101
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Basille D, Hybiak C, Dayen C, Toublanc B, Douadi Y, Francois G, Rault I, Andrejak C, Berna P, Jounieaux V. [Endobronchial ultrasound with transbronchial needle aspiration: Evaluation of clinical practice]. Rev Mal Respir 2018; 35:305-312. [PMID: 29395562 DOI: 10.1016/j.rmr.2017.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/02/2017] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has undergone a large increase in France since 2007. The aim is to study the evolution of the indications for EBUS-TBNA in our region during the period 2008-2013. MATERIAL AND METHODS We conducted a retrospective observational study including all the patients who underwent an EBUS-TBNA procedure in Picardie from 2008 to 2013. The respective proportion for each indication was noted. RESULTS During the study period, 1036 EBUS-TBNA procedures were performed with a continuous increase in number (86 in 2008 versus 275 in 2013). We observed an increase in the proportion of procedures performed for a suspected diagnosis of sarcoidosis (OR=1.31; IC 95% [1.09-1.58]; P=0.005) and for the simultaneous diagnosis and staging of lung cancer (OR=1.12; IC 95% [1.02-1.24]; P=0.022). For the diagnosis of sarcoidosis, we observed an improvement in the diagnostic yield between the periods [2008-2010] and [2011-2013] (42.9% versus 72.5%). CONCLUSION A continuous increase in the number of EBUS-TBNA procedures was observed during the period 2008-2013. It was associated with a modification in practice with an increased proportion of procedures performed for the diagnosis of sarcoidosis.
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Affiliation(s)
- D Basille
- Service de pneumologie et réanimation respiratoire, CHU Amiens-Picardie, 80054 Amiens cedex 1, France.
| | - C Hybiak
- Service de pneumologie et réanimation respiratoire, CHU Amiens-Picardie, 80054 Amiens cedex 1, France
| | - C Dayen
- Service de pneumologie, maladies infectieuses et tropicales, centre hospitalier Saint-Quentin, 02321 Saint-Quentin, France
| | - B Toublanc
- Service de pneumologie et réanimation respiratoire, CHU Amiens-Picardie, 80054 Amiens cedex 1, France
| | - Y Douadi
- Service de pneumologie, maladies infectieuses et tropicales, centre hospitalier Saint-Quentin, 02321 Saint-Quentin, France
| | - G Francois
- Service de pneumologie et réanimation respiratoire, CHU Amiens-Picardie, 80054 Amiens cedex 1, France
| | - I Rault
- Service de pneumologie, maladies infectieuses et tropicales, centre hospitalier Saint-Quentin, 02321 Saint-Quentin, France
| | - C Andrejak
- Service de pneumologie et réanimation respiratoire, CHU Amiens-Picardie, 80054 Amiens cedex 1, France
| | - P Berna
- Service de chirurgie thoracique, CHU Amiens-Picardie, 80054 Amiens cedex 1, France
| | - V Jounieaux
- Service de pneumologie et réanimation respiratoire, CHU Amiens-Picardie, 80054 Amiens cedex 1, France
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102
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Sun J, Zhang J, Zhao H, Shen J, Gu A, Han B. Role of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of bronchogenic carcinoma: Experience of a single institution in China. Thorac Cancer 2018; 1:28-34. [PMID: 27755785 DOI: 10.1111/j.1759-7714.2010.00010.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To evaluate diagnostic yield and the safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal/hilar lymph nodes and intrapulmonary masses. METHODS Between July 2009 and February 2010, 95 patients with mediastinal/hilar lymphadenopathy and/or intrathoracic peritracheal or peribronchial masses detected with computed tomography underwent EBUS-TBNA. One hundred and twelve samples were obtained from lymph nodes (LNs) and 11 samples were obtained from intrapulmonary lesions. All patients had cytological evaluation by smears and/or tissue evaluation of aspiration specimens. RESULTS Out of the 95 patients, 60 had lung cancer, 58 of these patients were diagnosed using EBUS-TBNA without onsite cytology assistance, false negative in 2 cases. Sensitivity the of convex probe EBUS-TBNA method in distinguishing benign from malignant lymph nodes or thoracic mass was 96.67%. In the absence of any major complications the procedure was uneventful. CONCLUSIONS EBUS-TBNA seems a safe and effective technique in the diagnosis making bronchogenic carcinoma for mediastinal/hilar lymph nodes (LNs) and intrapulmonary masses.
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Affiliation(s)
- Jiayuan Sun
- Pulmonary Department, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jian Zhang
- Pulmonary Department, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Heng Zhao
- Pulmonary Department, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jie Shen
- Pulmonary Department, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Aiqin Gu
- Pulmonary Department, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Baohui Han
- Pulmonary Department, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
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103
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Endobronchial ultrasound-guided transbronchial fine needle aspiration: Determinants of adequacy. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:123-131. [PMID: 32082721 DOI: 10.5606/tgkdc.dergisi.2018.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/20/2017] [Indexed: 11/21/2022]
Abstract
Background This study aims to evaluate the factors influencing the adequacy of endobronchial ultrasound-guided transbronchial fine needle aspiration specimens. Methods A retrospective analysis of 1,700 endobronchial ultrasound-guided transbronchial fine needle aspiration samples obtained from 822 patients (500 males, 322 females; mean age 56±13 years; range 16 to 83 years) was performed between March 2011 and March 2014 at our center. Variables potentially associated with sampling adequacy, such as all cytological materials and procedure notes (lymph node and/or lesion size, localization, needle pass number, and slide number) were examined. Results The overall specimen adequacy was 79.8%. The specimen adequacy was associated with needle pass number (p≤0.001). Adequacy rate was 66.9% for one needle pass and 85.8% for three needle passes. According to the sampling regions, adequacy rates showed a difference [69.2%-85.8%; (p≤0.005)]. In the multivariate logistic regression analysis of subcarinal (7) lymph node station, patient age (odds ratio, 0.983; 95% confidence interval, 0.966-1.000; p=0.049) and number of slides (odds ratio, 1.240; 95% confidence interval, 1.062-1.448; p=0.006) were independent determining factors of specimen adequacy. While independent determinants of specimen adequacy for the right paratracheal (4R) region were lymph node size (odds ratio, 1.486; 95% confidence interval, 0.973-2.268; p=0.067) and number of slides (odds ratio, 1.418; 95% confidence interval, 1.146-1.756; p=0.001), they were lymph node size (odds ratio, 1.594; 95% confidence interval, 0.960-2.645; p=0.071) and number of needle passes (odds ratio, 2.277; 95% confidence interval, 1.360-3.811; p=0.002) for the right interlobar (11R) region. Independent determinant of specimen adequacy for the left paratracheal (4L) lymph node station was the number of needle passes (odds ratio, 1.656; 95% confidence interval, 0.955-2.869; p=0.072). Conclusion During endobronchial ultrasound-guided transbronchial fine needle aspirations, particularly when rapid on site evaluation cannot be applied, consideration of factors affecting adequacy according to lymph node localizations may increase the chance for obtaining materials with suitable quality for cytologic evaluation.
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104
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Aljohaney AA. Utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration in patients with mediastinal and hilar lymphadenopathy: Western region experience. Ann Thorac Med 2018; 13:92-100. [PMID: 29675060 PMCID: PMC5892095 DOI: 10.4103/atm.atm_317_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AIMS The aim of the study was to evaluate the clinical utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with mediastinal and hilar lymphadenopathy and to explicitly describe the utility of this procedure in patient's outcome. METHODS A retrospective review and analysis was conducted on 52 patients with mediastinal or hilar lymphadenopathy who underwent EBUS-TBNA from June 2012 to June 2016. All the patients were evaluated by computed tomography (CT) chest with contrast before EBUS examination. Enlarged mediastinal or hilar lymph node was defined as >1 cm short axis on the enhanced CT. RESULTS Among the 52 patients studied, 57.7% were presented with mediastinal or hilar lymphadenopathy for diagnosis and 42.3% presented with suspected mediastinal malignancy. Paratracheal stations were the most common site for puncture in 33 lymph nodes (43%). The best diagnostic yield was obtained from subcarinal stations and the lowest yield from the hilar stations. Surgical biopsies confirmed lymphoma in six patients, tuberculosis (TB) in three, sarcoidosis in two and one had metastatic adenocarcinoma of unknown primary. The sensitivity, specificity, positive predictive value, and negative predictive value of EBUS-TBNA for diagnosis of mediastinal and hilar lymph node abnormalities were 78.6%, 100%, 100%, and 80%, respectively. The diagnostic yield of EBUS-TBNA in malignant and benign conditions was 79.0%. CONCLUSIONS EBUS-TBNA is a safe and efficacious procedure which can be performed using conscious sedation with high yields. It can be used for the staging of malignancies as well as for the diagnosis of inflammatory and infectious conditions such as sarcoidosis and TB.
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Affiliation(s)
- Ahmed A Aljohaney
- Department of Internal Medicine, Faculty of Medicine, King Abdul Aziz University, Jeddah, Saudi Arabia
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105
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Genere JR, Siddiqui UD. Endoscopic ultrasound-guided tissue acquisition of lymph nodes. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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106
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Fruchter O, Breslavsky A, Brozgol T, Grossman A, Kessi M, Bugayov A, Shimelis K, Vaknine H, Sukmanov O. The diagnostic value of tissue button technique for specimen accusation during endobronchial ultrasound-guided transbronchial fine-needle aspiration. CLINICAL RESPIRATORY JOURNAL 2017; 12:1802-1808. [PMID: 29124891 DOI: 10.1111/crj.12741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/01/2017] [Accepted: 11/05/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The quality of tissue acquisition during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a major determinant of the diagnostic yield of the procedure. In the tissue button (TB) technique, the retrieved cellular specimen is fixed in ethanol and subsequently scraped from slide using surgical blade into formaldehyde and processed like ordinary tissue biopsy thus potentially increasing its diagnostic value. OBJECTIVES To retrospectively evaluate the diagnostic yield of a TB technique in patients undergoing EBUS-TBNA for various malignant and benign conditions. METHODS The diagnostic yield of specimen obtained by two methods (TB and traditional cell-block technique) performed during the same procedure are outlined in 46 patients who underwent EBUS-TBNA (median age = 65, range 19-85 years). RESULTS Overall, in both malignant and benign conditions, TB resulted in clear diagnostic material in 43/46 (93.4%) patients. Specifically, TB provided clear histological diagnosis of malignancy (either primary lung cancer or metastases from extra-thoracic cancer) in 30/46 (65.2%) patients and granulomatous inflammation in 11/46 (23.9%) of patients. Only in two patients TB did not provide diagnostic material. CONCLUSIONS The newly introduced TB technique provides valuable histological diagnostic material during EBUS-TBNA both malignant and benign conditions. Given its simplicity and its high diagnostic yield, TB should be considered to be used as one of the preferred specimen acquisition modalities during EBUS-TBNA specimen processing. Direct comparison to alternative tissue processing techniques during EBUS-TBNA should be explored in further randomized prospective studies.
