Endobronchial ultrasound-guided transbronchial needle biopsy for diagnosis of mediastinal lymphadenopathy in patients with extrathoracic malignancy

EBUS-TBNA in Extrathoracic Malignancies: Diagnostic and Prognostic Implications

PURPOSE

In patients with extrathoracic malignancies (EM) the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the assessment of abnormal mediastinal lymph nodes (MLN) is controversial. The aim of this study was to assess the diagnostic yield and prognostic significance of EBUS-TBNA in these patients.

METHODS

Retrospective analysis of patients with EM and abnormal MLN detected by Computed Tomography (CT) and/or Positron Emission Tomography (PET).

RESULTS

A total of 161 patients with EM and abnormal MLN were included (93 males, 58%). The most common EM was melanoma (19%) and gastrointestinal cancer (17%). Assessed lymph nodes were mediastinal in 70% of cases and hilar in 30%. The most frequently sampled lymph nodes were subcarinal (45%) and lower right paratracheal (21%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EBUS-TBNA for the diagnosis of malignancy were 88%, 100%, 100% and 87%, respectively. These values were similar regardless the type of EM except for head and neck tumors where the NPV was particularly low (67%). The diagnosis of neoplastic involvement by EBUS-TBNA implied a worse prognosis in terms of overall survival (p < 0.02) and cancer-specific survival (p < 0.001).

CONCLUSIONS

In patients with EM and abnormal MLN, EBUS-TBNA has a high diagnostic yield. However, the NPV decrease in patients with head and neck tumors. Neoplastic MLN detected by EBUS-TBNA has prognostic implications in these patients.

Solitary Metastasis in the Mediastinal Lymph Node After Radical Nephrectomy for Clear Cell Renal Cell Carcinoma: A Case Report and Literature Review

Background

Renal cell carcinoma can metastasize to virtually any anatomical site throughout the body, especially the lung, bone, lymph nodes, liver, and brain. However, it is extremely rare for renal cell carcinoma to metastasize solely to the mediastinal lymph node more than 15 years after radical nephrectomy.

Case Presentation

The case we present here is that of a 50-year-old Chinese male with an isolated posterior mediastinal lymph node metastasis of clear cell renal cell carcinoma 16 years after radical nephrectomy. However, based on imaging examination, the mass was clinically misdiagnosed as Castleman’s disease before operation. Following surgical excision of the mass, it was finally judged to be a metastasis from clear cell renal cell carcinoma according to the patient’s medical history and immunohistochemical findings. Currently, there is no clinical or radiological finding the recurrence of metastasis after 10 months of follow-up.

Conclusion

We report a case of solitary metastasis in the posterior mediastinal lymph node 16 years after radical nephrectomy for clear cell renal cell carcinoma. Given the long disease-free interval between primary renal cell carcinoma to isolated mediastinal lymph node metastasis, it is important to conduct a lifelong regular follow-up, including thoracic computed tomography. In addition, surgical resection remains the best method of treatment for mediastinal lymph node metastases from clear cell renal cell carcinoma if the metastatic lesion is limited.

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

Background

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

Methods

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

Results

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

Conclusions

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

Diagnostic of mediastinal lymphadenopathy in extrathoracic cancer: A place for EBUS-TBNA in real life practice?

INTRODUCTION

Mediastinal lymphadenopathy in patients with extrathoracic malignancy is common. To obtain tissue proof of metastatic spread, EBUS-TBNA is an alternative to mediastinoscopy or thoracoscopy, but there are limited data about its diagnostic performance. The aim of this study was to determine the diagnostic accuracy of EBUS-TBNA for the evaluation of mediastinal lymphadenopathy in patients with extrathoracic cancers.

METHODS

We performed a multicenter retrospective study based on an online questionnaire to collect data from January 2011 to December 2012 in all patients with proven extrathoracic malignancy (current or past) and suspected mediastinal lymph node metastases who underwent EBUS-TBNA for diagnosis.

