the thin bronchoscope group (54.0% vs. 30.1%, respectively; p = 0.006). Univariate analysis demonstrated that the cryobiopsy diagnostic yields of the UTB group were significantly higher for lesions ≤ 20 mm, benign lesions, upper lobe lesions, lesions located lateral one-third from the hilum, and lesions without bronchus sign.

CONCLUSIONS

Ultrathin bronchoscopy combined with cryobiopsy has a superior ultrasound localization rate and diagnostic yield compared to a combination of cryobiopsy and thin bronchoscopy.

Improved diagnostic yield of peripheral pulmonary malignant lesions with emphysema using a combination of radial endobronchial ultrasonography and rapid on-site evaluation

BACKGROUND

This is a retrospective cohort study from a single center of Chest Medical District of Nanjing Brain Hospital Affiliated to Nanjing Medical University, Jiangsu Province, China. It was aim to evaluate the diagnostic value of radial endobronchial ultrasound (R-EBUS) combination with rapid on-site evaluation (ROSE) guided transbronchial lung biopsy (TBLB) for peripheral pulmonary lesions in patients with emphysema.

METHODS

All 170 patients who underwent PPLs with emphysema received an R-EBUS examination with or without the ROSE procedure, and the diagnostic yield, safety, and possible factors influencing diagnosis were analyzed between the two groups by the SPSS 25.0 software.

RESULTS

The pooled and benign diagnostic yields were not different in the two groups (P = 0.224, 0.924), but the diagnostic yield of malignant PPLs was significantly higher in the group with ROSE than the group without ROSE (P = 0.042). The sensitivity of ROSE was 79.10%, the specificity, 91.67%, the positive predictive value, 98.15%, and the negative predictive value, 84.62%. The diagnostic accuracy, was 95.52%. In the group of R-EBUS + ROSE, the procedural time and the number of times of biopsy or brushing were both significantly reduced (all P<0.05). The incidence of pneumothorax (1.20%) and bleeding (10.84%) in the group of R-EBUS + ROSE were also less than those in the group of R-EBUS (P<0.05). The lesion's diameter ≥ 2 cm, the distance between the pleura and the lesion ≥ 2 cm, the positive air bronchograms sign, the location of the ultrasound probe within the lesion, and the even echo with clear margin feature of lesion ultrasonic image, these factors are possibly relevant to a higher diagnostic yield. The diagnostic yield of PPLs those were adjacent to emphysema were lower than those PPLs which were away from emphysema (P = 0.048) in the group without ROSE, however, in the group of R-EBUS + ROSE, there was no such difference whether the lesion is adjacent to emphysema or not (P = 0.236).

CONCLUSION

Our study found that the combination of R-EBUS and ROSE during bronchoscopy procedure was a safe and effective modality to improve diagnostic yield of PPLs with emphysema, especially for malignant PPLs. The distance between the pleura and the lesion ≥ 2 cm, the positive air bronchograms sign, the location of the ultrasound probe within the lesion, and the even echo with clear margin feature of lesion ultrasonic image, these factors possibly indicated a higher diagnostic yield. Those lesions' position is adjacent to emphysema may reduce diagnostic yield but ROSE may make up for this deficiency.

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined.

AREAS COVERED

This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed.

EXPERT OPINION

The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Using cryoprobes of different sizes combined with cone-beam computed tomography-derived augmented fluoroscopy and endobronchial ultrasound to diagnose peripheral pulmonary lesions: a propensity-matched study

BACKGROUND

Endobronchial ultrasound (EBUS) and cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) are utilized for the diagnosis of peripheral pulmonary lesions (PPLs). Combining them with transbronchial cryobiopsy (TBC) can provide sufficient tissue for genetic analysis. However, cryoprobes of different sizes have varying degrees of flexibility, which can affect their ability to access the target bronchus and potentially impact the accuracy. The aim of this study was to compare the diagnostic efficacy of cryoprobes of varying sizes in CBCT-AF and EBUS for the diagnosis of PPLs.

METHODS

Patients who underwent endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) and TBC combined with CBCT-AF for PPLs diagnosis between January 2021 and May 2022 were included. Propensity score matching and competing-risks regression were utilized for data analysis. Primary outcome was the diagnostic accuracy of TBC.

RESULTS

A total of 284 patients underwent TBC, with 172 using a 1.7-mm cryoprobe (1.7 group) and 112 using a 1.1-mm cryoprobe (1.1 group). Finally, we included 99 paired patients following propensity score matching. The diagnostic accuracy of TBC was higher in the 1.1 group (80.8% vs. 69.7%, P = 0.050), with a similar rate of complications. Subgroup analysis also revealed that the 1.1 group had better accuracy when PPLs were located in the upper lobe (85.2% vs. 66.1%, P = 0.020), when PPLs were smaller than 20 mm (78.8% vs. 48.8%, P = 0.008), and when intra-procedural CBCT was needed to be used (79.5% vs. 42.3%, P = 0.001). TBC obtained larger specimens than TBB in both groups. There is still a trend of larger sample size obtained in the 1.7 group, but there is no statistically different between our two study groups (40.8 mm2 vs. 22.0 mm2, P = 0.283).

CONCLUSIONS

The combination of TBC with CBCT-AF and EBUS is effective in diagnosing PPLs, and a thin cryoprobe is preferred when the PPLs located in difficult areas.

Impact of Cough Severity on the Diagnostic Yield of Endobronchial Ultrasonography Transbronchial Biopsy with Guide Sheath: A Retrospective Observational Study

Bronchoscopy is an invasive procedure, and patient coughing during examination has been reported to cause patient distress. This study aimed to clarify the relationship between cough severity and diagnostic yield of endobronchial ultrasonography with guide sheath transbronchial biopsy (EBUS-GS-TBB). Data of patients who underwent bronchoscopy at Kyorin University Hospital between April 2019 and March 2022 were retrospectively evaluated. Bronchoscopists assessed the cough severity upon completion of the procedure using a four-point cough scale. Cough severity was included as a predictive factor along with those reportedly involved in bronchoscopic diagnosis, and their impact on diagnostic yield was evaluated. Predictors of cough severity were also examined. A total of 275 patients were enrolled in this study. In the multivariate analysis, the diagnostic group (n = 213) had significantly more 'within' radial endobronchial ultrasound findings (odds ratio [OR] 5.900, p < 0.001), a lower cough score (cough score per point; OR 0.455, p < 0.001), and fewer bronchial generations to target lesion(s) (OR 0.686, p < 0.001) than the non-diagnostic group (n = 62). The predictive factors for severe cough include the absence of virtual bronchoscopic navigation (VBN) and prolonged examination time. Decreased cough severity was a positive predictive factor for successful EBUS-GS-TBB, which may be controlled using VBN and awareness of the procedural duration.

Novel electromagnetic navigation bronchoscopy system for the diagnosis of peripheral pulmonary nodules: a prospective, multicentre study

BACKGROUND

Traditional electromagnetic navigation bronchoscopy (ENB) is a real-time image-guided system and used with thick bronchoscopes for the diagnosis of peripheral pulmonary nodules (PPNs). A novel ENB that could be used with thin bronchoscopes was developed. This study aimed to evaluate the diagnostic yield and the experience of using this ENB system in a real clinical scenario.

METHODS

This multicentre study enrolled consecutive patients with PPNs adopting ENB from March 2019 to August 2021. ENB was performed with different bronchoscopes, ancillary techniques and sampling instruments according to the characteristics of the nodule and the judgement of the operator. The primary endpoint was the diagnostic yield. The secondary endpoints included the diagnostic yield of subgroups, procedural details and complication rate.

RESULTS

In total, 479 patients with 479 nodules were enrolled in this study. The median lesion size was 20.9 (IQR, 15.9-25.9) mm. The overall diagnostic yield was 74.9% (359/479). A thin bronchoscope was used in 96.2% (461/479) nodules. ENB in combination with radial endobronchial ultrasound (rEBUS), a guide sheath (GS) and a thin bronchoscope was the most widely used guided method, producing a diagnostic yield of 74.1% (254/343). The median total procedural time was 1325.0 (IQR, 1014.0-1676.0) s. No severe complications occurred.

CONCLUSION

This novel ENB system can be used in combination with different bronchoscopes, ancillary techniques and sampling instruments with a high diagnostic yield and safety profile for the diagnosis of PPNs, of which the combination of thin bronchoscope, rEBUS and GS was the most common method in clinical practice.

TRIAL REGISTRATION NUMBER

NCT03716284.

