The Contribution of Endobronchial Ultrasound-guided Forceps Biopsy in the Diagnostic Workup of Unexplained Mediastinal and Hilar Lymphadenopathy

Utility and safety of endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy (EBUS-TMC): A systematic review and meta-analysis

BACKGROUND

Modalities to improve tissue acquisition during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have been investigated. Endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy (EBUS-TMC) is a modality to obtain larger histological samples by inserting a cryoprobe into the mediastinal lesion. We aimed to study the diagnostic yield and safety of EBUS-TMC.

METHODS

We performed a systematic search of the PubMed and Embase databases to extract the relevant studies. We then performed a meta-analysis to calculate the diagnostic yield of EBUS-TMC and compare it with EBUS-TBNA.

RESULTS

Following a systematic search, we identified 14 relevant studies (869 patients undergoing EBUS-TMC and EBUS-TBNA). We then performed a meta-analysis of the diagnostic yield of EBUS-TMC and EBUS-TBNA from studies wherein both procedures were performed. The pooled diagnostic yield of EBUS-TMC was 92% (95% confidence interval [CI], 89%-95%). The pooled diagnostic yield of EBUS-TBNA was 81% (95% CI, 77%-85%). The risk difference in yield was 11% (95% CI, 6%-15%, I2 = 0%) when EBUS-TMC and EBUS-TBNA were compared. The only complication reported commonly with EBUS-TMC was minor bleeding. The complication rate was comparable with EBUS-TBNA.

CONCLUSION

EBUS-TMC provides a greater diagnostic yield with a similar risk of adverse events compared to EBUS-TBNA. Future studies are required to clearly establish which patients are most likely to benefit from this modality.

Endobronchial Ultrasound-Guided Transbronchial Mediastinal Cryobiopsy versus Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Mediastinal Disorders: A Meta-Analysis

INTRODUCTION

Endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy (EBUS-TMC), a novel technique, has been reported to improve the diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal lesions in recent studies. Current literature suggests that this procedure has greater diagnostic efficacy compared to conventional EBUS-TBNA. This systematic review and meta-analysis aimed to evaluate the diagnostic yield and complications associated with EBUS-TMC in comparison to EBUS-TBNA, thereby exploring the potential of this novel technique in enhancing the diagnostic utility for mediastinal lesions.

METHODS

A comprehensive literature review was conducted by searching the PubMed, Embase, and Google Scholar databases for articles published from inception to December 31, 2023. The objective of this review was to evaluate the utilization of EBUS-TMC in diagnosing mediastinal disease, while also assessing the quality of each study using the QUADAS-2 tool. The diagnostic yield estimates were subjected to a meta-analysis utilizing inverse variance weighting. Furthermore, a comprehensive analysis of the complications associated with this procedure was performed.

RESULTS

The meta-analysis included 10 studies involving a total of 538 patients. The findings of the meta-analysis demonstrated that EBUS-TMC yielded an overall diagnostic rate of 89.59% (482/538), while EBUS-TBNA yielded a rate of 77.13% (415/538). The calculated inverse variance-weighted odds ratio was 2.63 (95% confidence interval, 1.86-3.72; p < 0.0001), and I2 value was 11%, indicating a statistically significant difference between the two techniques. The associated complications consisted of pneumothorax, pneumomediastinum, mediastinitis, and bleeding, with an incidence of 0.74% (4/538), 0.37% (2/538), 0.0% (0/538), and 1.12% (6/538), respectively. Moreover, the funnel plot displayed no discernible publication bias. Further subgroup analysis revealed a notable improvement in the diagnosis value for lymphoma (86.36% vs. 27.27%, p = 0.0006) and benign disorder (87.62% vs. 60.00%, p < 0.0001).

CONCLUSION

This review of the current available studies indicated that EBUS-TMC enhanced overall diagnostic yields compared to EBUS-TBNA, particularly for diagnosing benign disease and lymphoma. This procedure was not associated with any serious complications.

Comparison of cryobiopsy and forceps biopsy for the diagnosis of mediastinal lesions: A randomised clinical trial

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard approach for lung cancer staging. However, its diagnostic utility for other mediastinal diseases might be hampered by the limited tissue retrieved. Recent evidence suggests the novel sampling strategies of forceps biopsy and cryobiopsy as auxiliary techniques to EBUS-TBNA, considering their capacity for larger diagnostic samples.