RESULTS

Hundred and eighty-five patients were included. Extrathoracic malignancies observed were urological (43), breast (35), gastrointestinal (33), head and neck (30), melanoma (11), lymphoma (6), and others (27). EBUS-TBNA confirmed malignancy in 93 patients (50.3%): concordant metastases in 67 (36.2%); new lung cancer in 25 (13.5%); and 1 unidentified cancer. The diagnostic accuracy, sensitivity, specificity, negative predictive value, and positive predictive value were respectively 54.6%, 68.4%, 100%, 53.3%, and 100%.

CONCLUSION

Mediastinoscopy remain the reference, but EBUS-TBNA may be considered as first line investigation in patients with suspected mediastinal lymph node metastases and extrathoracic malignancy. It prevented a surgical procedure in 50.3% of patients.

Endobronchial ultrasound-guided transbronchial needle aspiration cytology in patients with known or suspected extra-pulmonary malignancies: A cytopathology-based study

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the primary modality for mediastinal lymph node staging in lung carcinoma. We aimed to evaluate its utility in extra-pulmonary malignancies (EPM).

METHODS

Database search of EBUS-TBNA aspirations (2013-2017) done in patients with known/suspected EPMs and mediastinal lymphadenopathy/masses was performed. All archived cytology/histology material was reviewed and categorised as positive, negative and unsatisfactory.

RESULTS

The selected 139 patients included 100 patients with known EPMs, 11 patients with known lymphoma, and 28 patients with suspected EPM of unknown primary. EBUS-TBNA was adequate in 110 patients (79%), including 21 patients who yielded only reactive lymphoid tissue. Satisfactory blood clot cores were obtained in 34 patients and contributed significantly to diagnosis and ancillary testing. Metastasis was detected in 45 patients with known EPM, predominantly originating from a known primary in the breast in females (56%) and squamous cell carcinomas of head and neck in males (60%). Granulomatous lymphadenopathy was identified in 16 patients with known EPM (16%). Lymphoma relapse and granulomatous lymphadenopathy were identified in three and four patients with known lymphoma, respectively. In patients with suspected EPM of unknown primary site, malignancy was confirmed in 21 patients, predominantly representing metastatic adenocarcinomas (n = 5) and neuroendocrine neoplasms (n = 5). Immunocytochemistry was performed in 16 of these cases and aided in characterisation of primary site/type of tumour in 12 cases.

CONCLUSION

EBUS-TBNA is efficient for screening mediastinal lymph nodes/masses for malignancy in EPMs. Procuring sufficient material for ancillary testing would improve diagnostic accuracy and reduce need for resampling.

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in the Diagnosis of Breast Cancer Thoracic Metastases and Detection of Receptor Discordance

BACKGROUND

Metastasis of breast cancer to mediastinal lymph nodes is common and biopsy of suspicious lesions can have important diagnostic, prognostic, and therapeutic implications, particularly with respect to tumor receptor status. Our aim was to show that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be used for the diagnosis of metastatic breast cancer and demonstrate reliable receptor evaluation that can result in change of therapy.

METHODS

A retrospective review of consecutive adult patients undergoing EBUS-TBNA from May 2007 to September 2012 was performed. Data collected for patients with a history of breast cancer included patient demographics, tumor pathology, receptor analysis, imaging, and bronchoscopy or surgical results.

RESULTS

Sixty-four patients with a history of breast cancer aged from 31 to 81 years underwent EBUS-TBNA for the evaluation of mediastinal lymphadenopathy of which 16 patients had not been previously treated for their breast cancer with systemic therapy. Eighty suspicious lymph nodes were biopsied measuring 0.8 to 3.1 cm in diameter. Fifty-nine (92%) patients had diagnostic cytology for malignancy or benign lymphoid tissue. Breast malignancy was identified in 33 (52%) patients and 23 (70%) of these had sufficient samples for the evaluation of estrogen, progesterone, and human epidermal growth factor receptor 2 status. Overall 48% of the patients with receptors analyzed had discordance between the primary tumor and metastasis.