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Affiliation(s)
- Oren Fruchter
- Pulmonary Division, Wolfson Medical Center, Holon, Israel.,The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel
| | - Anna Breslavsky
- Pulmonary Division, Wolfson Medical Center, Holon, Israel.,The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel
| | - Tatyana Brozgol
- Pulmonary Division, Wolfson Medical Center, Holon, Israel.,The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel
| | - Anna Grossman
- Pulmonary Division, Wolfson Medical Center, Holon, Israel.,The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel
| | - Mikhailova Kessi
- Pulmonary Division, Wolfson Medical Center, Holon, Israel.,The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel
| | - Alexey Bugayov
- Pulmonary Division, Wolfson Medical Center, Holon, Israel.,The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel
| | - Kassa Shimelis
- Pulmonary Division, Wolfson Medical Center, Holon, Israel.,The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel
| | - Hananya Vaknine
- The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel.,Pathology Department, Wolfson Medical Center, Holon, Israel
| | - Oleg Sukmanov
- The Sackler School of Medicine, Tel Aviv University, The Internal Medicine Division, Tel Aviv, Israel.,Pathology Department, Wolfson Medical Center, Holon, Israel
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107
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Complications of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration. Ann Thorac Surg 2017; 104:e363-e365. [PMID: 29054229 DOI: 10.1016/j.athoracsur.2017.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/30/2017] [Accepted: 06/02/2017] [Indexed: 11/21/2022]
Abstract
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered useful for the staging and diagnosis of lung cancer or thoracic lymph node enlargement; however, little is known about its complications. Between July 2009 and November 2016, 413 patients underwent EBUS-TBNA, and four complications (0.97%) occurred. Here we report four cases involving complications of EBUS-TBNA, including mediastinitis (n = 2), obstructive pneumonia (n = 1), and airway obstruction requiring admission to the intensive care unit (n = 1). All patients recovered with appropriate medical treatment. Despite their low incidence, the complications associated with EBUS-TBNA can be serious.
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108
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Lin CK, Lai CL, Chang LY, Wen YF, Ho CC. Learning curve and advantages of endobronchial ultrasound-guided transbronchial needle aspiration as a first-line diagnostic and staging procedure. Thorac Cancer 2017; 9:75-82. [PMID: 29082634 PMCID: PMC5754293 DOI: 10.1111/1759-7714.12539] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 09/14/2017] [Accepted: 09/14/2017] [Indexed: 12/25/2022] Open
Abstract
Background Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is now the standard for mediastinal lymph node staging of lung cancer. Training and maintenance of technical skills is very important in order to apply new techniques in clinical use. Methods A retrospective chart review was performed of patients who underwent EBUS‐TBNA from November 2009 to December 2015. We assessed the learning curve, accuracy (%), and whether this procedure shortened the duration of lung cancer staging. Results The EBUS‐TBNA learning curve continued to improve beyond 120 procedures. Diagnostic accuracy was similar between benign and malignant populations. There was no difference in the learning curve between the groups. Non‐small cell lung cancer patients who underwent EBUS‐TBNA as the first investigative procedure underwent fewer subsequent investigative procedures (1.47 vs. 2.05; P < 0.001), and had a shorter staging duration (4.52 vs. 11.05 days; P = 0.006) compared to those who underwent other procedures for the first investigation. Conclusion EBUS‐TBNA should be one of the preferred options for lung cancer diagnosis and staging because it reduces the staging duration compared to the use of other invasive procedures in initial investigation.
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Affiliation(s)
- Ching-Kai Lin
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Lun Lai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Biotechnology R&D Center, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Lih-Yu Chang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yueh-Feng Wen
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Chi Ho
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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109
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Yendamuri S, Battoo A, Dy G, Chen H, Gomez J, Singh AK, Hennon M, Nwogu CE, Dexter EU, Huang M, Picone A, Demmy TL. Transcervical Extended Mediastinal Lymphadenectomy: Experience From a North American Cancer Center. Ann Thorac Surg 2017; 104:1644-1649. [PMID: 28942077 DOI: 10.1016/j.athoracsur.2017.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 04/30/2017] [Accepted: 05/08/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Accurate staging of the mediastinum is a critical element of therapeutic decision making in non-small cell lung cancer. We sought to determine the utility of transcervical extended mediastinal lymphadenectomy (TEMLA) in staging non-small cell lung cancer for large central tumors and after induction therapy. METHODS A retrospective record review was performed of all patients who underwent TEMLA at our institution from 2010 to 2015. Clinical stage as assessed by positron emission tomography integrated with computed tomography (PET-CT), stage as assessed by TEMLA, final pathologic stage, lymph node yield, and clinical characteristics of tumors were assessed along with TEMLA-related perioperative morbidity. Accuracy of staging by TEMLA for restaging the mediastinum after neoadjuvant therapy was compared with that of PET-CT. RESULTS Of 164 patients who underwent TEMLA, 157 (95.7%) were completed successfully. Combined surgical resection along with TEMLA was performed in 138 of these patients, with 131 (94.2%) undergoing a video-assisted thoracoscopic resection. The recurrent laryngeal nerve injury rate was 6.7%. TEMLA was performed in 118 of 164 patients for restaging after neoadjuvant therapy, and 101 of these patients were also restaged by PET-CT. Based on TEMLA, 7 patients did not go on to have resection. Of the 101 patients who did have a resection, TEMLA was more accurate than PET-CT in staging the mediastinum (95% vs 73%, p < 0.0001). However, the pneumonia rate in this subgroup of patients was 13%. CONCLUSIONS TEMLA is a safe procedure and superior to PET-CT for restaging of the mediastinum after neoadjuvant therapy for non-small cell lung cancer. However, this increased accuracy comes with a high postoperative pneumonia rate.
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Affiliation(s)
- Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York.
| | - Athar Battoo
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York
| | - Grace Dy
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Hongbin Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Jorge Gomez
- Department of Radiation Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Anurag K Singh
- Department of Radiation Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Mark Hennon
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Chukwumere E Nwogu
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Elisabeth U Dexter
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Miriam Huang
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - Anthony Picone
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York
| | - Todd L Demmy
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York; Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
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110
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Sakakibara R, Inamura K, Tambo Y, Ninomiya H, Kitazono S, Yanagitani N, Horiike A, Ohyanagi F, Matsuura Y, Nakao M, Mun M, Okumura S, Inase N, Nishio M, Motoi N, Ishikawa Y. EBUS-TBNA as a Promising Method for the Evaluation of Tumor PD-L1 Expression in Lung Cancer. Clin Lung Cancer 2017; 18:527-534.e1. [DOI: 10.1016/j.cllc.2016.12.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/22/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
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111
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Abstract
Interstitial lung diseases (ILDs) form one of the most fascinating fields in pulmonary medicine. They also pose one of the greatest challenges for accurate diagnosis and proper treatment. Even within the recommended and warranted multidisciplinary approach, differentiating between one disease and another may lead to frustration, especially when proper lung tissue is not available for adequate pathological review. A surgical lung biopsy (SLB) might render enough tissue for histopathology, but this could come at the expense of high morbidity and even mortality, as in the case of usual interstitial pneumonia (UIP). Could bronchoscopy and its various techniques offer a safer and higher yield alternative? Since the very late 19th century, efforts have been made to better examine the airways, obtain tissue and treat various conditions. This resulted in the successive emergence of bronchoalveolar lavage (BAL), endobronchial and transbronchial forceps biopsies, until recently when transbronchial cryobiopsy surfaced as a nascent technique with much promise. The use of endobronchial ultrasound revolutionized the diagnosis and staging of lung cancer, while adding to the yield of other conditions such as sarcoidosis. Ongoing research, efforts and studies have continuously scrutinized the roles of various techniques in the approach to ILDs. For example, BAL seems to serve mostly to eliminate infection as an etiology or a complicating factor in the acute worsening of a fibrotic lung disease, while a predominant cellular component might be diagnostic, such as eosinophilia in eosinophilic lung disease, or lymphocytosis in hypersensitivity pneumonitis (HP). On the other hand, endobronchial biopsy's (EBB) role appears limited to sarcoidosis. As for transbronchial biopsy by forceps, the small sample size and related artifact appear to be limiting factors in making an accurate diagnosis. Recently, however, the use of cryotherapy via employing a cryoprobe in obtaining transbronchial lung biopsies is unfolding into a refined interventional method which might transform indefinitely our approach to the pathological diagnosis of the various ILDs.
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Affiliation(s)
- Jad Kebbe
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center and Oklahoma City VA Medical Center, Oklahoma, USA
| | - Tony Abdo
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center and Oklahoma City VA Medical Center, Oklahoma, USA
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112
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Vaidya PJ, Munavvar M, Leuppi JD, Mehta AC, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: Safe as it sounds. Respirology 2017. [DOI: 10.1111/resp.13094] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Preyas J. Vaidya
- Institute of Pulmonology, Medical Research and Development; Mumbai India
- Department of Pulmonary Medicine, Fortis Hospitals; Mumbai India
| | - Mohammed Munavvar
- Department of Pulmonary Medicine, Lancashire Teaching Hospitals; Preston UK
| | - Joerg D. Leuppi
- Department of Internal Medicine, Kantonsspital Baselland, Liestal; Basel Switzerland
| | - Atul C. Mehta
- Department of Pulmonary Medicine, Cleveland Clinic; Cleveland Ohio USA
| | - Prashant N. Chhajed
- Institute of Pulmonology, Medical Research and Development; Mumbai India
- Department of Pulmonary Medicine, Fortis Hospitals; Mumbai India
- Department of Internal Medicine, Kantonsspital Baselland, Liestal; Basel Switzerland
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113
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An Algorithmic Approach for Assessment of Mediastinal Lesions Using Conventional Transbronchial Needle Aspiration and Endoscopic Ultrasonography in a Single Procedure. Can Respir J 2017; 2017:1971629. [PMID: 28694713 PMCID: PMC5488226 DOI: 10.1155/2017/1971629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/17/2017] [Accepted: 05/18/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In the era of endobronchial/esophageal ultrasound (EBUS-TBNA/EUS-FNA), many centers forgo conventional transbronchial needle aspiration (C-TBNA) in favour of EBUS-TBNA/EUS-FNA despite no conclusive evidence showing better yields with EBUS-TBNA/EUS-FNA. OBJECTIVES Assess the feasibility of an algorithmic approach for mediastinal sampling beginning with C-TBNA utilizing rapid onsite cytologic evaluation. METHODS Descriptive analysis of 92 consecutive patients referred for adenopathy that underwent C-TBNA and subsequent EBUS-TBNA/EUS-FNA if C-TBNA was negative or nondiagnostic. RESULTS 92 procedures were analyzed. In 50 (54.3%) of cases, C-TBNA alone was sufficient. EBUS-TBNA was performed after C-TBNA in 27 (29.3%) of cases and EUS-FNA in 33 (35.9%) of cases. The yield was 92.9% for C-TBNA, 92.5% for EBUS-TBNA, and 89.7% for EUS-FNA. There were no statistically significant differences in yields by LN station (P = 0.51), the relationship between yield and LN size (P = 0.37), or time difference in procedures following the algorithm compared to EBUS/EUS only procedures (33.7 minutes versus 32.4 minutes on average [95% CI for difference: -9.1 to 11.7], P = 0.80). CONCLUSIONS An algorithmic approach to assess the mediastinum using C-TBNA initially is feasible without sacrificing yield or procedure times. C-TBNA was sufficient for diagnosis in 54.3% of cases and can be efficiently taught in an IP training program.