The Effect of Definitions and Cancer Prevalence on Diagnostic Yield Estimates of Bronchoscopy: A Simulation-based Analysis

Rationale: Studies of bronchoscopy have reported diagnostic yield (DY) using different calculation methods, which has hindered comparisons across studies. Objectives: To quantify the effect of the variability of four methods on DY estimates of bronchoscopy. Methods: We performed a simulation-based analysis of patients undergoing bronchoscopy using variations around base case assumptions for cancer prevalence (60%), distribution of nonmalignant findings, and degree of follow-up information at a fixed sensitivity of bronchoscopy for malignancy (80%). We calculated DY, the rate of true positives and true negatives (TNs), using four methods. Method 1 considered malignant and specific benign findings at index bronchoscopy as true positives and TNs, respectively. Method 2 included nonspecific benign findings as TNs. Method 3 considered nonspecific benign findings cases as TNs only if follow-up confirmed benign disease. Method 4 counted all cases with a nonmalignant diagnosis as TNs if follow-up confirmed benign disease. A scenario analysis and probabilistic sensitivity analysis were conducted to demonstrate the effect of parameter estimates on DY. A change in DY of >10% was considered clinically meaningful. Results: Across all pairwise comparisons of the four methods, a DY difference of >10% was observed in 76.7% of cases (45,992 of 60,000 comparisons). Method 4 resulted in DY estimates that were >10% higher than estimates made with other methods in >90% of scenarios. Variation in cancer prevalence had a large effect on DY. Conclusions: Across a wide range of clinical scenarios, the categorization of nonmalignant findings at index bronchoscopy and cancer prevalence had the largest impact on DY. The large variability in DY estimates across the four methods limits the interpretation of bronchoscopy studies and warrants standardization.

Clinical outcomes of transbronchial cryobiopsy using a 1.1-mm diameter cryoprobe for peripheral lung lesions - A prospective pilot study

OBJECTIVES

Transbronchial cryobiopsy (TBCB) is a novel technique for the diagnosis of peripheral lung lesions (PLLs). We aim to evaluate the clinical outcomes of TBCB using a new 1.1-mm diameter cryoprobe for the diagnosis of PLLs.

MATERIALS AND METHODS

We performed a prospective observational pilot study on the diagnosis of PLLs (diameter ≤30 mm) by TBCB, using a 1.1-mm diameter cryoprobe with radial endobronchial ultrasound (RP-EBUS), virtual bronchoscopic navigation and fluoroscopy from December 2021 to July 2022. Primary outcome was the pathological diagnostic yield of TBCB, and secondary outcome was adverse event.

RESULTS

A total of 50 patients were enrolled (mean lesion size, 21 mm). TBCB was performed in 49 patients up to three times except for the one with "invisible" finding on RP-EBUS. The overall diagnostic yield of TBCB was 90% (45/50). There was no difference in the diagnostic yield between size (20 mm vs. 20-30 mm; 88% [22/25] vs. 92% [23/25]; P = 1.000), RP-EBUS findings (concentric vs. others; 97% [28/29] vs. 81% [17/21]; P = 0.148), and acute angle location (apical segment of both upper lobes vs. others; 92% [12/13] vs. 89% [33/37]; P = 1.000). The cumulative diagnostic yields of the first, second, and third TBCB were 82% (41/50), 88% (44/50), and 90% (45/50), respectively. Mild bleeding was developed in 56% (28/50), and moderate bleeding was found in 26% (13/50).

CONCLUSION

TBCB using a 1.1-mm diameter cryoprobe is an effective, reasonable method for the diagnosis of PLLs regardless of its size, RP-EBUS finding, and anatomical location without serious complication.

TRIAL REGISTRATION

Clinical Trials.Gov (NCT05046093).

Radial Endobronchial Ultrasound-guided Transbronchial Cryobiopsy versus Forceps Biopsy for the Diagnosis of Solitary Pulmonary Nodules: A Prospective Randomised Trial

Background

Improvements in pulmonary diagnostic imaging and the development of lung cancer screening are increasing the prevalence of Solitary pulmonary nodules (SPNs). Fluoroscopically guided radial endobronchial ultrasound (EBUS) with transbronchial forceps biopsy (TB-FB) has been the conventional diagnostic method. Transbronchial cryobiopsy (TB-CB) is an alternative biopsy method. We sought to compare transbronchial cryobiopsy to transbronchial forceps biopsy for the diagnosis of SPNs.

Methods

A prospective, single-centre, randomised controlled trial was conducted at the Royal Adelaide Hospital (RAH). Patients with SPNs were randomised to either 5 transbronchial forceps biopsies or one transbronchial cryobiopsy. Complete blinding of investigators and participants was not possible, as transbronchial cryobiopsy required general anaesthesia. The primary outcome was diagnostic yield with secondary outcomes of specimen size, diagnostic yield for subsets challenging to access with forceps and safety.

Results

The overall diagnostic yield for the 28 enrolled subjects was 76.8%(22/28). The diagnostic yield was 91.7% (11/12 patients) for transbronchial cryobiopsy and 68.8% (11/16 patients) for forceps biopsy (p=0.14). Median biopsy sizes were consistently larger for the cryobiopsy arm at 7.0mm compared to 2.5mm(p<0.0001). An eccentric EBUS image signalling the probe was adjacent to the nodule occurred in 4/28 cases, and TB-CB confirmed a diagnosis in 3/3 randomised to this arm. There were no major complications with either technique.

Conclusion

Transbronchial cryobiopsy under the guidance of fluoroscopy and radial EBUS facilitates larger biopsy specimens without a significant increase in major complications. Further research is required to confirm the effect on diagnostic yield; however, our study supports a role for TB-CB in the diagnosis of SPNs and small, nodule-adjacent biopsies.

Clinical Trial Registration Number

Reference number of R20160213(HREC/16/RAH/37).

Close-to-lesion transbronchial biopsy: a novel technique to improve suitability of specimens for genetic testing in patients with peripheral pulmonary lesions

Bronchoscopy with radial-probe endobronchial ultrasound, a guide sheath, and electromagnetic navigation can improve the diagnostic yield of peripheral lung nodules. However, the suitability of specimens for genetic analysis remains unsatisfactory. We hypothesized that a transbronchial biopsy performed after closely approaching the bronchoscope tip to the lesion might provide more suitable specimens for genetic analysis. We enrolled 155 patients with peripheral pulmonary lesions who underwent bronchoscopy with a thin or ultrathin bronchoscope. Bronchoscopy was performed using virtual bronchoscopic navigation and radial-probe endobronchial ultrasound with a guide sheath. The bronchoscope tip was placed closer to the lesion during bronchoscopy to collect larger specimens with higher malignant cell content. The patients who underwent a close-to-lesion biopsy had higher rates of overall diagnostic yield, histopathological diagnostic yield, and specimen quality for genetic testing than those who did not. The significant determinants of the specimen's suitability were the close-to-lesion approach, within-the-lesion image, the use of standard 1.9-mm-forceps, and the number of cancer-cell-positive specimens. The significant predictors of the specimen's suitability for genetic analysis were close-to-lesion biopsy and the number of malignant cell-positive tissue samples. This study demonstrates that the close-to-lesion transbronchial biopsy significantly improves the suitability of bronchoscopic specimens for genetic analysis.

Predictive factors for improved diagnostic accuracy with the use of radial-probe EBUS

OBJECTIVE

To assess predictive factors for improved diagnostic accuracy with the use of radial-probe EBUS (RP-EBUS).

METHODS

This was a retrospective review of consecutive patients undergoing RP-EBUS between February of 2012 and January of 2020. Parameters including the presence of a bronchus sign on CT scans, the position of the radial EBUS probe, lesion size, lesion location, and lesion type were analyzed in relation to two defined outcomes (final diagnosis or no diagnosis). Univariate analysis was used in order to explore the individual effects of each parameter on diagnostic accuracy. Multivariate logistic regression was performed to identify significant predictors of diagnostic accuracy.

RESULTS

RP-EBUS was used for diagnostic purposes in 101 patients. The lesion was < 3 cm in size in 59 patients (58.4%) and predominantly solid in 60.3%. There was a positive correlation between radial EBUS probe position and diagnostic accuracy (p = 0.036), with 80.9% of the patients showing a bronchus sign on CT scans. Furthermore, 89% of the patients showed a bronchus sign on CT scans and a correlation with diagnostic accuracy (p = 0.030), with 65.8% of the lesions being located in the left/right upper lobe (p = 0.046). When the radial EBUS probe was within the target lesion, the diagnostic yield was = 80.8%. When the probe was adjacent to the lesion, the diagnostic yield was = 19.2%. A bronchus sign on CT scans was the only parameter that independently influenced diagnostic accuracy (adjusted OR, 3.20; 95% CI, 1.081-9.770; p = 0.036).

CONCLUSIONS

A bronchus sign on CT scans is a powerful predictor of successful diagnosis by RP-EBUS.

Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official World Association for Bronchology and Interventional Pulmonology Expert Panel consensus statement

BACKGROUND

Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes.