CONCLUSIONS

EBUS-TBNA is a useful tool for evaluating mediastinal lymphadenopathy in patients with a history of breast cancer and can provide information on the concordance of receptors status between the primary tumor and metastatic sites in the thorax.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal metastases of clear cell renal cell carcinoma

Evaluation of mediastinal lymphadenopathy in patients with a previous diagnosis of renal cell carcinoma (RCC) is critical for the determination of further treatment. A minimally invasive method of cytology sampling of mediastinal lymph nodes using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a useful tool in diagnosis. Between January 2010 and April 2018, we performed 1744 EBUS-TBNA studies of mediastinal and hilar lymph nodes for a variety of clinical indications including mediastinal malignancy. Sixteen patients (93.7% males, mean age 59.1 years, range 44-81 years) were diagnosed by cytological and cell block study to have metastatic clear cell RCC. Twelve patients had been diagnosed with clear cell RCC in the past (mean 39 months, range 4-89 months) while in four, the tumor was primarily diagnosed in the staging phase on the basis of EBUS-TBNA. The EBUS features of the mediastinal nodal masses included increase of size (mean 2.5 cm, range 1.6-3.8 cm), irregular, inhomogeneous, hypervascular, and hyperechoic echotexture. EBUS-TBNA is a procedure safe and effective for evaluating mediastinal lymphadenopathy in patients with clear cell RCC. Immunohistochemistry in the cell block is decisive for proper diagnosis. The cytologist plays a key role in the diagnosis of metastatic clear cell RCC due to the treatment implications that this neoplasm encompasses.

[Endobronchial ultrasound with transbronchial needle aspiration: Evaluation of clinical practice]

INTRODUCTION

Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has undergone a large increase in France since 2007. The aim is to study the evolution of the indications for EBUS-TBNA in our region during the period 2008-2013.

MATERIAL AND METHODS

We conducted a retrospective observational study including all the patients who underwent an EBUS-TBNA procedure in Picardie from 2008 to 2013. The respective proportion for each indication was noted.

RESULTS

During the study period, 1036 EBUS-TBNA procedures were performed with a continuous increase in number (86 in 2008 versus 275 in 2013). We observed an increase in the proportion of procedures performed for a suspected diagnosis of sarcoidosis (OR=1.31; IC 95% [1.09-1.58]; P=0.005) and for the simultaneous diagnosis and staging of lung cancer (OR=1.12; IC 95% [1.02-1.24]; P=0.022). For the diagnosis of sarcoidosis, we observed an improvement in the diagnostic yield between the periods [2008-2010] and [2011-2013] (42.9% versus 72.5%).

CONCLUSION

A continuous increase in the number of EBUS-TBNA procedures was observed during the period 2008-2013. It was associated with a modification in practice with an increased proportion of procedures performed for the diagnosis of sarcoidosis.

The role of endobronchial ultrasonography for mediastinal lymphadenopathy in cases with extrathoracic malignancy

INTRODUCTION

Many extrathoracic malignancies can metastasize to lungs and mediastinal lymph nodes. Whether mediastinal lesions are metastasis in these patients changes staging, prognosis, and treatment strategy. In this study, we aimed to find out the contribution of EBUS-TBNA to the diagnosis in cases with extrathoracic malignancy.

MATERIALS AND METHODS

Patients who had been previously diagnosed as extrapulmonary solid organ malignancy and in whom mediastinal or hilar lymphadenopathy developed during their follow-up and EBUS-TBNA was applied for diagnostic purposes were retrospectively included in this study.

RESULTS

A total of 91 patients consisting of 35 females (38.5 %) and 56 males (61.5 %) were included in the study. The mean age of the patients was 60.5 (±11.4). Malignancy was not observed in 54 (59.3 %) patients; primary malignancy metastasis was detected in 33 (36.3 %) patients, and primary lung cancer was detected in 4 (4.4 %) patients with EBUS-TBNA. The sensitivity of EBUS-TBNA in extrathoracic malignancies was determined as 90.2 %; its specificity was determined as 100 %, its negative predictive value as 92.5 %, its positive predictive value as 100 %, and its diagnostic accuracy as 95.6 %. The highest rate was determined in the left lower paratracheal lymph node when they were examined in terms of malignancy detection rate in lymph node stations.

