Radial probe endobronchial ultrasound assisted conventional transbronchial needle aspiration in the diagnosis of solitary peribronchial pulmonary lesion located in the segmental bronchi

Diagnostic efficacy and safety of radial probe endobronchial ultrasound-guided transbronchial needle aspiration for adjacent lesions in segmental or subsegmental bronchi: a single-center retrospective study

BACKGROUND

Peripheral lung lesions can be sampled using various techniques, including computer tomography-guided transthoracic needle aspiration, electromagnetic navigation bronchoscopy, virtual navigation bronchoscopy, and radial probe endobronchial ultrasound transbronchial lung biopsy. Mediastinal lesions can be sampled using techniques like convex probe endobronchial ultrasound-guided transbronchial needle aspiration (CEBUS-TBNA) and endoscopic ultrasound-fine-needle aspiration. However, effective, safe techniques for lesions adjacent to the segmental or subsegmental bronchi are lacking. Herein, we retrospectively evaluated the diagnostic yield and safety of radial probe endobronchial ultrasound-assisted transbronchial needle aspiration (REBUS-TBNA) for lesions adjacent to the segmental bronchi, and explored the factors related to diagnostic yield.

METHODS

We retrospectively analyzed the diagnostic yield and safety of REBUS-TBNA cases performed in our department from January 2019 to December 2022. Observation group patients had undergone REBUS-TBNA for lesions adjacent to the segmental bronchi; control group patients had undergone CEBUS-TBNA for mediastinal or hilar lesions. Patient characteristics and lesion sizes, diagnostic yield, adverse events, and relations between diagnostic yield and clinical characteristics were analyzed.

RESULTS

There were not statistically significant between-group differences in sex, age, diagnostic yield, or rate of adverse events. The observation group (n = 25; 17 male, 8 female) had a mean age of 64.76 ± 10.75 years. The average lesion size was 4.66 ± 1.07 cm, and lesions were predominantly in the upper lobes (80%). REBUS-TBNA diagnostic yield was 84%, with no adverse events reported. Diagnostic yield was not associated with lesion size or extent of bronchial stenosis; however, it was positively correlated with number of punctures. Patients with > 3 punctures had a significantly higher diagnostic yield than those with ≤ 3 punctures.

CONCLUSIONS

REBUS-TBNA is a safe, effective diagnostic technique, particularly for lesions adjacent to the segmental or subsegmental bronchi of the upper lobe. Performing more than three punctures during the procedure improves the diagnostic yield. Larger-scale studies are warranted to confirm these results, and to further explore the clinical value of REBUS-TBNA.

Endobronchial Radiofrequency Ablation for pulmonary nodules with Radial-Ebus and Navigation: Pros and Cons

Introduction: Pulmonary nodules are common in the everyday clinical practice. There is always a diagnostic issue with this imaging finding. Based on the size we can use a variety of imaging and diagnostic techniques. Moreover; in the case of primary lung cancer or metastasis we can use radiofrequency ablation endobronchially. Patients and Methods: We used the radial-endobronchial ultrasound with C-arm and Archemedes, Bronchus electromagnetic navigation in order to acquire biopsy sample and we also used rapid on-site evaluation as a rapid diagnosis for pulmonary nodules. After rapid diagnosis we used the radiofrequency ablation catheter in order to ablate central pulmonary nodules. Results: Both techniques provide efficient navigation, however, with the Bronchus system less time is needed. The new radiofrequency ablation catheter provides efficient results in central lesions with low watts ≤40. Conclusion: We provided in our research a protocol to diagnose and treat such lesions. Future larger studies will provide more data on this subject.

Safety and Diagnostic Accuracy of the Transnasal Approach for Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA)

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe and accurate diagnostic procedure used for investigating mediastinal pathologies. It is usually performed using an oral approach. The nasal route has been proposed but not extensively investigated. With the aim to report the use of linear EBUS through the nasal route and compare its accuracy and safety with the oral one, we conducted a retrospective analysis of the subjects who underwent an EBUS-TBNA procedure at our center. From January 2020 to December 2021, 464 subjects underwent an EBUS-TBNA, and in 417 patients, EBUS was performed through the nose or mouth. Nasal insertion of the EBUS bronchoscope was performed in 58.5% of the patients. No difference between the two insertion routes was observed in terms of location or number of stations sampled per subject. Procedure complications were mild and similar between the two groups (10.2% for the nasal group vs. 9.8% for the oral group). Minor epistaxis occurred in five subjects in the nasal group. Comparing the two groups, the rates of adequate specimens were similar (95.1% vs. 94.8%), as were the proportions of diagnostic specimens (84% vs. 82%). In conclusion, the nasal route for EBUS-TBNA is a valid alternative to the oral one.