METHODS

A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes.

RESULTS

Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented.

CONCLUSION

This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres.

Predictive value of the resistance of the probe to pass through the lesion in the diagnosis of peripheral pulmonary lesions using radial probe endobronchial ultrasound with a guide sheath

Background

Transbronchial lung biopsy guided by radial probe endobronchial ultrasonography with a guide sheath (EBUS-GS-TBLB) is becoming a significant approach for diagnosing peripheral pulmonary lesions (PPLs). We aimed to explore the clinical value of the resistance of the probe to pass through the lesion in the diagnosis of PPLs when performing EBUS-GS-TBLB, and to determine the optimum number of EBUS-GS-TBLB.

Methods

We performed a prospective, single-center study of 126 consecutive patients who underwent EBUS-GS-TBLB for solid and positive-bronchus-sign PPLs where the probe was located within the lesion from September 2019 to May 2022. The classification of probe resistance for each lesion was carried out by two bronchoscopists independently, and the final result depended on the bronchoscopist responsible for the procedures. The primary endpoint was the diagnostic yield according with the resistance pattern. The secondary endpoints were the optimum number of EBUS-GS-TBLB and factors affecting diagnostic yield. Procedural complications were also recorded.

Results

The total diagnostic yield of EBUS-GS-TBLB was 77.8%, including 83.8% malignant and 67.4% benign diseases (P=0.033). Probe resistance type II displayed the highest diagnostic yield (87.5%), followed by type III (81.0%) and type I (61.1%). A significant difference between the diagnostic yield of malignant and benign diseases was detected in type II (P = 0.008), whereas others did not. Although most of the malignant PPLs with a definitive diagnosis using EBUS-GS-TBLB in type II or type III could be diagnosed in the first biopsy, the fourth biopsy contributed the most sufficient biopsy samples. In contrast, considerably limited tissue specimens could be obtained for each biopsy in type I. The inter-observer agreement of the two blinded bronchoscopists for the classification of probe resistance was excellent (κ = 0.84).

Conclusion

The probe resistance is a useful predictive factor for successful EBUS-GS-TBLB diagnosis of solid and positive-bronchus-sign PPLs where the probe was located within the lesion. Four serial biopsies are appropriate for both probe resistance type II and type III, and additional diagnostic procedures are needed for type I.

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.

Guided Bronchoscopy for the Evaluation of Pulmonary Lesions: An Updated Meta-analysis

BACKGROUND

Guided bronchoscopy is increasingly used to diagnose peripheral pulmonary lesions (PPLs). A meta-analysis published in 2012 demonstrated a pooled diagnostic yield of 70%; however, recent publications have documented yields as low as 40% and as high as 90%.

RESEARCH QUESTION

Has the diagnostic yield of guided bronchoscopy in patients with PPLs improved over the past decade?

STUDY DESIGN AND METHODS

A comprehensive search was performed of studies evaluating the diagnostic yield of differing bronchoscopic technologies used to reach PPLs. Study quality was assessed using the Quality assessment of diagnostic accuracy of studies (QUADAS-2) assessment tool. Number of lesions, type of technology used, overall diagnostic yield, and yield by size were extracted. Adverse events were recorded. Meta-analytic techniques were used to summarize findings across all studies.

RESULTS

A total of 16,389 lesions from 126 studies were included. There was no significant difference in diagnostic yield prior to 2012 (39 studies; 3,052 lesions; yield 70.5%) vs after 2012 (87 studies; 13,535 lesions; yield 69.2%) (P > .05). Additionally, there was no significant difference in yield when comparing different technologies. Studies with low risk of overall bias had a lower diagnostic yield than those with high risk of bias (66% vs 71%, respectively; P = .018). Lesion size > 2 cm, presence of bronchus sign, and reports with a high prevalence of malignancy in the study population were associated with significantly higher diagnostic yield. Significant (P < .0001) between-study heterogeneity was also noted.

INTERPRETATION

Despite the reported advances in bronchoscopic technology to diagnose PPLs, the diagnostic yield of guided bronchoscopy has not improved.

The Additive Impact of Transbronchial Cryobiopsy Using a 1.1-mm Diameter Cryoprobe on Conventional Biopsy for Peripheral Lung Nodules

PURPOSE

The diagnostic yield of transbronchial biopsy (TBB) using radial probe endobronchial ultrasound (RP-EBUS) is 71%, which is lower than that of transthoracic needle biopsy. We investigated the performance and safety of sequential transbronchial cryobiopsy (TBC) using a novel 1.1-mm diameter cryoprobe, after conventional TBB using RP-EBUS for the diagnosis of peripheral lung lesions (PLLs).

Materials and Methods

From April 2021 to November 2021, 110 patients who underwent bronchoscopy using RP-EBUS for the diagnosis of PLL ≤ 30 mm were retrospectively included in our study. All records were followed until June 2022.

RESULTS

The overall diagnostic yield of combined TBB and TBC was 79.1%, which was higher than 60.9% of TBB alone (p=0.005). The diagnostic yield of sequential TBC was 65.5%, which increased the overall diagnostic yield by 18.2%. The surface area of tissues by TBC (mean area, 18.5 mm2) was significantly larger than those of TBB by 1.5-mm forceps (3.4 mm2, p < 0.001) and 1.9-mm forceps (3.7 mm2, p=0.011). In the multivariate analysis, PLLs with the longest diameter of ≤ 22 mm were found to be related to additional diagnostic benefits from sequential TBC (odds ratio, 3.51; 95% confidence interval, 1.043 to 11.775; p=0.042). Complications were found in 10.5% of the patients: pneumothorax (1.0%), infection (1.0%), and significant bleeding (8.6%). None of the patients developed any life-threatening complications.

CONCLUSION

Sequential TBC with a 1.1-mm cryoprobe improved the performance of conventional TBB using RP-EBUS without serious complications.

Virtual fluoroscopic preprocedural planning using Ziostation2 for transbronchial biopsy: A prospective self-controlled study

BACKGROUND

Bronchoscopes cannot reach the periphery of the lung because the bronchi are tapered. Therefore, selectively advancing a device-e.g., an endobronchial ultrasonography (EBUS) probe-to the targets can be challenging. Virtual fluoroscopic preprocedural planning (VFPP) is a method in which the route to the target is superimposed on an X-ray fluoroscopy-like image reconstructed from CT images, facilitating the advancement of the EBUS probe to the target. The VFPP method was integrated into the Ziostation2 bronchoscopic navigation system (Ziosoft, Inc., Tokyo, Japan) in 2018. Here, we prospectively examined the feasibility of the VFPP method using Ziostation2 (Zio-VFPP).

METHODS

Thirty-six patients who had pulmonary lesions with long axes ≤30 mm and who underwent thin-slice CT with ≤0.625-mm thickness were enrolled. We initiated bronchoscopy using EBUS with a guide sheath (EBUS-GS) while referring to Ziostation2 bronchoscopic navigation. When the probe was not "within" a lesion, we attempted to correct its position based on Zio-VFPP. EBUS findings before and after Zio-VFPP were compared.

RESULTS

Zio-VFPP was performed in 24 patients, and EBUS findings improved in nine patients. Before Zio-VFPP, 18 patients were "outside," but after Zio-VFPP, the number decreased to ten. Statistically, this difference was significant (p = 0.0392). There were no cases in which EBUS findings worsened with Zio-VFPP.

CONCLUSION

Zio-VPFPP improves EBUS findings and significantly reduces "outside" cases. However, further investigation is necessary to verify its effectiveness.

Value of adding ultrathin bronchoscopy to thin bronchoscopy for peripheral pulmonary lesions: A multicentre prospective study

BACKGROUND AND OBJECTIVE

The diagnostic yield of thin bronchoscopy with radial probe endobronchial ultrasound (rEBUS) of peripheral pulmonary lesions into which the rEBUS probe cannot be inserted is unsatisfactory. In such cases, adding ultrathin bronchoscopy may be an option. We evaluated the efficacy of sequential ultrathin bronchoscopy for peripheral pulmonary lesions into which the rEBUS probe could not be inserted during thin bronchoscopy.

METHODS

In this multicentre prospective study, patients with peripheral pulmonary lesions ≤30 mm in diameter underwent rEBUS-guided transbronchial biopsy using a 4.0 mm diameter thin bronchoscope. In patients with lesions into which a rEBUS probe could not be inserted using that bronchoscope, bronchoscopy using a 3.0 mm diameter ultrathin bronchoscope was performed.

