Guideline for the acquisition and preparation of conventional and endobronchial ultrasound-guided transbronchial needle aspiration specimens for the diagnosis and molecular testing of patients with known or suspected lung cancer

Comparison of Epidermal Growth Factor Receptor Mutations between Metastatic Lymph Node Diagnosed by EBUS-TBNA and Primary Tumor in Non-Small Cell Lung Cancer

Introduction

Although the use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is increasing for epidermal growth factor receptor (EGFR) testing in lung cancer, the discordance rate in EGFR mutations between lymph node (LN) samples obtained by EBUS-TBNA and primary tumor (PT) is not well known. Thus, we compared the EGFR mutation status of LN samples obtained by EBUS-TBNA and PTs to estimate the efficacy of using EBUS-TBNA specimens for EGFR testing in advanced, non-squamous, non-small cell lung cancer (NSCLC).

Materials and Methods

Using data of patients from the EBUS-TBNA database (N = 1914) obtained between January 2009 and January 2013, we identified 100 treatment-naïve, advanced, non-squamous NSCLC patients (stage 3 and 4) with matched LN specimens obtained by EBUS-TBNA and PT specimens. Of these, 74 patients with paired specimens were feasible for EGFR mutation analysis, which we performed using a direct sequencing method.

Results

Of the 74 cases, at least one major [exon 19 deleted (19del) and L858R] or minor (T790M, exon 20 insertion, and other point mutations) EGFR mutation was detected in 31 cases (41.9%), which included PT (n = 31, 41.9%) and LN (n = 28, 37.8%) specimens. Major mutations were detected in 25 PT (33.8%, 19del = 13, L858R = 12) and 22 LN (29.8%, 19del = 11, L858R = 11) specimens. The discordance rate in major mutations between matched PT and LN specimens was 4.1% (3/74). Among minor mutations, T790M was detected in LN specimen only in 2 cases with L858R in PT and LN. The discordance rate major and minor EGFR mutations combined between matched PT and LN specimens was 12% (9/74).

Conclusions

We observed a high concordance rate of major EGFR mutations between matched LN specimens sampled by EBUS-TBNA and PTs, suggesting that LN samples obtained by EBUS-TBNA from advanced non-squamous NSCLC patients are effective for use in EGFR mutation testing.

Linear endobronchial and endoesophageal ultrasound: a practice change in thoracic medicine

PURPOSE OF REVIEW

Linear endosonography, including intrathoracic lymph nodal sampling by endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) and endoesophageal ultrasound fine-needle aspiration (EUS-FNA), has an important role in the diagnosing and staging of lung cancer. Furthermore, endosonography is applied in the mediastinal evaluation of sarcoidosis, lymphoma, cysts, and nodal metastases of extrathoracic malignancies. Endosonography-related complications as well as sedation and training strategies are discussed. The purpose of this review is to summarize current practice, recent advances, and future directions.

RECENT FINDINGS

Lung cancer guidelines recommend endosonography - above mediastinoscopy - as the initial test for mediastinal nodal tissue staging. By introducing the EBUS-scope into the esophagus (EUS-B) - following an EBUS procedure - the complete mediastinum and the left adrenal gland can be investigated in a single scope procedure by one operator. In patients with suspected stage I/II sarcoidosis, EBUS-TBNA/EUS-FNA is the test with the highest granuloma detection rate. Diagnosing (recurrent) lymphoma is an increasingly accepted indication for endosonography. Systematic surveys showed that endosonography has a low complication rate. Simulator-based training and assessment tools measuring competency are important instruments to provide standardized and optimal implementation.

SUMMARY

Endosonography is generally accepted as a powerful and safe diagnostic test for various diseases affecting the mediastinum. Large-scale implementation is needed.

Rapid On-Site Evaluation Does Not Improve Endoscopic Ultrasound-Guided Fine Needle Aspiration Adequacy in Pancreatic Masses: A Meta-Analysis and Systematic Review

Background and Objectives

Rapid on-site evaluation (ROSE) during endoscopic ultrasonography-guided fine needle aspiration (EUS–FNA) of pancreatic masses has been reported to be associated with improved adequacy and diagnostic yield. However, recent observational data on the impact of ROSE have reported conflicting results. A meta-analysis and systematic review was therefore conducted to evaluate the contribution of ROSE during EUS-FNA of pancreatic masses.

