Endobronchial ultrasound-guided cryobiopsy for diagnosing a case of granulomatosis with polyangiitis

EBUS-TBNA has represented a revolution in the diagnosis of intrathoracic pathologies, particularly in lung cancer staging, replacing more invasive methods such as mediastinoscopy. However, its role in diagnosing rare benign or malignant mediastinal disorders is still a matter of debate. Over the past few years, the role of EBUS-guided cryobiopsy has been increasingly emerging as an innovative and minimally invasive technique in diagnosing these disorders, with an excellent safety profile. In this case report, we present the case of a young man brought to our attention after already undergoing a non-diagnostic trans thoracic needle aspiration (TTNA) procedure for lung consolidations. In our department, he underwent an initial EBUS-TBNA procedure with inconclusive rapid on-site evaluation (ROSE), leading to the decision to perform an EBUS-guided cryobiopsy, which yielded a diagnosis of granulomatosis with polyangiitis without complications. This clinical case demonstrates that in specific contexts, EBUS-cryobiopsy represents an excellent diagnostic tool.

Insufficient endobronchial ultrasound-guided transbronchial needle aspiration specimens. When and why? The analysis of criteria and reasons behind the insufficient specimens

BACKGROUND

The classification terminology systems for pulmonary cytology specimens have recently emerged. Inadequate samples, classified as "nondiagnostic," raise challenges in determining the threshold of cell numbers and the risk of malignancy (ROM).

METHODS

The study retrospectively reviewed 248 endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples: 46 insufficient samples, 60 low cellularity samples, and 142 adequate samples. Characteristics as cellularity, number of benign and malignant cells, and background features were assessed. Receiver operating characteristic curve analysis was performed to establish cell sufficiency thresholds for the diagnosis.

RESULTS

Out of the 248 samples analyzed, 108 were classified as benign, 94 as malignant, and 46 as insufficient. The study found that the cellularity thresholds for diagnosis in cell blocks and cytological samples were ≥50 cells and ≥100 cells, respectively. The thresholds for tumor cell counts were ≥1 - 10 cells for both types of cells, respectively. Considerably, some low cellularity samples were initially classified as insufficient despite meeting the diagnostic thresholds upon revision. The ROM varied across sample categories, with insufficient samples having a ROM of 10.9%, benign samples 15.7%, suspicious samples 92.0%, and malignant samples 100%.

CONCLUSION

Insufficient EBUS-TBNA samples raise challenges in diagnosis and management. This study identified the root cause of insufficient samples, including factors related to humans, diagnostic methods, sampling, and laboratory processing. By understanding the root causes, diagnostic recommendations can be developed to improve the diagnostic process. The findings emphasize the importance of standardized classification and terminology systems for clear communication among healthcare professionals and institutions, ultimately improving patient care and enabling quality assurance measures.

Accuracy of endobronchial ultrasound-guided transbronchial needle aspiration for staging of non-small cell lung cancer

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is routinely performed to confirm a lung cancer diagnosis and/or to clinically stage disease. EBUS-TBNA findings may be used to determine whether patients can be offered potentially curative surgery. In this study, we evaluated the reporting in our service of EBUS-TBNA cytology for early-stage (operable) non-small cell lung cancer (NSCLC), focusing on diagnostic accuracy and analyzing cases with discordant cytologic and post-surgical histopathologic conclusions.

METHODS

Cytology slides and cytopathology reports of 120 NSCLC patients who had undergone EBUS-TBNA and lobectomy in our hospital system between 2015 and 2021 were retrospectively reviewed.

RESULTS

Of 290 lymph nodes (110 cases) able to be reviewed, interpretation of 48 lymph nodes was discordant with the original cytopathology report. This included 31 lymph nodes originally reported as adequate, which were found to be non-diagnostic on review. The diagnostic accuracy (benign/malignant) of lymph nodes that were sampled at EBUS-TBNA and excised at surgery was 89%. Specific examination of cases where EBUS-TBNA cytology did not reflect post-surgical findings illustrated important features and limitations of the procedure. These included potential misclassification of lymph node stations, the presence of multiple, variably involved nodes at lymph node stations, and the failure to detect small volume disease.

CONCLUSIONS

Continuous evaluation of EBUS-TBNA performance identifies technical limitations and areas of improvement for cytopathology reporting. This is increasingly important in an era where lung cancer screening is expected to increase diagnosis of early-stage disease and with the advent of novel treatments, including non-surgical management options.

Comparison of the specimen quality of endobronchial ultrasound-guided intranodal forceps biopsy using standard-sized forceps versus mini forceps for lung cancer: A prospective study

BACKGROUND AND OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic procedure with adequate performance; however, its ability to provide specimens of sufficient quality and quantity for treatment decision-making in advanced-stage lung cancer may be limited, primarily due to blood contamination. The use of a 0.96-mm miniforceps biopsy (MFB) permits true histological sampling, but the resulting small specimens are unsuitable for the intended applications. Therefore, we introduced a 1.9-mm standard-sized forceps biopsy (SFB) and compared its utility to that of MFB.