Endobronchial ultrasound-guided transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis

The diagnosis of peripheral pulmonary lesions (PPLs) remains a challenge for physicians. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been applied in the diagnosis of PPLs, but its diagnostic rate varies widely. The systematic review and meta-analysis was conducted to figure out the accuracy and safety of EBUS-TBNA in the diagnosis of PPLs. We searched the PubMed and Embase databases for relevant studies published from January 1, 2000 to December 30, 2021 and used PICO (Participants, Intervention, Comparison, and Outcome) to worked out the diagnostic rate of EBUS-TBNA in PPLs. Two reviewers independently performed the data extraction and assessed study quality. Statistical analysis was carried out via R software. In 7 studies of totally 510 patients of PPLs, the overall EBUS-TBNA diagnosis yield is 0.75 (95% CI 0.67-0.84) by the random effect model. EBUS-TBNA showed a higher accuracy of 0.64 (95% CI 0.53-0.74) compared to 0.46 (95% CI 0.19-0.72) of endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) when EBUS probe is adjacent to lesions. In the case of malignant lesions, the diagnostic rate of EBUS-TBNA is 0.79 (95% CI 0.72-0.88). Combined EBUS-TBNA with conventional bronchoscopy procedures showed the highest diagnostic yield (0.83 (95% CI 0.79-0.87)). Collectively, EBUS-TBNA should be performed firstly in patients with PPLs suspected to lung cancer especially when the EBUS probe was adjacent to the lesions. No serious procedure-related complications were observed.

Non-Small-Cell Lung Cancer Immunotherapy and Sleep Characteristics: The Crossroad for Optimal Survival

INTRODUCTION

Non-small-cell lung cancer is still diagnosed at an inoperable stage and systematic treatment is the only option. Immunotherapy is currently considered to be the tip of the arrow as the first-line treatment for patients with a programmed death-ligand 1 ≥ 50. Sleep is known to be an essential part of our everyday life.

PATIENTS AND METHODS

We investigated, upon diagnosis and after nine months, 49 non-small-cell lung cancer patients undergoing immunotherapy treatment with nivolumab and pemprolisumab. A polysomnographic examination was conducted. Moreover, the patients completed the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Fatigue Severity Scale (FSS) and the Medical Research Council (MRC) dyspnea scale.

RESULTS

Tukey mean-difference plots, summary statistics, and the results of paired t-test of five questionnaire responses in accordance with the PD-L1 test across groups were examined. The results indicated that, upon diagnosis, patients had sleep disturbances which were not associated with brain metastases or their PD-L1 expression status. However, the PD-L1 status and disease control were strongly associated, since a PD-L1 ≥80 improved the disease status within the first 4 months. All data from the sleep questionnaires and polysomnography reports indicated that the majority of patients with a partial response and complete response had their initial sleep disturbances improved. There was no connection between nivolumab or pembrolisumab and sleep disturbances.

CONCLUSION

Upon diagnosis, lung cancer patients have sleep disorders such as anxiety, early morning wakening, late sleep onset, prolonged nocturnal waking periods, daytime sleepiness, and unrefreshing sleep. However, these symptoms tend to improve very quickly for patients with a PD-L1 expression ≥80, because disease status improves also very quickly within the first 4 months of treatment.

Predicting reachability to peripheral lesions in transbronchial biopsies using CT-derived geometrical attributes of the bronchial route

PURPOSE

The bronchoscopist's ability to locate the lesion with the bronchoscope is critical for a transbronchial biopsy. However, much less study has been done on the transbronchial biopsy route. This study aims to determine whether the geometrical attributes of the bronchial route can predict the difficulty of reaching tumors in bronchoscopic intervention.

METHODS

This study included patients who underwent bronchoscopic diagnosis of lung tumors using electromagnetic navigation. The biopsy instrument was considered "reached" and recorded as such if the tip of the tracked bronchoscope or extended working channel was in the tumors. Four geometrical indices were defined: Local curvature (LC), plane rotation (PR), radius, and global relative angle. A Mann-Whitney U test and logistic regression analysis were performed to analyze the difference in geometrical indices between the reachable and unreachable groups. Receiver operating characteristic analysis (ROC) was performed to evaluate the geometrical indices to predict reachability.