Method

A systematic search was conducted in MEDLINE/Pubmed and EMBASE databases for studies comparing the efficacy of ROSE between patients in two cohorts. Outcomes considered included diagnostic adequate rate, diagnostic yield, number of needle passes, pooled sensitivity and specificity. Findings from a random-effects model were expressed as pooled risk difference (RD) with 95% confidence intervals (CIs).

Results

A total of 7 studies (1299 patients) was finally included and further analyzed in the current meta-analysis. EUS-FNA with ROSE could not improve diagnostic adequacy (RD = 0.05, 95% CI: -0.01–0.11) and diagnostic yield (RD = 0.04 95%CI: -0.05, 0.13). The number of needle passes showed no statistically significant difference with and without ROSE (RD = -0.68 95%CI: -2.35, 0.98). The pooled sensitivity and specificity of ROSE group were 0.91 (95%CI: 0.87, 0.94) and 1 (95%CI: 0.94, 1.00). The pooled sensitivity and specificity of non-ROSE group were 0.85 (95%CI: 0.80, 0.89) and 1 (95%CI: 0.95, 1.00). ROSE group and non-ROSE group showed comparable sensitivity and specificity.

Conclusion

Compared to historical reports of its clinical efficacy in patients with pancreatic lesions, ROSE may be not associated with an improvement of diagnostic yield, adequate rate, pooled sensitivity and specificity.

The impact of immunohistochemistry on the classification of lung tumors

INTRODUCTION

To highlight the role of immunohistochemistry to lung cancer classification on the basis of existing guidelines and future perspectives.

AREAS COVERED

Four orienting key-issues were structured according to an extensive review on the English literature: a) cancer subtyping; b) best biomarkers and rules to follow; c) negative and positive profiling; d) suggestions towards an evidence-based proposal for lung cancer subtyping. A sparing material approach based on a limited number of specific markers is highly desirable. It includes p40 for squamous cell carcinoma ('no p40, no squamous'), TTF1 for adenocarcinoma, synaptophysin for neuroendocrine tumors and vimentin for sarcomatoid carcinoma. A close relationship between genotype and phenotype also supports a diagnostic role for negative profiles. Expert commentary: Highly specific and sensitive IHC markers according to positive and negative diagnostic algorithms seem appropriate for individual patients' lung cancer subtyping.

Bispectral Index Monitoring Reduces the Dosage of Propofol and Adverse Events in Sedation for Endobronchial Ultrasound

BACKGROUND

Current guidelines recommend monitoring the anesthetic depth of sedation during respiratory endoscopy by using clinical scales despite their subjective nature and the potential change in the level of sedation caused by frequent stimulation. Monitoring by means of the bispectral index (BIS) has shown its utility in reducing the use of drugs and their adverse events in general anesthesia, but evidence in prolonged sedation is insufficient.

OBJECTIVE

Our objective was to evaluate BIS in patients undergoing endobronchial ultrasound (EBUS).

METHODS

A randomized cohort study of 90 patients with mediastinal lymph node involvement and/or lung or mediastinal lesions for whom EBUS was indicated, comparing the modified observer's assessment of alertness/sedation scale clinical evaluation (n = 45) versus the BIS evaluation (n = 45) of sedation with propofol-remifentanil, was conducted in order to evaluate the clinical parameters, doses used, adverse events, and tolerance of the procedure.

RESULTS

We found a shorter waking time and a significantly lower dose of total propofol in the BIS group. Significantly fewer overall adverse events were recorded in the BIS group and included desaturation, hypotension, and bradypnea. Tolerance was better in the BIS group. No significant differences were found in terms of cough, memory of the procedure, or the level of difficulty of EBUS on the part of the pulmonologists.

CONCLUSIONS

BIS monitoring of sedation in EBUS makes it possible to reduce the dosage of propofol, thereby shortening the waking time and reducing adverse events. This form of monitoring should be taken into consideration in the future for systematic use in prolonged sedation, as in the case of EBUS.

International association for the study of lung cancer map, Wang lymph node map and rapid on-site evaluation in transbronchial needle aspiration

The invaluable role of transbronchial needle aspiration (TBNA) in the diagnosis and staging of mediastinal adenopathy and lung cancer has been well established. Different lymph nodes regional nomenclatures and maps had been described over the years. The international association for the study of lung cancer (IASLC) and Wang's maps complement each other benefiting patients with lung cancer. In this article we briefly reviewed the roles of IALSC, Wang's maps and ROSE in TBNA.

