Diagnostic Yield of Endobronchial Ultrasound-Guided Mediastinal Lymph Node Transbronchial Forceps Biopsies (EBUS-TBFB)

OBJECTIVE

The diagnostic accuracy and yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is not well established in lymphoma and other mediastinal-related diseases. The objective of this study was to examine the yield of a combined technique of EBUS-TBNA and endobronchial ultrasound-guided transbronchial forceps biopsies (EBUS-TBFB) compared with each modality alone in lymphoma and other mediastinal-related diseases.

METHODS

This was a retrospective review of cases of mediastinal lymphadenopathy of unknown etiology accessed using TBNA and TBFB. The McNemar test was used to compare the diagnostic yield of TBNA, TBFB, and the combined technique.

RESULTS

The combined approach yielded a definitive diagnosis in 31/35 cases (88.6%). In 9/10 cases (90%), Hodgkin's and non-Hodgkin's lymphomas were diagnosed and subtyped without further need for invasive testing. All of the granulomatous inflammation cases were confirmed using the combined technique. Two cases led to adequate whole-genome sequencing of lung cancer, and one patient was diagnosed as having dedifferentiated liposarcoma despite a nondiagnostic preprocedural mediastinoscopy. There was only one procedure-related complication, a pneumomediastinum that required no further intervention. There were no significant adverse events.

CONCLUSIONS

The combination of EBUS-TBFB and EBUS-TBNA is safe and provides a high yield in the diagnosis of mediastinal adenopathy of unknown etiology, especially lymphoma. Furthermore, the larger samples obtained from TBFB increased its sensitivity to detect granulomatous disease and provided specimens for clinical trials of malignancy when needle aspirates were insufficient.

Diagnosis of Hodgkin's Lymphoma Using Endobronchial Ultrasound-Guided Transbronchial Needle

Endobronchial ultrasound-guided transbronchial biopsy has emerged as an excellent tool in diagnosing lung cancer. However, its use to diagnose lymphoma has been questioned, since the gold standard for diagnosing lymphomas is an excisional biopsy of involved lymph nodes. However, the procedure is sometimes risky or difficult. Recent studies have been showing great results using endobronchial ultrasound-guided transbronchial needle aspiration when accompanied by immunohistochemistry and cytology. Here, we present a case of Hodgkin's lymphoma patient that was accurately diagnosed using endobronchial ultrasound-guided transbronchial needle aspiration.

Value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of lung and mediastinal lesions

OBJECTIVE

To evaluate the value of EBUS-TBNA in the diagnosis of lung and mediastinal lesions.

METHODS

Prospective cohort study that included 52 patients during a 2-year period (2016 to 2018) who underwent EBUS-TBNA.

RESULTS

Among the 52 individuals submitted to the procedure, 22 (42.31%) patients were diagnosed with locally advanced lung cancer (N2 or N3 lymph node involvement). EBUS-TBNA confirmed the diagnosis of metastases from other extrathoracic tumors in the mediastinum or lung in 5 patients (9.61%), confirmed small cell lung cancer in 3 patients (5.76%), mediastinal sarcoidosis in 1 patient (1.92%), and reactive mediastinal lymph node in 8 patients (15.38%); insufficient results were found for 3 patients (5.76%). Based on these results, EBUS-TBNA avoided further subsequent surgical procedures in 39 of 52 patients (75%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 86%, 100%, 100%, 77%, and 90%, respectively. No major complications were observed.

CONCLUSIONS

EBUS-TBNA is a safe, effective, and valuable method. This technique can significantly reduce the rate of subsequent surgical procedures required for the diagnosis of lung and mediastinal lesions.

The role of endobronchial ultrasound-guided transbronchial needle aspiration in isolated intrathoracic lymphadenopathy in non-neoplastic patients: a common dilemma in clinical practice

Objective:

To determine the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in non-neoplastic patients with isolated intrathoracic lymphadenopathy (IL).

Methods:

This was a retrospective study of patients with isolated IL referred for EBUS-TBNA. We calculated the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of EBUS-TBNA in the diagnosis of granulomatous, reactive, and neoplastic lymphadenopathy. In cases of nonspecific granulomas, reactive lymphadenopathy, or inconclusive results, a definitive diagnosis was established by other diagnostic procedures or during a follow-up period of at least 18 months.