RESULTS

A total of 342 patients were enrolled and 340 were analysed. Among them, 87 patients with lesions of a median longest diameter of 17.5 mm underwent thin bronchoscopy followed by ultrathin bronchoscopy. Of the 87 patients, the rEBUS probe was successfully inserted into the lesions via the ultrathin bronchoscope in 50 patients (57.5%). Of the 87 patients, the diagnostic yields of thin bronchoscopy and ultrathin bronchoscopy were 12.6% (11 of 87) and 41.4% (36 of 87), respectively (p < 0.001).

CONCLUSION

Ultrathin bronchoscopy affords a higher diagnostic yield for lesions into which a rEBUS probe cannot be inserted via a thin bronchoscope.

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.

Diagnostic performance of cryobiopsy guided by radial-probe EBUS with a guide sheath for peripheral pulmonary lesions

OBJECTIVE

Transbronchial lung cryobiopsy (TBCB) has developed rapidly and has become one of the research hotspots of lung biopsy technology. The present study sought to evaluate the efficacy of TBCB guided by radial-probe EBUS (RP-EBUS) and a guide sheath (GS) without fluoroscopy for peripheral pulmonary lesions.

METHODS

In this retrospective study, McNemar's test was used in order to compare TBCB and transbronchial forceps biopsy (TBFB) in terms of diagnostic performance. A multivariate logistic regression model was designed to explore the association between predictive variables and the diagnostic yield of TBCB.

RESULTS

A total of 168 patients underwent GS-guided RP-EBUS. Of those, 157 had lesions that were visible and 11 had lesions that were not. Of those 157 patients, 24 were excluded because of missing data or an unclear final diagnosis. Therefore, 133 patients underwent RP-EBUS-GS-guided TBFB and TBCB. The pooled diagnostic yield of RP-EBUS-GS-guided TBCB without fluoroscopy was 71.5% (103/144). In 133 patients, the diagnostic yield of TBCB was significantly higher than that of TBFB (77.4% vs. 59.4%; p < 0.05). Multivariate analysis indicated that lesion size and site were independently associated with the diagnostic yield of TBCB (OR = 2.8, p = 0.03 and OR = 4.1, p = 0.01, respectively), although cryoprobe size was not. There was no significant difference between the 1.1-mm cryoprobe and the 1.9-mm cryoprobe in terms of diagnostic performance (78.4% vs. 76.8%; p > 0.05).

CONCLUSIONS

GS-guided RP-EBUS is regarded as a practical option for guiding cryobiopsy, although it may not be able to replace fluoroscopy. Peripheral pulmonary lesions not located in the upper lobes or larger than 30 mm are significantly associated with a higher diagnostic yield of cryobiopsy.

Usefulness of endocytoscopy in evaluating transbronchial biopsy specimens

BACKGROUND

Endocytoscopy (ECS) provides a magnification of approximately 450× for real-time observation of lesion nuclei. Using ECS, we aimed to evaluate whether sufficient samples for diagnosis can be obtained during bronchoscopy. We also investigated whether ECS can enable two-class diagnosis of malignant or non-malignant transbronchial biopsy specimens in real-time during bronchoscopy.

METHODS

This was a single-facility, prospective, observational, ex vivo study. Forty cases with localized peripheral pulmonary lesions underwent transbronchial biopsy with endobronchial ultrasonography using a guide sheath. Each biopsy specimen was immediately observed and evaluated endocytoscopically after the collection by the bronchoscopic procedure.

RESULTS

Thirty-seven cases were enrolled. The diagnostic accuracy achieved by ECS was 91.9% (34/37). The agreement rate between the endocytoscopic evaluation and pathological diagnosis of each specimen (170 specimens) was 65.3% (111/170). The median time required for endocytoscopic evaluation per specimen was 70 s. When we judged a specimen to be malignant a second time on ECS evaluations of five specimens in one case, pathologically malignant specimens were collected in 26 of 27 cases (96.3%).

CONCLUSIONS

ECS with methylene blue staining may aid in the two-class diagnosis of malignant or non-malignant transbronchial biopsy specimens during bronchoscopy. This may reduce the number of tissue biopsies.

Virtual bronchoscopic navigation and endobronchial ultrasound with a guide sheath without fluoroscopy for diagnosing peripheral pulmonary lesions with a bronchus leading to or adjacent to the lesion: A randomized non‐inferiority trial

BACKGROUND AND OBJECTIVE

Transbronchial sampling of peripheral pulmonary lesions (PPLs) is routinely performed under fluoroscopy. However, advanced ancillary techniques have become available, such as virtual bronchoscopic navigation (VBN) and radial endobronchial ultrasound with a guide sheath (rEBUS-GS). This study was performed to determine whether the diagnostic utility of VBN and rEBUS with a GS is similar with or without fluoroscopy.

METHODS

This multicenter non-inferiority trial randomized patients to a VBN-rEBUS-GS with or without fluoroscopy group at three centres. The primary endpoint was the diagnostic yield. The secondary endpoints were the time for rEBUS, GS, and the total operation. Complications were also recorded.

RESULTS

Four hundred and ninety-six subjects were assessed and 426 subjects were included in the analysis (212 in non-fluoroscopy-guided-group and 214 in fluoroscopy-guided-group). The diagnostic yield in the non-fluoroscopy-guided-group (84.0%) was not inferior to that in the fluoroscopy-guided-group (84.6%), with a diagnostic difference of -0.6% (95% CI: -6.4%, 5.2%). Multivariable analysis confirmed that bronchus sign and lesion nature were valuable diagnostic predictors in non-fluoroscopy-guided-group. The non-fluoroscopy-guided-group had shorter rEBUS, GS, and total operation time. No severe complications occurred in either group.

CONCLUSION

Transbronchial diagnosis of PPLs suspicious of malignancy and presence of a bronchus leading to or adjacent to lesions using VBN-rEBUS-GS without fluoroscopy is a safe and effective method that is non-inferior to VBN-rEBUS-GS with fluoroscopy. Bronchus leading to lesions and malignant nature are associated with high diagnostic yield in VBN-rEBUS-GS without fluoroscopy for the diagnosis of PPLs.

Combined procedure with radial probe and convex probe endobronchial ultrasound

Background

Concurrent bronchoscopy using radial probe and convex endobronchial ultrasound (RP‐ and CP‐EBUS) is used to simultaneously evaluate both peripheral lung lesions for the histological diagnosis of the primary tumor and mediastinal lymph nodes for mediastinal staging. So far, little is known about the combined procedure with RP‐ and CP‐EBUS.

Methods

Between January 2020 and March 2021, the bronchoscopy database was reviewed to identify the clinical outcomes of the combined procedure with RP‐ and CP‐EBUS. Patients who underwent transbronchial biopsy using RP‐EBUS alone were classified as the RP‐EBUS group, while those who underwent a combined procedure with RP‐ and CP‐EBUS were classified as the combination group.

Results

The overall diagnostic yield of the bronchoscopic procedure in the combination group was significantly higher than the RP‐EBUS group (90.7% vs. 70.0%, p < 0.001). CP‐EBUS increased the diagnostic yield of the bronchoscopic procedure in the combination group by 9.3%. Although the mean procedure time was significantly longer, and the mean doses of midazolam and fentanyl were significantly higher in the combination group (p < 0.001), there were no differences in the overall complication rates between the two study groups (1.4% and 1.0% for the RP‐EBUS and combination groups, respectively, p = 0.766).

Conclusions

Combined bronchoscopy using RP‐ and CP‐EBUS is feasible and safe. In addition to mediastinal staging, CP‐EBUS increased the overall diagnostic yield of the bronchoscopic procedure by 9.3%.

A Novel Electromagnetic Navigation Bronchoscopy System for the Diagnosis of Peripheral Pulmonary Nodules: A Randomized Trial

RATIONALE

Endobronchial ultrasound (EBUS) combined with a guide sheath (GS) as an instrument for confirming the proximity of the bronchoscope and its relationship to the lesion can increase the diagnostic yield when conducting transbronchial lung biopsy of peripheral pulmonary nodules (PPNs). A novel electromagnetic navigational bronchoscopy (ENB) system comprising a thinner locatable sensor probe as a guidance instrument was developed to be suitable for a thin bronchoscope with a 2-mm-diameter working channel. The diagnostic efficacy of EBUS-GS with or without this ENB system has not been confirmed.

OBJECTIVES

To compare the diagnostic value and safety of EBUS-GS with or without ENB system for diagnosing PPNs.

METHODS

A prospective, multicenter, randomized controlled clinical trial was designed and conducted at 3 centers. Patients with PPNs suspected to be malignant were enrolled and randomly assigned to the ENB-EBUS-GS group or EBUS-GS group. The primary endpoint was the diagnostic yield in each group. The secondary endpoint was the procedural time and other factors affecting diagnostic yield. The safety endpoint was procedural complications.