RESULTS

Of the 41 patients enrolled in the study, 16 patients were assigned to the unreachable group and 25 patients to the reachable group. LC, PR, and radius have significantly higher values in unreachable cases than in reachable cases ([Formula: see text], [Formula: see text], [Formula: see text]). The logistic regression analysis showed that LC and PR were significantly associated with reachability ([Formula: see text], [Formula: see text]). The areas under the curve with ROC analysis of the LC and PR index were 0.903 and 0.618. The LC's cut-off value was 578.25.

CONCLUSION

We investigated whether the geometrical attributes of the bronchial route to the lesion can predict the difficulty of reaching the lesions in the bronchoscopic biopsy. LC, PR, and radius have significantly higher values in unreachable cases than in reachable cases. LC and PR index can be potentially used to predict the navigational success of the bronchoscope.

Case Report: Endoscopic radiofrequency ablation with radial-EBUS and ROSE

Background

Single pulmonary nodules are a common issue in everyday clinical practice. Currently, there are navigation systems with radial-endobronchial ultrasound and electromagnetic navigation for obtaining biopsies. Moreover, rapid on-site evaluation can be used for a quick assessment. These small lesions, even when they do not have any clinically significant information with positron emission tomography, are important to investigate.

Case description

Radiofrequency and microwave ablation have been evaluated as local treatment techniques. These techniques can be used as therapy for a patient population that cannot be operated on. Currently, one verified operating system is used for endoscopic radiofrequency ablation through the working channel of a bronchoscope.

Conclusion

In our case, a new system was used to perform radiofrequency ablation with long-term follow-up.

Cryo-Biopsy versus 19G needle versus 22G needle with EBUS-TBNA endoscopy

Introduction: We have been using cryo-biopsy for endobronchial lesions for lung cancer diagnosis and debulking. Cryo-biopsy is also known to be an excellent tool for diagnosis of lung interstitial disease. Recently cryo-biopsy with the 1.1mm probe was used for lymphnode biopsy.

Patients and Methods: 311 patients participated with lymphadenopathy and at least one lung lesion. The following tools were used for diagnosis; 22G Mediglobe Sonotip, 22G Medigolbe, 21G Olympus, 19G Olympus and 1.1mm cryo probe ERBE CRYO 2 system (3 seconds froze). A PENTAX Convex-probe EBUS was used for biopsy guidance.

Results: Cell-blocks slices had a higher number in the 19G needle group (19G> Cryo Probe>22G Mediglobe Sonotip >21G Olympus >22G Mediglobe).

Conclusion: Cryo biopsy of the lymphnodes is safe with the 1.1mm cryo probe. Further studies are needed in order to evaluate new probes and the technique specifications.

Cryobiopsy for pneumonitis diagnosis in NSCLC immunotherapy

Nowadays immunotherapy is considered the tip of the arrow as treatment for non-small cell lung cancer for inoperable patients. Programmed death-ligand 1 is considered a valuable marker for the success of immunotherapy. The higher the score ≥50% the more successful the treatment will be. However; previous studies have presented favorable data even for those patients where the programmed death-ligand 1 was ≤50% or even 0%, therefore it can be administered as first line treatment in these patients with the addition of chemotherapy or radiotherapy. Other treatment modalities are tested as surrogates like gene therapy with immunotherapy to improve the results in patients with programmed death-ligand 1 was ≤50% or even 0%. The main issue for these patients is an adverse effect pneumonitis, in case we will present the valuable method of lung parenchyma sampling with cryobiopsy for early diagnosis of immunotherapy induced pneumonitis.

Tracheal fistula repair with stent placement after failure of reconstruction with muscle tissue. A lung cancer surgery complication

A report a case of a 63 year old male diagnosed with lung cancer adenocarcinoma. The patient had a right paratracheal mass diagnosed with EBUS-TBNA 22G. The patient had surgery, however 7 days after the billau catheter was removed pneumothorax was diagnosed which did not resolved. Bronchoscopy reveled two minor fistulas in the interior wall of the trachea. An additional surgery was performed in order to add muscle patches on the exterior part of the trachea. Unfortunately additional stent placement was placed after a silicon stent since the muscle patches failed. We chose a metallic auto expandable stent since after three months of follow up a small metastatic lesion was observed in the liver. Stent placement is an option for these patients and the right stent has to be placed for each case.