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114
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Lilo MT, Allison DB, Younes BK, Cui M, Askin FB, Gabrielson E, Li QK. The critical role of EBUS-TBNA cytology in the staging of mediastinal lymph nodes in lung cancer patients: A correlation study with positron emission tomography findings. Cancer Cytopathol 2017; 125:717-725. [PMID: 28609021 DOI: 10.1002/cncy.21886] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/08/2017] [Accepted: 05/10/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The sensitivity and specificity of positron emission tomography (PET) have been significantly improved for the identification of malignancies in recent years; however, it is still necessary to confirm PET findings in a lymph node (LN) by direct tissue sampling. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the most commonly used approach for diagnosing and staging mediastinal LNs, particularly in lung cancer patients with locally advanced disease. Despite this fact, evidence-based studies of EBUS-TBNA cytology and PET findings are still suboptimal. METHODS The electronic database at the Johns Hopkins Medical Institutions and the pathology archives were searched to identify patients with mediastinal lymphadenopathy who had both EBUS-TBNA mediastinal LN sampling and a PET scan over a 14-month period. Patients suspected of having lung cancer and patients with a history of lung cancer were included in this study. Cytological diagnoses and follow-up surgical LN diagnoses were reviewed and correlated with PET scan findings. RESULTS A total of 140 LNs from 79 patients, including 86 PET-positive LNs and 54 PET-negative LNs, were included. The most frequently sampled LNs were 4R and 7. The average size of PET-positive and PET-negative LNs was 1.2 and 1.6 cm, respectively. Among PET-positive LNs, 41.9% were malignant, 41.9% showed reactive changes or granulomatous inflammation, and 9.3% were nondiagnostic by EBUS-TBNA. However, among PET-negative LNs, 74.1% showed reactive changes or granulomatous inflammation, 7.4% were malignant, and 18.5% were nondiagnostic by EBUS-TBNA. CONCLUSIONS The data demonstrate that EBUS-TBNA cytology improves the diagnostic accuracy of mediastinal LNs and clinical staging. Furthermore, EBUS-TBNA may identify additional malignant LNs (7.4%), and this highlights the risk for false-negative findings with PET scanning in isolation. Cancer Cytopathol 2017;125:717-25. © 2017 American Cancer Society.
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Affiliation(s)
- Mohammed T Lilo
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Derek B Allison
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Bouchra K Younes
- Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Min Cui
- Department of Pathology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Fred B Askin
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Edward Gabrielson
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Qing Kay Li
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Bronchoscopist-guided Sedation in EBUS-TBNA: Can the Pitcher Also be a Hitter? J Bronchology Interv Pulmonol 2017; 24:4-6. [PMID: 27984381 DOI: 10.1097/lbr.0000000000000351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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116
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Jeebun V, Harrison RN. Understanding local performance data for EBUS-TBNA: insights from an unselected case series at a high volume UK center. J Thorac Dis 2017; 9:S350-S362. [PMID: 28603645 DOI: 10.21037/jtd.2017.05.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We reviewed the diagnostic performance of endobronchial ultrasound transbronchial aspiration (EBUS-TBNA) on an unselected large cohort of patients who underwent the procedure in our institution in the past 3 years and to compare against published standards and existing literature. METHODS All consecutive patients who underwent EBUS from January 2013 to December 2015 were included in the retrospective analysis, with a minimum of 6 months of clinico-radiological follow up. For assessing EBUS-TBNA performance, patients were analysed in three subgroups based on the indication for the EBUS-TBNA: in investigation of isolated mediastinal and/or hilar lymphadenopathy (IMHL), in staging of suspected or confirmed non-small cell lung cancer (NSCLC) and in making a tissue diagnosis in suspected thoracic or extrathoracic cancer. For patients subjected to EBUS-TBNA for staging in suspected lung cancer, accuracy of EBUS was measured by its ability to determine the true N2 stage. RESULTS A total of 1,656 lymph nodes and 138 peribronchial/peritracheal masses were sampled in 940 patients over the study period. The prevalence of reactive lymphadenopathy was 34%. The overall sensitivity to detect pathological disease was 81.6% (95% CI: 74.2-87.6%) whilst NPV was 74.8% (95% CI: 65.2-82.8%). Amongst patients who underwent EBUS-TBNA for staging purposes, the sensitivity for N2 staging was 83.7% (95% CI: 76.2-89.6%) and NPV was 81.6% (95% CI: 73.2-88.2%). The prevalence of N2 disease was 58%. In the subgroup of patients who proceeded to surgical sampling, the sensitivity was higher with the N2/N3 disease prevalence of 67.4%. The sensitivity of EBUS-TBNA to make a tissue diagnosis of thoracic or extrathoracic cancer was 88% (95% CI: 85.1-90.5%) and a NPV of 62% (95% CI: 54.7-69.0%). The disease prevalence was 83.6%. CONCLUSIONS This retrospective study of a large volume of patients represents real life practice and provides an accurate representation of the typical cohort of patients referred in for EBUS-TBNA to the general respiratory physician in UK. Our study highlights the pitfalls in collecting and analyzing data but also demonstrates how they can be used to improve service performance.
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Affiliation(s)
- Vandana Jeebun
- Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Cleveland, UK
| | - Richard Neil Harrison
- Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Cleveland, UK
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Patel P, Wada H, Hu HP, Hirohashi K, Kato T, Ujiie H, Ahn JY, Lee D, Geddie W, Yasufuku K. First Evaluation of the New Thin Convex Probe Endobronchial Ultrasound Scope: A Human Ex Vivo Lung Study. Ann Thorac Surg 2017; 103:1158-1164. [DOI: 10.1016/j.athoracsur.2016.09.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 08/22/2016] [Accepted: 09/07/2016] [Indexed: 12/25/2022]
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Endobrochial Ultrasound Needle Breakdown During Transbronchial Needle Aspiration. J Bronchology Interv Pulmonol 2017; 23:e32-3. [PMID: 27454481 DOI: 10.1097/lbr.0000000000000295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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119
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Chen C, Mu CY, Su MQ, Mao JY, Zhu YH, Huang JA. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration Increases the Yield of Transbronchial Lung Biopsy for the Evaluation of Peribronchial Lesions. Chin Med J (Engl) 2017; 130:11-14. [PMID: 28051017 PMCID: PMC5221100 DOI: 10.4103/0366-6999.196567] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Due to absence of visible endobronchial target, the diagnostic yield of flexible bronchoscopy for peribronchial lesions has been unsatisfactory. Convex probe endobronchial ultrasound (CP-EBUS) has allowed for performing real-time transbronchial needle aspiration (TBNA) of enlarged hilar and mediastinal lymph nodes and therefore could also be used as a means of diagnosing proximal peribronchial lesions. METHODS We retrospectively analyzed the results related to 72 patients who underwent CP-EBUS for peribronchial lesions without endobronchial involvement and adjacent to three-grade bronchi based on chest computed tomography (CT) scan. We recorded the images during EBUS as well as the diagnostic results of TBNA and conventional-transbronchial lung biopsy/brush (C-TBLB/b), and final diagnoses were based on pathologic analysis and follow-up. RESULTS In all cases, the mass was able to be identified using EBUS in 97.2% patients (70/72) who were performed with EBUS-TBNA + C-TBLB/b. Sixty-six patients had a final diagnosis, 80.0% patients (56/70) had malignancies, and 14.3% patients (10/70) had benign disease. In malignancies, the diagnostic yield of C-TBLB/b was 57.1% (32/56) and in EBUS-TBNA was 85.7% (48/56), whereas pathologic diagnosis reached 94.6% when EBUS-TBNA was combined with C-TBLB/b. C-TBLB/b + EBUS-TBNA also exhibited stronger potency of histolytic diagnosis for malignancies than either EBUS-TBNA or C-TBLB/b alone. Furthermore, there are data supporting the value of EBUS-TBNA for the diagnosis of benign lung disease. CONCLUSION The combined endoscopic approach with EBUS-TBNA and C-TBLB/b is an accurate and effective method for the evaluation of peribronchial lesions, with better results than using each technique alone.
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Affiliation(s)
- Cheng Chen
- Respiratory Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Chuan-Yong Mu
- Institute of Respiratory Diseases, Soochow University, Suzhou, Jiangsu 215007, China
| | - Mei-Qin Su
- Respiratory Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Jing-Yu Mao
- Respiratory Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Ye-Han Zhu
- Respiratory Department, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Jian-An Huang
- Institute of Respiratory Diseases, Soochow University, Suzhou, Jiangsu 215007, China
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Czarnecka-Kujawa K, Yasufuku K. The role of endobronchial ultrasound versus mediastinoscopy for non-small cell lung cancer. J Thorac Dis 2017; 9:S83-S97. [PMID: 28446970 DOI: 10.21037/jtd.2017.03.102] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This review provides an update on the current role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and mediastinoscopy (Med) in assessment of patients with non-small cell lung cancer (NSCLC). Invasive mediastinal lymph node (LN) staging is the major application for both of these techniques. Up until recently, Med was the gold standard for invasive mediastinal LN staging in NSCLC. However, EBUS-TBNA has shown to be equivalent, and in some studies better than Med for invasive staging of lung cancer. EBUS-TBNA offers access to N1 LNs and development of the thin convex probe EBUS (TCP-EBUS) will expand EBUS-TBNA access from the paratracheal region and central airways to more distal parabronchial regions allowing for more extensive N1 LN assessment and sampling more distal lung tumors. EBUS-TBNA is more cost-effective than Med and it is currently recommended as the test of first choice for invasive mediastinal LN staging in lung cancer. Confirmatory Med should be performed selectively in patients with high pretest probability of metastatic disease. Addition of esophageal ultrasound fine needle aspiration (EUS-FNA) may increase diagnostic yield of EBUS-TBNA mediastinal staging. Both Med and EBUS-TBNA can be used in primary lung cancer diagnosis, restaging of the mediastinum following neoadjuvant therapy and in diagnosis of lung cancer recurrence. In the future, a combination of EBUS-TBNA with or without EUS-FNA and Med is most likely going to provide the most optimal invasive assessment of the mediastinum in patients with lung cancer. The decision on test choice and sequence should be made on a case-by-case basis and factoring in local resources and expertise.
