Transbronchial vs transesophageal needle aspiration using an ultrasound bronchoscope for the diagnosis of mediastinal lesions: a randomized study

Transesophageal ultrasound-guided bronchoscopic Acquire TBNB versus Vizishot2 TBNA needles for neoplastic lesions: A retrospective study

BACKGROUND

Lung cancer is often diagnosed at an advanced stage; however, it has shown improved therapeutic efficacy with the introduction of molecularly targeted drugs and immune checkpoint inhibitors, necessitating accurate molecular diagnosis for effective treatment planning. Traditional sampling techniques, including endobronchial ultrasound-guided transbronchial needle aspiration, frequently require multiple biopsies to obtain sufficient tissues for multiplex testing, highlighting the need for more efficient methods. Therefore, we explored the diagnostic utility of endoscopic ultrasound with bronchoscope-guided fine-needle biopsy (EUS-B-FNB) versus fine-needle aspiration (EUS-B-FNA) in patients with lung cancer, focusing on tissue sample collection for molecular testing. The introduction of the Franseen needle in EUS-B-FNB, characterized by three beveled edges, allows for more tissue collection in cylinder form.

METHODS

We retrospectively analyzed the data of 97 patients who underwent EUS-B-FNB or EUS-B-FNA at Hakodate Goryoukaku Hospital and evaluated diagnostic yields, safety, and nucleic acid concentrations using collected specimens.

RESULTS

The diagnostic yields of EUS-B-FNB and EUS-B-FNA were comparable (92.2% vs. 92.3%), with no significant differences in complications. However, EUS-B-FNB provided significantly higher DNA and RNA concentrations (DNA; 41.05 vs. 10.20 ng/mL; P < 0.0001, RNA; 36.80 vs. 11.80 ng/mL; P = 0.0009), essential for comprehensive molecular testing.

CONCLUSION

This study highlights the potential of EUS-B-FNB for enhancing the molecular diagnosis of lung cancer by ensuring adequate tissue sample collection for multiplex testing, paving the way for personalized medicine. This technique is comparable in safety and efficacy to traditional methods while offering a substantial improvement in the quality of molecular diagnostics.

Safety and effectivity of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration in elderly patients

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a well-established technique for assessing lesions near the central airway. While EBUS is typically used via the airway, the esophageal approach known as endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA) has gained popularity for evaluating previously inaccessible lesions. This study aimed to assess the safety and diagnostic contribution of EUS-B-FNA in elderly patients. This retrospective study included elderly patients (≥65 years) who underwent EUS-B-FNA with concurrent convex probe-EBUS (C-EBUS) between June 2019 and December 2022. Inclusion criteria were age >64, having chest computed tomography (CT) or FDG-PET/CT, and undergoing C-EBUS, with the exclusion of patients with prior malignancy diagnoses and undergoing EBUS-TBNA. Among 68 patients who underwent combined EBUS and EUS-B-FNA, 31 met the inclusion criteria. The mean age was 71.7 years and 74.2% were male. All EUS-B-FNA material provided adequate material for histopathological analysis. Among patients, 67.7% received a malignancy diagnosis. Samples were obtained from mass lesions (58.1%) and lymph nodes (41.9%), primarily from the subcarinal (station 7) and left paratracheal (station 4L) regions. The mean number of needle passes was 2.83, with an average procedure duration of 9.4 min. No significant complications occurred. EUS-B-FNA is a safe and effective diagnostic method in elderly patients, offering an alternative when the transbronchial approach is not feasible. This underscores the importance of bronchoscopists' training in the transesophageal approach via EBUS scope.

Usefulness of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration for next-generation sequencing in patients with non-small cell lung cancer: A comparison with other bronchoscopic techniques

BACKGROUND

Next-generation sequencing (NGS) is essential in treating advanced lung cancer. However, the effectiveness of endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) in NGS remains unclear. This study examined the usefulness of EUS-B-FNA in lung cancer NGS cases where EUS-B-FNA was performed for specimen submission in a nationwide genomic screening platform (LC-SCRUM-Asia) and compared specimens collected using other bronchoscopy methods (endobronchial ultrasound-guided transbronchial needle aspiration [EBUS-TBNA] and EBUS-guided transbronchial biopsy with a guide sheath [EBUS-GS-TBB]) during the same period.

METHODS

We retrospectively compared the NGS success rates of NGS, DNA and RNA yields for EUS-B-FNA, EBUS-TBNA, and EBUS-GS-TBB from the records of the patients recruited for the Lung Cancer Genomic Screening Project for Individualized Medicine (LC-SCRUM)-Asia.

RESULTS

Fifty-one patients were enrolled, and the NGS success rates were comparable for samples obtained by EUS-B-FNA, EBUS-TBNA, and EBUS-GS-TBB (100%, 90.9%, and 81.0%, respectively). Genetic alterations were detected in 73.7%, 90.9%, and 85.7% of patients, respectively, with druggable genetic alterations found in 31.6%, 72.7%, and 61.9% of patients, respectively. The DNA and RNA yields were significantly higher in EUS-B-FNA samples than in EBUS-GS-TBB samples (50.4 (interquartile range (IR): 15.45-72.35) ng/μl and 33.9 (IR: 9-76.8) ng/μl from EUS-B-FNA, and 3.3 (IR: 1.4-7.1) ng/μl and 15.1 (IR: 8.3-31.5) ng/μl from EBUS-GS-TBB, respectively, p < 0.05).