RESULTS

Four hundred participants were enrolled from July 2018 to October 2019 and 385 patients were analyzed, with 193 in the ENB-EBUS-GS group and 192 in the EBUS-GS group. The mean nodule size was 21.7±5.3 mm. The diagnostic yields were 82.9% (95% confidence interval (CI), 77.6%-88.2%) in the ENB-EBUS-GS group and 73.4% (95% CI, 67.2%-79.7%) in the EBUS-GS group. The difference between the two groups was 9.5% (95% CI, 2.6%-16.3%), with an adjusted difference of 9.0% (95% CI, 2.3%-15.8%), after adjusting for the stratification factors and center. The time for finding lesions in the ENB-EBUS-GS was shorter than that in the EBUS-GS group (213.2±145.6s vs. 264.8±189.5s, p=0.003). And intraoperative hemorrhage occurred 3.6% in the ENB-EBUS-GS group and 3.1% in the EBUS-GS group, without significant differences between the two groups.

CONCLUSIONS

The novel ENB system combined with EBUS-GS demonstrated improved ability to locate PPNs, achieving a high diagnostic yield for PPNs compared to EBUS-GS alone in a safe and efficient procedure. Clinical trial registered with ClinicalTrials.gov (NCT03569306).

Effectiveness of Endobronchial Ultrasound-Guided Transbronchial Biopsy Combined With Tissue Culture for the Diagnosis of Sputum Smear-Negative Pulmonary Tuberculosis

Background

Microorganisms of tuberculosis (TB) are frequently difficult to identify from the airway specimen; therefore, lung biopsy for further histologic and microbiologic study is required. Endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) is used for the diagnosis of pulmonary malignancy, but is rarely in the TB population. The purpose of this study was to verify the effectiveness and safety of EBUS-TBB with histologic study and tissue culture in the diagnosis of sputum smear-negative pulmonary TB.

Methods

Patients who underwent EBUS-TBB with histologic study and TB tissue culture for clinically suspected, but sputum smear-negative pulmonary TB from January 2016 to December 2018, were included. The accuracy of each diagnostic modality was calculated, respectively. Factors that might influence the positive rate of TB culture (washing fluid and tissue specimen) were also evaluated.

Results

One hundred sixty-one patients who underwent EBUS-TBB for clinically suspected, but sputum smear-negative pulmonary TB, were enrolled, and 43 of them were finally diagnosed as having pulmonary TB. The sensitivity of washing fluid (a combination of smear, culture, and polymerase chain reaction for TB) and tissue specimen (a combination of pathology and tissue culture) via EBUS-TBB for TB diagnosis were 48.8 and 55.8%, respectively. The sensitivity for TB diagnosis would be elevated to 67.4% when both washing fluid and tissue specimens are used. The positive TB culture rate would not statistically increase with a combination of tissue specimens and washing fluid. Univariate analysis revealed that TB microorganisms would be more easily cultivated when lesions had an abscess or cavity on the computed tomography (CT) image (presence vs. absence; 62.5 vs. 26.3%, p = 0.022), heterogeneous echogenicity on the EBUS finding (heterogeneous vs. homogeneous; 93.3 vs. 21.4%, p = 0.001), or a necrotic pattern via histologic study (presence vs. absence; 70.6 vs. 30.8%, p = 0.013). Heterogeneous echogenicity in the EBUS finding was the independent predictor according to the results of multivariate analysis. None of our patients encountered major adverse events or received further intensive care after EBUS-TBB.

Conclusion

Endobronchial ultrasound-guided transbronchial biopsy is safe and effective for use in diagnosing sputum smear-negative pulmonary TB. EBUS echoic feature is also a predictor of the positive TB culture rate in pulmonary TB. However, tissue culture via EBUS-TBB has little effect in improving the positive TB culture rate.

Comparison of the analytical performance of the Oncomine dx target test focusing on bronchoscopic biopsy forceps size in non-small cell lung cancer

BACKGROUND

Next-generation sequencing (NGS) has been implemented in clinical oncology to analyze multiple genes and to guide targeted therapy. Although the pathological diagnosis and biomarker tests for patients with advanced lung cancer have mostly been obtained with small biopsy samples, especially with bronchoscopic approaches, the performance for NGS with respect to the different sizes of biopsy forceps remains little known.

METHODS

We retrospectively reviewed consecutive patients with non-small cell lung cancer, whose FFPE samples were obtained by endobronchial biopsy/transbronchial biopsy and were submitted for the Oncomine Dx Target Test (ODxTT). We compared the analytical performance for ODxTT with respect to the size of biopsy forceps.

RESULTS

A total of 103 samples were identified. The success rate of the ODxTT for the group with all samples obtained with small forceps biopsies (70%) was lower than that of the group with some or all samples obtained with standard forceps biopsies (83%), although without a statistically significant difference (p = 0.20). With regard to the reason for unsuccessful analysis, the proportion of the samples which did not pass the nucleic acid concentration threshold in the former group (15%) was higher compared with that of the latter group (4%) (p = 0.08). The proportion of tissue size 4 mm² or larger in the former group (70%) was lower than that in the latter group (93%) (p = 0.01).

CONCLUSION

The analysis of ODxTT for specimens biopsied using only small forceps is prone to be unsuccessful due to an insufficient amount of nucleic acid.

Impact of rapid on-site evaluation combined with endobronchial ultrasound and virtual bronchoscopic navigation in diagnosing peripheral lung lesions

BACKGROUND

To investigate the value of endobronchial ultrasound (EBUS) and virtual bronchoscopic navigation (VBN) combined with rapid on-site evaluation (ROSE) in diagnosing peripheral pulmonary lesions (PPLs).

METHODS

Between January 1st 2019 to September 1st 2021, EBUS and VBN examination were performed in expected consecutive patients with PPLs who were admitted to Zhangzhou Affiliated Hospital of Fujian Medical University (Fujian, China). Finally, based on the calculation of expected diagnostic yield of R-EBUS biopsy and drop out, 198 eligible patients were randomly divided into ROSE group (100 cases) and non-ROSE group (98 cases). The diagnostic yield of brushing and biopsy, the complications, the procedure time, the diagnosis time and expense during diagnosis were analyzed.

RESULTS

In the ROSE group, the positive rate of EBUS brushing and biopsy were 68%, 84%, respectively. The average procedure time and diagnosis time were 18.6 ± 6.8 min, 3.84 ± 4.28 days, respectively, and the average expense was 643.44 ± 706.56 US.$ (4093.15 ± 4494.67 yuan ¥). In the controls, the positive rate of brushing and biopsy were 44%, 74%, respectively. The average procedure time and diagnosis time were 15.4 ± 5.7 min, 6.46 ± 3.66 days, respectively. And the average expense during diagnosis was 1009.27 ± 713.89 US.$ (6420.28 ± 4541.33 yuan ¥). There was significant difference in the positive rate of EBUS brushing and biopsy, diagnosis time and expense during diagnosis between both groups. And no significant difference was observed in the complications and the procedure time. Additionally, the impact of ROSE on diagnostic yield in right upper lobe and the size of lesion ≤ 2 cm in diameter was significant.

CONCLUSION

In combination with ROSE, EBUS could significantly improve the positive rate of diagnosing PPLs, shorten diagnosis time and reduce expense during diagnosis. ROSE will be of great importance in the diagnosis of PPLs and medical resource.

Efficacy and safety of virtual bronchoscopic navigation with fused fluoroscopy and vessel mapping for access of pulmonary lesions

BACKGROUND AND OBJECTIVE

Virtual bronchoscopic navigation (VBN) with fused fluoroscopy and vessel mapping provides a point of entry (POE) for puncturing airway wall to biopsy lesions. The study was designed to evaluate the safety and efficacy of this technology to diagnose peripheral pulmonary lesions.

METHODS

It was a prospective, single-arm, multicentre study. Patients underwent lesions biopsy with the Archimedes® VBN System via a POE using one of the two techniques: (1) bronchoscopic transparenchymal nodule access (BTPNA) and (2) guided transbronchial needle aspiration (TBNA). Biopsy yield, sampling yield and diagnostic yield were mainly determined in lesions biopsy attempted.

RESULTS

One hundred and thirty patients underwent anaesthesia and constituted the intention-to-treat population. One hundred and four patients with 114 lesions had biopsy attempted. Mean lesion size was 2.4 ± 1.13 cm. Sufficient tissue samples were obtained from 86 lesions with a biopsy yield of 75.4%. Nevertheless, sufficient samples for diagnosis based on histology ± cytology were obtained from 107 lesions with a sampling yield of 93.9%. Follow-up was conducted for more than 1 year, with a diagnostic yield of 75.4% and 72.8%, respectively, on high and low estimate with consideration of three lesions without follow-up. Two (1.9%) pneumothoraxes and one (1.0%) mild bleeding occurred.