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Affiliation(s)
- Katarzyna Czarnecka-Kujawa
- Division of Respirology, University Health Network, Canada University of Toronto, Toronto, Canada.,Division of Thoracic Surgery, University Health Network, Canada University of Toronto, Toronto, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, University Health Network, Canada University of Toronto, Toronto, Canada
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121
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Hegde PVC, Liberman M. Mediastinal Staging: Endosonographic Ultrasound Lymph Node Biopsy or Mediastinoscopy. Thorac Surg Clin 2017; 26:243-9. [PMID: 27427519 DOI: 10.1016/j.thorsurg.2016.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Combined endosonographic lymph node biopsy techniques are a minimally invasive alternative to surgical staging in non-small cell lung cancer and may be superior to standard mediastinoscopy and surgical mediastinal staging techniques. Endosonography allows for the biopsy of lymph nodes and metastases unattainable with standard mediastinoscopy. Standard cervical mediastinoscopy is an invasive procedure, which requires general anesthesia and is associated with higher risk, cost, and major complication rates compared with minimally invasive endosonographic biopsy techniques. Combined endosonographic procedures are the new gold standard in staging of non-small cell lung cancer when performed by an experienced operator.
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Affiliation(s)
- Pravachan V C Hegde
- Fresno Medical Education Program, Advanced Interventional Thoracic Endoscopy/Interventional Pulmonology, Division of Pulmonary & Critical Care Medicine, University of California San Francisco (UCSF), 2335 East Kashian Lane, Suite 260, Fresno, CA 93701, USA.
| | - Moishe Liberman
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), Centre Hospitalier de l'Université de Montréal, University of Montreal, 1560 Sherbrooke Street East, 8e CD, Pavillon Lachapelle, Suite D-8051, Montreal, Quebec H2L 4M1, Canada
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122
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Cetinkaya E, Usluer O, Yılmaz A, Tutar N, Çam E, Özgül MA, Demirci NY. Is endobronchial ultrasound-guided transbronchial needle aspiration an effective diagnostic procedure in restaging of non-small cell lung cancer patients? Endosc Ultrasound 2017. [PMID: 28621292 PMCID: PMC5488518 DOI: 10.4103/eus.eus_3_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background and Objectives: Selecting the diagnostic procedure for mediastinal restaging after chemotherapy and/or radiotherapy in Stage IIIA-N2 non-small cell lung cancer (NSCLC) patients remains a problem. The aim of the study was to determine the efficacy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the evaluation of mediastinal lymph nodes in the restaging of NSCLC patients. Materials and Methods: The present multicentric study retrospectively analyzed the results of Stage IIIA-N2 NSCLC patients who had undergone EBUS for mediastinal restaging after preoperative chemotherapy or radiotherapy or both. Results: In 44 patients with 73 N2 nodes, malignant cells were identified in EBUS-TBNA from 23 patients (57.5%) and 25 lymph nodes (34.2%). Twenty-one patients (42.5%) and 48 lymph nodes (65.8%) were negative for nodal metastasis. All of these patients with negative results subsequently underwent mediastinoscopy or surgery (n = 9 and n = 12, respectively). Metastasis was detected in 5 (23.8%) of 21 patients and 6 (12.5%) of 48 lymph nodes. The diagnostic sensitivity, specificity, positive predictive value, negative predicted value and accuracy of EBUS-TBNA based on number of patients were 82.1%, 100%, 100%, 76.2%, and 88.6%, respectively. Conclusions: EBUS-TBNA should be done before invasive procedures in restaging of the mediastinum in patients previously treated with neoadjuvant therapy because of high diagnostic accuracy rate. However, negative results should be confirmed with invasive procedures such as mediastinoscopy and thoracoscopy.
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Affiliation(s)
- Erdoğan Cetinkaya
- Department of Pulmonary Medicine, Yedikule Chest Disease and Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ozan Usluer
- Department of Pulmonary Medicine, Izmir Suat Seren Chest Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Aydın Yılmaz
- Department of Pulmonary Medicine, Atatürk Chest Disease and Surgery Training and Research Hospital, Ankara, Turkey
| | - Nuri Tutar
- Department of Pulmonary Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - Ertan Çam
- Department of Pulmonary Medicine, Yedikule Chest Disease and Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Akif Özgül
- Department of Pulmonary Medicine, Yedikule Chest Disease and Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nilgün Yılmaz Demirci
- Department of Pulmonary Medicine, Atatürk Chest Disease and Surgery Training and Research Hospital, Ankara, Turkey
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123
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Kim SY, Lee JW, Park YS, Lee CH, Lee SM, Yim JJ, Kim YW, Han SK, Yoo CG. Incidence of Fever Following Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration. Tuberc Respir Dis (Seoul) 2016; 80:45-51. [PMID: 28119746 PMCID: PMC5256340 DOI: 10.4046/trd.2017.80.1.45] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 09/12/2016] [Accepted: 10/04/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic method for mediastinal and hilar lymphadenopathy. This study aimed to investigate the incidence of fever following EBUS-TBNA. METHODS A total of 684 patients who underwent EBUS-TBNA from May 2010 to July 2012 at Seoul National University Hospital were retrospectively reviewed. The patients were evaluated for fever by a physician every 6-8 hours during the first 24 hours following EBUS-TBNA. Fever was defined as an increase in axillary body temperature over 37.8℃. RESULTS Fever after EBUS-TBNA developed in 110 of 552 patients (20%). The median onset time and duration of fever was 7 hours (range, 0.5-32 hours) after EBUS-TBNA and 7 hours (range, 1-52 hours), respectively, and the median peak body temperature was 38.3℃ (range, 37.8-39.9℃). In most patients, fever subsided within 24 hours; however, six cases (1.1%) developed fever lasting longer than 24 hours. Infectious complications developed in three cases (0.54%) (pneumonia, 2; mediastinal abscess, 1), and all three patients had diabetes mellitus. The number or location of sampled lymph nodes and necrosis of lymph node were not associated with fever after EBUS-TBNA. Multiple logistic regression analysis did not reveal any risk factors for developing fever after EBUS-TBNA. CONCLUSION Fever is relatively common after EBUS-TBNA, but is transient in most patients. However, clinicians should be aware of the possibility of infectious complications among patients with diabetes mellitus.
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Affiliation(s)
- Seo Yun Kim
- Division of Pulmonology, Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Jin Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Young Sik Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Chang-Hoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Young Whan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Chul-Gyu Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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Andolfi M, Potenza R, Capozzi R, Liparulo V, Puma F, Yasufuku K. The role of bronchoscopy in the diagnosis of early lung cancer: a review. J Thorac Dis 2016; 8:3329-3337. [PMID: 28066614 PMCID: PMC5179455 DOI: 10.21037/jtd.2016.11.81] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/20/2016] [Indexed: 12/25/2022]
Abstract
Lung cancer is the leading cause of cancer-related deaths worldwide with an overall 5-year survival rate of 17% after diagnoses. Indeed many patients tend to have a very poor prognosis, due to being diagnosed at an advanced stage. Conversely patients who are diagnosed at an early stage have a 5-year survival >70%, indicating that early detection of lung cancer is crucial to improve survival. Although flexible bronchoscopy is a relatively non-invasive procedure for patients suspected of having lung cancer, only 29% of carcinoma in situ (CIS) and 69% of microinvasive tumors were detectable using white light bronchoscopy (WLB) alone. As a result, in the past two decades, new bronchoscopic techniques have been developed to increase the yield and diagnostic accuracy, such as autofluorescence bronchoscopy (AFB), narrow band imaging (NBI) and high magnification bronchovideoscopy (HMB). However, due to the low specificity and the limitation to detect only proximal bronchial tree, new probe-based technologies have been introduced: radial endobronchial ultrasound (R-EBUS), optical coherence tomography (OCT), confocal laser endomicroscopy (CLE) and laser Raman spectroscopy (LRS). To date, although tissue biopsy remains the gold standard for diagnosing malignant/premalignant airway disease and some techniques are still investigational, bronchoscopic technologies can be considered the safest and most accurate tools to evaluate both central and distal airway mucosa.
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Affiliation(s)
- Marco Andolfi
- Division of Thoracic Surgery, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Rossella Potenza
- Division of Thoracic Surgery, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Rosanna Capozzi
- Division of Thoracic Surgery, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Valeria Liparulo
- Division of Thoracic Surgery, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Francesco Puma
- Division of Thoracic Surgery, S. Maria della Misericordia Hospital, University of Perugia Medical School, Perugia, Italy
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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Martín-Ontiyuelo C, Pijuan L, Sánchez-Font A. Piece of cartilage detected in a lymph node introduced by endobronchial ultrasound-guided transbronchial needle aspiration. Arch Bronconeumol 2016; 52:560. [PMID: 26796315 DOI: 10.1016/j.arbres.2015.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/10/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Clara Martín-Ontiyuelo
- Servei de Pneumologia, Hospital del Mar, Parc de Salut Mar, UAB, CIBERES, ISCIII, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Lara Pijuan
- Servei de Patologia, Hospital del Mar, Parc de Salut Mar, UAB, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España
| | - Albert Sánchez-Font
- Servei de Pneumologia, Hospital del Mar, Parc de Salut Mar, UAB, CIBERES, ISCIII, Barcelona, España; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, España.