CONCLUSION

EUS-B-FNA emerges as a promising bronchoscopic method for obtaining adequate samples for NGS in advanced lung cancer cases.

Added value of EUS-B-FNA to bronchoscopy and EBUS-TBNA in diagnosing and staging of lung cancer

Background

Bronchoscopy and EBUS are standard procedures in lung cancer work-up but have low diagnostic yield in lesions outside the central airways and hilar/mediastinal lymph nodes. Growing evidence on introducing the EBUS endoscope into the oesophagus (EUS-B) in the same session as bronchoscopy/EBUS gives access to new anatomical areas that can be safely biopsied.

Objective

To summarize the current evidence of the added value of EUS-B-FNA to bronchoscopy and EBUS-TBNA in lung cancer work-up.

Methods

A narrative review.

Results

Few randomized trials or prospective studies are available. Prospective studies show that add-on EUS-B-FNA increases diagnostic yield when sampling abnormal mediastinal lymph nodes, para-oesophageal lung and left adrenal gland. A large retrospective series on EUS-B-FNA from retroperitoneal lymph nodes suggests high diagnostic yield without safety concerns, as do casuistic reports on EUS-B-FNA from mediastinal pleural thickening, pancreatic lesions, ascites fluid and pericardial effusions. No study has systematically assessed both diagnostic yield, safety, patient reported outcomes, adverse events and costs.

Conclusion

The diagnostic value of add-on EUS-B to standard bronchoscopy and EBUS in lung cancer work-up appears very promising without safety concerns, giving the pulmonologist access to a variety of sites out of reach with other minimally invasive techniques. Little is known on patient-reported outcomes and costs. Future and prospective research should focus on effectiveness aspects to clarify whether overall benefits of add-on EUS-B sufficiently exceed overall downsides.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): revolutionizing the landscape of lung disease diagnostics

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a revolutionary diagnostic tool for lung diseases, including lung cancer, sarcoidosis, and lymphoproliferative diseases. This minimally invasive procedure offers a superior diagnostic yield while ensuring maximum patient safety when compared to traditional invasive techniques such as mediastinoscopy and thoracoscopy. By enabling real-time imaging and sampling of mediastinal and hilar lymph nodes and masses directly from the bronchoscope, EBUS-TBNA has redefined the precision of diagnostic bronchoscopy. This comprehensive review explores the origins, development, and current status of EBUS-TBNA, highlighting its successes and identifying potential areas for improvement. Technological advancements have continuously enhanced the reliability and efficacy of EBUS-TBNA over time. The mechanisms underlying the superior diagnostic yield of EBUS-TBNA are thoroughly discussed, further solidifying its position as the gold standard for lung cancer staging and diagnosis. Furthermore, this review delves into the crucial role of EBUS-TBNA in lung cancer diagnosis, supported by studies comparing its accuracy, safety, and cost-effectiveness to other diagnostic tools. Looking ahead, ongoing research aims to expand the applications of EBUS-TBNA and improve its diagnostic performance. Notable advancements in needle design and sampling techniques hold promise for further enhancing its efficacy. Maximizing its potential through comprehensive training and continuous technological developments will enable broader clinical applications, ultimately leading to improved patient outcomes. As EBUS-TBNA continues to evolve, its diagnostic impact is expected to increase, solidifying its position as an indispensable tool in the diagnosis and management of lung diseases.

Clinical Applications of Endobronchial Ultrasound (EBUS) Scope: Challenges and Opportunities

Endobronchial Ultrasound (EBUS) has been widely used to stage lung tumors and to diagnose mediastinal diseases. In the last decade, this procedure has evolved in several technical aspects, with new tools available to optimize tissue sampling and to increase its diagnostic yield, like elastography, different types of needles and, most recently, miniforceps and cryobiopsy. Accordingly, the indications for the use of the EBUS scope into the airways to perform the Endobronchial Ultrasound-TransBronchial Needle Aspiration (EBUS-TBNA) has also extended beyond the endobronchial and thoracic boundaries to sample lesions from the liver, left adrenal gland and retroperitoneal lymph nodes via the gastroesophageal tract, performing the Endoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In this review, we summarize and critically discuss the main indication for the use of the EBUS scope, even the more uncommon, to underline its utility and versatility in clinical practice.

Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations

Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.

Safety and utility of Endoscopic Ultrasound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA) in suspected lung cancer patients with poor respiratory or general conditions: a prospective three-center observational study

BACKGROUND

Although transbronchial diagnostic procedures are sometimes difficult to perform because of the patient's respiratory or general conditions, endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA), a known transesophageal diagnostic procedure, might be useful for such cases. We conducted this prospective three-center observational study to evaluate the safety and efficacy of EUS-B-FNA in suspected lung cancer patients with poor respiratory or general conditions.