CONCLUSION

EBUS-TBNA is a minimally invasive method with quite a low complication rate that does not require general anesthesia. It should be the first step method to be used in the diagnosis of mediastinal and hilar lymphadenopathies seen in extrathoracic malignancies since it has high diagnostic accuracy, sensitivity, and specificity. EBUS-TBNA significantly reduces the need for surgical intervention. Further surgical interventions can be planned in patients in whom diagnostic competence is not ensured.

Negative Predictive Value of Granulomas on EBUS-TBNA in Suspected Extrathoracic Malignancy

PURPOSE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a well-established diagnostic tool for lung cancer, sarcoidosis, and suspected metastatic extrathoracic malignancy. EBUS-TBNA carries a high diagnostic yield, but its negative predictive value (NPV) requires further clarification.

METHODS

We reviewed EBUS-TBNA at our cancer center from 2008 to 2015. We identified negative diagnostic samples for adenopathy suspected to represent metastatic disease from extrathoracic malignancy.

RESULTS

We reviewed 529 EBUS-TBNAs. Ninety patients underwent EBUS-TBNA sampling of the hilum and/or mediastinum (121 nodes, 14 masses) for suspected extrathoracic malignancy. Thirty-seven patients had negative samples (lymph node, granulomas or non-diagnostic specimens). The overall NPV was 98 %. Granulomas (11 patients, 25 nodes) seen on histology had a 100 % NPV, including those that were FDG-PET (fluorodeoxyglucose positron emission tomography) avid (n = 14 nodes).

CONCLUSION

Negative EBUS-TBNA in patients with extrathoracic malignancy and suspected secondary hilar or mediastinal metastases can infer a high NPV especially if granulomas are seen on histology. Larger prospective investigations are needed to confirm the high NPV of EBUS-TBNA with granulomas in extrathoracic malignancies.

Mediastinal and Hilar Lymph Node Measurements. Comparison of Multidetector-Row Computed Tomography and Endobronchial Ultrasound

RATIONALE

Multidetector-row chest computed tomography scan is a common initial imaging modality and endobronchial ultrasound is a minimally invasive diagnostic tool used to evaluate enlarged lymph nodes, but comparisons of imaging results are lacking.

OBJECTIVES

To determine the size of thoracic lymph nodes and the strength of agreement between each measurement from coronal plane computed tomography and static endobronchial ultrasound images.

METHODS

A retrospective review of consecutive patients who underwent endobronchial ultrasound-transbronchial needle aspiration of their lymph nodes because of clinical suspicion of benign or malignant thoracic disease.

MEASUREMENTS AND MAIN RESULTS

One hundred and twenty-four lymph nodes from the mediastinal (74.2%) and hilar (25.8%) stations were measured in 59 patients (mean age, 64.5 yr; 33 males). The mean (standard deviation) short-axis diameter on computed tomography was 14.1 (6.7) mm compared with 12.6 (6.6) mm on endobronchial ultrasound. Benign lymph nodes (n = 42) were larger on computed tomography than on endobronchial ultrasound (14.1 [6.2] vs. 11.5 [6.2] mm). Malignant lymph nodes (n = 35) were larger on endobronchial ultrasound than on computed tomography (17.3 [6.4] vs. 16.2 [6.7] mm). Sixty-five percent of the lymph nodes that were initially interpreted as not enlarged on axial computed tomography images measured greater than 10 mm on each imaging modality (12.5 [5.9] mm on computed tomography and 10.5 [5.6] mm on endobronchial ultrasound) and 24% of the sampled lymph nodes from this group contained malignant cells. Random-effects maximal likelihood linear regression showed a statistically significant difference between endobronchial ultrasound and the computed tomography method for measuring short-axis diameter in all 124 lymph nodes. There was a weak agreement (intraclass correlation, rho: 0.44 [95% confidence interval, 0.31-0.59]) between short-axis diameter measurements from each imaging modality.