METHODS

This study determined the added value of forceps biopsy and cryobiopsy for the diagnosis of mediastinal diseases. Consecutive patients with mediastinal lesions of 1 cm or more in the short axis were enrolled. Following completion of needle aspiration, three forceps biopsies and one cryobiopsy were performed in a randomised pattern. Primary endpoints included diagnostic yield defined as the percentage of patients for whom mediastinal biopsy led to a definite diagnosis, and procedure-related complications.

RESULTS

In total, 155 patients were recruited and randomly assigned. Supplementing EBUS-TBNA with either forceps biopsy or cryobiopsy increased diagnostic yield, with no significant difference between EBUS-TBNA plus forceps biopsy and EBUS-TBNA plus cryobiopsy (85.7 % versus 91.6 %, P = 0.106). Yet, samples obtained by additional cryobiopsies were more qualified for lung cancer molecular testing than those from forceps biopsies (100.0 % versus 89.5 %, P = 0.036). When compared directly, the overall diagnostic yield of cryobiopsy was superior to forceps biopsy (85.7 % versus 70.8 %, P = 0.001). Cryobiopsies produced greater samples in shorter procedural time than forceps biopsies. Two (1.3 %) cases of postprocedural pneumothorax were detected.

CONCLUSIONS

Transbronchial mediastinal cryobiopsy might be a promising complementary tool to supplement traditional needle biopsy for increased diagnostic yield and tissue harvesting.

TRIAL REGISTRATION

ChiCTR2000030373.

Early experience of endobronchial ultrasound-guided transbronchial nodal cryobiopsy: a case series from Sabah, Malaysia

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established minimally invasive method for the diagnosis of benign and malignant conditions. Continuous efforts are underway to improve the material adequacy of EBUS-TBNA, including the introduction of a new technique called EBUS-guided transbronchial nodal cryobiopsy (EBUS-TBNC). This method allows for the retrieval of larger and well-preserved histologic samples from the mediastinum. We present a case series of four patients who underwent combined EBUS-TBNA and EBUS-TBNC procedures in our centre. All procedures were performed under general anaesthesia using a convex probe EBUS scope (Pentax EB-1970UK). Two patients were diagnosed with malignancy and two with benign disorders (silicosis and tuberculosis). In the malignant cases, both EBUS-TBNA/cell block and cryobiopsy provided a diagnosis but cryobiopsy yielded more material for ancillary tests in one patient. However, in the benign cases, there was discordance between EBUS-TBNA/cell block and cryobiopsy. Only cryobiopsy detected granuloma in the patient with TB (tuberculosis), and in the patient with silicosis, TBNC provided a better overall histological evaluation, leading to a definitive diagnosis. No complications were observed. This case series supports the potential diagnostic value of combining EBUS-TBNA and EBUS-TBNC, particularly in benign mediastinal lesions (granulomatous diseases), and in cases requiring additional molecular tests in cancer diagnosis.

What is new in mediastinal staging?

PURPOSE OF REVIEW

Appropriate staging is of utmost importance in nonsmall cell lung cancer (NSCLC), as the pathologic stage dictates both overall prognosis and appropriate therapeutic pathways. This article seeks to review the current recommendations for mediastinal staging of NSCLC and available modalities to achieve this. Landmark publications pertaining to recent advancements in NSCLC treatments are also highlighted and the role of specific bronchoscopic modalities for tissue acquisition are reviewed.

RECENT FINDINGS

Recent advancements in the treatment of NSCLC have made accurate mediastinal staging more important than ever. Guidelines and recommendations outlining patients that warrant invasive mediastinal staging are available and a systematic approach should be utilized when sampling is performed. Ensuring the adequacy of tissue for the growing number of molecular biomarkers that must be tested has been the focus of many recent studies.

SUMMARY

Appropriate mediastinal staging is crucial for the management of patients with NSCLC as is obtaining adequate tissue for diagnostic and therapeutic purposes. EBUS-TBNA is sufficient for the diagnosis of nonsmall cell and small cell lung carcinomas, but EBUS-guided intranodal forceps and cryobiopsy may provide more optimal specimen for patients with benign disease, such as sarcoidosis, or in cases of lymphoma. Further studies are necessary to better delineate the role of these techniques in the diagnosis and staging of mediastinal diseases before they become the primary diagnostic modalities.

Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations

Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.