CONCLUSION

BTPNA and guided TBNA contribute to safe and effective sampling of peripheral pulmonary lesions. A relatively high biopsy yield was obtained independent of the presence or absence of a bronchus sign (BS), and high sampling yield and diagnostic yield were obtained independent of location, lesion size and presence or absence of a BS.

Diagnosis of diffuse parenchymal lung diseases using transbronchial cryobiopsy guided by endobronchial ultrasound compared to clinicoradiological diagnosis

BACKGROUND

This study aimed to evaluate the safety and effect of transbronchial cryobiopsy guided by radial probe endobronchial ultrasound (RP-EBUS) compared with clinicoradiological diagnoses in diffuse parenchymal lung diseases (DPLDs).

METHODS

A total of 60 patients with DPLDs confirmed by chest computed tomography (CT) who underwent transbronchial lung cryobiopsy guided by RP-EBUS were enrolled. The ultrasound images were obtained and identified together with corresponding chest CT characteristics. The cryobiopsy samples were evaluated histopathologically and compared with CT imaging, and the complications were analyzed.

RESULTS

The multidisciplinary diagnosis was clear in 51 (85%) participants but unclear in the remaining 9 (15%) participants. In transbronchial cryobiopsy guided by RP-EBUS, 36 (60%) participants had the biopsy in 1 lobe while 24 (40%) had a biopsy in 2 different lobes, with a mean biopsy specimen size of 43.17±15.25 mm². The histopathologic diagnosis based on biopsy confirmed the preprocedural clinicoradiological diagnosis in 51 (85%) patients and clarified the diagnosis in the other 9 patients with unclear clinicoradiological diagnosis, including alveolated lung parenchyma with interstitial chronic inflammation in 4 (6.7%) cases and chronic bronchiolitis and interstitial lymphocytic infiltrates in the other 5 (8.3%). Intraprocedural complications occurred in 57 (95%) patients, including pneumothorax in 9 (15%), bleeding in 47 (78.3%), and hypoxemia in 1 (1.7%). The ultrasound images of DPLDs were normal, mesh (n=24), nodular (n=9), and alveolar type (n=27).

CONCLUSIONS

Transbronchial cryobiopsy guided by RP-EBUS is safe and effective and can supply additional information to the clinicoradiological approach for correct diagnosis of DPLDs.

Safety profile and risk factors for bleeding in transbronchial cryobiopsy using a two-scope technique for peripheral pulmonary lesions

Background

A balloon occlusion technique is suggested for use in cryobiopsy for interstitial lung diseases because of the bleeding risk. However, it may interfere with selection of the involved bronchus for peripheral pulmonary lesions (PPLs). A two-scope technique, in which two scopes are prepared and hemostasis is started using the second scope immediately after cryobiopsy, has also been reported. This study aimed to evaluate the safety and diagnostic utility of transbronchial cryobiopsy using the two-scope technique for PPLs.

Methods

Data of patients who underwent conventional biopsy followed by cryobiopsy using the two-scope technique for PPLs from November 2019 to March 2021 were collected. The incidence of complications and risk factors for clinically significant bleeding (moderate to life-threatening) were investigated. Diagnostic yields were also compared among conventional biopsy, cryobiopsy, and the combination of them.

Results

A total of 139 patients were analyzed. Moderate bleeding occurred in 25 (18.0%) patients without severe/life-threatening bleeding. Although five cases required transbronchial instillation of thrombin, all bleeding was completely controlled using the two-scope technique. Other complications included two pneumothoraces and one asthmatic attack. On multivariable analysis, only ground-glass features (P < 0.001, odds ratio: 9.30) were associated with clinically significant bleeding. The diagnostic yields of conventional biopsy and cryobiopsy were 76.3% and 81.3%, respectively (P = 0.28). The total diagnostic yield was 89.9%, significantly higher than conventional biopsy alone (P < 0.001).

Conclusions

The two-scope technique provides useful hemostasis for safe cryobiopsy for PPLs, with a careful decision needed for ground-glass lesions.

Efficacy and Safety of Endobronchial Ultrasonography with a Guide-sheath for Acute Pulmonary Lesions in Patients with Haematological Diseases

Objective Acute pulmonary lesions (APLs), defined as an acute infiltrate or nodular lung field, are a major complication in patients with haematological diseases. Recently, endobronchial ultrasonography with a guide-sheath (EBUS-GS) was established as a useful technique for diagnosing pulmonary lesions. This study aimed to evaluate the efficacy and safety of EBUS-GS for managing APLs in patients with haematological diseases. Methods Our single-centre, retrospective, observational, single-arm, descriptive study enrolled 22 consecutive adult (>20-year-old) patients with haematological diseases and concomitant APL who underwent EBUS-GS between January 2011 and June 2016 at Kameda Medical Center, Chiba, Japan. The primary endpoint was the contribution of EBUS-GS to clinical decision-making. Secondary endpoints were an adequate tissue collection rate, diagnostic yield, complication rate, and 30-day mortality. Results The median patient age was 70 years old, and 63.6% were men. Acute myeloid leukaemia was the most frequent underlying disease, accounting for 54.5% of patients. The contribution of EBUS-GS to clinical decision-making was recognised in 11 (50.0%) patients. Adequate tissue collection was achieved in 21 (95.5%) patients. The aetiology of the APL was identified in 9 (40.9%) patients. No complications, including severe haemorrhaging and pneumothorax, were observed in any patients, and the 30-day mortality rate was 0%. Conclusion EBUS-GS may be a suitable diagnostic option for APL in patients with haematological diseases. Further larger-scale and randomised controlled trials are needed to confirm our results.

Comparison of radial endobronchial ultrasound-guided transbronchial lung biopsy with distance measurement versus with guide sheath in diagnosing peripheral pulmonary lesions with a diameter ≥3 cm by thin bronchoscope

OBJECTIVE:

This study aims to explore the diagnostic values of radial endobronchial ultrasound-guided transbronchial lung biopsy with distance (rEBUS-D-TBLB) measurement and with guide sheath (rEBUS-GS-TBLB) for peripheral pulmonary lesions (PPLs) with a diameter ≥3 cm by thin bronchoscope.

PATIENTS AND METHODS:

Six hundred and three patients with PPL (diameter ≥3 cm) were enrolled in this study. The subjects were divided into the rEBUS-D-TBLB and rEBUS-GS-TBLB groups by the random number table method. Patients were assigned to undergo rEBUS-D-TBLB or rEBUS-GS-TBLB, respectively. The histopathology, positive diagnosis rates, duration of the procedure, and postoperative adverse effects between the two groups were examined.

RESULTS:

A total of 569 patients were included in this study according to the inclusion and exclusion criteria, with 282 cases in the rEBUS-D-TBLB group and 287 cases in the rEBUS-GS-TBLB group. For malignant diseases, the positive diagnosis rates of PPL in the outer/inner-middle lung bands and the right-upper/-lower lung lobes by rEBUS-D-TBLB were noninferior to those of rEBUS-GS-TBLB. The duration of the procedure of rEBUS-D-TBLB was longer than that of rEBUS-GS-TBLB. There were 14 cases of hemorrhage >50 mL, 1 case of postoperative chest pain in the rEBUS-D-TBLB group, and 3 cases of hemorrhage >50 mL in the rEBUS-GS-TBLB group.

CONCLUSION:

REBUS-D-TBLB by thin bronchoscope has a high diagnostic value for PPL with a diameter ≥3 cm, which may be considered a useful alternative for rEBUS-GS-TBLB in the clinic.

Cone-Beam Computed Tomography-Derived Augmented Fluoroscopy Improves the Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Biopsy for Peripheral Pulmonary Lesions

Background: Endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) is used for the diagnosis of peripheral pulmonary lesions (PPLs), but the diagnostic yield is not adequate. Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) can be utilized to assess the location of PPLs and biopsy devices, and has the potential to improve the diagnostic accuracy of bronchoscopic techniques. The purpose of this study was to verify the contribution of CBCT-AF to EBUS-TBB. Methods: Patients who underwent EBUS-TBB for diagnosis of PPLs were enrolled. The navigation success rate and diagnostic yield were used to evaluate the effectiveness of CBCT-AF in EBUS-TBB. Results: In this study, 236 patients who underwent EBUS-TBB for PPL diagnosis were enrolled. One hundred fifteen patients were in CBCT-AF group and 121 were in non-AF group. The navigation success rate was significantly higher in the CBCT-AF group (96.5% vs. 86.8%, p = 0.006). The diagnostic yield was even better in the CBCT-AF group when the target lesion was small in size (68.8% vs. 0%, p = 0.026 for lesions ≤10 mm and 77.5% vs. 46.4%, p = 0.016 for lesions 10–20 mm, respectively). The diagnostic yield of the two study groups became similar when the procedures with a failure of navigation were excluded. The procedure-related complication rate was similar between the two study groups. Conclusion: CBCT-AF is safe, and effectively enhances the navigation success rate, thereby increasing the diagnostic yield of EBUS-TBB for PPLs.