Effective early diagnosis for NSCLC: an algorithm

INTRODUCTION

Lung cancer still remains undiagnosed for most patients until the disease is inoperable.

AREAS COVERED

We performed search on PubMed with the keywords: EBUS, radial-EBUS, bronchoscopy, lung cancer, electromagnetic navigation, ct-biopsy, transthoracic biopsy. We present diagnostic equipment and imaging techniques such as positron emission tomography, endoscopical navigation systems, endobronchial ultrasound, radial-endobronchial ultrasound, transthoracic ultrasound biopsy, and computed tomography guided biopsies.

EXPERT OPINION

However, lack of early disease symptoms remains the most important issue and therefore we should direct our efforts to screening and early disease diagnosis. An algorithm is proposed for biopsy upon initial disease diagnosis.

Radial endobronchial ultrasound-assisted transbronchial needle aspiration for pulmonary peripheral lesions in the segmental bronchi adjacent to the central airway

Background

Tissue samples from lesions located in the 3rd to 5th segmental bronchi are challenging to obtain. In this retrospective study, we aimed to evaluate the diagnostic rate of pulmonary peripheral lesions located in the 3rd to 5th segmental bronchi, near the inner field of lung on the computed tomography (CT) image and outside the bronchus, using radial endobronchial ultrasound (REBUS) followed by transbronchial needle aspiration (TBNA).

Methods

This retrospective study enrolled patients whose preoperative CT examinations showed a lesion located in the segmental bronchi (3rd to 5th), yet adjacent to the inner field of lung on the CT image. REBUS followed by TBNA was used to acquire tissue samples from these lesions. A bronchoscope was used to reach the bronchi surrounding the lesion, and an ultrasound probe was used to determine the lesion's location. Then, the ultrasound probe was withdrawn, and puncture was performed at the location that was determined by ultrasound. The tissue specimens obtained were subjected to pathological examination.

Results

Nineteen patients were enrolled in this study including 15 males and 4 females with an average age of 55 years old. Of the enrollees, 8 patients (42.1%) were successfully diagnosed with samples obtained through TBNA, including 6 cases of lung cancer, 1 case of non-specific inflammation, and 1 case of cryptococcal infection. The diagnostic rate was 42.1%. No post-procedural complications were observed among the patients. There was no significant difference in nodule diameter between patients with a diagnostic sample and those in whom TBNA failed to provide a diagnosis (2.99±0.96 vs. 2.26±1.27 cm, P=0.20).

Conclusions

With the assistance of REBUS, TBNA can acquire sufficient samples to achieve a reasonably diagnostic rate for parenchymal lung lesions located near the inner field of lung on the CT image without intrabronchial invasion.

Diagnosis of unexposed tumours using endobronchial ultrasonography with a guide sheath and a thin transbronchial needle

Transbronchial diagnosis of unexposed lung tumours is challenging in clinical practice. Although modified transbronchial needle aspiration (TBNA) is used for this purpose, the diagnostic yield is unsatisfactory. In such cases, conventional endobronchial ultrasonography with a guide sheath and transbronchial biopsy (TBB) is also ineffective. We found TBB was feasible by placing a guide sheath with a thin transbronchial needle into the tumours. We report two cases of unexposed tumours diagnosed successfully with this technique. Case 1 presents a typical carcinoid in the peripheral lung. Case 2 presents a squamous cell carcinoma at the third bifurcation of the right lung. TBB samples obtained this way were larger than TBNA samples. Moreover, multiple TBBs were possible once the guide sheath was inserted intratumourally. In the modern era of precision medicine, larger amounts of tissues are required for multiple downstream analyses. This novel technique will make a significant contribution towards diagnosing unexposed lung tumours.

Application of a Simulator-Based Teaching Method in the Training of the Flexible Bronchoscope-Guided Intubation

BACKGROUND

The study aimed to explore the effect of a bronchoscopic simulator-based comprehensive teaching method in the training of flexible bronchoscope-guided intubation for suspected lung cancer patients for doctors without bronchofibroscopic operation background.

METHODS

We designed a prospective self-control study involved in 35 trainees from the Navy Military Medical University's affiliated hospital to evaluate flexible bronchoscope-guided intubation's training outcome. Before and after the practice training, we recorded the flexible bronchoscope passing time from nasal to visible glottis and carina, tracheal placement tube, and ventilation.