The Utility of EBUS-Guided Transbronchial Forceps Biopsy With or Without an Electrocautery Knife for the Diagnosis of Mediastinal and Hilar Lymphadenopathy

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to have a high diagnostic yield for mediastinal and hilar lymph node sampling, particularly in diagnosing and staging non-small cell lung cancer. However, the diagnostic yield is lower in patients with granulomatous and lymphoproliferative disorders. We prospectively compared the feasibility, safety, and diagnostic yield of EBUS-guided lymph node forceps biopsy (EBUS-TBFB) with electrocautery knife compared to EBUS-TBNA of lymph nodes in patients with suspected granulomatous and lymphoproliferative disease.

METHODS

Patients over 18 years of age with mediastinal/hilar lymph node >10 mm in size in short axis (on CT chest) who had suspected sarcoidosis/lymphoma radiologically/clinically were included in the study. Patients had EBUS-TBNA first with 21 or 22G needles which were followed by biopsy of the node with small forceps (EBUS-TBFB) through the same aspiration site to obtain samples. Electrocautery knife at 20W was used in patients where mucosal penetration was difficult, followed by passage of forceps through that site.

RESULTS

A total of 30 patients were enrolled in the study, of which 25 patients underwent EBUS-TBFB. Eight patients had a history of lymphoma, one patient had history of squamous cell carcinoma, and one patient had history of chronic lymphocytic leukemia. A 22 gauge needle was used for aspiration in all the cases that were performed, and 1.5 mm or 1.8 mm forceps were used for the biopsy. The use of electrocautery knife at 20W (Olympus America Inc.) was required in 10/25 patients. The EC knife allowed all 10 of those to have successful entry of forceps into the lymph node. The cytology (aspiration from EBUS needle) and histopathology (from forceps) were concordant in 17 patients while it was discordant in eight patients. One patient developed pneumomediastinum after needle and forceps biopsy that required no intervention.

CONCLUSION

EBUS-guided forceps biopsy is a safe procedure. EC knife did successfully allow forceps entry into the lymph node in all EC knife procedures. The diagnostic yield was 73% (22/30) which improved to 86% (26/30) when both techniques were combined (TBNA and TBFB).

Transbronchial needle aspiration combined with cryobiopsy in the diagnosis of mediastinal diseases: a multicentre, open-label, randomised trial

BACKGROUND

Transbronchial mediastinal cryobiopsy is a novel sampling technique for mediastinal disease. Despite the possibility of lung cancer misdiagnosis, the improved diagnostic yield of this approach for non-lung-cancer lesions compared with standard endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) highlights its diagnostic potential as a complementary technique to conventional biopsy. We aimed to evaluate the safety profile and added value of the combined use of transbronchial mediastinal cryobiopsy and standard EBUS-TBNA for the diagnosis of mediastinal diseases.

METHODS

We conducted an open-label, randomised trial at three hospital sites in Europe and Asia. Eligible patients were aged 15 years or older, with at least one mediastinal lesion of 1 cm or longer in the short axis that required diagnostic bronchoscopy. Participants were randomly assigned (1:1) using a block randomisation scheme generated by a computer (block size of four participants based on a random table from an independent statistician) to the combined use of EBUS-TBNA and transbronchial mediastinal cryobiopsy (combined group) or EBUS-TBNA alone (control group). Because of the nature of the intervention, neither participants nor investigators were masked to group assignment. The coprimary outcomes were differences in procedure-related complications and diagnostic yield (defined as the proportion of participants for whom mediastinal biopsy led to a definitive diagnosis), assessed in the full analysis set, including all the patients who met the eligibility criteria and had a biopsy. A fully paired, intraindividual diagnostic analysis in participants who had both needle aspiration and mediastinal cryobiopsy was conducted, in addition to interindividual comparisons. This trial is now complete and is registered with ClinicalTrials.gov, NCT04572984.