Safety and Diagnostic Yield of Radial Probe Endobronchial Ultrasound-Guided Biopsy for Peripheral Lung Lesions in Patients with Idiopathic Pulmonary Fibrosis: A Multicenter Cross-Sectional Study

BACKGROUND

Radial probe endobronchial ultrasound-guided transbronchial lung biopsy (RP-EBUS-TBLB) is widely used for diagnosis of peripheral lung lesions (PLLs). To date, there have been no reports regarding the clinical outcomes of RP-EBUS-TBLB for PLLs in patients with idiopathic pulmonary fibrosis (IPF).

OBJECTIVES

This study was performed between October 2017 and December 2019 to identify the safety and diagnostic performance of RP-EBUS-TBLB in IPF patients.

METHODS

Patients were divided into the usual interstitial pneumonia (UIP) group (n = 39, 4%), the probable UIP group (n = 12, 1%), and the noninterstitial lung disease (non-ILD) group (n = 903, 95%).

RESULTS

The diagnostic yield was significantly lower in the UIP group than in the non-ILD group (62% vs. 76%; p = 0.042), but there were no significant differences between the UIP and probable UIP groups (62% vs. 83%; p = 0.293) or the probable UIP and non-ILD groups (83% vs. 76%; p = 0.741). Multivariate logistic analysis showed that the mean diameter of PLLs, positive bronchus sign on CT, and "within the lesion" status on EBUS were independently associated with success of the procedure. Especially, the presence of the UIP pattern on CT (OR, 0.385; 95% CI: 0.172-0.863; p = 0.020) was independently associated with failed diagnosis. Among patients with UIP, "within the lesion" status on EBUS (OR, 25.432; 95% CI: 2.321-278.666; p = 0.008) was shown to be a factor contributing to a successful diagnosis. Overall, there were no significant differences in complication rates among the 3 study groups.

CONCLUSION

RP-EBUS-TBLB can be performed safely with an acceptable diagnostic yield, even in patients with IPF.

Advances in Diagnostic Bronchoscopy

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

Guide sheath versus non-guide sheath method for endobronchial ultrasound-guided biopsy of peripheral pulmonary lesions: A multicenter randomized trial

INTRODUCTION

Guide sheaths (GSs) have been widely used during radial probe endobronchial ultrasound-guided transbronchial biopsy (rEBUS-TBB) of peripheral pulmonary lesions. However, it remains unknown whether a GS enhances the diagnostic yield. We compared the diagnostic yields of small peripheral pulmonary lesions between rEBUS-TBB with and without a GS.

METHODS

In eight institutions, patients with peripheral pulmonary lesions≤30 mm in diameter were enrolled and randomized to undergo rEBUS-TBB with a GS (GS group) or without a GS (non-GS group) using a 4.0-mm thin bronchoscope, virtual bronchoscopic navigation, and fluoroscopy. The primary endpoint was the diagnostic yield of the histology specimens.

RESULTS

A total of 605 patients were enrolled; ultimately, data on 596 (300 in the GS group and 296 in the non-GS group) with peripheral pulmonary lesions having a longest median diameter of 19.6 mm were analyzed. The diagnostic yield of histological specimens from the GS group was significantly higher than that from the non-GS group (55.3% versus 46.6%, respectively; p=0.033). Interactions were evident between the diagnostic yields, procedures, lobar locations (upper lobe versus other regions, p=0.003), and lesion texture (solid versus part-solid nodules, p=0.072).

CONCLUSIONS

The diagnostic yield for small peripheral pulmonary lesions afforded by rEBUS-TBB using a GS was higher than that without a GS.

The Value of Additional Conventional Transbronchial Biopsy in the Negative Results of Rapid On-site Evaluation During Endobronchial Ultrasound With Guide Sheath to Diagnose Small Peripheral Lung Cancer

Objective: The accuracy of rapid on-site evaluation (ROSE) during endobronchial ultrasonography with guide sheath (EBUS-GS) was reported to be approximately 90% for diagnosing small peripheral pulmonary lesions (PPLs). When ROSE during EBUS-GS for diagnosing small peripheral lung cancer is carried out and does not include malignant cells in a position whereby the probe was located within or adjacent to the lesion, the best technique for overcoming the lower diagnostic yield remains unknown. This study aimed to evaluate factors affecting positive results of ROSE during EBUS-GS in such a probe position. Moreover, when the results of ROSE were consistently negative, we evaluated the effectiveness of conventional transbronchial biopsy (TBB) in addition to EBUS-GS alone. Methods: We performed a retrospective analysis of consecutive patients who underwent EBUS-GS combined with ROSE for diagnosing small peripheral lung cancer (≤30 mm). We classified the results of ROSE into two groups based on the presence of malignant cells: the ROSE positive group (included malignant cells) and the ROSE negative group (did not include malignant cells). The significant predictors of positive ROSE results during EBUS-GS were analyzed using multivariate logistic regression analyses. Results: We identified 67 lesions (43 lesions in the ROSE positive group and 24 lesions in the ROSE negative group, respectively). Multivariate logistic analysis revealed that the significant factor affecting positive ROSE results was lesion size (>15 mm) (OR = 9.901). The diagnostic yield of additional conventional TBB to EBUS-GS was significantly higher than that of EBUS-GS alone (75.0% vs 33.3%, P = .041). Conclusion: The positive results of ROSE during EBUS-GS were significantly influenced by lesion size (>15 mm). When the results of ROSE during EBUS-GS were consistently negative in a position whereby the probe was located within or adjacent to the lesion, additional conventional TBB was effective to improve the diagnostic yield compared with EBUS-GS alone.

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

Endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) is a common procedure used to diagnose peripheral pulmonary lesions (PPLs). However, existing literature did not conclusively show a difference in the ability of EBUS-TBB with and without a guide sheath (GS) to diagnose PPLs. This multicenter cohort study enrolled patients presenting for EBUS-TBB of PPLs that finally proved to be malignant. The diagnostic yield and complication rate were compared between patients undergoing EBUS-TBB with and without a GS (EBUS-TBB+GS versus EBUS-TBB-GS). A propensity score matching method was used to balance differences of pertinent clinical features between the two groups. The original cohort consisted of 975 patients (556 in EBUS-TBB-GS; 419 in EBUS-TBB+GS). GS guidance was more likely to be used with smaller (40 mm versus 44 mm) and middle or lower lobe (60% versus 35%) lesions. After propensity score matching, 720 (360 in each group) patients were included; the diagnostic yields for PPLs were 79% and 78% for EBUS-TBB-GS and EBUS-TBB+GS groups, respectively (p=0.649). The complication rates (5.8% versus 7.2% for bleeding; 0.6% versus 1.9% for pneumothorax) appeared to be lower in the EBUS-TBB+GS group, but the differences did not reach statistical significance. The procedure time was significantly longer in the EBUS-TBB+GS group than in the EBUS-TBB-GS group (29 min versus 24 min; p<0.001). In conclusion, adding a GS to EBUS-TBB did not improve the diagnostic yield for malignant PPLs. GS guidance was seemingly associated with a lower number of complications after TBB but contributed significantly to a longer procedure time.

[Expert Consensus on Technical Specifications of Domestic Electromagnetic Navigation Bronchoscopy System in Diagnosis, Localization and Treatment (2021 Edition)]

Electromagnetic navigation bronchoscopy (ENB) is a novel type of bronchoscopy based on electromagnetic positioning technique combined with virtual bronchoscopy, three-dimensional computed tomography (CT) imaging and respiratory gating technique, which has been widely applied in clinic practice. In recent years, the domestic electromagnetic navigation system has also been developed rapidly, and its effectiveness and safety in the diagnosis, localization, and treatment of peripheral pulmonary lesions have been initially verified. In order to optimize and standardize the technical specifications of domestic ENB and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Respiratory Equipment Technology of Chinese Medical Equipment Association and the Expert Group on Technical of Domestic Electromagnetic Navigation Bronchoscopy.
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Radial EBUS-Guided Cryobiopsy of Peripheral Lung Lesions With Flexible Bronchoscopy Without Using Guide-Sheath

BACKGROUND

A guide-sheath (GS) is conventionally used as a conduit for biopsy forceps under the guidance of radial endobronchial ultrasound (REBUS) for sampling the peripheral pulmonary lesions (PPLs). As compared with forceps, the cryoprobe has the advantage of obtaining larger samples. There is a paucity of literature on the use of cryobiopsy for PPL. We evaluated the diagnostic yield and safety of the REBUS-guided cryobiopsy (REBUS-CB) without using GS for the diagnosis of PPL.