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Yan JH, Pan L, Chen XL, Chen JW, Yan LM, Liu B, Guo YZ. Endobronchial ultrasound versus conventional transbronchial needle aspiration in the diagnosis of mediastinal lymphadenopathy: a meta-analysis. SPRINGERPLUS 2016; 5:1716. [PMID: 27777852 PMCID: PMC5052246 DOI: 10.1186/s40064-016-3348-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/21/2016] [Indexed: 12/25/2022]
Abstract
Currently, whether endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is superior to conventional TBNA (cTBNA) in the diagnosis of mediastinal lymphadenopathy remains controversial. We undertook a meta-analysis of randomized controlled trials (RCTs) to evaluate the diagnostic yield of EBUS-TBNA versus cTBNA in the diagnosis of mediastinal lymphadenopathy, both in benign and malignant etiologies. Computer-based retrieval was performed on PubMed and EMBASE. The quality was evaluated according to the quality assessment of diagnostic accuracy studies-2, and Meta-Disc was adopted to perform meta-analysis. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95 % confidence intervals (CIs) were calculated. The summary receiving operating characteristic curve as well as the areas under curve (AUC) was measured. Four studies with a total of 440 patients met the inclusion criteria. Our results showed that the pooled sensitivity was 0.90 (95 % CI 0.85-0.94) and 0.76 (95 % CI 0.68-0.82), pooled specificity was 0.75 (95 % CI 0.60-0.87) and 0.94 (95 % CI 0.86-0.98), DOR was 75.38 (95 % CI 16.38-346.97) and 108.17 (95 % CI 13.84-845.35), and AUC was 0.9339 and 0.9732 for EBUS-TBNA group and cTBNA group, respectively. Although EBUS-TBNA with a higher sensitivity performs better than cTBNA, there is lack of enough evidence regarding EBUS-TBNA being superior to cTBNA in the diagnosis of mediastinal lymphadenopathy. Considering the limitations of methodology and limited data, further robust RCTs are needed to verify the current findings and investigate the optimal choice in patients receiving TBNA.
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Affiliation(s)
- Jun-Hong Yan
- Department of Ultrasonography, Binzhou Medical University Hospital, Binzhou, 256603 China
| | - Lei Pan
- Department of Respiratory and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, 256603 China
| | - Xiao-Li Chen
- Department of Critical Care Medicine, Jining First People's Hospital, Jining, 272001 China
| | - Jian-Wei Chen
- Department of Infection Management, Binzhou Medical University Hospital, Binzhou, 256603 China
| | - Li-Ming Yan
- Department of Infection Management, Binzhou Medical University Hospital, Binzhou, 256603 China
| | - Bao Liu
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, 450003 China
| | - Yong-Zhong Guo
- Department of Respiratory Medicine, Xuzhou Central Hospital, The Affiliated Xuzhou Center Hospital of Nanjing University of Chinese Medicine, 199 South Jiefang Road, Xuzhou, 221009 Jiangsu China
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Ho CC, Lin CK, Yang CY, Chang LY, Lin SY, Yu CJ. Current advances of endobronchial ultrasonography in the diagnosis and staging of lung cancer. J Thorac Dis 2016; 8:S690-S696. [PMID: 28066671 DOI: 10.21037/jtd.2016.08.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The diagnosis and staging of patients with lung cancer has relied on tissue sampling. Endobronchial ultrasound (EBUS) is a minimally invasive procedure for the rapid and safe acquisition of tissue and can be done easily and repeatedly. EBUS transbronchial needle aspiration (TBNA) is now the standard for diagnosis of mediastinal and hilar lymphadenopathy and should be considered in patients who have a high probability of lymph node metastases without systemic involvement. EBUS also provides guidance for biopsy of peripheral lung lesions. Recent advances of EBUS with new techniques help to improve the diagnostic yield and decrease the complication rate and total procedure time.
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Affiliation(s)
- Chao-Chi Ho
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Kai Lin
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, National Taiwan University College of Medicine, Hsin-Chu, Taiwan
| | - Ching-Yao Yang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lih-Yu Chang
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, National Taiwan University College of Medicine, Hsin-Chu, Taiwan
| | - Shu-Yung Lin
- Department of Internal Medicine, National Taiwan University Hospital, Jinshan Branch, National Taiwan University College of Medicine, New Taipei City, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Wang CH, Xu CC, Jiang JH, Chen YB, Zhan SH. Diagnosis of a rare primary pulmonary synovial sarcoma with endobronchial ultrasound-guided transbronchial needle aspiration. Thorac Cancer 2016; 7:684-688. [PMID: 27755806 PMCID: PMC5093178 DOI: 10.1111/1759-7714.12385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 11/30/2022] Open
Abstract
Primary pulmonary synovial sarcoma (PPSS) is a rare disease. Diagnosis is made postoperatively following resection of the tumor. We describe the case of a 39‐year‐old non‐smoking woman whose chest imaging revealed a heterogeneous mass (5.4 cm × 4.6 cm), with soft tissue density in the right upper lobe and pleural effusion in the right hemithorax. The tumor was enhanced on a computed tomography scan, in which enlargement of the mediastinal lymph nodes compressing the adjacent superior vena cava was observed. Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) was then performed, which demonstrated PPSS, subsequently confirmed by immunohistochemistry and the detection of a SYT‐SSX fusion gene. We believe that a diagnostic approach of EBUS‐TBNA for lung sarcoma would provide helpful information to clinicians.
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Affiliation(s)
- Cai-Hua Wang
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chuan-Cai Xu
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jun-Hong Jiang
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China.
| | - Yan-Bin Chen
- Department of Respiratory Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Sheng-Hua Zhan
- Department of Pathology, The First Affiliated Hospital of Soochow University, Suzhou, China
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Dhooria S, Sehgal IS, Gupta N, Ram B, Aggarwal AN, Behera D, Agarwal R. Yield of new versus reused endobronchial ultrasound-guided transbronchial needle aspiration needles: A retrospective analysis of 500 patients. Lung India 2016; 33:367-71. [PMID: 27578927 PMCID: PMC4948222 DOI: 10.4103/0970-2113.184867] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) requires a dedicated needle for aspiration of mediastinal lesions. There is no data on reuse of these needles. Methods: This is a retrospective study of patients who underwent EBUS-TBNA with either new or reused EBUS-TBNA needles. The needles were reused after thorough cleaning with filtered water and organic cleaning solution, disinfection with 2.4% glutaraldehyde solution followed by ethylene oxide sterilization. The yield of EBUS-TBNA was compared between the two groups. Results: A total of 500 EBUS-TBNA procedures (351 new, 149 reused needles) were performed. The baseline characteristics were different in the two groups with suspected granulomatous disorders (sarcoidosis or tuberculosis) being significantly more common in the new compared to the reused needle group. Similarly, the median, interquartile range number of lymph node stations sampled, and the total number of passes were significantly higher in the new versus the reused needle group. The diagnostic yield was significantly higher with new needle as compared to reused needle (65.2% vs. 53.7%, P = 0.02). On multivariate logistic regression analysis, clinical suspicion of granulomatous disorders (odds ratio 1.86 [95% confidence interval, 1.20-2.87], P = 0.005) was the only predictor of diagnostic yield, after adjusting for the type of needle (new or reused), total number of passes and the number of lymph node stations sampled. No case of mediastinitis was encountered in either group. Conclusions: The yield of EBUS-TBNA might be similar with single reuse of needles as compared to new needles. However, reuse of needle should be performed only when absolutely necessary.
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Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nalini Gupta
- Department of Cytology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Babu Ram
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
BACKGROUND An endobronchial infusion catheter introduced through a flexible bronchoscope channel has not been previously described. The aim of this study was to evaluate the technical feasibility of a new device. METHODS Four porcine models underwent bronchoscopy with the infusion catheter. In the first experiment, methylene blue was injected into airway in volumes of 0.1, 0.3, or 1.0 mL into 2 animals. One animal was killed at 1 hour and the other at 24 hours after the procedure and gross dye diffusion was visually assessed. In the second experiment, a mixture of 80% sterile normal saline and 20% contrast media was injected into the airway in volumes of 0.3, 1.0, and 3.0 mL into 2 animals. One animal was killed at 7 days and the other at 20 days. Histologic evaluations were performed according to a bronchial damage scoring system. RESULTS There was no perioperative morbidity. In the first experiment, infusion volumes of 0.1, 0.3, and 1.0 mL resulted in dye surrounding 67%±29%, 55%±17%, and 80%±20% of the infusion-site circumference, and longitudinal distribution of 4.0±1.7, 8.1±4.1, and 18.0±3.0 mm each, respectively. In the second experiment, infusion of 0.3 to 3.0 mL resulted in mild injury, inflammation, and hemorrhage/fibrin/thrombus at 7 and 20 days after surgery. CONCLUSIONS Endobronchial infusion of dye and contrast media by the endobronchial drug delivery catheter showed that the media spread in a dose-dependent manner macroscopically and histologically. Further investigation will be required to assess the catheter as a new tool for localized drug delivery into the airway.
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Izumo T, Matsumoto Y, Chavez C, Tsuchida T. Re-biopsy by endobronchial ultrasound procedures for mutation analysis of non-small cell lung cancer after EGFR tyrosine kinase inhibitor treatment. BMC Pulm Med 2016; 16:106. [PMID: 27457475 PMCID: PMC4960795 DOI: 10.1186/s12890-016-0268-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 07/19/2016] [Indexed: 12/24/2022] Open
Abstract
Background Re-biopsy for resistant non-small cell lung cancer (NSCLC) after treatment with epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) is important for selection of better therapy, but there have been no reports about the utility of endobronchial ultrasound (EBUS)-guided procedures for such purpose. The aim of this study was to evaluate the utility of EBUS-guided re-biopsy for resistant NSCLC after treatment with EGFR-TKIs. Methods From January 2013 to December 2015, 53 consecutive patients who underwent EBUS-guided re-biopsy for mutation analysis of NSCLC after EGFR-TKI treatment were assessed. Results Nine patients underwent EBUS-guided transbronchial needle aspiration (EBUS-TBNA) and 44 patients underwent EBUS with a guide sheath (EBUS-GS) transbronchial biopsy. The technical success rates were 100 %. As for mutation analysis, all 9 specimens (100 %) from EBUS-TBNA and 33 specimens (75.0 %) from EBUS-GS were adequate for gene profiling. The remaining 11 specimens from EBUS-GS procedures were inadequate for mutation analysis owing to the absence of tumor component in the sample (n = 6) or insufficient specimen (n = 5). There were no related severe complications. Conclusions Re-biopsy by both EBUS-TBNA and EBUS-GS were useful and safe sampling procedures for mutation analysis of EGFR-TKI resistant NSCLC.