METHODS

Patients with suspected lung cancer with respiratory failure, Eastern Cooperative Oncology Group performance status of 2 or higher, or severe respiratory symptoms, were enrolled. The primary endpoints were the diagnostic yield of lung cancer and its safety, and the secondary endpoints were the success rate of molecular and programmed death ligand 1 (PD-L1) analyses, and the 6-month survival rate in patients with lung cancer.

RESULTS

We enrolled 30 patients, of which 29 were included in the analysis. Among them, 26 were eventually diagnosed with lung cancer. The diagnostic yield for lung cancer was 100% (26/26). There were no adverse events associated with EUS-B-FNA requiring procedure discontinuation. The success rates of molecular analysis for EGFR, ALK, ROS-1, and BRAF were 100% (14/14), 100% (11/11), 100% (9/9), and 75% (6/8), respectively. The success rate of the PD-L1 analysis was 100% (15/15). The 6-month survival rate in patients with lung cancer was 53.8% (95% confidence interval [CI]: 33.4-76.4), and the median overall survival (OS) was 196 days (95% CI: 142-446).

CONCLUSIONS

EUS-B-FNA is a safe and effective diagnostic method, even in patients with suspected lung cancer with poor respiratory or general conditions.

TRIAL REGISTRATION

This clinical trial was registered at https://www.umin.ac.jp/ctr/index.htm (UMIN000041235, approved on 28/07/2020).

Role of Endoscopy in Esophageal Tuberculosis: A Narrative Review

Esophageal tuberculosis (ET) is a rare infectious disease of the gastrointestinal tract. Awareness of ET is deficient due to its low incidence. Unexplained dysphagia and upper gastrointestinal bleeding are the most common symptoms of ET. The prognosis is generally good if patients are diagnosed properly and receive anti-tubercular treatment promptly. However, ET is difficult to differentiate from other diseases. Endoscopic techniques such as esophagogastroduodenoscopy (EGD), endoscopic ultrasonography (EUS), contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS), elastography, and endoscopic ultrasound--guided fine-needle aspiration (EUS-FNA) improve the diagnosis of ET. Thus, the characteristics of ET and other difficult-to-detect diseases according to EGD and EUS were summarized. Intriguingly, there is no literature relevant to the application of CH-EUS and elastography in ET. The authors' research center was first in introducing CH-EUS and elastography into the field of ET. The specific manifestation of ET based on CH-EUS was discovered for the first time. Correlative experience and representative cases were shared. The role of endoscopy in acquiring esophageal specimens and treatment for ET was also established. In this review, we aim to introduce a promising technology for the diagnosis and treatment of ET.

Interventional pulmonology in elderly in tuberculosis and respiratory diseases-challenges

With the increasing number of the elderly population, the number of people with respiratory diseases along with other comorbidities is also increasing. With the good number of available evidence, the use of interventional pulmonary procedures is also increasing. However, the studies on the safety and therapeutic benefit of these procedures in the elderly population are limited. Because of the paucity of data, we decided to do a systematic review of the scientific literature that is currently available, to boost confidence to do these procedures by clinicians. This review deals with the procedures that are commonly performed in elderly respiratory patients, their indications, safety and the diagnostic and therapeutic yield, and compares them with the results in the younger population. It also focuses on the safety of anaesthetic techniques used for these procedures in the elderly. The bottom line of this review is that there is no significant difference between the older and younger age groups with regard to the above parameters and that age alone is not a criterion to decide whether the patients may undergo interventional pulmonary procedures.

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

INTRODUCTION

Endobronchial ultrasound (EBUS) bronchoscopes have been used mainly through the airway for EBUS-guided transbronchial needle aspiration (EBUS-TBNA); however, they can also be used through the esophagus. The esophageal approach, endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA), has gradually become popular, as it can evaluate lesions that cannot be accessed through the airway.

PURPOSE

This study aimed to evaluate the value of adding EUS-B-FNA to EBUS-TBNA performed by pulmonologists for intrathoracic lesions in the clinical setting.

METHODS

Between March 2009 and March 2020, all patients who underwent EUS-B-FNA and EBUS-TBNA for diagnostic purposes were included and retrospectively analyzed at a single institution.

RESULTS

A total of 1794 procedures using an EBUS bronchoscope including, EBUS-TBNA, EUS-B-FNA, and the combination of EBUS-TBNA and EUS-B-FNA for evaluating intrathoracic lesions, were performed. We finally analyzed 276 patients who underwent EUS-B-FNA for diagnostic purposes. EUS-B-FNA provided diagnostic materials from only EBUS-TBNA-inaccessible lesions in 26 patients and in 18 patients whose conditions were inappropriate for bronchoscopy (e.g., respiratory failure, airway stenosis, etc.). EUS-B-FNA provided diagnostic results in four patients with non-diagnostic EBUS-TBNA results. EUS-B-FNA was preferable to EBUS-TBNA in 4.4% (48 of 1091) of patients; therefore, adding EUS-B-FNA to EBUS-TBNA increased the diagnostic yield from 72.6% (1043 of 1437) to 75.9% (1091 of 1437).