Results:

Among the 58 patients included in the study, EBUS-TBNA established a diagnosis of granulomatous disease in 22 (38%), reactive lymphadenopathy in 15 (26%), cancer in 8 (14%), and other diseases in 3 (5%). Results were inconclusive in 10 (17%), the diagnosis being established by other bronchoscopic procedures in 2 (20%) and by surgical procedures in 8 (80%). A final diagnosis of reactive lymphadenopathy was established in 12. Of those, 11 (92%) had their diagnosis confirmed during follow-up and 1 (8%) had their diagnosis confirmed by mediastinoscopy. In another 3, a final diagnosis of sarcoidosis or neoplasm was established. For the diagnosis of granulomatous disease, neoplasms, and reactive lymphadenopathy, EBUS-TBNA was found to have a sensitivity of 73%, 68%, and 92%, respectively; a specificity of 100%, 100%, and 93%, respectively; an accuracy of 86%, 93%, and 93%, respectively; a PPV of 100%, 100%, and 80%, respectively; and an NPV of 78%, 92%, and 98%, respectively.

Conclusions:

In non-neoplastic patients, granulomatous disease and reactive lymphadenopathy appear to be common causes of isolated IL. EBUS-TBNA shows promising results as a first-line minimally invasive diagnostic procedure. The results obtained by EBUS-TBNA can be optimized by examining clinical and radiological findings during follow-up or by comparison with the results obtained with other bronchoscopic methods.

Endobronchial ultrasound-guided mediastinal lymph node forceps biopsy in patients with negative rapid-on-site-evaluation: A new step in the diagnostic algorithm

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) provides a high diagnostic yield in lung cancer, but the yield for benign conditions and lymphoma is lower. The material obtained by EBUS-TBNA is limited by the lack of histopathological samples in some cases. The current 'expanded' aims of mediastinal lymph node (MLN) sampling are both an accurate diagnosis and adequate material for 'targeted' processing in malignant and benign disease. The sample obtained with the 21/22G EBUS needle may not be sufficient in all situations.

OBJECTIVES

The aim of the study was to evaluate the role of a novel technique for EBUS-guided MLN forceps biopsy (EBUS-TBFB) when EBUS-TBNA with rapid on-site-evaluation (ROSE) failed to provide a diagnosis. In addition, the technical aspects and safety of EBUS-TBFB were studied.

METHODS

About 30 consecutive patients with enlarged MLN, with a negative EBUS-TBNA ROSE were included. EBUS-TBFB was done by the method described below. The histopathology and complications were recorded.

RESULTS

Adequate samples for analysis were obtained in all the patients with both EBUS-TBNA and EBUS-TBFB. In patients with a non-diagnostic EBUS-ROSE, EBUS-TBFB led to positive diagnostic results in an additional 8/30 patients (27%). Mild bleeding was noted in two patients who underwent EBUS-TBFB, which resolved with conservative management. The procedure was safe with no major complications.

CONCLUSION

In patients with a negative EBUS-ROSE, EBUS-TBFB using this technique is safe and augments the diagnostic yield. EBUS-TBFB adds to the armamentarium of EBUS, especially in benign aetiologies of MLN enlargement.

Endobronchial Ultrasound Transbronchial Needle Aspiration for the Diagnosis of Lymphoma

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) presents a minimally invasive way to evaluate abnormal mediastinal and hilar adenopathy. Although EBUS has been established as an effective modality to diagnose lung cancer, its sensitivity for the diagnosis of lymphoma has been demonstrated to be lower. Because of these lower yields uncertainty persists about the ability of EBUS-TBNA to reliably diagnose lymphoma and questions remain regarding the utility of EBUS-TBNA as a first-line biopsy modality for patients suspected of having lymphoma.

METHODS

We conducted a review of our database (n=806 EBUS-TBNAs) for patients undergoing EBUS-TBNA for mediastinal and/or hilar lymphadenopathy over an 8-year span to identify patients diagnosed with lymphoma.

RESULTS

Twenty patients (2.3%) who underwent EBUS-TBNA were ultimately diagnosed with lymphoma. In total, 17 of the 20 patients with lymphoma obtained a diagnosis using EBUS-TBNA. The overall sensitivity of EBUS-TBNA for lymphoma was 85%. The sensitivity for de novo diagnosis was 78% (7/9), and sensitivity for recurrence was 91% (10/11). All patients who achieved a diagnosis by EBUS-TBNA could be adequately subtyped, allowing treatment recommendations.

CONCLUSION

Although the sensitivity of EBUS-TBNA for the diagnosis of lymphoma did not reach values of published data for non-small cell lung cancer, EBUS-TBNA can be considered as a first-line diagnostic tool for patients with mediastinal and/or hilar lymphadenopathy suspected to be lymphoma. Because of the inherent limitations in small volume needle biopsies it is essential that negative samples obtained in the setting of high clinical suspicion warrant further evaluation.