METHODS

We retrospectively analyzed the database of 126 patients with PPL between November 2015 and December 2019. The REBUS-CB was performed using a flexible bronchoscopy without GS. Multidisciplinary consensus diagnostic yield was determined and procedural complications were recorded.

RESULTS

The histopathologic diagnosis by REBUS-CB, which is the primary objective of the study was obtained in 99 (78.6%) of total 126 cases. Yield was significantly higher in central lesions as compared to adjacent lesions visualized by the REBUS probe (81.4% versus 53.8%, P=0.021) but not significantly different between large (≥30 mm) and small (<30 mm) lesions (81.6% versus 71.8%, P=0.214). The average largest diameter of biopsy specimens was 6.9 mm (range 1-12, SD 2.132). We witnessed moderate bleeding in 7 (5.6%) and post procedure hypoxic respiratory failure in 4 (3.2%) cases which could be managed without escalation of care.

CONCLUSION

The REBUS-CB from peripheral lung lesions are feasible even without using GS and significantly large samples can be obtained.

Diagnostic Outcomes and Safety of Cryobiopsy Added to Conventional Sampling Methods: An Observational Study

BACKGROUND

Cryobiopsy enables specialists to perform high-quality, large, entirely circumferential biopsies; therefore, it may improve the diagnostic yield of peripheral pulmonary lesions (PPLs), as has been previously observed regarding endobronchial tumors and interstitial lung diseases.

RESEARCH QUESTION

How do the diagnostic accuracy and safety change by cryobiopsy when performed alongside conventional biopsy for PPLs?

STUDY DESIGN AND METHODS

Consecutive patients who underwent cryobiopsy in addition to conventional biopsies for PPL diagnosis at our institution between June 2017 and May 2018 were reviewed retrospectively. The target location was estimated and sampling was performed using conventional devices (ie, forceps, brush, aspiration needle), and cryobiopsy was performed at the same location. Diagnostic outcomes and cryobiopsy safety when performed in addition to conventional sampling methods were analyzed in this observational study.

RESULTS

In total, 257 patients were analyzed, and the overall diagnostic yield was 89.9%. Among them, 22 lesions were diagnosable by cryobiopsy exclusively, which improved the rate of diagnosis by 8.6%. Advantages of the use of cryobiopsy were the most apparent when lesions were adjacent to areas assessed via radial endobronchial ultrasound (69.4% vs 84.3%). Multivariable analysis identified bronchus sign (positive/negative, P = .001), lobe (other lobes/right upper lobe and left upper segment, P = .028), and visibility on radiograph (visible/invisible, P = .047) as factors that significantly affected diagnostic yield. On the other hand, three instances of severe hemorrhage (1.2%) and two of pneumothorax (0.8%) occurred. Although most complications were minor, two patients required hospitalization because of cerebral infarction and lung abscess.

INTERPRETATION

Cryobiopsy improves the diagnostic yield of PPLs when combined with other conventional sampling methods; however, caution is required because of the possibility of complications.

A Randomized Controlled Trial on Optimal Sampling Sequence in Radial Guide Sheath Endobronchial Ultrasound Lung Biopsy

BACKGROUND

An optimal sampling sequence in radial guide sheath endobronchial ultrasound lung biopsy (R-EBUS) is unclear. This prospective single-center pilot randomized controlled trial aimed to determine if the initial method and sequence of sampling affect the diagnostic accuracy of the procedure.

METHODS

Consecutive patients undergoing R-EBUS for lesions >15 mm with a bronchus sign were randomly assigned (1:1:1) to biopsy first (group A), brushings first (group B) or combination (group C). The primary outcome was a positive diagnosis from any sampling method.

RESULTS

Fifty-four patients were randomized. The overall diagnostic yield of the procedure was 77.8% (95% confidence interval: 66%-89%), with no difference between groups. A higher rate of positive cytology from brushings was seen if the biopsies were performed before brushings (77.8% in group A vs. 44.4% in group B, P=0.03). The rate of positive cytology from washings was higher if the washings were obtained just after the brushings (61.1% in group A vs. 11.1% in group B, P=0.02). There was no difference in the rate of positive biopsy histology in the groups (P=0.27). All 3 sampling modalities were more likely to be positive in group A (50.0% vs. 11.1% in group B and 22.2% in group C, P=0.04). Complications rate was low and not significantly different between groups.

CONCLUSION

The overall rate of a positive R-EBUS procedure was not affected by the initial sampling method or sequence. However, all 3 sampling modalities were more likely to be positive if biopsies were performed first, followed by brushings and washings.

Diagnostic value of endobronchial ultrasound combined with rapid on-site evaluation of transbronchial lung biopsy for peripheral pulmonary lesions

BACKGROUND

Rapid on-site evaluation (ROSE) has the potential to increase endobronchial ultrasound (EBUS) guide transbronchial lung biopsy (TBLB) accuracy in the diagnosis of peripheral pulmonary lesions (PPLs). However, studies have reported controversial results. The aim of the study was to evaluate the diagnostic value of EBUS-TBLB combination with ROSE in PPLs.

METHODS

A total of 152 patients with PPLs underwent EBUS were enrolled and completed this study. Patients were divided into EBUS combined with ROSE group (EBUS+ROSE group) and EBUS group (EBUS group). The diagnostic yield, operation time, and complications were compared between the two groups.

RESULTS

The diagnostic yield in EBUS+ROSE group was 85.9%, the operation time was (24.6 ± 6.8) min, the diagnostic yield in EBUS group was 70.3%, and the operative time was (32.4 ± 8.7) min, there were significant differences in diagnostic yield (χ² = 5.456, P = .016) and operation time (t = 3.167, P = .001) between the two groups. No severe procedure related complications were observed, such as, pneumothorax and hemorrhage.

CONCLUSIONS

ROSE can improve the diagnostic yield and shorten the operation time. EBUS combined with ROSE is an effective diagnostic method for PPLs.

Cone-beam computed tomography versus computed tomography-guided ultrathin bronchoscopic diagnosis for peripheral pulmonary lesions: A propensity score-matched analysis

BACKGROUND AND OBJECTIVE

CBCT-guided TBB using a UTB under VBN is a useful method for the diagnosis of peripheral small pulmonary lesions. CBCT-guided TBB using UTB under VBN has been used as an alternative to CT-guided TBB. However, the advantage of CBCT-guided TBB using UTB under VBN over CT-guided TBB is still unknown. This study aimed to compare the diagnostic yield of CT-guided TBB and CBCT-guided TBB using a propensity score-matched analysis.

METHODS

Patients with peripheral pulmonary lesions ≤30 mm were included. Lesions whose bronchus could not be determined by CT were excluded. A UTB and biopsy forceps were advanced to the target bronchus under VBN, 2D-fluoroscopy and CT or CBCT. The CT-guided and CBCT-guided groups were matched for their propensity scores based on patient characteristics.

RESULTS

We retrospectively reviewed 93 patients in the CT-guided group and 79 patients in the CBCT-guided group for this study. Furthermore, 48 distinct examination pairs were generated by propensity score matching. In the overall diagnostic yield, the CBCT-guided group showed better results (72.9%) than did the CT-guided group (47.9%) (P = 0.012). The median examination time lasted for 43 (IQR: 37-51) min in the CBCT-guided group and 50 (IQR: 43-62) min in the CT-guided group. The examination time in the CBCT-guided group was significantly shorter than that of the CT-guided group (P = 0.001).

CONCLUSION

CBCT-guided TBB had a better diagnostic yield and shorter examination time than did CT-guided TBB.

Diagnostic Value of Virtual Bronchoscopic Navigation Combined With Endobronchial Ultrasound Guided Transbronchial Lung Biopsy for Peripheral Pulmonary Lesions

Objective:

X-ray guided transbronchial ultrasound-guided transbronchial lung biopsy (EBUS-TBLB) can improve the diagnostic yield of peripheral pulmonary lesions (PPLs), but it needs special requirements. The purpose of this study was to investigate the clinical value of virtual bronchoscopy navigation (VBN) combined with EBUS-TBLB in the diagnosis of PPLs without X-ray guidance.

Methods:

The 105 patients with PPLs underwent EBUS-TBLB with or without VBN randomly. The diagnostic yield, the operation time and complications were evaluated in the 2 groups.

Results:

No significant difference was found between the VBN+EBUS group and the EBUS group (76.0% vs. 65.5%, P = 0.287). The operation time of VBN+EBUS group was significantly shorter than that of EBUS group (20.6 ± 12.8 min vs. 28.6 ± 14.3 min, P = 0.023). No severe procedure related complications occurred.

Conclusions:

VBN can shorten the operation time. The combination of VBN and EBUS-TBLB is a safe and effective diagnosis technique for PPLs.