Usefulness of Conventional Transbronchial Needle Aspiration for Sampling of Mediastinal Lymph Nodes in Lung Cancer

BACKGROUND

Transbronchial needle aspiration (TBNA) is recognized as a valuable tool for the sampling of mediastinal lymph nodes. In this study, we report data about the diagnostic yield of conventional TBNA in the diagnosis and staging of lung cancer.

METHODS

All patients with suspected lung cancer who underwent bronchoscopy with conventional TBNA in the years 2008 to 2012 were evaluated. TBNA was performed on mediastinal lymph nodes enlarged at chest computed tomography scan and/or with increased fluorodeoxyglucose uptake on positron emission tomography/computed tomography scan. Cytologic results derived from TBNA have been compared, with the final diagnosis obtained with other more invasive procedures and/or with a clinical-radiologic follow-up of at least 12 months.

RESULTS

TBNA was performed on 375 patients. However, 19 patients were lost to follow-up, and data from 356 patients with a total 459 TBNA specimens were analyzed. TBNA was positive for metastatic involvement of lymph nodes in 172 of 282 patients with cancer, with a sensitivity of 61%. Sensitivity achieved 65% when we considered the total of 459 TBNA specimens. The overall diagnostic accuracy of TBNA was 69%. The nodal stations more frequently examined were 7 (subcarinal: 190 TBNAs), 4R (right lower paratracheal: 147 TBNAs), and 10R (right hilar: 76 TBNAs), with a sensitivity of 66%, 66%, and 67%, respectively.

CONCLUSION

Conventional TBNA remains a useful method for the diagnosis and staging of lung cancer, with a good diagnostic yield in several nodal stations.

Utilization of ancillary studies in the cytologic diagnosis of respiratory lesions: The papanicolaou society of cytopathology consensus recommendations for respiratory cytology

The Papanicolaou Society of Cytopathology has developed a set of guidelines for respiratory cytology including indications for sputum examination, bronchial washings and brushings, CT-guided FNA and endobronchial ultrasound guided fine needle aspiration (EBUS-FNA), as well as recommendations for classification and criteria, ancillary testing and post-cytologic diagnosis management and follow-up. All recommendation documents are based on the expertise of committee members, an extensive literature review, and feedback from presentations at national and international conferences. The guideline documents selectively present the results of these discussions. The present document summarizes recommendations for ancillary testing of cytologic samples. Ancillary testing including microbiologic, immunocytochemical, flow cytometric, and molecular testing, including next-generation sequencing are discussed. Diagn. Cytopathol. 2016;44:1000-1009. © 2016 Wiley Periodicals, Inc.

Common Fluorescence In Situ Hybridization Applications in Cytology

Context.—

Fluorescence in situ hybridization (FISH) is a well-established method for detection of genomic aberrations in diagnostic, prognostic, and predictive marker testing.

Objective.—

To review common applications of FISH in cytology.

Data Sources.—

The published literature was reviewed.

Conclusions.—

Cytology is particularly well suited for all kinds of FISH applications, which is highlighted in respiratory tract cytology with an increasing demand for predictive FISH testing in lung cancer. Fluorescence in situ hybridization is the gold standard for detection of predictive anaplastic lymphoma kinase gene (ALK) rearrangements, and the same evaluation criteria as in histology apply to cytology. Several other gene rearrangements, including ROS proto-oncogene 1 receptor tyrosine kinase (ROS1), are becoming clinically important and share the same underlining cytogenetic mechanisms with ALK. MET amplification is one of the most common mechanisms of acquired resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors and can be targeted by crizotinib. As genomic aberrations are a hallmark of malignant cells, FISH is a valuable objective ancillary diagnostic tool. In urinary tract cytology, atypical urothelial cells equivocal for malignancy are a common diagnostic dilemma and multitarget FISH can help clarify such cells. Diagnosis of malignant mesothelioma remains one of the most challenging fields in effusion cytology, and ancillary FISH is useful in establishing the diagnosis. Fluorescence in situ hybridization is a morphology-based technique, and the prerequisite for reliable FISH results is a targeted evaluation of the cells in question (eg, cancer or atypical cells). Cytopathologists and cytotechnicians should therefore be involved in molecular testing in order to select the best material and to provide their morphologic expertise.

Usefulness of conventional transbronchial needle aspiration in the diagnosis, staging and molecular characterization of pulmonary neoplasias by thin-prep based cytology: experience of a single oncological institute

BACKGROUND

Conventional transbronchial needle aspiration (c-TBNA) contributed to improve the bronchoscopic examination, allowing to sample lesions located even outside the tracheo-bronchial tree and in the hilo-mediastinal district, both for diagnostic and staging purposes.

