Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer

Restaging after induction therapy for non-small-cell lung cancer

SUMMARY Select patients with stage IIIa-N2 non-small-cell lung cancer will benefit from treatment with induction chemoradiotherapy followed by surgical resection. The identification of patients with residual N2 disease may allow for selection of those patients most likely to benefit from resection. The optimal strategy for restaging of mediastinal lymph nodes following induction therapy is controversial. Noninvasive, imaging-based strategies are largely ineffective. Minimally invasive approaches such as endobronchial ultrasound-transbronchial needle aspiration and endoscopic ultrasound-guided fine needle aspiration may identify residual nodal disease, but require surgical confirmation of negative results. Repeat mediastinoscopy may be effective at centers that specialize in this technique, but in the authors opinion its use cannot be broadly recommended. A thoughtful and minimally invasive approach to initial staging of N2 nodes is recommended, reserving mediastinoscopy for restaging whenever possible.

The importance of a satisfactory biopsy for the diagnosis of lung cancer in the era of personalized treatment

Advances in molecular biology are improving the understanding of lung cancer and changing the approach to treatment. A satisfactory biopsy that allows for histologic characterization and mutation analysis is becoming increasingly important. Most patients with lung cancer are diagnosed at an advanced stage, and diagnosis is often based on a small biopsy or cytology specimen. Here, we review the techniques available for making a diagnosis of lung cancer, including bronchoscopy, ultrasound-guided bronchoscopy, mediastinoscopy, transthoracic needle aspiration, thoracentesis, and medical thoracoscopy. We also discuss the indications, complications, and tissue yields of those techniques, especially as they pertain to testing for molecular markers.

[Role of endoscopic ultrasound (EUS) and endobronchial ultrasound (EBUS) for the evaluation of mediastinal adenopathy]

Mediastinal lymphadenopathy may be detected by CT-scan or positron emission tomography. Malignant (e.g, lung cancer, metastatic cancer, lymphoma), infectious (e.g, tuberculosis, histoplasmosis), and systemic processes (e.g, sarcoidosis) can cause mediastinal adenopathy. In the posterior and inferior mediastinum, endoscopic ultrasound visualizes and directs transesophageal fine needle aspiration of adenopathy. In the anterior mediastinum, endobronchial ultrasound visualizes and directs transbronchial fine needle aspiration of adenopathy. We discuss the role of EUS and EBUS in the evaluation of mediastinal adenopathy according to their anatomical localization.

Mediastinal re-staging of non small-cell lung cancer

Selected patients with non small-cell lung cancer (NSCLC) with mediastinal lymph node involvement may have a survival benefit from surgical resection, particularly if mediastinal nodal down-staging occurs after induction therapy and complete resection is achieved with lobectomy. Accurate re-staging of the mediastinum after induction therapy is therefore crucial in determining prognosis and subsequent treatment. Non-invasive imaging techniques usually require a confirmatory tissue sampling method to improve the accuracy of mediastinal re-staging. As in the initial staging of the mediastinum, minimally invasive endosonography-guided needle sampling techniques such as endobronchial ultrasound-guided fine-needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine-needle aspiration show promise in re-staging the mediastinum, though invasive surgical re-staging remains the gold standard. Despite a lower sensitivity in the mediastinal re-staging of NSCLC, EBUS-TBNA with or without EUS-FNA may still be the preferred initial mediastinal re-staging technique.

Update on interventional bronchoscopy for the thoracic radiologist

Interventional bronchoscopy, together with other domains of interventional pulmonology, has experienced tremendous technological advances. Diagnostic applications include endobronchial ultrasound, which enables endoscopists to see through airway walls. White light videobronchoscopy, autofluorescence imaging, and narrow band imaging have enhanced the ability to detect early lung cancer at a preinvasive stage. Electromagnetic navigational bronchoscopy, ultrathin bronchoscopy, and virtual bronchoscopy increase the diagnostic yield of biopsy of small peripheral lung lesions. The options that are currently available for the relief of central airway obstruction are also numerous, with both flexible and rigid bronchoscopic applications. Stents, although dichotomized to silicone and metal, come in various sizes and shapes to suit the requirements of the pathology being treated. Ablative techniques are categorized into those with an immediate effect and those with a delayed effect. Laser, electrocautery, and argon plasma coagulation can immediately relieve obstruction and control hemoptysis, whereas cryosurgery, brachytherapy, and photodynamic therapy have established roles in subacute airway obstruction and in the treatment of early lung cancer. Microdebriders have recently been added to the armamentarium of modalities for mechanical debulking of tumor. Distal airway obstruction has also been targeted with bronchial thermoplasty treatment of refractory asthma and with bronchoscopic lung volume reduction for the management of severe emphysema. This array of new technology has fostered collaborative work with a wide range of other medical specialties to deliver safer, more effective, minimally invasive treatment.