CONCLUSIONS

Our single-center study shows that there was poor correlation between computed tomography and endobronchial ultrasound for the measurement of mediastinal and hilar lymph nodes. Malignant cells were recovered by ultrasound-guided needle aspiration from a substantial fraction of lymph nodes that were initially interpreted as normal in size. If these findings are confirmed, new criteria may be needed for lymph node measurement on computed tomography that will guide selection of lymph nodes for endobronchial ultrasound-transbronchial needle aspiration.

[Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in the Diagnosis of Intrathoracic Metastasis from Extrapulmonary Malignancy]

BACKGROUND AND OBJECTIVE

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been widely applied in diagnosing mediastinal and hilar adenopathy. This study is further to evaluate value and safety of EBUS-TBNA in diagnosing intrathoracic metastasis from extrapulmonary malignancy.

METHODS

Prospectively analysis of 41 patients suspected intrathoracic metastasis from previous diagnosed/concurrent extrapulmonary malignancies in Shanghai Chest Hospital, with radiologic findings showing mediastinal/hilar lymph node enlargement or intrapulmonary lesion requiring EBUS-TBNA examination for pathological diagnosis.

RESULTS

41 candidate patients enrolled, and 67 mediastinal/hilar lymph nodes and 5 intrapulmonary lesions were aspirated. 14 intrathoracic metastasis, 10 primary lung cancer, 9 reactive lymphadenitis, 4 sarcoid-like reactions, and 1 tuberculosis was diagnosed by EBUS-TBNA. Sensitivity and accuracy of EBUS-TBNA in diagnosing intrathoracic metastasis was 87.50% and 95.12%, respectively. Immunohistochemistry (IHC) was performed in 18 malignant tumors to obtain definite type or origin, twelve intrathoracic metastasis and 6 primary lung cancer were further confirmed.

CONCLUSIONS

EBUS-TBNA is a safe, effective method for the diagnosis of intrathoracic metastasis from extrapulmonary malignancy. IHC can provide additional evidence for distinguishing extrapulmonary malignancy from primary lung cancer.

Endobronchial ultrasound-guided transbronchial needle aspiration is a sensitive method to evaluate patients who should not undergo pulmonary metastasectomy†

OBJECTIVES

Pulmonary metastasectomy is considered an effective treatment in selected patients with extrapulmonary cancer and oligometastatic disease. We know that the presence of mediastinal lymph node metastases reduces survival significantly, but the mediastinum is rarely evaluated before metastasectomy in these patients. We prospectively evaluated how endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) could identify metastases to the mediastinal lymph nodes in patients referred for pulmonary metastasectomy.

METHODS

All patients with extrapulmonary cancer and oligometastatic disease confined to the lungs on positron emission tomography-computed tomography, and who were considered eligible for pulmonary metastasectomy, routinely underwent EBUS-TBNA of the mediastinal lymph nodes. If EBUS-TBNA did not reveal malignant spread, the patient subsequently underwent pulmonary metastasectomy with systematic sampling of mediastinal lymph nodes for histological evaluation.

RESULTS

One hundred and three eligible patients were referred for EBUS-TBNA during a 4-year period. The primary cancers were located in the colon/rectum (n = 64), kidney (n = 16) and other sites (n = 23). EBUS-TBNA sampled 248 lymph nodes and adequate cytology was obtained in 93 patients (90%). EBUS-TBNA found lymph node metastases in 17 patients (16.5%) and during subsequent pulmonary metastasectomy in the remaining 86 patients 1 (1.0%) had a lymph node metastasis. The sensitivity, specificity, NPV and PPV of EBUS-TBNA for diagnosis of mediastinal lymph node metastasis were 94.4, 100, 98.8 and 100%, respectively.

CONCLUSIONS

EBUS-TBNA is a sensitive minimally invasive modality for evaluation of mediastinal lymph node metastases in patients with oligometastatic pulmonary disease. It allows surgeons to select patients who will not benefit from pulmonary metastasectomy.

[Diagnostic performance of EBUS-TBNA in patients with mediastinal lymphadenopathy and extrathoracic malignancy]

INTRODUCTION

There is limited data about the diagnostic performance of EBUS-TBNA in patients with mediastinal lymphadenopathy and extrathoracic malignancy.