FINDINGS

Between Oct 12, 2020, and Sept 9, 2021, 297 consecutive patients were assessed for eligibility and 271 were enrolled and randomly assigned to the combined group (n=136) or the control group (n=135). The addition of cryobiopsy to standard sampling significantly increased the overall diagnostic yield for mediastinal lesions, as shown by both interindividual (126 [93%] of 136 participants in the combined group vs 109 [81%] of 135 in the control group; risk ratio [RR] 1·15 [95% CI 1·04-1·26]; p=0·0039) and intraindividual (126 [94%] of 134 vs 110 [82%] of 134; RR 1·15 [95% CI 1·05-1·25]; p=0·0026) analyses. In subgroup analyses in the intraindividual population, diagnostic yields were similar for mediastinal metastasis (68 [99%] of 69 participants in the combined group vs 68 [99%] of 69 in the control group; RR 1·00 [95% CI 0·96-1·04]; p=1·00), whereas the combined approach was more sensitive than standard needle aspiration in benign disorders (45 [94%] of 48 vs 32 [67%] of 48; RR 1·41 [95% CI 1·14-1·74]; p=0·0009). The combined approach also resulted in an improved suitability of tissue samples for molecular and immunological analyses of non-small-cell lung cancer. The incidence of adverse events related to the biopsy procedure did not differ between trial groups, as grade 3-4 airway bleeding occurred in three (2%) patients in the combined group and two (1%) in the control group (RR 0·67 [95% CI 0·11-3·96]; p=1·00). There were no severe complications causing death or disability.

INTERPRETATION

The addition of mediastinal cryobiopsy to standard EBUS-TBNA resulted in a significant improvement in diagnostic yield for mediastinal lesions, with a good safety profile. These data suggest that this combined approach is a valid first-line diagnostic tool for mediastinal diseases.

FUNDING

National Natural Science Foundation of China.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endobronchial Ultrasound-Guided Transbronchial Forceps Biopsy: A Retrospective Bicentric Study Using the Olympus 1.5 mm Mini-Forceps

When evaluating mediastinal/hilar lymphadenopathy (LAD) or masses, guidelines recommend endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) as an initial technique for tissue analysis and diagnosis. However, owing to the small sample size obtained by needle aspiration, its diagnostic yield (DY) is limited. EBUS transbronchial forceps biopsy (TBFB) used as a complimentary technique to EBUS-TBNA might allow for better histopathological evaluation, thus improving DY. In this retrospective bicentric study, we assessed the DY and safety of an EBUS-guided 1.5 mm mini-forceps biopsy combined with EBUS-TBNA for the diagnosis of mediastinal/hilar LAD or masses compared to EBUS-TBNA alone. In total, 105 patients were enrolled. The overall DY was 61.9% and 85.7% for TBNA alone and EBUS-TBNA combined with EBUS-TBFB, respectively (p < 0.001). While the combined approach was associated with a significantly higher DY for lung cancer diagnosis (97.1% vs. 76.5%, p = 0.016) and sarcoidosis (85.2% vs. 44.4%, p = 0.001), no significant differences in DY were calculated for subgroups with smaller sample sizes such as lymphoma. No major adverse events were observed. Using a 1.5 mm mini-forceps is a safe and feasible technique for biopsy of mediastinal or hilar LAD or masses with superior overall DY compared to EBUS-TBNA as a standalone technique.

Flexible Bronchoscopy Biopsy Tools and Techniques to Optimize Diagnostic Yield: A Contemporary Review

Background:

Flexible bronchoscopy is essential in diagnosing many pathologic conditions, and tools such as lavage and biopsies using brushes, forceps, and needles are paramount to success.

Introduction:

Bronchoscopists worldwide are routinely confronted with questions about such tools regarding the type, size, utility, costs, safety, anticipated yield, and others. Does the underlying suspected condition matter to the choice of instruments used? What is the anticipated outcome for benign versus malignant diseases? These and other questions are raised daily by bronchoscopists.

Methods:

Pubmed was reviewed for research in the English language pertaining to diagnostic bronchoscopy. The literature is conflicting on the benefits of the types of tools available. The success of brush biopsies, forceps, and transbronchial needle aspiration is only partially dependent on the size of the instrument used or its other characteristics. Multiple biopsies are needed, and different approaches may be complementary in some circumstances.

Results:

By understanding the factors that involve in a biopsy, the bronchoscopist is more likely to be successful when a crucial diagnosis is mandatory.

Conclusion:

This review aims to be a reference to bronchoscopists everywhere as they contemplate their approach to flexible diagnostic bronchoscopy.

Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal lesions: a randomised trial

BACKGROUND

Guidelines recommend endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as an initial investigation technique for mediastinal nodal staging in lung cancer. However, EBUS-TBNA can be limited by the inadequacy of intact tissues, which might restrict its diagnostic yield in mediastinal lesions of certain etiologies. We have previously shown that EBUS-guided transbronchial mediastinal cryobiopsy can provide intact samples with greater volume.