Video-assisted mediastinoscopic lymphadenectomy and transcervical extended mediastinal lymphadenectomy

This article describes in detail the operative technique of the new surgical methods, video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA). Both techniques enable the removal of the mediastinal nodes with the surrounding fatty tissue. VAMLA and TEMLA have very high diagnostic yield and can be combined with minimally invasive video-assisted lobectomy.

Endobronchial ultrasonography with a guide sheath in the diagnosis of benign peripheral diseases

BACKGROUND

For appropriate treatment, such as the selection of antibiotics or initiation of steroid therapy, correctly diagnosing benign pulmonary diseases located at the periphery is vital. This study assessed the usefulness of bronchoscopy using endobronchial ultrasonography with a guide sheath (EBUS-GS) in the diagnosis of benign pulmonary diseases, especially those presenting peripheral nodular lesions.

METHODS

We retrospectively reviewed 159 patients with 171 peripheral pulmonary lesions (PPLs) that were subsequently diagnosed as benign diseases. To examine the role of bronchoscopy with EBUS-GS, the contribution of bronchoscopy was classified into 4 categories. We also retrospectively reviewed 24 patients with 25 PPLs that were subsequently diagnosed as benign diseases by bronchoscopy without EBUS-GS (historical control).

RESULTS

The ultimate diagnosis of 171 PPLs included 45 cases of mycobacteriosis, 45 cases of bronchiolitis obliterans organizing pneumonia/chronic organized pneumonia (BOOP), 23 cases of bacterial pneumonia, 13 abscesses, 11 cases of sarcoidosis, and 34 other benign diseases. Among them, a definitive diagnosis was obtained by bronchoscopy with EBUS-GS in 99 lesions (58%). Lesions in which the probe was positioned within the lesion had a higher diagnostic yield (64%) than did lesions in which the probe was positioned adjacent to the lesion (52%) or outside the lesion (20%; P=0.01). The diagnostic yield of bronchoscopy with EBUS-GS was higher compared with that of the historical control (58% versus 28%; P=0.04).

CONCLUSIONS

Bronchoscopy using EBUS-GS is a reasonable option as a diagnostic procedure for PPLs, even if they are suspected to be benign in nature.

Transesophageal ultrasound-guided fine-needle aspiration for the mediastinal restaging of non-small cell lung cancer

INTRODUCTION

Selected patients with stage III (N2/N3) non-small cell lung cancer (NSCLC) who are downstaged to N0 by chemoradiation therapy might benefit from subsequent surgical resection of the tumor. How mediastinal lymph nodes can be best reevaluated is subject of debate. Transesophageal ultrasound-guided fine-needle aspiration (EUS-FNA) is a minimally invasive technique to sample mediastinal nodes. We assessed sensitivity and false-negative rate of EUS-FNA for the mediastinal restaging of patients with stage III NSCLC.

METHODS

Fifty-eight consecutive patients with stage III NSCLC and tissue-proven lymph node metastases N2/N3) who underwent EUS-FNA for restaging purposes after chemoradiation therapy were retrospectively analyzed. Surgical-pathological staging was used as the reference standard for nodal metastases.

RESULTS

EUS-FNA found persistent nodal metastases (N2/N3) in 15 patients (26%). Of the 43 patients without persistent mediastinal metastases at EUS, 33 patients subsequently underwent surgical verification of the mediastinal nodes in whom persistent metastases (yN2/N3) were found in 19 patients (58%), and loco-regional downstaging (yN0) was achieved in the other 14 (42%). The prevalence of persistent nodal metastases in the 48 patients who could be analyzed was 71%. Sensitivity and the false-negative rate of EUS-FNA for mediastinal restaging were 44 and 58%, respectively.

DISCUSSION

For mediastinal restaging of stage III NSCLC, EUS-FNA is a minimally invasive and safe method to confirm persistent nodal metastases, but this technique has a low negative predictive value and is therefore not useful for the exclusion of mediastinal metastases. Surgical restaging is indicated in the absence of mediastinal metastases at EUS-FNA.

Significance of a new fluorodeoxyglucose-positive lesion on restaging positron emission tomography/computed tomography after induction therapy for non-small-cell lung cancer

OBJECTIVES

Restaging of patients with locally advanced non-small-cell lung cancer (NSCLC) is of paramount importance, since only patients with down-staging after induction therapy will benefit from surgery. In this study, we assessed the aetiology of new (18)fluoro-2-deoxy-d-glucose (FDG)-positive focal abnormalities on restaging positron emission tomography/computed tomography (PET/CT) in patients with a good response after induction chemotherapy in the primary tumour and lymph nodes.