METHODS

From January 2007 to July 2011, EBUS-TBNA was performed in 68 patients with a history of extrathoracic malignancy (current or past) and suspected mediastinal lymph node metastases.

RESULTS

Thirty-one patients had a final diagnosis of cancer. In nineteen patients, the same histology was identified in the mediastinal nodes as in their prior extrathoracic cancer (colorectal cancer, esophageal cancer and lymphoma). In 12, the diagnosis was not "as expected" (ten lung cancers, one colorectal cancer, one unidentified cancer). Among 37 patients without diagnosis, biopsies in 27 showed normal lymphoid material, two had non-specific inflammation and eight had no contributory results. It was noted that procedures were reported to have been more difficult in these patients.

CONCLUSIONS

Diagnostic performance of EBUS-TBNA in the context of extrathoracic malignancy is very variable depending on the origin of the cancer. Nevertheless, a diagnosis is concluded in almost 50% of the cases. These results underline the necessity to select carefully the indications of EBUS-TBNA in extrathoracic cancer.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of intrathoracic lymph node metastases from extrathoracic malignancies

Intrathoracic lymph node enlargement is a common finding in patients with extrathoracic malignancies. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a technique that is commonly used for lung cancer diagnosis and staging but that has not been widely investigated for the diagnosis of enlarged mediastinal and lobar lymph nodes in patients with extrathoracic malignancies. We conducted a retrospective study of 117 patients with extrathoracic malignancies who underwent EBUS-TBNA for diagnosis of intrathoracic lymph node enlargement from October 2005 to December 2009 and compared the EBUS-TBNA findings with the final diagnoses. EBUS-TBNA diagnosed mediastinal metastases in 51 of the 117 (43.6 %) cases and gave an alternate diagnosis or ruled out the presence of malignancy in 35 (56.4 %). Fourteen of these 35 patients underwent further surgical investigation, while the remaining 21 had clinical and radiological follow-up for 18 months. No false negatives were found in the surgery group. In the follow-up group, 13 patients had stable or regressive lymphadenopathy, and eight developed clinicoradiological progression and were assumed to have been false negatives by EBUS-TBNA. The sensitivity and negative predictive value of EBUS-TBNA were 86.4 and 75 %, respectively. Immunohistochemical staining (IHC) was performed in 80.4 % of the samples obtained by EBUS-TBNA. In samples obtained from ten patients with metastatic breast cancer, estrogen receptor expression was successfully assessed in eight patients and progesterone receptor and human epidermal growth factor receptor 2 in four. EBUS-TBNA is an accurate procedure for the diagnosis of thoracic lymph node metastases in patients with extrathoracic malignancies and should be an initial diagnostic tool in these patients. Furthermore, EBUS-TBNA can obtain high-quality specimens from metastatic lymph nodes for use in molecular analyses.

Diagnostic value of blood clot core during endobronchial ultrasound-guided transbronchial needle aspirate

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is being increasingly used in the sampling of pulmonary masses and mediastinal lymphadenopathy. The blood clot core (BCC) often obtained during EBUS-TBNA may not be a true core and therefore may not be submitted for histological analysis. The frequency in which the blood clot core is positive in patients with negative cytology undergoing EBUS-TBNA is not known. The purpose of this study was to evaluate the diagnostic role of the blood clot core obtained during EBUS-TBNA.

METHODS

An Institutional Review Board-approved retrospective chart review was performed from January through September 2011 for all patients who underwent EBUS-TBNA at The Ohio State University. The data collection included cytology and histology results for each procedure. Blood clot cores obtained from the EBUS-TBNA needle were sent in formalin for histological examination.

RESULTS

Seventy patients underwent EBUS-TBNA and 51 (72.8 %) patients had procedures that yielded a BCC for histology and aspirate for cytology. Forty-nine percent of patients with a BCC were diagnosed with malignancy. Of those with a BCC obtained, five (9.8 %) patients diagnosed with malignancy were done so based only on the results of blood clot core alone with negative cytology.