METHODS

This randomised study determined the diagnostic yield and safety of transbronchial mediastinal cryobiopsy monitored by endosonography for the diagnosis of mediastinal lesions. Patients with mediastinal lesion of 1 cm or more in the short axis were recruited. Following identification of the mediastinal lesion by linear EBUS, fine-needle aspiration and cryobiopsy were sequently performed in a randomised order. Primary endpoints were diagnostic yield defined as the percentage of patients for whom mediastinal biopsy provided a definite diagnosis, and procedure-related adverse events.

RESULTS

One hundred and ninety-seven patients were enrolled and randomly allocated. The overall diagnostic yield was 79.9% and 91.8% for TBNA and transbronchial mediastinal cryobiopsy, respectively (p=0.001). Diagnostic yields were similar for metastatic lymphadenopathy (94.1% versus 95.6%, p=0.58), while cryobiopsy was more sensitive than TBNA in uncommon tumors (91.7% versus 25.0%, p=0.001) and benign disorders (80.9% versus 53.2%, p=0.004). No significant differences in diagnostic yield were detected between TBNA first and cryobiopsy first groups. We observed 2 cases of pneumothorax and 1 case of pneumomediastinum.

CONCLUSIONS

Transbronchial cryobiopsy performed under EBUS guidance is a safe and useful approach that offers diagnostic histological samples of mediastinal lesions.

Interventional Pulmonology: Diagnostic and Therapeutic Advances in Bronchoscopy

BACKGROUND

Interventional pulmonology is a rapidly evolving subspecialty of pulmonary medicine that offers advanced consultative and procedural services to patients with airway diseases, pleural diseases, as well as in the diagnosis and management of patients with thoracic malignancy.

AREAS OF UNCERTAINTY

The institution of lung cancer screening modalities as well as the search of additional minimally invasive diagnostic and treatment modalities for lung cancer and other chronic lung diseases has led to an increased focus on the field of interventional pulmonology. Rapid advancements in the field over the last 2 decades has led to development of various new minimally invasive bronchoscopic approaches and techniques for patients with cancer as well as for patients with chronic lung diseases.

DATA SOURCES

A review of literature was performed using PubMed database to identify all articles published up till October 2020 relevant to the field of interventional pulmonology and bronchoscopy. The reference list of each article was searched to look for additional articles, and all relevant articles were included in the article.

THERAPEUTIC ADVANCES

Newer technologies are now available such navigation platforms to diagnose and possibly treat peripheral pulmonary nodules, endobronchial ultrasound in diagnosis of mediastinal and hilar adenopathy as well as cryobiopsy in the diagnosis of diffuse lung diseases. In addition, flexible and rigid bronchoscopy continues to provide new and expanding ability to manage patients with benign and malignant central airway obstruction. Interventions are also available for diseases such as asthma, chronic bronchitis, chronic obstructive pulmonary disease, and emphysema that were traditionally treated with medical management alone.

CONCLUSIONS

With continued high quality research and an increasing body of evidence, interventional bronchoscopy has enormous potential to provide both safe and effective options for patients with a variety of lung diseases.

Combined EBUS-IFB and EBUS-TBNA vs EBUS-TBNA alone for intrathoracic adenopathy: A Meta-analysis

BACKGROUND

Endobronchial ultrasound (EBUS) guided intranodal forceps biopsy (IFB) is considered complimentary to EBUS-TBNA for patients with intrathoracic lymphadenopathy when either additional tissue is requested for comprehensive molecular testing, or for suspected lymphoma and sarcoidosis. This is a systematic review and meta-analysis to investigate the diagnostic yield and complications of combined EBUS-IFB and EBUS-TBNA compared to EBUS-TBNA alone.

METHODS

We performed a systematic search of MEDLINE, Embase, and Google Scholar for studies evaluating the use of EBUS-IFB for diagnosis of intrathoracic adenopathy, assessing the quality of each study using the QUADAS-2 tool. Using inverse-variance weighting, we performed a meta-analysis of diagnostic yield estimations. We also reviewed the complications related to the procedure.

RESULTS

Six observational studies with 443 patients undergoing 467 biopsies were included in the final analysis. Meta-analysis yielded a pooled overall diagnostic yield of 67% (312/467) for EBUS-TBNA and 92% (428/467) for EBUS-TBNA + EBUS-IFB, with an inverse variance - weighted OR of 5.87 (95% CI, 3081 to 9.04, p<0.00001) and an I ²of 15%. The overall complications included pnuemomediastinum (1%), bleeding (0.8%) and respiratory failure (0.6%). The funnel plot analysis illustrated no major publication bias. Subgroup analysis showed increased diagnostic yield for lymphoma (86% vs 30%, p=0.03) and sarcoidosis (93% vs 58%, p<0.00001).