METHODS

Between 2004 and 2008, 31 patients with histological proven stage III NSCLC had a PET/CT prior and after induction chemotherapy. Their medical charts were retrospectively reviewed.

RESULTS

Restaging PET/CT revealed a new FDG-positive lesion in 6 of 31 (20%) patients. The initial clinical stage of the disease was IIIA N2 in four and IIIB T4 in two patients. The maximal standard uptake value in the primary tumour (P = 0.043) and in the initially involved mediastinal nodes (P = 0.068) decreased after induction treatment in all patients. The new PET/CT findings were located in an ipsilateral cervical lymph node in two patients, a contralateral mediastinal in one patient and an ipsilateral mammary internal lymph node in one patient. Two other patients had a lesion on the contralateral lung. Malignant lymph node infiltrations were excluded following fine-needle puncture, intraoperative biopsy or follow-up PET/CT. Contralateral pulmonary lesions were diagnosed as benign following mini thoracotomy and pulmonary wedge resection.

CONCLUSIONS

New solitary FDG-positive lesions on restaging PET/CT after induction chemotherapy for NSCLC are not rare in good responders to chemotherapy. In our experience, all these lesions were not associated with malignancy.

Induction therapy for lung cancer: sailing across the pillars of Hercules

In spite of numerous clinical trials, the jury is still out on the value of induction therapy for locally advanced lung cancer. We elected to address this topic from the multifaceted views of the clinicians often involved in lung cancer management and according the most recent views on locally advanced NSCLC. The concept of a prognostic stratification of N2 disease subsets, especially single vs multiple zone, has been introduced and this may lead to a new interpretation of locally advanced NSCLC. Ten crucial issues were identified that may have an impact on the approach to patients with locally advanced lung cancer in everyday practice.

[Indications for surgery in non-small cell lung cancer with lymph node invasion]

Surgery is indicated for N1 non-small cell lung cancer and performed, with good results in some patients, when N2 disease is not diagnosed preoperatively "minimal N2". Following the publication of the "EORTC 08941" and "Intergroup 0139" trials, it remains debatable for patients with proven N2 disease. Good prognostic factors before treatment or post-induction favour surgery, which seems superior to radiochemotherapy if the operative risk is low (lobectomies, and some pneumonectomies). N3 status is a contraindication to surgery, except in some rare cases with a strong response to induction treatment.

Usefulness of endobronchial ultrasound in patients with previously treated thoracic malignancy

Diagnosis of mediastinal/hilar lymph nodes and tumours is often challenging for patients with previously treated thoracic malignancy, especially when they have a history of thoracotomy. Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has been proposed as a safe, less-invasive modality for such patients. We retrospectively evaluated the role of EBUS-TBNA in the assessment of newly developed mediastinal/hilar abnormalities in patients with previously treated thoracic malignancy. Of 79 patients who underwent EBUS-TBNA between July 2009 and July 2011, 14 patients (18%) had a history of treatment for thoracic malignancy. In all patients, malignancy was confirmed again for the newly developed mediastinal/hilar abnormalities and three of them (21%) presented with a different pathology from the previous malignancy. Out of 14 patients, 12 had a history of thoracotomy and EBUS-TBNA was a useful, less-invasive diagnostic method particularly for these patients. Out of 14 patients, 11 (79%) had a history of lung cancer and 10 of them (91%) had received surgical resection. In conclusion, we confirmed that EBUS-TBNA obtained the pathological diagnosis in a less-invasive manner in all cases. Despite the small number of cases, our results can reveal the usefulness of EBUS-TBNA particularly in patients with previously treated thoracic malignancy.

Scientific evidence and principles for the use of endobronchial ultrasound and transbronchial needle aspiration

Endobronchial ultrasound (EBUS), using the radial EBUS probe and convex-probe EBUS-guided transbronchial needle aspiration, are increasingly advocated for a wide array of minimally invasive thoracic procedures. The effectiveness of EBUS-guided procedures has been demonstrated to a degree that, in many institutions, EBUS is becoming standard of practice for the diagnosis, staging and restaging of mediastinal lymphadenopathy in lung cancer, the diagnosis of sarcoidosis, and for bronchoscopic biopsy of peripheral lung lesions. Its role in other bronchoscopic procedures requires further study despite an already strong body of literature: diagnosis of lymphoma and benign infectious disease, diagnosis of early lung cancer and airway wall disorders, imaging of thoracic vascular disease such as pulmonary embolism, and therapeutic procedures such as placement of fiducial markers. In this article, we illustrate some of the principles of EBUS, describe major technical aspects pertaining to the procedure itself and provide a narrative review of original research addressing proposed roles of EBUS in a variety of indications. In closing, we describe future perspectives including new educational processes and philosophies that could favorably impact the rapid and safe dissemination of this evolving technology into clinical practice.