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Affiliation(s)
- Takehiro Izumo
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1, Tsukiji Chou-ku, Tokyo, 104-0045, Japan.
| | - Yuji Matsumoto
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1, Tsukiji Chou-ku, Tokyo, 104-0045, Japan
| | - Christine Chavez
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1, Tsukiji Chou-ku, Tokyo, 104-0045, Japan
| | - Takaaki Tsuchida
- Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital, 5-1-1, Tsukiji Chou-ku, Tokyo, 104-0045, Japan
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Ortakoylu MG, Iliaz S, Bahadir A, Aslan A, Iliaz R, Ozgul MA, Urer HN. Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in various lung diseases. J Bras Pneumol 2016; 41:410-4. [PMID: 26578131 PMCID: PMC4635086 DOI: 10.1590/s1806-37132015000004493] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 06/11/2015] [Indexed: 12/25/2022] Open
Abstract
Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of lung disease, and its use is increasing worldwide. It has been used as a means of diagnosing lung cancer in its initial stages, and there are data supporting its use for the diagnosis of benign lung disease. The aim of this study was to share our experience with EBUS-TBNA and discuss its diagnostic value. Methods: We retrospectively analyzed the results related to 159 patients who underwent EBUS-TBNA at our pulmonary medicine clinic between 2010 and 2013. We recorded the location and size of lymph nodes seen during EBUS. Lymph nodes that appeared to be affected on EBUS were sampled at least twice. We recorded the diagnostic results of EBUS-TBNA and (for cases in which EBUS-TBNA yielded an inconclusive diagnosis) the final diagnoses after further investigation and follow-up. Results: We evaluated 159 patients, of whom 89 (56%) were male and 70 (44%) were female. The mean age was 54.6 ± 14.2 years among the male patients and 51.9 ± 11.3 years among the female patients. Of the 159 patients evaluated, 115 (84%) were correctly diagnosed by EBUS. The diagnostic accuracy of EBUS-TBNA was 83% for benign granulomatous diseases and 77% for malignant diseases. Conclusions: The diagnostic value of EBUS-TBNA is also high for benign pathologies, such as sarcoidosis and tuberculosis. In patients with mediastinal disorders, the use of EBUS-TBNA should be encouraged, primarily because it markedly reduces the need for mediastinoscopy.
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Affiliation(s)
- Mediha Gonenc Ortakoylu
- Department of Pulmonology, Istanbul Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sinem Iliaz
- Department of Pulmonology, Istanbul Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ayse Bahadir
- Department of Pulmonology, Istanbul Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Asuman Aslan
- Department of Pulmonology, Istanbul Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Raim Iliaz
- Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mehmet Akif Ozgul
- Department of Pulmonology, Istanbul Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Halide Nur Urer
- Department of Pathology, Istanbul Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
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Bronchoscopist-directed Continuous Propofol Infusion for Targeting Moderate Sedation During Endobronchial Ultrasound Bronchoscopy: A Practical and Effective Protocol. J Bronchology Interv Pulmonol 2016; 22:226-36. [PMID: 26165893 DOI: 10.1097/lbr.0000000000000187] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Propofol use for sedation during routine flexible bronchoscopy is expanding. However, there are concerns over propofol's reliability in targeting moderate sedation during more complex and lengthy procedures, such as endobronchial ultrasound (EBUS) bronchoscopy. Its delivery by continuous infusion, which provides a steady sedation effect, may be a practical model for achieving reliable outcomes in this setting. METHODS We tested a continuous propofol infusion protocol targeting moderate sedation for EBUS bronchoscopy. A fixed loading rate of 125 mcg/kg/min and initial maintenance rate of 75 mcg/kg/min were used. Sedation assessments were performed every 2.5 minutes. The infusion was adjusted by a nurse under the direction of the bronchoscopist to maintain moderate sedation, normal vital signs, and patient comfort. Prospectively collected data from the first 31 patients using the protocol were analyzed. RESULTS A mix of EBUS types was performed in a fellowship training environment. Median procedure duration was 51 minutes (interquartile range, 41 to 75 min). Ninety-four percent of total bronchoscopy time was spent in moderate sedation, whereas only 1.9% was occupied by agitation-related delays. Average propofol dose per case was 0.07 mg/kg/min (±0.020), and infusion adjustments were required once every 8 minutes. Sampling goals were met in all patients, and diagnostic and nodal staging accuracies were 90% and 91%, respectively. All tumor specimens sent for genetics were sufficient for analysis. There were no major procedure-related complications. CONCLUSION Bronchoscopist-directed continuous propofol infusion is effective and practical for reliably and safely targeting moderate sedation during EBUS bronchoscopy, without sacrificing the breadth and accuracy of the procedure.
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Mediastinal and Hilar Lymph Node Measurements. Comparison of Multidetector-Row Computed Tomography and Endobronchial Ultrasound. Ann Am Thorac Soc 2016; 12:914-20. [PMID: 25211346 DOI: 10.1513/annalsats.201312-430oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Multidetector-row chest computed tomography scan is a common initial imaging modality and endobronchial ultrasound is a minimally invasive diagnostic tool used to evaluate enlarged lymph nodes, but comparisons of imaging results are lacking. OBJECTIVES To determine the size of thoracic lymph nodes and the strength of agreement between each measurement from coronal plane computed tomography and static endobronchial ultrasound images. METHODS A retrospective review of consecutive patients who underwent endobronchial ultrasound-transbronchial needle aspiration of their lymph nodes because of clinical suspicion of benign or malignant thoracic disease. MEASUREMENTS AND MAIN RESULTS One hundred and twenty-four lymph nodes from the mediastinal (74.2%) and hilar (25.8%) stations were measured in 59 patients (mean age, 64.5 yr; 33 males). The mean (standard deviation) short-axis diameter on computed tomography was 14.1 (6.7) mm compared with 12.6 (6.6) mm on endobronchial ultrasound. Benign lymph nodes (n = 42) were larger on computed tomography than on endobronchial ultrasound (14.1 [6.2] vs. 11.5 [6.2] mm). Malignant lymph nodes (n = 35) were larger on endobronchial ultrasound than on computed tomography (17.3 [6.4] vs. 16.2 [6.7] mm). Sixty-five percent of the lymph nodes that were initially interpreted as not enlarged on axial computed tomography images measured greater than 10 mm on each imaging modality (12.5 [5.9] mm on computed tomography and 10.5 [5.6] mm on endobronchial ultrasound) and 24% of the sampled lymph nodes from this group contained malignant cells. Random-effects maximal likelihood linear regression showed a statistically significant difference between endobronchial ultrasound and the computed tomography method for measuring short-axis diameter in all 124 lymph nodes. There was a weak agreement (intraclass correlation, rho: 0.44 [95% confidence interval, 0.31-0.59]) between short-axis diameter measurements from each imaging modality. CONCLUSIONS Our single-center study shows that there was poor correlation between computed tomography and endobronchial ultrasound for the measurement of mediastinal and hilar lymph nodes. Malignant cells were recovered by ultrasound-guided needle aspiration from a substantial fraction of lymph nodes that were initially interpreted as normal in size. If these findings are confirmed, new criteria may be needed for lymph node measurement on computed tomography that will guide selection of lymph nodes for endobronchial ultrasound-transbronchial needle aspiration.
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Abstract
The era of bronchoscopy began with Gustav Killian in 1876 when he removed a pork bone from a farmer's airway, using an esophagoscope. Prompted by this accomplishment, Chevalier Jackson, an American otolaryngologist, laid the platform for the modern-day rigid bronchoscope in the early twentieth century. In 1967 Shigeto Ikeda revolutionized the field of bronchoscopy by his innovation of the fiberoptic bronchoscope. Today, bronchoscopy and interventional pulmonology have become an integral part of pulmonary medicine and an established subspecialty. Numerous innovators have furthered the horizons of this technology. In the early 1980s Ko-Pen Wang introduced transbronchial needle aspiration to sample mediastinal lesions while Jean-François Dumon developed methods for laser photoresection and for placing stents thorough the bronchoscope. More recently, application of endobronchial ultrasound and electromagnetic navigation tools has further galvanized the role of bronchoscopy. The success of lung transplantation also belongs in part to flexible bronchoscopy. Today, researchers are looking into treating emphysema as well as asthma, using bronchoscopic techniques. We believe 2015 is a good time to look back on the history of bronchoscopy and to recognize its major milestones. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps future generations improve the welfare of patients with lung ailments.
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Mallya V, Kumar SP, Meganathan P, Shivkumar S, Mehta R. The utility of ROSE (rapid on-site evaluation) in endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA): Is the picture rosy? J Cytol 2016; 32:230-3. [PMID: 26811569 PMCID: PMC4707783 DOI: 10.4103/0970-9371.171226] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Mediastinal lymphadenopathy (ML) presents a diagnostic challenge. The technique to sample the lymph nodes has evolved from conventional "blind" transbronchial needle aspiration (TBNA) to the present day endobronchial ultrasound (EBUS)-guided procedure that improves the accuracy of sampling. OBJECTIVE This study was undertaken to evaluate the utility of "rapid on-site evaluation" (ROSE) in EBUS-guided TBNA (EBUS-TBNA) for the diagnosis of ML. PATIENTS AND METHODS This prospective study included 80 patients who underwent EBUS-TBNA for computed tomography/positron emission tomography (CT/PET) diagnosed ML over a 4-month period at a single tertiary care center. All 80 of these patients underwent histopathological evaluation (HPE) in addition to cytology. Three out of these 80 (3.7%) patients were excluded in view of inadequate material on EBUS-TBNA. After the sampling of nodes was done, the slides were stained with rapid hematoxylin and eosin (H&E) and then on-site evaluation was done. The tissue derived was also processed for HPE in all cases. RESULTS ROSE revealed granuloma in 27 patients and malignancy in 14 patients, and the remaining patients showed nonspecific inflammation. Concomitant histopathology revealed granuloma in 34 patients and malignancy in 14 patients. Considering HPE as gold standard, the overall sensitivity and specificity of EBUS-TBNA for diagnosis were 85.4% and 89.6%, respectively. For malignancy alone, the sensitivity and specificity were 100% and 98.4%, respectively. CONCLUSION This novel approach is safe, has good diagnostic yield, and has an excellent potential in assisting safe and accurate diagnostic interventional bronchoscope.
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Affiliation(s)
- Varuna Mallya
- Department of Pathology, Dr. BR Ambedkar Medical College, Bengaluru, Karnataka, India
| | - Sandeep P Kumar
- Department of Pathology, Dr. BR Ambedkar Medical College, Bengaluru, Karnataka, India
| | - Prabhu Meganathan
- Department of Pathology, Apollo Hospital, Bengaluru, Karnataka, India
| | - Swarna Shivkumar
- Department of Pathology, Apollo Hospital, Bengaluru, Karnataka, India
| | - Ravindra Mehta
- Department of Pulmonology, Apollo Hospital, Bengaluru, Karnataka, India
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Abstract
Conventional transbronchial needle aspiration (C-TBNA) provides an opportunity to diagnose mediastinal lesions and stage bronchogenic carcinoma in a minimally invasive fashion. The procedure is easy to learn and requires zero upfront cost. Any community pulmonologist can acquire and maintain the skills of C-TBNA without undergoing formal interventional pulmonary fellowship training. Besides being used for the diagnosis and staging of lung cancer, C-TBNA can be used in patients suspected to have benign conditions such as sarcoidosis and tuberculosis. It also contributes in improving the diagnostic yield of flexible bronchoscopy while dealing with endobronchial, submucosal, peribronchial, or peripheral lesions. C-TBNA may be the only diagnostic modality that can be performed in patients in whom mediastinoscopy is contraindicated due to a bleeding diathesis. The procedure is safe and has great potential to augment the welfare of patients with pulmonary ailments. The learning curve of the procedure is short and steep. Every community pulmonologist should be able to perform C-TBNA.