RESULTS

All 35 trainees could complete flexible bronchoscope-guided intubation independently after training.

CONCLUSIONS

The bronchial diagnosis for suspected lung cancer patients and treatment-based model can be widely applied in tracheal intubation training.

The development of bronchoscopy in China: a national cross-sectional study

Objective: To investigate the development of bronchoscopy in China and compare it with its application in the early 21st century. Methods: The data collection was based on questionnaires. Three hundred and nineteen hospitals, which distributed across 30 provinces and 130 cities, were included in the study. Data about the application of bronchoscopy in Shanghai and Hunan province in the early 21st century are also involved for comparison. Results: The median period of performing diagnostic and therapeutic bronchoscopy was 19.7±11.0 and 7.4±7.0 years, respectively. On average, about 155.2 cases and 28.4 cases received diagnostic and therapeutic bronchoscopy in each hospital per month. The average area and number of the examination room was 122.7m² and 2.2m², respectively. More examination items were performed in specialty hospitals than those in general hospitals (P<0.05) and specialty hospitals owned more rooms exclusively for bronchoscopy (P<0.05), while no difference of the number of allocated doctors was found (P>0.05). On the other side, the whole amount of diagnosis and therapeutic items in teaching hospitals was slightly higher than that in non-teaching hospitals (P<0.01). Comparison of diagnosis and therapeutic endoscopy in Shanghai and Hunan province shows that the number of flexible bronchoscopy increased by 5.8 times in Shanghai from 2002 to 2017, while that increased by 3.4 times in Hunan province from 2005 to 2017. Furthermore, the average number of allocated doctors increased by 0.85 times in Shanghai, which was more rapidly compared with that of Hunan province (0.66 times) (P<0.05). Besides, the development rate of the diagnosis and therapeutic projects in Shanghai was significantly higher than that in Hunan province (P<0.05). Conclusion: All different classes of hospitals in China are capable of carrying out conventional bronchoscopy diagnosis and therapeutic projects, and newly developed bronchoscopy technology has gradually spread in high-level hospitals since 21st century. The higher class the hospital was, the earlier bronchoscopy was performed. Respiratory endoscopy in China has developed rapidly since the early 21st century and the construction of respiratory endoscopy center and the personnel training are on the right track, but it is also faced with inadequate equipment, unbalanced regional development and insufficient personnel allocation.

Endobronchial removal of a metallic needle using a flexible diagnostic bronchoscope and biopsy forceps. A case report from Djibouti

Foreign body removal is a challenging procedure. Firstly we have to identify properly the foreign body and the position of the obstruction. Secondly we have to choose the proper removal equipment and finally the appropriate method of patient ventilation during the procedure. In our case report we present a challenging procedure with the removal of a metallic needle with minimum resources and equipment in a young girl in Djibouti, Africa.

EBUS-TNBA 22G samples: Comparison of PD-L1 expression between DAKO and BIOCARE®

Introduction: Lung cancer is diagnosed at advanced stage due to lack of early disease symptoms. Currently we have several different biopsy techniques such as; radial endobronchial ultrasound, convex probe endobronchial ultrasound, electromagnetic navigation, ct guided biospy and transthoracic ultrasound biopsy. Novel therapies such as; immunotherapy is being used for non-small cell lung cancer in the everyday clinical practice as first and second line treatment. Programmed ligand-1 is essential in order to administer immunotherapy as first line treatment. Patients and Methods: Two thousands and two patients were included in our study where programmed ligand 1 was evaluated with DAKO technique and BIOCARE®. Cell blocks were obtain with convex probe ebus-tbna 22G needle. Results: The Deming regression between DAKO and BIOCARE clone revealed an amazingly strong linear relationship as the coefficient of determination indicated (R2=0.999) and the variance ratio close to 1 (0.978), proving that both techniques can equally well be substituted for each other. The regression coefficient equals to 1 and the intercept hardly differs from 0 (0.936). In practice, this relationship permits adopting the economically affordable BIOCARE clone for further medical considerations. Conclusion: No statistical difference was observed between DAKO and BIOCARE®, therefore we propose that both techniques can be used in order to investigate the expression of programmed ligand 1 with safety. PD-L1 expression was higher in the central mass instead of the lymphnodes.