A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer

OBJECTIVE

The study objective was to compare endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) with mediastinoscopy for mediastinal lymph node staging of potentially resectable non-small cell lung cancer.

METHODS

Patients with confirmed or suspected non-small cell lung cancer who required mediastinoscopy to determine suitability for lung cancer resection were entered into the trial. All patients underwent EBUS-TBNA followed by mediastinoscopy under general anesthesia. If both were negative for N2 or N3 disease, the patient underwent pulmonary resection and mediastinal lymphadenectomy.

RESULTS

Between July 2006 and August 2010, 190 patients were registered in the study, 159 enrolled, and 153 were eligible for analysis. EBUS-TBNA and mediastinoscopy sampled an average of 3 and 4 lymph node stations per patient, respectively. The mean short axis of the lymph node biopsied by EBUS-TBNA was 6.9 ± 2.9 mm. The prevalence of N2/N3 disease was 35% (53/153). There was excellent agreement between EBUS-TBNA and mediastinoscopy for mediastinal staging in 136 patients (91%; Kappa, 0.8; 95% confidence interval, 0.7-0.9). Specificity and positive predictive value for both techniques were 100%. The sensitivity, negative predictive value, and diagnostic accuracy for mediastinal lymph node staging for EBUS-TBNA and mediastinoscopy were 81%, 91%, 93%, and 79%, 90%, 93%, respectively. No significant differences were found between EBUS-TBNA and mediastinoscopy in determining the true pathologic N stage (McNemar's test, P = .78). There were no complications from EBUS-TBNA. Minor complications from mediastinoscopy were observed in 4 patients (2.6%).

CONCLUSIONS

EBUS-TBNA and mediastinoscopy achieve similar results for the mediastinal staging of lung cancer. As performed in this study, EBUS-TBNA can replace mediastinoscopy in patients with potentially resectable non-small cell lung cancer.

SEPAR guidelines for lung cancer staging

The latest tumour, lymph node and metastasis (TNM) classification by the International Association for the Study of Lung Cancer (IASLC), based on the analysis of patients from all over the world, has incorporated changes in the descriptors, especially those regarding tumor size, while proposing new group staging. A new lymph node map has also been developed with the intention of facilitating the classification of the "N" component. SEPAR recommends using this new classification. As for the procedures recommended for staging, in addition to the generalized use of computed tomography (CT), it points to the role of positron emission tomography (PET) or image fusion methods (PET/CT), which provide a better evaluation of the mediastinum and extrathoracic metastases. Endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for obtaining cytohistological samples have been incorporated in the staging algorithm, and it emphasizes the importance of precise re-staging after induction treatment in order to make new therapeutic decisions. Comment is made on the foreseeable incorporation in the near future of molecular staging, and systematic lymph node dissection is recommended with the intention of making a more exact surgical-pathological classification.

Role of surgery for stage IIIA-N2 non-small cell lung cancer

Perhaps no topic other than stage IIIA-N2 non-small-cell lung cancer management is as controversial among surgeons, radiologists and medical oncologists. Much of the debate relates to the choice between surgical resection and radiation as the local control modality. Although limited, available evidence from randomized controlled trails raised concerns about the role of surgical resection. However, there is no perfect study, and the results should not be over-interpreted. This mini review will scrutinize these trials, focusing on the study design, results and, most importantly, limitations, and will explore the possible role of surgery for stage IIIA-N2 non-small-cell lung cancer.

[New endoscopic ultrasound (EUS) applications in lung cancer: evaluation of patients with negative mediastinal CT and re-staging after neoadjuvant treatment]

The main purpose of staging in non-small cell lung cancer (NSCLC) is to assess mediastinal lymph node involvement, with thoracic CT being the main non-invasive test for this. However, given that up to 15% of patients who show no mediastinal lymph node involvement in the CT have lymph node metastasis during surgery, other examinations are required. Endoscopic ultrasonography guided fine-needle aspiration (EUS-FNA) has shown to be able to detect advanced disease (metastatic mediastinal lymph nodes, adrenal metastasis, mediastinal invasion by the tumour) in approximately 25% of patients with a CT that suggested a non-advanced disease. Another situation in which CT has a very limited value is in the evaluation of the response to induction therapy, with its most limiting factor being its intrinsic inability to distinguish between a tumour and necrosis. In this context, EUS-FNA has shown to have a good performance, with a sensitivity, negative predictive value and precision of 75%, 67% and 83%, respectively. In conclusion, EUS-FNA may be considered a good alternative in the pre-operative staging of patients with NSCLC, with and without diseased mediastinal lymph nodes in CT, and could play an important role in the mediastinal re-staging of these patients by identifying a patient sub-group who might benefit from additional surgical treatment.