CONCLUSIONS

The addition of EBUS-IFB to EBUS-TBNA improves the overall diagnostic yield of sampling intrathoracic adenopathy when compared to EBUS-TBNA alone. The complication rates of the combined approach are higher than with EBUS-TBNA, but are reportedly lower than with transbronchial or surgical biopsies.

Endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB)-technical review

Endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) have changed the landscape of pulmonology. Mediastinal structures beyond the confines of airway walls are visualized in real-time with EBUS, leading to improved accuracy of tissue sampling and diagnostic yield. With the development of various needle sizes ranging from 25-G to 19-G, the sampling of lymph nodes is becoming easier and more commonplace. Yet, certain conditions such as sarcoidosis and lymphoma may still be difficult to diagnose via EBUS-TBNA. Furthermore, in the age of targeted therapy, there are more demands on EBUS-TBNA samples for molecular marker testing and next-generation sequencing. Here, we present a complementary methodology, EBUS-guided intranodal forceps biopsy (EBUS-IFB), for tissue acquisition that may help address these deficiencies. Specifically, we aim to propose indications, contraindications, outline approaches in performing IFB, and provide an overview of the data for this complementary technique.

Biopsy needles for mediastinal lymph node sampling by endosonography: current knowledge and future perspectives

Due to the increasing role of endosonography [endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound-guided fine needle aspiration (EUS-FNA)] in the diagnosis of several lung diseases, the knowledge of technical aspects is mandatory to optimize the success of the procedure. Among those technicalities related to the procedure, the choice of a needle over another one-either in terms of dimension and type-may have a role in the diagnostic process, especially in some diseases such as lymphoproliferative disorders. In this review, we analyze the current knowledge about the biopsy needle for endosonography, providing also some hints for the future.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Pilot Study to Evaluate the Utility of the ProCore Biopsy Needle for Lymph Node Sampling

OBJECTIVE

The ProCore ultrasound biopsy needle, used primarily to obtain intra-abdominal tissue core biopsies, has not been widely used for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In this pilot study we evaluated the utility of the ProCore needle for sampling mediastinal or hilar lymph nodes during EBUS-TBNA.

DESIGN

Thirty-two patients were identified using both ProCore and conventional fine-needle aspiration (FNA) needles for sampling mediastinal or hilar lymph nodes (the study group). Another 33 patients underwent EBUS-TBNA using an FNA needle only (the control group). Specimen satisfactory rates were compared between the study and control groups. Aspirate smears and cell blocks were evaluated for the cellularity of lesional cells and bronchial contamination in a subset of patients in the study group.

RESULTS

Overall, the ProCore needle did not show additive value to specimen adequacy when comparing the satisfactory rates of the study and control groups (94 vs. 89%). The ProCore needle also did not procure significantly more lesional cells than the FNA needle.

CONCLUSION

Our experience shows that the ProCore needle does not provide additive value when performing an FNA of mediastinal or hilar lymph nodes. The evaluation of more cases with this new technique is necessary to better determine the clinical utility of using ProCore during EBUS-TBNA.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Localized Subcarinal Adenitis following Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure for the diagnosis of mediastinal lymph nodes and masses. Its complications are rare and include hemorrhage, pneumothorax and infections such as mediastinitis. We report the case of a 51-year-old patient who presented with a localized subcarinal adenitis after EBUS-TBNA. Germs colonizing the oropharynx may have been dragged along by the echobronchoscope, inoculating the punctured mediastinal lymph node.

Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging: early experience in Brazil

Objective:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe and accurate method for collecting samples from mediastinal and hilar lymph nodes. This study focused on the initial results obtained with EBUS-TBNA for lung cancer and lymph node staging at three teaching hospitals in Brazil.

Methods:

This was a retrospective analysis of patients diagnosed with lung cancer and submitted to EBUS-TBNA for mediastinal lymph node staging. The EBUS-TBNA procedures, which involved the use of an EBUS scope, an ultrasound processor, and a compatible, disposable 22 G needle, were performed while the patients were under general anesthesia.