CONCLUSION

Pulmonologists are able to enhance diagnostic yields by acquiring the EUS-B-FNA technique.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interventional Pulmonology and Esophagus: Combined Endobronchial Ultrasound and Endoscopic Ultrasound for Mediastinal Staging

Endoscopic ultrasound (EUS) techniques in addition to endobronchial ultrasound (EBUS) can lead to diagnosis and complete accurate staging of the mediastinum in a single session. This allows for decreased health care costs, less delay in diagnosis and treatment, reduced patient discomfort, and decreased morbidity compared with invasive surgical staging techniques. In comparison to conventional mediastinoscopy, the cost-effectiveness and reduced complication profile of the endoscopic approach has made this a superior initial step in the staging and diagnosis of lung cancer. Moreover, compared with EBUS alone, combined EUS and EBUS has significantly increased yield, as well as diagnostic sensitivity making a combined approach preferable as the emerging gold-standard technique for initial minimally invasive mediastinal staging. We discuss the advantage of using EUS in combination with EBUS and highlight techniques, lymph node landmarks, utility in staging and restaging of the mediastinum, roles in diagnosing mediastinal infections and granulomatous lesions, and future directions in endosonography.

Mediastinal Lymph Node Metastasis of Esophageal Cancer with Esophageal Stenosis Diagnosed via Transesophageal Endoscopic Ultrasound with Bronchoscope-guided Fine-needle Aspiration

An 80-year-old man underwent follow-up examinations after endoscopic submucosal dissection (ESD) for esophageal cancer. Computed tomography showed enlarged lymph nodes of the right recurrent nerve. The patient had esophageal stenosis due to repeated ESD for multiple esophageal tumors. The stenosis made the passage of an endoscopic ultrasound (EUS) scope through the esophagus difficult. Thus, an endobronchial ultrasound bronchoscope, which had a thinner diameter than that of the EUS scope, was used for transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration. This technique led to the diagnosis of mediastinal lymph node metastasis of esophageal cancer.

EBUS versus EUS-B for diagnosing sarcoidosis: The International Sarcoidosis Assessment (ISA) randomized clinical trial

Background and objective

Endosonography with intrathoracic nodal sampling is proposed as the single test with the highest granuloma detection rate in suspected sarcoidosis stage I/II. However, most studies have been performed in limited geographical regions. Studies suggest that oesophageal endosonographic nodal sampling has higher diagnostic yield than endobronchial endosonographic nodal sampling, but a head‐to‐head comparison of both routes has never been performed.

Methods

Global (14 hospitals, nine countries, four continents) randomized clinical trial was conducted in consecutive patients with suspected sarcoidosis stage I/II presenting between May 2015 and August 2017. Using an endobronchial ultrasound (EBUS) scope, patients were randomized to EBUS or endoscopic ultrasound (EUS)‐B‐guided nodal sampling, and to 22‐ or 25‐G ProCore needle aspiration (2 × 2 factorial design). Granuloma detection rate was the primary study endpoint. Final diagnosis was based on cytology/pathology outcomes and clinical/radiological follow‐up at 6 months.

Results

A total of 358 patients were randomized: 185 patients to EBUS‐transbronchial needle aspiration (EBUS‐TBNA) and 173 to EUS‐B‐fine‐needle aspiration (FNA). Final diagnosis was sarcoidosis in 306 patients (86%). Granuloma detection rate was 70% (130/185; 95% CI, 63–76) for EBUS‐TBNA and 68% (118/173; 95% CI, 61–75) for EUS‐B‐FNA (p = 0.67). Sensitivity for diagnosing sarcoidosis was 78% (129/165; 95% CI, 71–84) for EBUS‐TBNA and 82% (115/141; 95% CI, 74–87) for EUS‐B‐FNA (p = 0.46). There was no significant difference between the two needle types in granuloma detection rate or sensitivity.

Conclusion

Granuloma detection rate of mediastinal/hilar nodes by endosonography in patients with suspected sarcoidosis stage I/II is high and similar for EBUS and EUS‐B. These findings imply that both diagnostic tests can be safely and universally used in suspected sarcoidosis patients.

This global RCT in patients with suspected sarcoidosis stage I/II with an indication for endosonographic nodal sampling showed a similarly high granuloma detection rate and sensitivity for diagnosing sarcoidosis with endobronchial ultrasound versus endoscopic ultrasound‐B. The findings imply that both diagnostic tests (endobronchial/oesophageal) can be used safely and universally in suspected sarcoidosis patients.

Update on sarcoidosis guidelines

PURPOSE OF REVIEW

The current review summarizes recent guidance in the diagnosis and management of sarcoidosis. Until recently, the main guidelines were the 1999 International Statement on Sarcoidosis. However, in 2020 two new guidelines were published by the American and British Thoracic Societies. They have a number of key updates and this review aims to summarize these.

RECENT FINDINGS

The key findings from 2020 revolve around several themes. First, the need for a histological diagnosis should be supported by a multidisciplinary team approach. When a histological biopsy is needed of the lungs, thought is given to the approach taken for this and to whether an endobronchial ultrasound, endoscopic ultrasound or transbronchial biopsy is needed. Second, information regarding supporting tests including blood biomarkers, lung function and imaging. Third, a section specific to cardiac sarcoidosis. Finally, a summary of guidance for treating sarcoidosis including the need to treat fatigue.