Endobronchial ultrasound: A new innovation in bronchoscopy

Technical development in last two decades has made it possible for pulmonologists to do endobronchial ultrasound (EBUS). With EBUS mini-probe, the multilayered structure of the tracheobronchial wall can be analyzed better than any other imaging modality. Instead of fluoroscopic guided biopsy, EBUS can be used to biopsy peripheral lesions. EBUS-transbronchial needle aspiration has proved valuable for mediastinal lymph node staging of lung cancer. Studies have shown that EBUS is cost-effective as it reduces the need for more morbid and costly invasive procedure like mediastinoscopy or thoracotomy. Prospective studies are needed in India to see how EBUS will help in populations with high prevalence of tuberculosis.

EBUS-TBNA in mediastinal/hilar lymphadenopathies and/or masses: an Italian case series

INTRODUCTION

Transbronchial needle aspiration (TBNA) is an established method to diagnose hilar/mediastinal lymphadenopathies and/or masses. Real-time endobronchial ultrasound (EBUS) is a method that involves TBNA, and has been shown to increase the diagnostic yield in this context.

OBJECTIVES

A descriptive study has been conducted to test real-time EBUS in the diagnosis of hilar-mediastinal lymphadenopathies/masses with a shorter diameter less then 2.5 cm or with a previous negative 'blind' TBNA.

METHODS

Consecutive patients referred for EBUS-TBNA of hilar/mediastinal lymph nodes were included in the study, when a node or mass was detected on a chest computed tomography scan. The primary end point was the number of successful biopsy specimens. Lymph node stations were classified according to the American Thoracic Society scheme.

RESULTS

Ninety-four patients (66 males, 28 females) of mean age 62 years (range: 17-86) underwent EBUS-TBNA: EBUS-TBNA could be performed in all patients. The procedure was diagnostic in 80 patients (89.4%); positive samples were 73 (52 lung cancer, 18 sarcoidosis and 3 tuberculosis), negative samples were 17, inadequate specimens were obtained in four patients (4.25%) and surgically proven false negative results were found in six cases (6.38%). Biopsy specimens were taken from lymph nodes in region 2L (1 case), 2R (5 cases), 4R (20 cases), 4L (7 cases), 7 (47 cases), 10R (9 cases), 10L (2 cases), 11R (6 cases) and 11L (3 cases). Sensitivity was 92.4%, and specificity was 100%. No complications occurred.

CONCLUSIONS

EBUS-TBNA is a safe and reliable method for sampling mediastinal lymph nodes.

Diagnostic value of EBUS-TBNA for lung cancer with non-enlarged lymph nodes: a study in a tuberculosis-endemic country

BACKGROUND

In tuberculosis (TB)-endemic areas, contrast-enhanced computed tomography (CT) and positron emission tomography (PET) findings of lung cancer patients with non-enlarged lymph nodes are frequently discrepant. Endobronchial ultrasound-guided transbronchial aspiration (EBUS-TBNA) enables real-time nodal sampling, and thereby improves nodal diagnosis accuracy. This study aimed to compare the accuracy of nodal diagnosis by using EBUS-TBNA, and PET.

METHODS

We studied 43 lung cancer patients with CT-defined non-enlarged mediastinal and hilar lymph nodes and examined 78 lymph nodes using EBUS-TBNA.

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of EBUS-TBNA were 80.6%, 100%, 100%, and 85.7%, respectively. PET had low specificity (18.9%) and a low positive predictive value (44.4%). The diagnostic accuracy of EBUS-TBNA was higher than that of PET (91% vs. 47.4%; p<0.001). Compared to CT-based nodal assessment, PET yielded a positive diagnostic impact in 36.9% nodes, a negative diagnostic impact in 46.2% nodes, and no diagnostic impact in 16.9% nodes. Patients with lymph nodes showing negative PET diagnostic impact had a high incidence of previous pulmonary TB. Multivariate analysis indicated that detection of hilar nodes on PET was an independent predictor of negative diagnostic impact of PET.

CONCLUSION

In a TB-endemic area with a condition of CT-defined non-enlarged lymph node, the negative diagnostic impact of PET limits its clinical usefulness for nodal staging; therefore, EBUS-TBNA, which facilitates direct diagnosis, is preferred.