METHODS

We have evaluated the sensitivity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the c-TBNA performed during the 2005-2015 period for suspicious lung neoplasia and/or hilar and mediastinal lymphadenopathy at the Thoracic endoscopy of the Thoracic Surgery Department of the Regina Elena National Cancer Institute, Rome. Data from 273 consecutive patients (205 males and 68 females) were analyzed.

RESULTS

Among 158 (58%) adequate specimens, 112 (41%) were neoplastic or contained atypical cells, 46 (17%) were negative or not diagnostic. We considered in the analysis first the overall period; then we compared the findings of the first [2005-2011] and second period [2012-2015] and, finally, only those of adequate specimens. During the overall period, sensibility and accuracy values were respectively of 53% and 63%, in the first period they reached 41% and 53% respectively; in the second period sensibility and accuracy reached 60% and 68%. Considering only the adequate specimens, sensibility and accuracy during the overall period were respectively of 80% and 82%; the values obtained for the first period were 68% and 72%. Finally, in the second period, sensibility reached 86% and accuracy 89%. Carcinoma-subtyping was possible in 112 cases, adenocarcinomas being diagnosed in 50 cases; further, in 30 cases molecular predictive data could be obtained.

CONCLUSIONS

The c-TBNA proved to be an efficient method for the diagnosis/staging of lung neoplasms and for the diagnosis of mediastinal lymphadenopathy. Endoscopist's skill and technical development, associated to thin-prep cytology and to a rapid on site examination (ROSE), were able to provide by c-TBNA a high diagnostic yield and molecular predictive data in advanced lung carcinomas.

Endobronchial ultrasound in real life: primary diagnosis and mediastinal staging of lung cancer in patients submitted to thoracic surgery

BACKGROUND

Since the first articles published for over 10 years ago, endobronchial ultrasound (EBUS) has gained a strong scientific backing and has been incorporated into routine medical practice in pulmonology and thoracic surgery centers. How is EBUS performing outside the scientific environment, as a diagnostic and mediastinal staging tool in a subset of patients that undergo thoracic surgery, is an interesting question.

METHODS

This study evaluated consecutive patients who, during the period from January 2010 to August 2012, were submitted to EBUS and later to thoracic surgery. The samples obtained by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) were compared to surgical samples. The primary endpoint was the proportion of patients with a final diagnosis of non-small cell lung cancer (NSCLC) by EBUS-TBNA correctly subtyped. The secondary endpoint was the negative predictive value (NPV) of EBUS-TBNA for mediastinal staging of lung cancer.

RESULTS

Two hundred eighty seven patients were studied. Considering 84 patients with a final diagnosis of NSCLC by EBUS-TBNA, 79 % (CI 95 % 70.1-87.3) were correctly subclassified. The NPV of EBUS-TBNA for mediastinal staging was 89 % (IC 95 % 84.9-92.7). From a total of 21 false negative cases of mediastinal staging, 16 (76 %) did not undergo positron emission tomography-computed tomography (PET-CT) before the EBUS and in 15 (71 %) the affected lymph node chain was not punctured by EBUS-TBNA. Ten (47 %) patients had only lymph node metastases not directly accessible by the EBUS.

CONCLUSIONS

Performed in hospital routine and in patients submitted to thoracic surgery, EBUS-TBNA proved to be a good tool for proper pathological diagnosis of lung cancer. The negative predictive value of 89 % for mediastinal staging of lung cancer is comparable to that reported in previous studies, but the relatively high number of 21 false negative cases points to the need for standardization of routine strategies before, during and after EBUS.

Recent advances in endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for sampling of mediastinal and hilar lymph nodes as well as pulmonary lesions adjacent to the airway. Guidelines for staging of lung cancer suggest that EBUS-TBNA should be considered the best first test of nodal staging for radiologically abnormal lymph nodes that are accessible by this approach. The application of EBUS-TBNA in pulmonary medicine and thoracic oncology is expanding with its role in the diagnosis of sarcoidosis, lymphoma, and tuberculosis. Especially for patients with early-stage sarcoidosis with adenopathy and minimal changes in the lung parenchyma, EBUS-TBNA has a significantly higher diagnostic yield compared to the conventional bronchoscopic modalities. Multidirectional analysis of samples obtained by EBUS-TBNA has allowed assessment of lymphoma and molecular analysis in lung cancer. Histological evaluation with immunohistochemistry, flow cytometry, fluorescence in situ hybridization, and chromosome analysis can be performed if good-quality samples can be obtained. Molecular analyses such as identification of epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) fusion gene detection now are being performed routinely with good sampling. One of the advantages of EBUS-TBNA is the ability to perform repeat procedures in a minimally invasive way. Restaging of the mediastinum after induction therapy can be done safely and with ease compared to repeat surgical procedures. With improvement in molecular analysis technology, comprehensive gene expression analysis will become important in the management of patients with lung cancer. Further advances in EBUS technology and needles for tissue sampling likely will help bronchoscopists to acquire ideal tissue.