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Affiliation(s)
- Elif Küpeli
- Pulmonary Diseases Department, School of Medicine, Başkent University, Bahcelievler 06490, Ankara, Turkey
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Yang H, Zhang Y, Wang KP, Ma Y. Transbronchial needle aspiration: development history, current status and future perspective. J Thorac Dis 2016; 7:S279-86. [PMID: 26807275 DOI: 10.3978/j.issn.2072-1439.2015.11.36] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transbronchial needle aspiration (TBNA) technology was underutilized by clinicians because it is "blind". Recent development of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) renewed the interest and confident of TBNA. TBNA without EBUS is referred as conventional transbronchial needle aspiration (C-TBNA). METHODS This paper focuses on C-TBNA technology development history, present situation and future development to do a detailed introduction. RESULTS TBNA is a simple, cost effective and minimally invasive technique for diagnosing disease of the mediastinum and lung in adult as well as children patients. CONCLUSIONS More improvements of TBNA technology should be made, including employing technological advances to perfect the instruments and techniques, focusing on patient comfort, optimizing yield, simplifying instruments, maximizing ease of use and minimizing training requirements for the pulmonologist. The ideal TBNA scope deserves further evaluation and study.
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Affiliation(s)
- Huizhen Yang
- 1 Department of Respiratory and Critical Care Medicine, People's Hospital, Zhengzhou University, Zhengzhou 450003, China ; 2 Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200092, China ; 3 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yuan Zhang
- 1 Department of Respiratory and Critical Care Medicine, People's Hospital, Zhengzhou University, Zhengzhou 450003, China ; 2 Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200092, China ; 3 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ko-Pen Wang
- 1 Department of Respiratory and Critical Care Medicine, People's Hospital, Zhengzhou University, Zhengzhou 450003, China ; 2 Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200092, China ; 3 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yun Ma
- 1 Department of Respiratory and Critical Care Medicine, People's Hospital, Zhengzhou University, Zhengzhou 450003, China ; 2 Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200092, China ; 3 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Jiang JH, Turner JF, Huang JA. Endobronchial ultrasound elastography: a new method in endobronchial ultrasound-guided transbronchial needle aspiration. J Thorac Dis 2016; 7:S272-8. [PMID: 26807274 DOI: 10.3978/j.issn.2072-1439.2015.12.53] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Jun-Hong Jiang
- 1 Department of Respiratory, the First Affiliated Hospital of Soochow University, Suzhou 215006, China, 2 Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - J Francis Turner
- 1 Department of Respiratory, the First Affiliated Hospital of Soochow University, Suzhou 215006, China, 2 Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Jian-An Huang
- 1 Department of Respiratory, the First Affiliated Hospital of Soochow University, Suzhou 215006, China, 2 Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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Wahidi MM, Herth F, Yasufuku K, Shepherd RW, Yarmus L, Chawla M, Lamb C, Casey KR, Patel S, Silvestri GA, Feller-Kopman DJ. Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report. Chest 2016; 149:816-35. [PMID: 26402427 DOI: 10.1378/chest.15-1216] [Citation(s) in RCA: 246] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/22/2015] [Accepted: 08/13/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians. METHODS Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion. RESULTS Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement. CONCLUSIONS Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure.
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Affiliation(s)
- Momen M Wahidi
- Duke University Medical Center, Division of Pulmonary and Critical Care Medicine, Durham, NC.
| | - Felix Herth
- Division of Pulmonary and Critical Care Medicine, University of Heidelberg, Heidelberg, Germany
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Mohit Chawla
- Division of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Carla Lamb
- Division of Pulmonary and Critical Care Medicine, Lahey Clinic Hospital, Burlington, MA
| | - Kenneth R Casey
- Division of Pulmonary and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Gerard A Silvestri
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - David J Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
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141
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Motegi H, Kobayashi H, Terasaka S, Yamaguchi S, Ishi Y, Ito Y, Houkin K. Application of endoscopic ultrasonography to intraventricular lesions. Acta Neurochir (Wien) 2016; 158:87-92. [PMID: 26542528 DOI: 10.1007/s00701-015-2617-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/16/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anatomical landmarks such as choroid plexus and foramen of Monro are very important to undergo intraventricular surgery safely and effectually. These landmarks would be unclear in cases with a huge cyst or repeat surgery. We report the usability and precautions to apply a bronchoscope with an ultrasonic convex probe to intraventricular surgery. METHODS Two patients diagnosed with obstructive hydrocephalus, one with a large cyst and the other with recurrent craniopharyngioma in the third ventricle, were applied to the EBUS system. RESULTS In both patients, the EBUS system was applied safely, and lesions beyond the wall of ventricles or the cyst were visible. Color Doppler ultrasonography detected choroid plexus and internal cerebral veins. Furthermore, we performed real-time ultrasound-guided cyst puncture safely on the case with a large cyst. The most important precaution is that the curved portion of the EBUS system is too long to be bent within cerebral ventricles. CONCLUSIONS The new EBUS system with an ultrasonic convex probe is a novel and effectual device to perform intraventricular surgery.
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142
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Osinka K, Zielińska-Krawczyk M, Korczyński P, Górnicka B, Krenke R. Impact of Endobronchial Ultrasound Guided Transbronchial Needle Aspiration on Diagnostic Yield of Bronchoscopy in Patients with Mediastinal Lymph Node Enlargement. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 911:33-43. [PMID: 26987324 DOI: 10.1007/5584_2016_222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) had an enormous impact on the current advancement in diagnostic bronchoscopy. The aims of the present study were: (1) to evaluate the added value of EBUS-TBNA to routine diagnostic bronchoscopy performed in patients with mediastinal lymph node enlargement and (2) to identify factors that affect the diagnostic yield of EBUS-TBNA. We retrospectively analyzed 712 EBUS-TBNA procedures out of the 4081 bronchoscopies performed in the years 2009-2014. The number of EBUS-TBNA procedures increased from 61 (8.8 % of all bronchoscopies) in 2009 to 160 (21.4 %) in 2014. In 625 (87.8 %) patients adequate cytological material was obtained. Based on cytological examination of EBUS-TBNA aspirates, specific diagnosis was made in 367 (51.5 %) patients. The forceps biopsy of endobronchial lesions provided specific diagnosis in only 204 (28.6 %) patients. The percentage of patients with EBUS-TBNA based diagnosis increased steadily from 34.4 % in 2009 to 65.0 % in 2014 (p < 0.0001). The median lymph node diameter in patients with positive EBUS-TBNA findings was 20 (IQR 15-30) mm and was significantly larger than that in patients with negative EBUS-TBNA results (15 (IQR 10-20) mm, p = 0.0001). The highest diagnostic yield (78.5 %) was found in patients with lymph node dimension between 31 mm and 40 mm. We conclude that EBUS-TBNA is a valuable diagnostic method in an unselected group of patients with mediastinal lymph node enlargement. The percentage of positive EBUS-TBNA diagnoses is related to lymph node dimensions. The overall efficacy of EBUS-TBNA improves with increasing years of experience.
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Affiliation(s)
- K Osinka
- Medical Student Research Group 'Alveolous', Medical University of Warsaw, Warsaw, Poland
| | - M Zielińska-Krawczyk
- Department of Internal Medicine, Pneumology and Allergology, Medical University of Warsaw, 1A Banacha St, 02-097, Warsaw, Poland
| | - P Korczyński
- Department of Internal Medicine, Pneumology and Allergology, Medical University of Warsaw, 1A Banacha St, 02-097, Warsaw, Poland.
| | - B Górnicka
- Department of Pathology, Medical University of Warsaw, Warsaw, Poland
| | - R Krenke
- Department of Internal Medicine, Pneumology and Allergology, Medical University of Warsaw, 1A Banacha St, 02-097, Warsaw, Poland
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Youk DM, Jhala NC, Gupta PK. Characterizing specimen quality of cell block samples in an era of personalized diagnostics: analysis of 221 lymph node fine-needle aspirations. J Am Soc Cytopathol 2016; 5:154-161. [PMID: 31042518 DOI: 10.1016/j.jasc.2015.09.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/21/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Cell block (CB) preparations of fine-needle aspirates (FNAs) are utilized for patient management, which requires retention of representative material on slides. Personalized medicine demands quality CB specimens. There is no standard protocol for CB preparation, often resulting in suboptimal slides. The utility of using two CB slides in lymph node (LN) FNA cases was investigated. MATERIALS AND METHODS We cut 10 serial sections from each CB, slides 1 and 5 are stained and considered the first and second cuts, respectively; the remaining slides are reserved for ancillary studies. Hematoxylin and eosin-stained CBs of 221 consecutive LN FNA cases were reviewed; qualitative and quantitative assessment of diagnostic value was made on sections 1 and 5. RESULTS Of the 221 cases, 46.1% (102) had comparable diagnostic cellularity (equally representative) on both slides, whereas 26.7% (59) and 27.1% (60) had more representative material on the first and second cuts, respectively (P = 0.52). Differences between the representativeness of first and second CB cuts of intrathoracic lymph nodes were minor (n = 192, P = 0.065). Differences between the first and the second slide representativeness of superficial (n = 22, P = 0.98) and intra-abdominal lymph nodes (n = 7, P = 0.38) are limited because of small sample sizes. CONCLUSION One CB cut can be suboptimal for diagnosis. In our study, inclusion of a second slide increases equal representativeness from 46.1% to 73.2%. These limited observations recognize the need for additional investigations regarding the collection and preparation of CBs.