The utility of endobronchial ultrasound-guided transbronchial needle aspiration biopsy in the diagnosis of mediastinal lymphoproliferative disorders

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is routinely used to stage lung cancer; however, its usefulness in diagnosing lymphoproliferative disorders has not been well established. In this retrospective study, we determined the utility of EBUS-TBNA in evaluating mediastinal lymphadenopathy in patients with suspected lymphoproliferative disorders.

METHODS

The authors searched the pathology database at their institution to identify all patients who had undergone EBUS-TBNA biopsy for possible lymphoproliferative disorders. The cytologic diagnoses were correlated with concurrent and subsequent biopsy findings and clinical follow-up data.

RESULTS

Of 886 lymph nodes evaluated by EBUS-TBNA biopsy, 91 nodes from 33 patients (23 men and 10 women) were eligible. Fourteen patients had a history of lymphoma. Adequate material for diagnosis was obtained in 31 of 34 procedures (1 patient had 2 procedures). The cytologic diagnoses of the 31 adequate procedures included 19 with benign disease (8 reactive lymph nodes and 11 granulomatous inflammation), 8 with lymphoma (2 large B-cell, 2 small lymphocytic, 2 Hodgkin, 1 mantle cell, and 1 T-cell lymphoblastic), 2 with cells suspicious for Hodgkin lymphoma, and 2 cases with atypical cells.

CONCLUSIONS

EBUS-TBNA proved to be useful for evaluating mediastinal lymphadenopathy in patients with suspected lymphoproliferative disorders. Its use may decrease the need for invasive diagnostic procedures. Immediate assessment is valuable in these cases because of the need to triage material for immunophenotyping or other studies to determine optimal and clinically meaningful diagnoses.

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

Mediastinal lymphadenopathy associated with extrathoracic malignancy or a metastasis of unknown origin (MUO) requires pathological verification. Surgical exploration or endoscopic ultrasound-guided fine needle aspiration is limited to application. We investigated the effectiveness of endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) for evaluating mediastinal lymphadenopathy in patients with an extrathoracic malignancy. We retrospectively analyzed data from 59 patients who underwent EBUS-TBNA with a core biopsy because of a suspected mediastinal metastasis between September 2008 and August 2010. All patients had previously been diagnosed with an extrathoracic malignancy (n = 39, 66.1%) or a suspected MUO without a thoracic lesion (n = 20, 33.9%). A total of 88 lymph nodes was analyzed. EBUS-TBNA findings indicated malignancies in 34 patients (57.6%). The EBUS-TBNA sensitivity and specificity for the detection of mediastinal malignancy in patients with a previous extrathoracic malignancy were 96.3% and 100%, respectively. For MUO patients without a thoracic lesion, the sensitivity and specificity were 61.5% and 100%, respectively. The overall sensitivity and specificity were 81.0% and 100%, respectively (P = 0.053). EBUS-TBNA is a safe and effective modality for evaluating mediastinal lymphadenopathy in patients with a previous extrathoracic malignancy or a MUO without a thoracic lesion. The application of this diagnostic tool is likely to have significant clinical implications.

Direct nodal sampling by echoendoscopy in lung cancer: the clinician's expectations: Direct nodal sampling by echoendoscopy in lung cancer

BACKGROUND: Mediastinal lymph node staging for lung cancer remains one of the most important factors to determine patient outcome. METHODS: Noninvasive imaging techniques such as CT, MRI, PET and PET-CT provide some answers but no tissue diagnosis. RESULTS: The development of endo-oesophageal (EUS) and endobronchial ultrasound (EBUS) with fine-needle aspiration has provided the clinician with a tool to investigate the mediastinum and the adrenal gland with a safe, minimally invasive procedure that can be performed on an outpatient basis. CONCLUSION: The aim of this article was to give radiologists an overview of the techniques of EUS and EBUS and their role in the staging of lung cancer patients.

The Techniques of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for mediastinal lymph node staging in lung cancer patients as well as for the diagnosis of mediastinal and hilar adenopathy. The high diagnostic yield of EBUS-TBNA for lymph node staging has been shown in systematic reviews and meta-analysis. It has attracted physicians and surgeons as an alternative modality to surgical biopsy for the assessment of patients with enlarged mediastinal and/or hilar lymph nodes. Cell blocks obtained by EBUS-TBNA can be applicable not only for pathologic diagnosis but also for further investigations such as immunohistochemistry and fluorescence in situ hybridization. In addition, samples obtained by EBUS-TBNA can also be used for molecular analysis. Unlike regular bronchoscopy, EBUS-TBNA uses the convex probe EBUS with an ultrasound probe on the tip of a flexible bronchoscope. It is important for the bronchoscopist to fully understand the mediastinal anatomy and be able to correlate it with the ultrasound images for a successful EBUS-TBNA. The dedicated transbronchial needle used for EBUS-TBNA is somewhat different from an ordinary transbronchial biopsy forceps. Training is mandatory for achieving high diagnostic yield without complications. The learning curve of EBUS-TBNA is different from each physician, and continuous training program will be needed for impartiality. This article explains the detailed techniques of EBUS-TBNA to master this innovative procedure.