SUMMARY

The recent guidance suggests that a histological biopsy is only needed in cases of diagnostic uncertainty or in patients with typical long standing features on imaging. The guidelines also provide a clear pathway on the type of lung biopsy needed depending on the extent of mediastinal or parenchymal involvement. Support is given to steroid regimens and indication for second-line immunosuppression.

Utility of Endoscopic Ultrasound with Bronchoscope-guided Fine-needle Aspiration for Detecting Driver Oncogenes in Non-small-cell Lung Cancer during Emergency Situations: Case Series

Since it is difficult to obtain tumor tissue via airway observation for lung cancer patients with a poor respiratory condition, endoscopic ultrasound with bronchoscope-guided fine-needle-aspiration (EUS-B-FNA), a transesophageal procedure, is effective for such patients. We herein report three patients with driver oncogenes taken to the emergency department because of lung cancer-related symptoms. EUS-B-FNA was performed because of the patients' poor respiratory conditions to detect driver oncogenes. The general conditions improved, and the patients achieved a long-term survival with tyrosine kinase inhibitors. Our findings suggest that EUS-B-FNA should be considered to detect driver oncogenes in lung cancer patients despite poor respiratory conditions in emergency departments.

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

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

EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial

BACKGROUND

Endobronchial Ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard of care modality for the evaluation of mediastinal lymphadenopathy. Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-B-FNA), wherein one introduces the EBUS bronchoscope through the esophageal route, is also a safe and efficacious diagnostic modality for sampling the mediastinal lymph nodes. The objective of this study was to compare the diagnostic yield and patient comfort with these two available approaches.

METHODS

We randomized subjects with predominant subcarinal or lower left paratracheal mediastinal lymph node enlargement to either EBUS-TBNA or EUS-B-FNA (50 to each group). Co-Primary objectives were the comparison of adequate and diagnostic aspirates between groups. Key secondary objectives were a comparison of Operator rated cough and Operator rated procedural comfort on Visual Analog scale (VAS), procedure duration and complications between the groups.

RESULTS

Baseline characteristics were comparable between the groups. The proportion of adequate (EBUS-TBNA 46/50; 92% and EUS-B-FNA 48/50;96%, P = 0.4) and diagnostic aspirates (EBUS-TBNA 38/50; 76% and EUS-B-FNA 36/50;74%, P = 0.4) were similar between the two groups. Operator rated cough was significantly less, and Operator rated patient comfort significantly higher with the EUS-B-FNA approach. Procedure duration was significantly shorter with EUS-B-FNA [18.1(14.4) minutes versus 16.4 (49.6) minutes, P < 0.001]. Minor complications occurred in one patient in the EBUS-TBNA group and none in the EUS-B-FNA group.

CONCLUSION

During the endosonographic evaluation for undiagnosed mediastinal lymphadenopathy located at predominantly the subcarinal or lower left paratracheal stations, EUS-B-FNA as compared with EBUS-TBNA provides greater patient comfort with a similar diagnostic yield.

Bronchoscopic sampling techniques in the era of technological bronchoscopy

Flexible bronchoscopy is a key diagnostic and therapeutic tool. New endoscopes and technologically advanced navigational modalities have been recently introduced on the market and in clinical practice, mainly for the diagnosis of mediastinal lymph adenopathies and peripheral lung nodules. Bronchoscopic sampling tools have not changed significantly in the last three decades, with the sole exception of cryobiopsy. We carried out a non-systematic, narrative literature review aimed at summarizing the scientific evidence on the main indications/contraindications, diagnostic yield, and safety of the available bronchoscopic sampling techniques. Performance of bronchoalveolar lavage, bronchial washing, brushing, forceps biopsy, cryobiopsy and needle aspiration techniques are described, focusing on indications and diagnostic accuracy in the work-up of endobronchial lesions, peripheral pulmonary abnormalities, interstitial lung diseases, and/or hilar-mediastinal lymph adenopathies. Main factors affecting the diagnostic yield and the navigational methods are evaluated. Preliminary data on the utility of the newest sampling techniques (i.e., new needles, triple cytology needle brush, core biopsy system, and cautery-assisted transbronchial forceps biopsy) are shown. TAKE HOME MESSAGE: A deep knowledge of bronchoscopic sampling techniques is crucial in the era of technological bronchoscopy for an optimal management of respiratory diseases.

Safe performance of diagnostic bronchoscopy/EBUS during the SARS-CoV-2 pandemic

The SARS‐CoV‐2 pandemic is unprecedented in our professional lives and much effort and resources will be devoted to care of patients (and HCW) affected by this illness. We must also continue to aim for the same standard of care for our non‐COVID respiratory patients, while minimizing risks of infection transmission to our colleagues. This commentary addresses the key paired issues of minimizing performance of diagnostic/staging bronchoscopy in patients with suspected/known lung cancer while maximizing the safety of the procedure with respect to HCW transmission of COVID‐19.