Results:

Between January of 2011 and January of 2014, 149 patients underwent EBUS-TBNA for lymph node staging. The mean age was 66 ± 12 years, and 58% were male. A total of 407 lymph nodes were sampled by EBUS-TBNA. The most common types of lung neoplasm were adenocarcinoma (in 67%) and squamous cell carcinoma (in 24%). For lung cancer staging, EBUS-TBNA was found to have a sensitivity of 96%, a specificity of 100%, and a negative predictive value of 85%.

Conclusions:

We found EBUS-TBNA to be a safe and accurate method for lymph node staging in lung cancer patients.

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

RATIONALE

Conventional transbronchial needle aspiration (TBNA) and endobronchial ultrasound (EBUS)-TBNA are widely accepted tools for the diagnosis and staging of lung cancer and the initial procedure of choice for staging. Obtaining adequate specimens is key to provide a specific histologic and molecular diagnosis of lung cancer.

OBJECTIVES

To develop practice guidelines on the acquisition and preparation of conventional TBNA and EBUS-TBNA specimens for the diagnosis and molecular testing of (suspected) lung cancer. We hope to improve the global unification of procedure standards, maximize the yield and identify areas for research.

METHODS

Systematic electronic database searches were conducted to identify relevant studies for inclusion in the guideline [PubMed and the Cochrane Library (including the Cochrane Database of Systematic Reviews)].

MAIN RESULTS

The number of needle aspirations with both conventional TBNA and EBUS-TBNA was found to impact the diagnostic yield, with at least 3 passes needed for optimal performance. Neither needle gauge nor the use of miniforceps, the use of suction or the type of sedation/anesthesia has been found to improve the diagnostic yield for lung cancer. The use of rapid on-site cytology examination does not increase the diagnostic yield. Molecular analysis (i.e. EGFR, KRAS and ALK) can be routinely performed on the majority of cytological samples obtained by EBUS-TBNA and conventional TBNA. There does not appear to be a superior method for specimen preparation (i.e. slide staining, cell blocks or core tissue). It is likely that optimal specimen preparation may vary between institutions depending on the expertise of pathology colleagues.

A pitfall during endobronchial ultrasound-guided transbronchial forceps biopsy of the mediastinal lymph nodes

The high diagnostic yield and favorable safety profile of endobronchial ultrasound-guided transbronchial forceps biopsy of the mediastinal lymph nodes have been recently demonstrated. We report an unusual technical problem during endobronchial ultrasound-guided transbronchial forceps biopsy that could be a prerequisite for severe complications. A rupture of the steering band precluded closure of the forceps jaws opened in the subcarinal lymph node. A solution to the problem is presented, together with other procedure-related complications reported in the literature. The report emphasizes that a dysfunction of the forceps steering band can result in severe complications when it occurs during transbronchial sampling of mediastinal lesions.

The cryo-needle: a new tool for histological biopsies. A feasibility study

PURPOSE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard procedure for intrathoracic lymph node biopsies. The newly developed cryo-needle operates in a similar way to the EBUS-TBNA but is able to obtain specimens for histological evaluation. The purpose of this animal study was to evaluate the feasibility, effect, and safety of the cryo-needle biopsies.

METHODS

Four EBUS-guided cryo-needle biopsies were obtained from a mediastinal lymph node of a healthy pig. In an open surgery approach, cryo-needle biopsies using activation times of 1, 2, and 3 s (A1/A2/A3) and needle biopsies using a 21-gauge EBUS-TBNA needle were obtained from mesenteric lymph nodes. Cryo-needle biopsies A2 were performed with (A2+) and without (A2-) an oversheath. The size, weight, percentage of lymphatic tissue and artefact-free area of each cryobiopsy were evaluated. Smears were made with the TBNA-needle aspirates to determine the number of lymphocytes per high-power field (HPF). The bleeding duration was measured.

RESULTS

We successfully obtained EBUS-guided cryo-needle biopsies. The area and weight of the biopsies A3 and A2+ were significantly larger compared with A1 (1.7 ± 0.8 and 1.4 ± 0.3 vs. 0.9 ± 0.4 mm(2); 5.2 ± 2.4 and 3.4 ± 1.8 vs. 1.5 ± 0.7 mg). The percentage of lymphatic tissue of the cryobiopsies was 90 ± 25 and 98 % of samples were artefact-free. The number of lymphocytes/HPF of TBNA-needle smears was 128 ± 54.3. There was no difference in bleeding duration between the techniques.

CONCLUSIONS

The cryo-needle yields large histological specimens of high quality.