METHODS

We prospectively enrolled patients from three institutions who presented with hilar/mediastinal lymphadenopathy and suspected advanced-stage lung cancer, or those who were already diagnosed but required additional tissue specimens for biomarker analysis. Each patient underwent MFB followed by SFB three or four times through the tract created by TBNA using a 22-gauge needle on the same lymph node (LN). Two pathologists assessed the quality and size of each specimen using a virtual slide system, and diagnostic performance was compared between the MFB and SFB groups.

RESULTS

Among the 60 enrolled patients, 70.0% were diagnosed with adenocarcinoma. The most frequently targeted sites were the lower paratracheal LNs, followed by the interlobar LNs. The diagnostic yields of TBNA, MFB and SFB were 91.7%, 93.3% and 96.7%, respectively. The sampling rate of high-quality specimens was significantly higher in the SFB group. Moreover, the mean specimen size for SFB was three times larger than for MFB.

CONCLUSION

SFB is useful for obtaining sufficient qualitative and quantitative specimens.

Importance of mediastinal granulomatous/sarcoid-like lymphadenopathy in extrathoracic malignancies

BACKGROUND

In patients with extrathoracic malignancies (ETM), granulomatous lymph adenopathy called sarcoid-like reactions (SLR) can be seen in the regional or draining lymph nodes. We hypothesized that SLR may be a sign of imminent metastasis and investigated the clinical course and rate of recurrence in patients with ETM and granulomatous mediastinal lymphadenopathy (MLN).

METHODS

In this retrospective observational study, we reviewed the medical files of patients with known ETM and who underwent EBUS-TBNA for initial staging or detection of recurrence from 2011 to 2023. Patients with granulomatous MLN were included.

RESULTS

Forty-one patients (29 female) enrolled in the study. Breast and colorectal carcinomas were the most common malignancies. A total of 81 lymph nodes were sampled. The final diagnosis of patients was five sarcoidosis, one tuberculosis, one second primary, one drug reaction, and 33 SLR. Among patients with SLR, in one patient lymph nodes progressed during the follow-up and were accepted as false-negative without confirmatory biopsy. The negative predictive value (NPV) of granulomatous MLN for metastasis was 97.05%.

CONCLUSION

Granulomatous MLN may be due to tuberculosis, drug reaction, sarcoidosis, or SLR in patients with ETM. SLR has a high NPV in patients with ETM. Follow-up imaging rather than confirmatory biopsy is reasonable in these patients.

Bacterial pericardial effusion secondary to endobronchial ultrasound guided needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a widely used procedure in lung cancer diagnosis with few serious complications. We present a rare case of pericardial effusion secondary to EBUS-TBNA. An 80-year-old male with interstitial lung disease, developed a pericardial effusion composed exclusively of oropharyngeal flora following EBUS-TBNA. Bacterial pericardial effusion following EBUS-TBNA has only been reported in the literature seven previous times. The majority of these cases reported a biopsy of the 4R lymph node. This case highlights the potential risk of pericardial effusion when sampling lymph nodes, particularly station 4R, in patients with a high-riding superior pericardial recess.

A case of prominent immunoglobulin G4-positive lymphadenopathy in response to microscopic lung cancer

Immunoglobulin G4 (IgG4)-related disease is established as a new clinical entity, characterized by high levels of plasma IgG4 and IgG4-positive plasma cell infiltration. However, the elevation of plasma IgG4 and infiltration of IgG4-positive cells have been observed in other diseases, including malignancy. We experienced a case of prominent IgG4-positive lymphadenopathy, which was diagnosed as a reactive lesion in response to lung cancer. The cancerous lesion was so small in size that it was difficult to reveal the coexisting lung cancer. Surgical lymph node biopsy and endobronchial ultrasound-guided transbronchial needle aspiration did not reveal lymph node metastasis of cancer. Mediastinal lymph node dissection finally revealed it. After the right upper lobectomy, the patient underwent postoperative chemotherapy and remains cancer-free after 1 year. Our case suggests that close examination and careful follow-up are necessary when IgG4-positive lymphadenopathy is observed.

Disseminated cryptococcosis presenting as mediastinal and hilar lymphadenopathy in an immunocompetent patient

We herein report a rare case of disseminated cryptococcosis presenting as mediastinal and hilar lymphadenopathy in a young immunocompetent man. A previously healthy 26‐year‐old man presented with persistent headache and nonproductive cough. Chest computed tomography indicated mediastinal and hilar lymphadenopathy. Cryptococcal lymphadenitis and meningitis was confirmed by endobronchial ultrasound‐guided transbronchial needle aspiration and central spinal fluid examination, respectively. He received liposomal amphotericin B and flucytosine followed by fluconazole and finally improved.