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.

Transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis

Fluoroscopy-guided transbronchial needle aspiration (TBNA) has long been used in the diagnosis of peripheral pulmonary lesions (PPLs), although its diagnostic performance varies considerably.We conducted a systematic review and meta-analysis evaluating the accuracy of TBNA in the diagnosis of PPLs, comparing its diagnostic yield with transbronchial biopsy (TBB) and assessing the main predictors of a successful aspirate.In 18 studies, the overall TBNA yield was 0.53 (95% CI 0.44-0.61). TBNA showed a higher accuracy when directly compared to TBB (0.60 (95% CI 0.49-0.71) versus 0.45 (95% CI 0.37-0.54)). The subgroup analyses documented a higher TBNA yield when the computed tomography (CT) bronchus sign was present (0.70 (95% CI 0.63-0.77) versus 0.51 (95% CI 0.38-0.64)), when rapid on-site evaluation (ROSE) was performed (0.62 (95% CI 0.43-0.79) versus 0.51 (95% CI 0.42-0.60)), in the case of malignant lesions (0.55 (95% CI 0.44-0.66) versus 0.17 (95% CI 0.11-0.24)) and for lesions >3 cm (0.81 (95% CI 0.73-0.87) versus 0.55 (95% CI 0.47-0.63)).Conventional TBNA is a useful sampling technique for the diagnosis of PPL, with a higher diagnostic yield than TBB. The presence of CT bronchus sign, an underlying malignant process, lesion size >3 cm and ROSE employment are predictors of a higher yield.

Convex probe EBUS for centrally located parenchymal lesions without a bronchus sign

BACKGROUND

Convex probe endobronchial ultrasound (CP-EBUS) has proven safe and accurate for identifying malignancy and granulomatous disease affecting the mediastinum and hilum. For the diagnosis of parenchymal lung lesions, conventional techniques such as transbronchial biopsy, brush and lavage are useful, particularly when an airway leads directly to the lesion. For centrally located intraparenchymal lesions, CP-EBUS has been shown to be efficacious.

OBJECTIVE

To expand on the existing literature in an effort to highlight the important diagnostic role of CP-EBUS in centrally located lesions, particularly those without a bronchus sign.

METHODS

In our cohort of 430 patients undergoing CP-EBUS between 03/2009-03/2012, we retrospectively identified 32 who underwent transbronchial needle aspiration (TBNA) of a centrally located parenchymal lung lesion. All lesions were completely surrounded by lung parenchyma and not visualized during white light bronchoscopy. Diagnostic yield was determined and compared to conventional bronchoscopic biopsy techniques, when performed.

RESULTS

The mean lesion size was 25.6 mm and 24/32 (75%) lesions were located in the lower lobes. A definitive diagnosis was obtained in 27/32 (84.4%) of parenchymal lesions without a bronchus sign biopsied using CP-EBUS. CP-EBUS provided the exclusive method of diagnosis in 15/32 (46.9%) patients in this cohort. Most lesions (26/32) were diagnosed as non-small cell carcinoma. There were no procedural complications.

CONCLUSION

CP-EBUS is useful for diagnosing parenchymal lung abnormalities without a bronchus sign, extending its scope beyond mediastinal and hilar lymph nodes. It is imperative that physicians performing EBUS maintain this tool as a complement to conventional bronchoscopic techniques.

Endobronchial Ultrasound-Guided Cautery-Assisted Transbronchial Forceps Biopsies: Safety and Sensitivity Relative to Transbronchial Needle Aspiration

BACKGROUND

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is important in the evaluation of thoracic lymphadenopathy. Reliably providing excellent diagnostic yield for malignancy, its diagnosis of sarcoidosis is inconsistent. Furthermore, TBNA may not suffice when larger "core biopsy" samples of malignant tissue are required. The primary objective of this study was to determine if the sequential use of TBNA and a novel technique called cautery-assisted transbronchial forceps biopsy (ca-TBFB) was safe. Secondary outcomes included sensitivity and successful acquisition of tissue.