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Affiliation(s)
- David M Youk
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical, Center, 6 Founders Pavilion 3400 Spruce Street, Philadelphia, Pennsylvania.
| | - Nirag C Jhala
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical, Center, 6 Founders Pavilion 3400 Spruce Street, Philadelphia, Pennsylvania
| | - Prabodh K Gupta
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical, Center, 6 Founders Pavilion 3400 Spruce Street, Philadelphia, Pennsylvania
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Aswanetmanee P, Limsuwat C, Kabach M, Alraiyes AH, Kheir F. The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: Systematic review. Endosc Ultrasound 2016; 5:300-306. [PMID: 27803902 PMCID: PMC5070287 DOI: 10.4103/2303-9027.191608] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in diagnosis and staging of mediastinal lymph node (LN) lesions in lung cancer. Adequate sedation is an important part of the procedure since it provides patient's comfort and potentially increases diagnostic yield. We aimed to compare deep sedation (DS) versus moderate sedation (MS) in patients undergoing EBUS-TBNA procedure. METHODS PubMed, EMBASE, MEDLINE, and Cochrane Library were searched for English studies of clinical trials comparing the two different methods of sedations in EBUS-TBNA until December 2015. The overall diagnostic yield, LN size sampling, procedural time, complication, and safety were evaluated. RESULTS Six studies with 3000 patients which compared two different modalities of sedation in patients performing EBUS-TBNA were included in the study. The overall diagnostic yield of DS method was 52.3%-100% and MS method was 46.1%-85.7%. The overall sensitivity of EBUS-TBNA of DS method was 98.15%-100% as compared with 80%-98.08% in MS method. The overall procedural times were 27.2-50.9 min and 20.6-44.1 min in DS and MS groups, respectively. The numbers of LN sampled were between 1.33-3.20 nodes and 1.36-2.80 nodes in DS and MS groups, respectively. The numbers of passes per LN were 3.21-3.70 passes in DS group as compared to 2.73-3.00 passes in MS group. The mean of LN size was indifferent between two groups. None of the studies included reported serious adverse events. CONCLUSIONS Using MS in EBUS-TBNA has comparable diagnostic yield and safety profile to DS. The decision on the method of sedation for EBUS-TBNA should be individually selected based on operator experience, patient preference, as well as duration of the anticipated procedure.
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Affiliation(s)
- Pantaree Aswanetmanee
- Tulane University Health Sciences Center, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, New Orleans, Louisiana, USA
| | - Chok Limsuwat
- Tulane University Health Sciences Center, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, New Orleans, Louisiana, USA
| | - Mohamad Kabach
- University of Miami Miller School of Medicine, Palm Beach Regional Campus, Florida, USA
| | - Abdul Hamid Alraiyes
- Department of Medicine, Interventional Pulmonary Section, Roswell Park Cancer Institute, Buffalo, New York, USA; Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Fayez Kheir
- Tulane University Health Sciences Center, Section of Pulmonary Diseases, Critical Care and Environmental Medicine, New Orleans, Louisiana, USA
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Daddi N, Sagrini E, Lugaresi M, Perrone O, Candoli P, Ragusa M, Puma F, Mattioli S. Ex vivo pulmonary nodule detection with miniaturized ultrasound convex probes. J Surg Res 2015; 202:49-57. [PMID: 27083947 DOI: 10.1016/j.jss.2015.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 10/24/2015] [Accepted: 12/07/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND The intraoperative localization of small and deep pulmonary nodules is often difficult during minimally invasive thoracic surgery. We compared the performance of three miniaturized ultrasound (US) convex probes, one of which is currently used for thoracic endoscopic diagnostic procedures, for the detection of lung nodules in an ex vivo lung perfusion model. METHODS Three porcine cardiopulmonary blocks were perfused, preserved at 4°C for 6 h and reconditioned. Lungs were randomly seeded with different patterns of echogenicity target nodules (9 water balls, 10 fat, and 11 muscles; total n = 30). Three micro-convex US probes were assessed in an open setting on the pleural surface: PROBE 1, endobronchial US 5-10 MHz; PROBE 2, laparoscopic 4-13 MHz; PROBE 3, fingertip micro-convex probe 5-10 MHz. US probes were evaluated regarding the number of nodules localized/not localized, the correlation between US and open specimen measurements, and imaging quality. RESULTS For detecting target nodules, the sensitivity was 100% for PROBE 1, 86.6% for PROBE 2, and 78.1% for PROBE 3. A closer correlation between US and open specimen measurements of target diameter (r = 0.87; P = 0.0001) and intrapulmonary depth (r = 0.97; P = 0.0001) was calculated for PROBE 1 than for PROBES 2 and 3. The imaging quality was significantly higher for PROBE 1 than for PROBES 2 and 3 (P < 0.04). CONCLUSIONS US examination with micro-convex probes to detect pulmonary nodules is feasible in an ex vivo lung perfusion model. PROBE 1 achieved the best performance. Clinical research with the endobronchial US micro-convex probe during minimally invasive thoracic surgery is advisable.
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Affiliation(s)
- Niccolò Daddi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Elisabetta Sagrini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Division of Internal Medicine, University of Bologna, Bologna, Italy; PhD Course in Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Marialuisa Lugaresi
- Division of Thoracic Surgery, Maria Cecilia Hospital-GVM Care and Research, Cotignola, Ravenna, Italy
| | - Ottorino Perrone
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; Division of Internal Medicine, University of Bologna, Bologna, Italy; PhD Course in Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Piero Candoli
- Division of Pneumology, AUSL Ravenna, Area Vasta Romagna, Ravenna, Italy
| | - Mark Ragusa
- Thoracic Surgery Unit, Department of Surgical-Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Francesco Puma
- Thoracic Surgery Unit, Department of Surgical-Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Sandro Mattioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy; PhD Course in Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Division of Thoracic Surgery, Maria Cecilia Hospital-GVM Care and Research, Cotignola, Ravenna, Italy.
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Endo S, Sasaki T, Onishi K, Kazebayashi Y, Hirai N, Minami Y, Toyoshima E, Yamamoto Y, Kishino S, Ohsaki Y. Analysis of garenoxacin distribution in the mediastinum using endobronchial ultrasound-guided transbronchial needle aspiration. Int J Antimicrob Agents 2015; 46:721-2. [PMID: 26597933 DOI: 10.1016/j.ijantimicag.2015.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 09/30/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Satoshi Endo
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Takaaki Sasaki
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan.
| | - Kaori Onishi
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Yoshihiro Kazebayashi
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Noriko Hirai
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Yoshinori Minami
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Eri Toyoshima
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Yasushi Yamamoto
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Satoshi Kishino
- Department of Medication Use Analysis and Clinical Research, Meiji Pharmaceutical University, Tokyo, Japan
| | - Yoshinobu Ohsaki
- Respiratory Center, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
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Endobronchial ultrasound transbronchial needle injection: ex vivo measurement of dead space volume of the needle assembly. Ann Am Thorac Soc 2015; 12:616-8. [PMID: 25897746 DOI: 10.1513/annalsats.201501-052le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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148
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Dietrich CF, Annema JT, Clementsen P, Cui XW, Borst MM, Jenssen C. 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. J Thorac Dis 2015; 7:E311-25. [PMID: 26543620 DOI: 10.3978/j.issn.2072-1439.2015.09.40] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Christoph Frank Dietrich
- 1 Medical Department 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 2 Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands ; 3 Department of Pulmonary Medicine, Gentofte University Hospital, Denmark and Centre for Clinical Education, Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Hellerup, Denmark ; 4 Medical Department 1, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 5 Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Germany
| | - Jouke Tabe Annema
- 1 Medical Department 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 2 Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands ; 3 Department of Pulmonary Medicine, Gentofte University Hospital, Denmark and Centre for Clinical Education, Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Hellerup, Denmark ; 4 Medical Department 1, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 5 Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Germany
| | - Paul Clementsen
- 1 Medical Department 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 2 Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands ; 3 Department of Pulmonary Medicine, Gentofte University Hospital, Denmark and Centre for Clinical Education, Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Hellerup, Denmark ; 4 Medical Department 1, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 5 Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Germany
| | - Xin Wu Cui
- 1 Medical Department 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 2 Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands ; 3 Department of Pulmonary Medicine, Gentofte University Hospital, Denmark and Centre for Clinical Education, Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Hellerup, Denmark ; 4 Medical Department 1, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 5 Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Germany
| | - Mathias Maximilian Borst
- 1 Medical Department 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 2 Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands ; 3 Department of Pulmonary Medicine, Gentofte University Hospital, Denmark and Centre for Clinical Education, Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Hellerup, Denmark ; 4 Medical Department 1, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 5 Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Germany
| | - Christian Jenssen
- 1 Medical Department 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 2 Department of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands ; 3 Department of Pulmonary Medicine, Gentofte University Hospital, Denmark and Centre for Clinical Education, Rigshospitalet, University of Copenhagen and the Capital Region of Denmark, Hellerup, Denmark ; 4 Medical Department 1, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Würzburg, Germany ; 5 Department of Internal Medicine, Krankenhaus Märkisch Oderland, Strausberg/Wriezen, Germany
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Li P, Zheng W, Zhao L. Convex probe endobronchial ultrasound: applications beyond conventional indications. J Thorac Dis 2015; 7:E289-97. [PMID: 26543618 DOI: 10.3978/j.issn.2072-1439.2015.09.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is maturing and gaining acceptance by more and more clinicians for lymph node staging of lung cancer and diagnosis of mediastinal and hilar masses or lymph node enlargement by convex probe endobronchial ultrasound (CP-EBUS). The application of CP-EBUS, however, is not limited to conventional indications. Diagnostically, elastography is a new technology for the differentiation of benign and malignant lymph nodes before aspiration. CP-EBUS can also be used for pulmonary vascular diseases, such as pulmonary embolism (PE) and non-thrombotic endovascular lesions (NELs). Therapeutically, CP-EBUS can be used for cyst drainage and drug injections. CP-EBUS is not limited to observation and aspiration of mediastinal masses and lymph nodes, but is also suitable for exploration of other tissues external to the central airway, which necessitates unprecedented skills for the bronchoscopist.
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Affiliation(s)
- Peng Li
- Department of Respiratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Wei Zheng
- Department of Respiratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Li Zhao
- Department of Respiratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
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150
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Kim SH, Lee Y, Park S, Choi CM, Jo J, Lee JC. Endobronchial mass formation after endobronchial ultrasound-transbronchial needle aspiration mimicking implantation metastasis. Clin Case Rep 2015; 3:983-6. [PMID: 26734133 PMCID: PMC4693703 DOI: 10.1002/ccr3.414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/29/2015] [Accepted: 09/18/2015] [Indexed: 11/25/2022] Open
Abstract
Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has been widely used for diagnosing intrathoracic lymphadenopathy. Here, we present two cases of endobronchial polyp formation after an EBUS‐TBNA for suspicious malignant lymph nodes. An inflammatory polyp should be considered as a possible differential diagnosis for a newly developed mass after an EBUS‐TBNA.
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Affiliation(s)
- Soo Han Kim
- Department of Pulmonary and Critical Care Medicine Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Yunkyoung Lee
- Department of Pulmonary and Critical Care Medicine Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Shinhee Park
- Department of Pulmonary and Critical Care Medicine Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Chang Min Choi
- Department of Pulmonary and Critical Care Medicine Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Jungmin Jo
- Department of Oncology/Hematology Daegu Catholic University Hospital Daegu Korea
| | - Jae Cheol Lee
- Department of Oncology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
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