[Endobronchial ultrasound-guided tranbronchial needle aspiration (EBUS-TBNA) in the diagnosis and staging of lung cancer]

经支气管超声引导针吸活检（endobronchial ultrasound guided tranbronchial needle aspiration, EBUS-TBNA）支气管镜具有一置入的微型超声探头，以便实现实时的TBNA活检。在肺癌中，EBUS-TBNA的敏感性为88%-90%，特异性为100%。受试者工作特征曲线下面积低于0.99时，测试效果良好。其诊断率显著优于传统盲法TBNA。然而，其假阴性率仍然很高，大约为20%。因此，阴性针吸结果需经纵隔镜检查、外科取样或临床随访证实。新辅助化疗后纵隔的再分期并不十分乐观，据报道，EBUS-TBNA的敏感性仅为76%，阴性预测值仅为20%。该方法亦已被成功用于获取气管旁及支气管周围区域原发肿瘤的活检标本，敏感性为82%-94%。EBUS-TBNA的优势在于其可在门诊中实施，患者仅需中度镇静，且无需电离辐射消毒。尽管在多数研究机构中EBUS-TBNA目前仍仅用于肿大淋巴结的靶向取样，但也有可能实现影像学检查正常的纵隔的完全分期。因此，如果设备及专家条件具备，EBUS-TBNA可作为肺癌诊断及有创分期的一线方案之一。

[Initial experience on endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and staging of lung cancer]

背景与目的

经支气管超声引导针吸活检（endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA）是近年来新的纵隔淋巴结定性诊断方法。本研究旨在探讨其应用于肺癌诊断及分期中的价值。

方法

2009年4月1日-2010年2月8日，75例本院胸部增强CT提示肺内占位伴多发纵隔淋巴结肿大患者接受EBUS-TBNA检查。以最终病理诊断为金标准，检验EBUS-TBNA诊断肺癌纵隔淋巴结转移的准确性、敏感性、特异性、阳性及阴性预测值，并判断其用于非小细胞肺癌N分期的准确率。

结果

75例患者共计穿刺177组病灶区域，平均穿刺2.4组/例。75例患者，组织病理标本送检率为49.33%。以177组穿刺区域计算，组织病理标本送检率为28.81%。75例患者EBUS-TBNA诊断准确率为98.66%，敏感性为98.43%，特异性为100.00%，阳性预测值为100.00%，阴性预测值为91.67%。以177组穿刺区域计算EBUS-TBNA诊断准确率为96.05%，敏感性为95.10%，特异性为100.00%，阳性预测值为100.00%，阴性预测值为82.93%。上述指标除敏感性（P=0.435）外，均高于CT检查（P < 0.05）。73例可行N分期患者中，19例（26.03%）患者EBUS-TBNA检查后出现分期改变。

结论

EBUS-TBNA准确率较高，创伤小，是用于肺癌诊断及分期的较好方法。

[Endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging of lung cancer and diagnosis of intrathoracic lesions]

既往研究显示，经支气管超声引导针吸活检（endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA）是一项微创技术，可用于肺癌患者的纵隔分期、胸腔内病变的诊断、不明原因淋巴结肿大的诊断以及非小细胞肺癌（non-small cell lung cancer, NSCLC）新辅助化疗后的纵隔再分期。

本综述旨在关注EBUS在NSCLC纵隔分期中的作用，以及EBUS在进一步评估通过常规检查仍诊断未明的胸腔内病变中的应用。总之，就NSCLC患者纵隔分期而言，由于EBUS的诊断敏感性和特异性均较高，其为纵隔镜检查的有效替代，亦可用于疑似胸腔病变的活检，且不会给患者带来任何并发症风险。

Endobronchial and endoscopic ultrasound-guided fine-needle aspiration: a must for thoracic surgeons

A thoracic surgeon facile in endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can accurately sample mediastinal lymph nodes (MLNs) for histologic assessment of mediastinal adenopathy and for thoracic malignancy staging. Although mediastinoscopy is the gold standard for histologic MLN assessment, EBUS-FNA and EUS-FNA have emerged as useful, less-invasive sampling techniques that offer access to a wider range of MLN stations than mediastinoscopy and can be used to biopsy suspicious lesions within (ie, peribronchial masses) and outside the mediastinum (ie, left adrenal gland masses, liver lesions, and enlarged celiac lymph nodes). The negative predictive value of EBUS-TBNA and EUS-FNA in patients with malignancy is somewhat lower than the negative predictive value of mediastinoscopy. Therefore, we recommend that nonmalignant EBUS or EUS cytologic findings should be confirmed with a surgical MLN biopsy (ie, mediastinoscopy or thoracoscopy) if the pretest probability of malignancy is high.