CONCLUSIONS

Blood clot cores obtained at EBUS-TBNA contain diagnostic material and should be subjected histopathological examination. When blood clot cores are sent for analysis, there is the potential to spare up to 10 % of patients more invasive diagnostic biopsy procedures.

The utility of endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal or hilar lymph node evaluation in extrathoracic malignancy: Benign or malignant?

OBJECTIVE

Newly arising enlarged or hypermetabolic mediastinal/hilar lymph nodes (LNs) in patients with previously diagnosed extrathoracic malignancies raise suspicion of metastasis. Relatively high proportion of these LNs is due to a benign condition. We aimed to determine frequency of malignant LNs and role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for clarification of the origin of suspicious LNs in these patients.

METHODS

Consecutive patients with a known extrathoracic malignancy and suspected hilar/mediastinal LN were included in this prospective study. Computed tomography (CT) of thorax and positron emission tomography-CT of all patients were taken. LNs with short axis >1 cm at CT of thorax and SUV ≥ 2.5 were accepted suspicious for malignancy. All patients underwent EBUS-TBNA for pathological verification of LNs. Patients with benign diagnosis either underwent invasive procedures or were followed up. The results were evaluated for frequency of malignant hilar/mediastinal LNs and sensitivity, specificity, and diagnostic values of EBUS-TBNA.

RESULTS

A total of 48 cases with a mean age of 57.4±11.6 were included. All cases had the diagnosis of an extrathoracic malignancy. 78 LNs were aspirated with EBUS-TBNA in 48 cases (1.62 LNs/patient). The mean short axis of aspirated LNs was 1.51±0.63. Results of EBUS-TBNA revealed malignancy in 15 cases (31.2%), tuberculosis in six cases (12.5%), sarcoidosis in four cases (8.3%), and reactive adenitis in 23 cases (48%). The sensitivity, specificity, and negative predictive value of EBUS-TBNA for malignancy were 83.3%, 100%, and 90.9%, respectively. When both benign and malignant diseases were considered, sensitivity, specificity, negative predictive value, and diagnostic accuracy of EBUS-TBNA were 89.2%, 100%, 86.9%, and 93.7%, respectively.

CONCLUSIONS

The ratio of benign LNs in patients with extrathoracic malignancies is relatively high. EBUS-TBNA is a safe, minimally invasive, and effective method for clarification of intrathoracic LNs.

The role of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal and hilar lymph node metastases in patients with extrapulmonary malignancy

OBJECTIVE

The determination of mediastinal lymphadenopathy is important in the management of extrapulmonary malignancy. The purpose of this study was to determine the diagnostic performance of EBUS-TBNA in the diagnosis of mediastinal and hilar lymphadenopathy in patients with proven or suspicious extrapulmonary malignancy.

PATIENTS AND METHODS

Retrospective analysis was performed in 57 patients (81 lesions) with proven (n=51) or suspicious (n=6) extrapulmonary malignancies who underwent EBUS-TBNA between May 2009 and January 2011.

RESULTS

There were 37 male and 20 female patients, with a median age of 64 years. Thirty-five (61.4%) patients were confirmed as malignancy (34 extrapulmonary malignancy and 1 primary lung cancer) and 22 (38.6%) patients were confirmed as benign. EBUS-TBNA identified malignancy in 30 patients. One patient who was diagnosed as primary lung cancer was excluded from diagnostic performance analysis. Overall cancer prevalence was 61% in 56 study patients. The diagnostic sensitivity, accuracy, and negative predictive value of EBUS-TBNA per patient were 88%, 93%, and 85%. The diagnostic sensitivity, accuracy, and negative predictive value of PET/CT scan per patient were 81%, 82%, and 71%, respectively. There were no serious complications related to EBUS-TBNA.

CONCLUSION

Since mediastinal and hilar lymphadenopathy do not always result from metastases in patients with extrapulmonary malignancy, histopathologic confirmation is mandatory. EBUS-TBNA is a sensitive modality and can be considered as the initial test for the histopathological diagnosis of mediastinal and hilar lymphadenopathy in patients with extrapulmonary malignancy.