Transesophageal needle aspiration using a third-generation Olympus ultrasound bronchoscope for subaortic lesions: a report of two cases

Transesophageal endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA) has been reported to be useful for evaluating paraesophageal lesions; however, its ability to access subaortic lesions is relatively limited. The third-generation Olympus ultrasound bronchoscope, which was released in 2018, has a wider up-angulation range, which is theoretically preferable to previous models for puncturing the subaortic lesions. We report herein two cases with subaortic lesions that could not be evaluated using a conventional ultrasound bronchoscope, but that were successfully evaluated and diagnosed via EUS-B-FNA employing a new ultrasound bronchoscope.

EUS-B-FNA for Diagnosing Liver and Celiac Metastases in Lung Cancer Patients

BACKGROUND

In patients with suspected or proven lung cancer, assessment of regional nodal and distant metastases is key before treatment planning. By introducing the endobronchial ultrasound (EBUS)-guided scope into the esophagus and stomach (EUS-B), liver lesions and celiac nodes can be visualized. To date, the utility of EUS-B in diagnosing liver lesions and retroperitoneal lymph nodes is unknown.

OBJECTIVES

To assess the feasibility, safety, and diagnostic yield of sampling of liver lesions and retroperitoneal nodes by EUS-B fine-needle aspiration (FNA) in a lung cancer staging setting.

METHOD

Consecutive patients suspected of lung cancer in 2 Danish centers between 1 January 2015 and 31 December 2017 were included retrospectively when a lesion in the liver or a retroperitoneal lymph node was visualized and biopsied with EUS-B-FNA.

RESULTS

23 left liver lobe lesions and 19 retroperitoneal lymph nodes were sampled by EUS-B-FNA. Sensitivity and diagnostic yield of sampled liver lesions were 86 and 83%, respectively. In 19/23 patients, there was a cytopathological diagnosis of malignancy. Sensitivity and diagnostic yield from retroperitoneal lymph node samples were 83 and 63%, respectively. In 10/19 patients, the diagnosis was malignancy. No complications were observed.

CONCLUSION

EUS-B-FNA enables safe sampling of left liver lobe lesions and retroperitoneal lymph nodes. EUS-B should be considered as a minimally invasive technique to provide tissue proof of distant metastases lung cancer patients.

Transoesophageal ultrasound-guided bronchoscopic aspiration of a superior mediastinal tumour using the BF-UC290F instrument

A 46-year-old male with a superior mediastinal mass presented with a one-month history of hoarseness and chest pain and was referred to our hospital. Although endobronchial, ultrasound-guided, transbronchial needle aspiration (EBUS-TBNA) was initially performed, we could not obtain an adequate specimen because of his severe cough and an inadequate EBUS view. During the same endoscopic session, we performed endoscopic, ultrasound-guided, bronchoscopic fine-needle aspiration (EUS-B-FNA) via a transoesophageal approach using the BF-UC290F (Olympus, Tokyo, Japan), a third-generation EBUS-TBNA endoscope. The BF-UC290F enabled smooth access through the oesophagus and a clear EBUS view of the mass, attributable, respectively, to the compact distal tip and the powerful angulation. Rapid on-site cytology revealed that an adequate specimen had been obtained, and we terminated the procedure without inducing a severe cough. Histologically, the mass was a squamous cell carcinoma. EUS-B-FNA employing the BF-UC290F was useful to diagnose the superior mediastinal mass.

Interventional pulmonology techniques in elderly patients with comorbidities

Respiratory diseases are common cause of disability in the elderly and are often concomitant with other non-respiratory medical conditions. Interventional pulmonology includes advanced diagnostic and therapeutic techniques, successfully employed for benign and malignant pulmonary diseases with a good safety profile. A few studies are available on the efficacy and the safety of these procedures (both bronchoscopic and pleural techniques) in the elderly. Paucity of data in these patients may support reluctant clinicians. We carried out a non-systematic review aimed at describing the scientific literature on interventional pulmonology techniques in elderly patients with comorbidities. We summarized indications, performance characteristics, and safety profile of bronchoscopic techniques in the elderly, comparing outcomes between older and younger patients. We explored the role of age on anesthesia and sedation protocols during endoscopic procedures and assessed the influence of comorbidities on bronchoscopic outcomes. This review underlines that older age is not a barrier for implementing interventional pulmonology for diagnostic and therapeutic purposes.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lung cancer staging: a concise update

Diagnosis and clinical staging of lung cancer are fundamental to planning therapy. The techniques for clinical staging, i.e anatomic and metabolic imaging, endoscopies and minimally invasive surgical procedures, should be performed sequentially and with an increasing degree of invasiveness. Intraoperative staging, assessing the magnitude of the primary tumour, the involved structures, and the loco-regional lymphatic spread by means of systematic nodal dissection, is essential in order to achieve a complete resection. In resected tumours, pathological staging, with the systematic study of the resected specimens, is the strongest prognostic indicator and is essential to make further decisions on therapy. In the present decade, the guidelines on lung cancer staging of the American College of Chest Physicians and the European Society of Thoracic Surgeons are based on the best available evidence and are widely followed. Recent advances in the classification of the adenocarcinoma of the lung, with the definition of adenocarcinoma in situ, minimally invasive adenocarcinoma and lepidic predominant adenocarcinoma, and the publication of the eighth edition of the tumour, node and metastasis classification of lung cancer, have to be integrated into the staging process. The present review complements the latest guidelines on lung cancer staging by providing an update of all these issues.

