Accuracy of rapid on-site evaluation of endobronchial ultrasound guided transbronchial needle aspirates by respiratory registrars in training and medical scientists compared to specialist pathologists-an initial pilot study

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.

Interobserver agreement between pathologist, pulmonologist and molecular pathologist to estimate the tumour burden in rapid on-site evaluation smears from endosonography and guided bronchoscopy

OBJECTIVE

A growing number of studies have suggested that non-pathologists can reliably assess the adequacy and malignancy in rapid on-site evaluation (ROSE) smears prepared during endoscopic sampling procedures. However, no study has verified whether they can also consistently estimate the tumour burden, which is critical for the molecular profiling of lung cancer. We aimed to assess the interobserver agreement (IOA) between a pathologist, a pulmonologist (previously trained in lung and lymph node cytopathology) and a molecular pathologist for the tumour burden in ROSE smears.

METHODS

The ROSE smears of consecutive patients with suspected lung cancer undergoing endosonography or guided bronchoscopy were assessed independently by a pathologist, a pulmonologist and a molecular pathologist (gold standard). The IOA for the tumour burden, assessed through k-statistics, was the primary outcome.

RESULTS

A total of 322 ROSE smears obtained from 162 patients were evaluated. The IOA between the molecular pathologist and pulmonologist was very good (moderate to substantial), although slightly inferior to the IOA between the molecular pathologist and pathologist in the whole slide set (k: 0.707, 95% confidence interval [CI]: 0.677-0.739 vs 0.793, 95% CI: 0.762-0.815), as well as in smears prepared from lymphadenopathy (k: 0.783, 95% CI: 0.760-0.855 vs 0.827, 95% CI: 0.728-0.892) or from pulmonary nodules/masses (k: 0.558, 95% CI: 0.416-0.686 vs 0.715, 95% CI: 0.621-0.767).

CONCLUSIONS

A professionally trained pulmonologist can reliably estimate the tumour burden in bronchoscopically derived ROSE smears, especially in the setting of lymphadenopathy. This can be particularly useful in institutions where a cytopathologist is not available regularly.

Rapid On-Site Cytologic Evaluation: A Feasibility Study Using Ancillary Interventional Pulmonary Personnel

BACKGROUND

Ancillary health professionals helping in a procedural service is a common practice everywhere.

OBJECTIVES

This was a proof-of-concept study to assess feasibility of using ancillary personnel for rapid on-site cytologic evaluation (ROSE) at interventional pulmonary procedures.

METHODS

After a training interval, a respiratory therapist (RT) performed ROSE on consecutive interventional pulmonary specimens. Sample sites included lymph nodes, lung, liver, and the left adrenal gland. RT findings were subsequently correlated with blinded cytopathology-performed ROSE and with final histopathology results, with primary foci of adequacy and the presence or absence of malignancy.

RESULTS

Seventy consecutive cases involved 163 separate sites for ROSE analysis. Adequacy: There was a high level of concordance between RT-performed ROSE (RT-ROSE) and cytopathology ROSE (CYTO-ROSE). They agreed upon the adequacy of 159 specimens. The Cohen's κ coefficient ± asymptotic standard error (ASE) was 0.74 ± 0.175, with p < 0.0001. Malignancy: RT-ROSE concurred highly with CYTO-ROSE, with agreement on 150 (92%) of the 163 specimens. Cohen's κ coefficient ± ASE was 0.83 ± 0.045, with p < 0.0001. When the comparison was for malignancy by case rather than individual site, Cohen's κ coefficient ± ASE was 0.68 ± 0.08, with p < 0.0001.

CONCLUSION

This study demonstrates that ancillary personnel supporting an interventional pulmonary service can be trained to perform initial ROSE. Cytopathology can be called after sampling and staining have produced adequate samples. This setup streamlines ROSE evaluation with regard to time and cost.

Efficacy of rapid on-site evaluation for diagnosing pulmonary lesions and mediastinal lymph nodes: a systematic review and meta-analysis

Background

Although rapid on-site evaluation (ROSE) is gradually becoming an integral part of the modern Interventional Pulmonology, the clinical benefit of ROSE is still a matter of controversy. The objective of this meta-analysis was to clarify whether ROSE is effective in diagnosing pulmonary lesions and mediastinal lymph nodes, synchronously, to assess circumstances under which ROSE makes more sense.

Methods

MEDLINE and EMBASE were searched for studies comparing any outcome between ROSE and no-ROSE group in diagnosing pulmonary lesions and mediastinal lymph nodes. Statistical calculations were conducted using Review Manager, version 5.3, and Stata Release 12.0. Meta-analysis was completed using a random-effects model when I²≥50% or a fixed-effect otherwise. Heterogeneity was assessed by the I²-statistic test. Publication bias was assessed by the Begg's test.

Results

This Literature search yielded 27 studies altogether. The pooled risk difference of adequate rate was 0.12 [95% confidence intervals (CI): 0.07-0.16, I²=0%], the combined risk difference (RD) of diagnostic yield was 0.14 (95% CI: 0.09-0.18, I²=57%) while the pooled RD of sensitivity for malignancy was 0.10 (95% CI: 0.06-0.14, I² =20%). Significant heterogeneity only existed in diagnostic yield (I²=57%, P=0.001). Further subgroup analysis documented a higher increase in diagnostic yield when sampling solid pulmonary lesions than sampling hilar/mediastinal lymph nodes 0.16 (95% CI: 0.12-0.20, I²=0%) versus 0.08 (95% CI: 0.04-0.13, I²=10%) and when applied to patients with suspected/diagnosed lung cancer than unselected patients 0.12 (95% CI: 0.06 to 0.18) versus 0.11 (95% CI: -0.07 to 0.28).

Conclusions

ROSE is a useful technology in diagnosing pulmonary lesions and mediastinal lymph nodes, especially when sampling solid pulmonary lesions or applied to patients with suspected lung cancer.