Endobronchial ultrasound convex probe for lymphoma, sarcoidosis, lung cancer and other thoracic entities. A case series

Endobronchial ultrasound endoscopy is a state of the art diagnostic endoscopic procedure for the thorax. Firstly it was designed mainly for the staging of lung cancer and of course for the diagnosis of suspicious findings in large central airways. The main limitation of the equipment is the diameter of the instrument and therefore it can only be guided through large airways. However; the diameter of the working channel also provides a large tissue sample nowadays with the 19G biopsy needle. We will provide our experience with the 22G needle of the endobronchial convex-probe in several medical situations of the thorax.

Diagnosing Hodgkin Lymphoma From an Endobronchial Ultrasound Core Needle Biopsy

Hodgkin lymphoma (HL) commonly presents as isolated mediastinal adenopathy. Although there is evidence to support minimally invasive techniques such as endobronchial ultrasound (EBUS) fine-needle aspiration as the initial diagnostic test for suspected lymphoma involving the mediastinum, it consistently performs the poorest at definitively diagnosing HL for a variety of reasons, and therefore histology specimens are usually required. We present a case of HL presenting as isolated mediastinal adenopathy that was definitively diagnosed on EBUS using a 22 G coring needle in which cellular and histologic specimens were obtained, allowing the core biopsy to be fixed in formalin and treated as a surgical specimen. The patient started treatment soon after the procedure without requiring any further invasive tests. Although it seems intuitive that a coring EBUS needle would be advantageous in diseases such as HL, further studies are needed before definitive recommendations can be made.

Diagnostic yield of EBUS-TBNA for lymphoma and review of the literature

Aim:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which enables cytological examination of mediastinal lymph node (LN) aspiration samples, is a safe and minimally invasive method for diagnosis and staging of lung cancer and diagnosis of diseases affecting mediastinal LNs. In this study, we investigated the yield of EBUS-TBNA for diagnosis of lymphoma and reviewed the literature since the British Thoracic Society (BTS) guidelines were published.

Materials and Methods:

We retrospectively evaluated our database for patients who underwent EBUS between March 2011 and December 2014. One hundred eighty-nine patients with isolated mediastinal lymphadenopathy were included in the study. Patients with other causes of lymphadenopathy, such as lung cancer or extrathoracic malignancy, and those with pulmonary lesions accompanying mediastinal lymphadenopathy were excluded from the study. Patients with final diagnosed lymphoma were included in the study on the basis of a history of lymphoma or newly evaluated mediastinal lymphadenopathy. The sensitivity and negative predictive value (NPV) of EBUS-TBNA were calculated.

Results:

There were 13 patients with the final diagnosis of lymphoma. Eleven of them were new diagnoses and 2 patients were known chronic lymphocytic leukemia (CLL), and underwent EBUS-TBNA for determination of recurrence. Twelve EBUS-TBNA procedures were performed for suspected new cases. Three (25%) were diagnostic, 2 (16.7%) were suspicious for lymphoma and underwent further interventions for definite diagnosis, and 7 (58.3%) were false negative. All 3 patients diagnosed with EBUS-TBNA were non-Hodgkin lymphoma (NHL). None of the Hodgkin lymphoma (HL) cases could be diagnosed with EBUS-TBNA. The overall diagnostic sensitivity and NPV of EBUS-TBNA in detecting lymphoma was 65% and 96.1%, respectively. For the newly diagnosed lymphoma cases, EBUS-TBNA had a sensitivity of 61.1%.

Conclusion:

In conclusion, we believe that since the publication of the BTS guidelines, the value of EBUS-TBNA in the diagnosis of lymphoma still remains controversial. EBUS-TBNA can be the first diagnostic modality in diagnosis of recurrent lymphomas. However, for suspected new cases, especially for HL, the diagnostic yield of EBUS-TBNA is low and negative results do not exclude lymphoma. Further interventions such as mediastinoscopy should be performed for high-suspicion patients.

The role of bronchoscopy in the diagnosis of airway disease

Endoscopy of the airway is a valuable tool for the evaluation and management of airway disease. It can be used to evaluate many different bronchopulmonary diseases including airway foreign bodies, tumors, infectious and inflammatory conditions, airway stenosis, and bronchopulmonary hemorrhage. Traditionally, options for evaluation were limited to flexible and rigid bronchoscopy. Recently, more sophisticated technology has led to the development of endobronchial ultrasound (EBUS) and electromagnetic navigational bronchoscopy (ENB). These technological advances, combined with increasing provider experience have resulted in a higher diagnostic yield with endoscopic biopsies. This review will focus on the role of bronchoscopy, including EBUS, ENB, and rigid bronchoscopy in the diagnosis of bronchopulmonary diseases. In addition, it will cover the anesthetic considerations, equipment, diagnostic yield, and potential complications.

Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in solitary mediastinal, hilar lymphadenectasis, or peribronchial lesions: Six cases reports and review of literature

BACKGROUND

Patients with isolated mediastinal or hilar lymphadenopathy, or peribronchial lesions, are common presentation to clinicians. Due to the difficulty in tissue sampling, the pathological diagnosis is not so easy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established, highly effective, minimally invasive technique for sampling. The current study was conducted to investigate the value of EBUS-TBNA in patients of solitary mediastinal, hilar lymphadenectasis, or peribronchial lesions.

METHODS

Six patients with different pathological results diagnosed via EBUS-TBNA were retrospectively analyzed in this study.

RESULTS

All 6 patients of solitary mediastinal, hilar lymphadenectasis, or peribronchial lesions underwent conventional flexible bronchoscopy before EBUS-TBNA, but only EBUS-TBNA was helpful for the finally definite diagnosis. No complication was observed.

CONCLUSION

EBUS-TBNA is a safe and highly effective diagnostic procedure for both benign and malignant diseases, especially for patients with solitary mediastinal, hilar lymphadenectasis, or peribronchial lesions.

The utility of endobronchial ultrasound-transbronchial needle aspiration in lymphoma

BACKGROUND AND OBJECTIVES

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has a well-established role in the diagnosis and staging of lung cancer. This technology is also widely used for the diagnosis of mediastinal masses and cysts as well as other inflammatory disorders such as sarcoidosis. However, the utility of this procedure in the diagnosis and subclassification of lymphoproliferative disorders (LPDs) is not clear. We performed a systematic review to evaluate EBUS-TBNA use in LPDs.

MATERIALS AND METHODS

PubMed, EMBASE, MEDLINE, Cochrane Library Plus, and ISI Web of Knowledge were searched for studies of clinical trials in English reporting diagnostic performance of EBUS-TBNA in lymphoma until September 2014. The overall sensitivity, negative predictive value (NPV), and diagnostic accuracy were evaluated.

RESULTS

Six trials involving 346 patients with suspected lymphoma were included. The overall sensitivity, NPV, and diagnostic accuracy ranged 38%-91%, 83%-96.4%, and 91%-97%, respectively. Further invasive surgery was needed only in 13-43% of the patients. None of the studies included in the present review reported important complications.

CONCLUSION

Current evidence suggests that EBUS-TBNA can be used as an initial evaluation for patients with suspected lymphoma. Additional surgical procedures may be necessary if a sample is inadequate or negative with high suspicion of lymphoma. Further multicenter trials are needed to evaluate the diagnostic yield of EBUS-TBNA in lymphoma patients.

Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report

BACKGROUND

Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians.

METHODS

Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion.

RESULTS

Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement.

CONCLUSIONS

Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure.

Endobronchial ultrasound-guided transbronchial needle aspiration is useful as an initial procedure for the diagnosis of lymphoma

BACKGROUND

The usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for evaluating hilar, mediastinal and central parenchymal lesions has been well established. However, its utility for diagnosing lymphoma is controversial. The aim of this study was to evaluate the diagnostic utility of EBUS-TBNA for the definitive diagnosis of de novo lymphoma with subtype classification.

METHODS

Patients with lymphoma who underwent EBUS-TBNA for diagnostic purposes at a single institution between March 2004 and May 2013 were retrospectively reviewed.

RESULTS

Of the 971 patients who underwent EBUS-TBNA during the study period, 19 patients, who did not have a previous history of lymphoma, had a final diagnosis of lymphoma. EBUS-TBNA provided a diagnosis accompanied with subtype classification in 6 patients (32%), a suspicious but not definitive classification in 10 patients (53%), and a negative classification in 3 patients (16%). Immunohistochemical staining for definitive diagnosis was performed in 15 of 16 patients (94%), with suspicious results from routine hematoxylin and eosin staining. No procedure-related complications occurred.

CONCLUSIONS

EBUS-TBNA is a useful initial diagnostic procedure, aiding decisions for the management of patients with suspected lymphoma, even though the sensitivity of EBUS-TBNA for diagnosing lymphoma with subtype classification was lower than previously reported.

A rare case of mediastinal metastasis of ovarian carcinoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a minimally invasive tool with excellent diagnostic accuracy and low risk of complications in the diagnosis of thoracic diseases, including lung cancers and primary mediastinal lesions. Occasionally, EBUS-TBNA may be useful in identifying thoracic metastasis from distant tumors. Here we report an interesting and rare case of mediastinal metastasis of ovarian carcinoma diagnosed by EBUS-TBNA.