Respiratory failure patient with lung cancer diagnosed by transesophageal bronchoscopic ultrasound-guided aspirates

A 71-year-old man, who had received long-term oxygen therapy for respiratory failure caused by chronic obstructive pulmonary disease, had an enlarged mediastinal lymph node for one year. As his lung function was poor, we tried performing endobronchial ultrasound-guided transbronchial needle aspiration under non-invasive positive pressure ventilation for diagnosis but could not obtain sufficient specimens. Later, we performed an endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) using a transesophageal approach. Rapid on-site cytology revealed that adequate specimens were obtained, and we could terminate the procedure in 12 min without any complications. The histological findings revealed lung adenocarcinoma. EUS-B-FNA, which can be performed by a pulmonologist, is a useful alternative for diagnosing mediastinal lesions in patients with respiratory failure.

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

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

Anesthetic Considerations for Mediastinal Staging Procedures for Lung Cancer

Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.

Pulmonologist-performed transoesophageal sampling for lung cancer staging using an endobronchial ultrasound video-bronchoscope: an Australian experience

BACKGROUND

Transoesophageal endobronchial ultrasound (EBUS) video-bronchoscope insertion provides pulmonologists access to conduct endoscopic fine-needle aspiration (EUS-B-FNA) of mediastinal lymph node (LN) lesions and also assist in lung cancer staging by sampling left adrenal gland (LAG) lesions. Limited literature has described additional diagnostic value whilst maintaining patient safety. To elicit whether combining endoscopic transoesophageal fine-needle aspiration using convex probe bronchoscope (EUS-B-FNA) and EBUS bronchoscopy enhances the diagnostic yield of mediastinal nodal staging in lung cancer, whilst maintaining safety.

METHODS

All eligible patients with paraoesophageal lesions on thoracic computed tomography (CT) underwent pulmonologist-performed EUS-B-FNA at two tertiary centres and were included in this prospective observational cohort study.

RESULTS

EUS-B-FNA sampling was performed at 69 mediastinal LN lesion sites, including 17 sites inaccessible to bronchoscopic sampling. Four LAG lesions were sampled via EUS-B-FNA. There were no complications. EBUS-TBNA was augmented by EUS-B-FNA because of accessibility of sampling lesions otherwise unamenable bronchoscopically, thereby increasing diagnostic utility. Diagnostic sensitivity of EUS-B-FNA for malignancy in mediastinal LN lesions was 88% (51 of 58). For mediastinal LN lesions not amenable to EBUS-TBNA, the sensitivity for diagnosis of malignancy via EUS-B-FNA was 88% (15 of 17). Diagnostic sensitivity of EUS-B-FNA for malignancy in LAG lesions was 50% (2 of 4).

CONCLUSION

EUS-B-FNA is a precise and safe approach in the evaluation and staging of lung cancer when performed by a pulmonologist. It complements and increases the diagnostic utility of EBUS-TBNA by further coverage of mediastinal LN stations and access to LAG lesions.

Pulmonologist-Performed Per-Esophageal Needle Aspiration of Parenchymal Lung Lesions Using an EBUS Bronchoscope: Diagnostic Utility and Safety

BACKGROUND

Transesophageal introduction of the endobronchial ultrasound (EBUS) videobronchoscope allows pulmonologists to perform endoscopic ultrasound fine-needle aspiration (EUS-B-FNA) of mediastinal lesions. Safety, diagnostic accuracy, and feasibility of EUS-B-FNA in evaluation of pulmonary parenchymal lesions are not established.

METHODS

All patients undergoing pulmonologist-performed EUS-B-FNA of parenchymal lung lesions at 2 tertiary centers were included in this prospective observational cohort study.

RESULTS

EUS-B-FNA sampling of parenchymal lesions was performed in 27 patients. Mean (±SD) lesion size was 36±16 mm. Seven lesions were ≤18 mm. Pneumothorax occurred in 1 patient (3.7%, 95% confidence interval, 0.001%-19%). Ten target lesions (36%) were in locations inaccessible to bronchoscopic sampling via the airways, and 9 lesions were inaccessible to EBUS-guided transbronchial needle aspiration and in locations associated with low diagnostic yield from radial EBUS. EUS-B-FNA was diagnostic in 26 patients (96%), and sensitivity of EUS-B-FNA was 100% (95% confidence interval, 87%-100%) for both lung cancer (n=21) and for pulmonary metastatic lesions (n=5).

CONCLUSIONS

Pulmonologist-performed EUS-B-FNA is safe and accurate in the evaluation parenchymal lung lesions. Diagnostic accuracy is high. EUS-B-FNA may achieve access to sites not amenable to other forms of bronchoscopic sampling, or increase diagnostic accuracy in patients where anatomic position predicts a low diagnostic yield.

Transesophageal Bronchoscopic Ultrasound-Guided Fine-Needle Aspiration for Metastatic Vertebral Body Lesion

Malignant neoplasms frequently cause vertebral metastases. Traditionally, either image-guided percutaneous biopsy or open biopsy has been performed for sampling specimens for the definitive diagnosis. We herein report a case with suspected multiple metastases but unknown primary, who underwent endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal lymph nodes with negative results by rapid onsite cytologic evaluation, followed by the transesophageal approach with the ultrasound bronchoscope for the vertebral body lesion at the same setting that provided a definitive diagnosis of metastatic hepatocellular carcinoma.