Flexible bronchoscopy and its role in the staging of non-small cell lung cancer

Technologic advances in bronchoscopy continue to improve the ability to perform minimally invasive, accurate evaluations of the tracheobronchial tree and to perform an ever-increasing array of diagnostic, staging, therapeutic, and palliative interventions. The role of both old and new diagnostic bronchoscopy will continue to evolve as further improvements are made in bronchoscopes, accessory equipment, and imaging technologies. The major challenge is the adoption of the many new bronchoscopic techniques into routine clinical practice. There is a need for well-designed studies to delineate the appropriate use of these interventions and to better define their limitations and cost effectiveness.

Validity and reliability of transbronchial needle aspiration for diagnosing mediastinal adenopathies

Background

The aim is to assess the validity and reliability of transbronchial needle aspiration (TBNA) of mediastinal and hilar adenopathies and to evaluate factors predictive of TBNA outcome.

Methods

We performed an analysis of prospectively collected data of patients (n = 580) who underwent TBNA (n = 685) from January 1998 to December 2007 in our center. Validity and reliability were evaluated for the overall sample and according to specific pathology. Factors predicting the successful acquisition of diagnostic samples were analyzed by multivariate analysis.

Results

Overall sensitivity, specificity, accuracy, and positive and negative predictive (NPV) values for TBNA were 68%, 100%, 68.8%, 100%, and 10%, respectively. The most sensitive and accurate TBNAs were obtained for patients with small cell lung carcinoma and the worst results were for patients with lymphomas. NPV were similar for all pathologies. The most predictive factors of outcome were adenopathy size and the presence of indirect signs at the puncture site.

Conclusion

The sensitivity and accuracy of TBNA are high in small cell lung cancer, followed by other types of carcinoma, sarcoidosis, and tuberculosis, and low for lymphoproliferative diseases. The NPV of TBNA for all individual pathologies is low. The size of the adenopathy and the presence of indirect signs at the puncture site predict the achievement of diagnostic samples.

Endobronchial ultrasound-guided transbronchial needle aspiration and its role in non-small cell lung cancer: Diagnostic impact and limitations

A diagnostic work-up to evaluate possible mediastinal lymph node involvement in patients with non-small cell lung cancer (NSCLC) should be performed once suspected as a result of computed tomography. Cytological/histological verification is always compulsory. In recent years, diagnostic tools for mediastinal evaluation have made great technical progress with the introduction of endosonographic real-time ultrasound techniques such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Mediastinal masses as well as lymph node enlargement can be clarified by endosonographic guided biopsies and play a key role in cytological examination of mediastinal lymph nodes. The proven high sensitivity of endosonographic guided biopsies and the high negative predictive value of 20% may challenge mediastinoscopy, which has a sensitivity of 80-95%. However, with a higher positive predictive value and being the best explored method in the literature, mediastinoscopy still has a better diagnostic yield for mediastinal staging. However, according to us EBUS-TBNA should be considered for staging in patients with NSCLC primarily, but negative results must be followed by mediastinoscopic evaluation.

Advances in diagnostic bronchoscopy

Diagnostic bronchoscopy has undergone two major paradigm shifts in the last 40 years. First, the advent of flexible bronchoscopy gave chest physicians improved access to the tracheobronchial tree with a rapid learning curve and greater patient comfort compared with rigid bronchoscopy. The second paradigm shift has evolved over the last 5 years with the proliferation of new technologies that have significantly enhanced the diagnostic capabilities of flexible bronchoscopy compared with traditional methods. At the forefront of these new technologies is endobronchial ultrasound. In its various forms, endobronchial ultrasound has improved diagnostic yield for pulmonary masses, nodules, intrathoracic adenopathy, and disease extent, thereby reducing the need for more invasive surgical interventions. Various navigational bronchoscopy systems have become available to increase flexible bronchoscope access to small peripheral pulmonary lesions. Furthermore, various modalities of airway assessment, including optical microscopic imaging technologies, may play significant roles in the diagnosis of a variety of pulmonary diseases in the future. Finally, the combination of new diagnostic bronchoscopy technologies and novel approaches in molecular analysis and biomarker assessment hold promise for enhanced diagnosis and personalized management of many pulmonary disorders. In this review, we provide a contemporary review of diagnostic bronchoscopy developments over the past decade.