METHODS

The study prospectively enrolled 50 unselected patients undergoing convex-probe EBUS. All lymph nodes exceeding 1 cm were sequentially biopsied under EBUS guidance using TBNA and ca-TBFB. Safety and sensitivity were assessed at the nodal level for 111 nodes. Results of each technique were also reported for each patient.

RESULTS

There were no significant adverse events. In nodes determined to be malignant, TBNA provided higher sensitivity (100%) than ca-TBFB (78%). However, among nodes with granulomatous inflammation, ca-TBFB exhibited higher sensitivity (90%) than TBNA (33%). On the one hand, for analysis based on patients rather than nodes, 6 of the 31 patients with malignancy would have been missed or understaged if the diagnosis were based on samples obtained by ca-TBFB. On the other hand, 3 of 8 patients with sarcoidosis would have been missed if analysis were based only on TBNA samples. In some patients, only ca-TBFB acquired sufficient tissue for the core samples needed in clinical trials of malignancy.

CONCLUSIONS

The sequential use of TBNA and ca-TBFB appears to be safe. The larger samples obtained from ca-TBFB increased its sensitivity to detect granulomatous disease and provided adequate specimens for clinical trials of malignancy when specimens from needle biopsies were insufficient. For thoracic surgeons and advanced bronchoscopists, we advocate ca-TBFB as an alternative to TBNA in select clinical scenarios.

Systematic Endobronchial Ultrasound-guided Mediastinal Staging Versus Positron Emission Tomography for Comprehensive Mediastinal Staging in NSCLC Before Radical Radiotherapy of Non-small Cell Lung Cancer: A Pilot Study

Despite known limitations of positron emission tomography (PET) for mediastinal staging of non-small cell lung cancer (NSCLC), radiation treatment fields are generally based on PET-identified disease extent. However, no studies have examined the accuracy of FDG-PET/CT on a per-node basis in patients being considered for curative-intent radiotherapy in NSCLC.In a prospective trial, patients with NSCLC being considered for definitive thoracic radiotherapy (± systemic chemotherapy) underwent minimally invasive systematic mediastinal evaluation with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) following noninvasive staging with integrated PET-CT.Thirty patients underwent EBUS-TBNA, with TBNA performed from a mean 2.5 lymph node (LN) stations per patient (median 3, range 1-5). Discordant findings between PET-CT and EBUS-TBNA were observed in 10 patients (33%, 95% CI 19%-51%). PET-occult LN metastases were demonstrated by EBUS in 4 patients, whereas a lesser extent of mediastinal involvement, compared with FDG-PET, was demonstrated by EBUS in 6 patients, including 2 patients downstaged from cN3 to pN2. LNs upstaged by EBUS were significantly smaller than nodes downstaged by EBUS, 7.5 mm (range 7-9) versus 12 mm (range 6-21), P = 0.005.A significant proportion of patients considered for definitive radiotherapy (+/-chemotherapy) undergoing systematic mediastinal evaluation with EBUS-TBNA in this study have an extent of mediastinal NSCLC involvement discordant with that indicated by PET-CT. Systematic EBUS-TBNA may aid in defining the extent of mediastinal involvement in NSCLC patients undergoing radiotherapy. Systematic EBUS-TBNA has the potential to contribute significantly to radiotherapy planning and delivery, by either identifying occult nodal metastases, or demonstrating FDG-avid LNs to be disease-free.

Endobronchial ultrasound elastography: a new method in endobronchial ultrasound-guided transbronchial needle aspiration

BACKGROUND

TBNA through the flexible bronchoscope is a 37-year-old technology that utilizes a TBNA needle to puncture the bronchial wall and obtain specimens of peribronchial and mediastinal lesions through the flexible bronchoscope for the diagnosis of benign and malignant diseases in the mediastinum and lung.

METHODS

Since 2002, the Olympus Company developed the first generation ultrasound equipment for use in the airway, initially utilizing an ultrasound probe introduced through the working channel followed by incoroporation of a fixed linear ultrasound array at the distal tip of the bronchoscope. This new bronchoscope equipped with a convex type ultrasound probe on the tip was subsequently introduced into clinical practice. The convex probe (CP)-EBUS allows real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of mediastinal and hilar lymph nodes. EBUS-TBNA is a minimally invasive procedure performed under local anesthesia that has been shown to have a high sensitivity and diagnostic yield for lymph node staging of lung cancer.