Linear endobronchial and endoesophageal ultrasound: a practice change in thoracic medicine

PURPOSE OF REVIEW

Linear endosonography, including intrathoracic lymph nodal sampling by endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) and endoesophageal ultrasound fine-needle aspiration (EUS-FNA), has an important role in the diagnosing and staging of lung cancer. Furthermore, endosonography is applied in the mediastinal evaluation of sarcoidosis, lymphoma, cysts, and nodal metastases of extrathoracic malignancies. Endosonography-related complications as well as sedation and training strategies are discussed. The purpose of this review is to summarize current practice, recent advances, and future directions.

RECENT FINDINGS

Lung cancer guidelines recommend endosonography - above mediastinoscopy - as the initial test for mediastinal nodal tissue staging. By introducing the EBUS-scope into the esophagus (EUS-B) - following an EBUS procedure - the complete mediastinum and the left adrenal gland can be investigated in a single scope procedure by one operator. In patients with suspected stage I/II sarcoidosis, EBUS-TBNA/EUS-FNA is the test with the highest granuloma detection rate. Diagnosing (recurrent) lymphoma is an increasingly accepted indication for endosonography. Systematic surveys showed that endosonography has a low complication rate. Simulator-based training and assessment tools measuring competency are important instruments to provide standardized and optimal implementation.

SUMMARY

Endosonography is generally accepted as a powerful and safe diagnostic test for various diseases affecting the mediastinum. Large-scale implementation is needed.

Evaluation of lymph node metastasis in lung cancer: who is the chief justice?

Accurate determination of the diagnosis and the stage of lung cancer play a critical role to ensure that patients are provided the optimal treatment. However, the process is usually beyond complex. Early studies have suggested lymph nodes (LNs) >1.0 cm in size on computed tomography (CT) are considered as metastatic nodes, while the sensitivity of this criterion is not satisfied. Subsequently, positron emission tomography-computed tomography (PET-CT) was shown to be superior to CT alone on assessment of nodal involvement and was widely used to estimate suitability for resection with curative intent, but the dependability also remains controversial. Furthermore, transbronchial needle aspiration (TBNA) with and without endobronchial ultrasound (EBUS), as a well-accepted minimally invasive approach for LN biopsy, has been documented as an efficient tool in evaluation of CT and PET-CT negative LNs. Additionally, radiographic features including ground-glass/solid nodules ratio, referring as imaging biomarker, were indicated to be correlated with metastasis. Hence, we highlight the importance of comprehensive estimation of mediastinal and hilar LNs, and we suggested the judgment of LNs by radiographic tools alone might not be reliable and TBNA is indispensable in certain circumstances.

Endoscopic ultrasound in the diagnosis of mediastinal diseases

EUS is a useful tool for diagnosis of mediastinal diseases. EUS-FNA plays an important role in staging of lung cancer and in tissue acquisition in patients with mediastinal masses. In this review, the following issues will be addressed: EUS-FNA and EBUS-TBNA, metastatic mediastinal lymph nodes diagnosed by EUS, EUS in assessment of mediastinal lymph node status for staging of lung cancer, mediastinal lymphoma diagnosed by EUS, sarcoidosis and tuberculosis diagnosed by EUS.

Endosonography for mediastinal disease: esophageal ultrasound vs. endobronchial ultrasound

BACKGROUND AND STUDY AIMS

One can approach mediastinal pathology via esophageal ultrasound (EUS) and/or endobronchial ultrasound (EBUS). It has been suggested that EUS is better tolerated by patients. If so, EUS might be the procedure of choice when suspect lesions are accessible via EUS. We studied procedural characteristics of EUS with fine needle aspiration (EUS-FNA) and EBUS with transbronchial needle aspiration (EBUS-TBNA) to see how they differed.

PATIENTS AND METHODS

Retrospective review of consecutive EBUS and EUS procedures performed on patients over nine months. One hundred fifty-five procedures were analyzed (61 EUS, 73 EBUS, 21 EUS + EBUS). For EUS, EBUS, and EUS + EBUS, 1.4, 2.0 and 2.5 sites (mean) were sampled, respectively. EUS required approximately one-half of the time of EBUS or the combined procedures; 13.1 vs. 24.1 and 26.9 min, respectively (P < 0.0001 for EUS vs. both EBUS and EUS + EBUS). Sedation dosing was statistically lower for EUS and not significantly different between EBUS and the combined approach. EUS also involved lower oxygen requirements and shorter time to discharge. Because fewer mean sites were sampled with EUS than with EBUS or the combined procedure, we performed analysis restricted to procedures that involved sampling of ≤ 2 sites to determine whether approach-related differences in procedure characteristics were preserved. There were 56 such EUS procedures and 52 such EBUS procedures. EUS remained significantly faster and required less patient sedation.

CONCLUSIONS

EUS involved statistically significant economies of time and sedation. This has implications with respect to safety and productivity. When applicable, EUS is the procedure of choice.