RESULTS

In 10 years of EBUS development, the Olympus Company developed the second generation EBUS bronchoscope (BF-UC260FW) with the ultrasound image processor (EU-M1), and in 2013 introduced a new ultrasound image processor (EU-M2) into clinical practice. FUJI company has also developed a curvilinear array endobronchial ultrasound bronchoscope (EB-530 US) that makes it easier for the operator to master the operation of the ultrasonic bronchoscope. Also, the new thin convex probe endobronchial ultrasound bronchoscope (TCP-EBUS) is able to visualize one to three bifurcations distal to the current CP-EBUS.

CONCLUSIONS

The emergence of EBUS-TBNA has also been accompanied by innovation in EBUS instruments. EBUS elastography is, then, a new technique for describing the compliance of structures during EBUS, which may be of use in the determination of metastasis to the mediastinal and hilar lymph nodes. This article describes these new EBUS techniques and reviews the relevant literature.

Randomized Trial of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration With and Without Rapid On-site Evaluation for Lung Cancer Genotyping

BACKGROUND

Experts and scientific society guidelines recommend that rapid on-site evaluation (ROSE) be used with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to optimize lung cancer genotyping, but no comparative trial has been carried out to confirm and quantify its usefulness.

METHODS

To assess the influence of ROSE on the yield of EBUS-TBNA for a multigene molecular analysis of lung cancer samples, consecutive patients with suspected or known advanced lung cancer were randomized to undergo EBUS-TBNA without ROSE (EBUS arm) or with ROSE (ROSE arm). The primary end point was the rate of the successful accomplishment of the institution's clinical protocol for molecular profiling of nonsquamous non-small cell lung cancer (EGFR and KRAS testing, followed by ALK testing for tumors with EGFR and KRAS wild-type status).

RESULTS

Complete genotyping was achieved in 108 of 126 patients (85.7%) (90.8% in the ROSE arm vs 80.3% in the EBUS arm, P = .09). The patients in the ROSE arm were less likely to have samples that could be used only for pathologic diagnosis because of minimal tumor burden (0 vs 6, P = .05), and were more likely to have the bronchoscopy terminated after a single biopsy site (58.9% vs 44.1%, P = .01).

CONCLUSIONS

ROSE prevents the need for a repeat invasive diagnostic procedure aimed at molecular profiling in at least one out of 10 patients with advanced lung cancer and significantly reduces the risk of retrieving samples that can be used only for pathologic subtyping because of minimal tumor burden.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01799382; URL: www.clinicaltrials.gov.

Ten Years of Linear Endobronchial Ultrasound: Evidence of Efficacy, Safety and Cost-effectiveness

Real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is one of the major landmarks in the history of bronchoscopy. In the 10 years since it was introduced, a vast body of literature on the procedure and its results support the use of this technique in the study of various mediastinal and pulmonary lesions. This article is a comprehensive, systematic review of all the available scientific evidence on the more general indications for this technique. Results of specific studies on efficacy, safety and cost-effectiveness available to date are examined. The analysis shows that EBUS-TBNA is a safe, cost-effective technique with a high grade of evidence that is a valuable tool in the diagnosis and mediastinal staging of patients with suspected or confirmed lung cancer. However, more studies are needed to guide decision-making in the case of a negative result. Evidence on the role of EBUS-TBNA in the diagnosis of sarcoidosis and extrathoracic malignancies is also high, but much lower when used in the study of tuberculosis, lymphoma and for the re-staging of lung cancer after neoadjuvant chemotherapy. Nevertheless, due to its good safety record and lack of invasiveness compared to surgical techniques, the grade of evidence for recommending EBUS-TBNA as the initial diagnostic test in patients with these diseases is very high in most cases.

Ultrasound techniques in the evaluation of the mediastinum, part I: endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS) and transcutaneous mediastinal ultrasound (TMUS), introduction into ultrasound techniques

Ultrasound imaging has gained importance in pulmonary medicine over the last decades including conventional transcutaneous ultrasound (TUS), endoscopic ultrasound (EUS), and endobronchial ultrasound (EBUS). Mediastinal lymph node staging affects the management of patients with both operable and inoperable lung cancer (e.g., surgery vs. combined chemoradiation therapy). Tissue sampling is often indicated for accurate nodal staging. Recent international lung cancer staging guidelines clearly state that endosonography (EUS and EBUS) should be the initial tissue sampling test over surgical staging. Mediastinal nodes can be sampled from the airways [EBUS combined with transbronchial needle aspiration (EBUS-TBNA)] or the esophagus [EUS fine needle aspiration (EUS-FNA)]. EBUS and EUS have a complementary diagnostic yield and in combination virtually all mediastinal lymph nodes can be biopsied. Additionally endosonography has an excellent yield in assessing granulomas in patients suspected of sarcoidosis. The aim of this review, in two integrative parts, is to discuss the current role and future perspectives of all ultrasound techniques available for the evaluation of mediastinal lymphadenopathy and mediastinal staging of lung cancer. A specific emphasis will be on learning mediastinal endosonography. Part I is dealing with an introduction into ultrasound techniques, mediastinal lymph node anatomy and diagnostic reach of ultrasound techniques and part II with the clinical work up of neoplastic and inflammatory mediastinal lymphadenopathy using ultrasound techniques and how to learn mediastinal endosonography.

Lung cancer diagnosis and staging in the minimally invasive age with increasing demands for tissue analysis

The diagnosis and staging of patients with lung cancer in recent decades has increasingly relied on minimally invasive tissue sampling techniques, such as endobronchial ultrasound (EBUS) or endoscopic ultrasound (EUS) needle aspiration, transbronchial biopsy, and transthoracic image guided core needle biopsy. These modalities have been shown to have low complication rates, and provide adequate cellular material for pathologic diagnosis and necessary ancillary molecular testing. As an important component to a multidisciplinary team approach in the care of patients with lung cancer, these minimally invasive modalities have proven invaluable for the rapid and safe acquisition of tissue used for the diagnosis, staging, and molecular testing of tumors to identify the best evidence-based treatment plan. The continuous evolution of the field of lung cancer staging and treatment has translated into improvements in survival and quality of life for patients. Although differences in clinical practice between academic and community hospital settings still exist, improvements in physician education and training as well as adoption of technological advancements should help narrow this gap going forward.

Comparison of 19-gauge eXcelon and WANG MW-319 transbronchial aspiration needles

Conventional transbronchial needle aspiration (TBNA) using 19‐gauge needles can obtain larger histological specimens for hilar‐mediastinal diagnosis. A new 19‐gauge eXcelon needle was introduced in Taiwan in July 2012. We prospectively enrolled patients with hilar‐mediastinal lesions and pathology results of suspected benign origin or lymphoproliferative processes, to perform TBNA using a 19‐gauge eXcelon needle, between July 2012 and December 2012. The results were compared with historical control of TBNA using a WANG MW‐319 needle between January 2011 and June 2012. The procedure was performed by the same pulmonologist, and rapid on‐site cytologic evaluation was used. The 19‐gauge eXcelon needle was used in nine patients with 15 lymph nodes aspirated, with a mean diameter of 23.3 ± 10.7 mm. The mean number of needle passes was 2.7 ± 1.4, with a diagnostic accuracy of 77.8%. The MW‐319 needle was used in 12 patients with 18 lymph nodes aspirated, with a mean diameter of 21.3 ± 5.7 mm. The mean number of needle passes was 2.2 ± 0.4, with a diagnostic accuracy of 75.0%. Neither technical nor major clinical complications were noted in either group. We concluded that the 19‐gauge eXcelon needle was as safe and effective as the MW‐319 needle. A more adequate specimen could be obtained and fewer needle passes were required with the MW‐319 needle, although the difference did not reach significance.

Classification of different patterns of pulmonary adenocarcinomas

The epidemic increase of adenocarcinoma histology accounting for more than 50% of primary lung malignancies and the advent of effective molecular targeted-therapies against specific gene alterations characterizing this tumor type have led to the reconsideration of the pathologic classification of lung cancer. The new 2015 WHO classification provided the basis for a multidisciplinary approach emphasizing the close correlation among clinical, radiologic and molecular characteristics and histopathologic pattern of lung adenocarcinoma. The terms 'bronchioloalveolar carcinoma' and 'mixed adenocarcinoma' have been eliminated, introducing the concepts of 'adenocarcinoma in situ', 'minimally invasive adenocarcinoma' and the use of descriptive predominant patterns in invasive adenocarcinomas (lepidic, acinar, papillary, solid and micropapillary patterns). 'Invasive mucinous adenocarcinoma' is the new definition for mucinous bronchioloalveolar carcinoma, and some variants of invasive adenocarcinoma have been included, namely colloid, enteric and fetal-type adenocarcinomas. A concise update of the immunomorphologic, radiological and molecular characteristics of the different histologic patterns of lung adenocarcinoma is reported here.