The efficacy of EBUS-guided transbronchial needle aspiration for molecular testing in lung adenocarcinoma

Physician-led thoracic ultrasound-guided biopsy; a district general hospital perspective

BACKGROUND

Physician-led thoracic ultrasound (TUS)-guided biopsies provide a prompt route to tissue diagnosis in pleural and peripheral lung malignancies. This retrospective study reviews the diagnostic performance and safety of this approach in a UK District General Hospital.

METHODS

Time to biopsy, diagnostic yield and complication rate were analysed in a cohort of 49 patients undergoing ultrasound-guided tissue sampling between September 2019 and December 2022.

RESULTS

Fifty-one TUS-guided biopsies were attempted. Mean time from decision to biopsy was 5 days. The overall diagnostic yield was 82%. Complication rate was low; 3 minor adverse effects were reported which led to no change in routine care.

CONCLUSION

This single centre retrospective study shows that physician-led TUS-guided biopsy provides a safe and timely method of obtaining a tissue diagnosis in thoracic malignancy. It offers an alternative to computer tomography (CT)-guided or thoracoscopic biopsies and should be considered in selected patients where local procedural expertise exists.

Prospective Optimization of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Lymph Node Assessment for Lung Cancer: Three Needle Agitations Are Noninferior to 10 Agitations for Adequate Tumor Cell and DNA Yield

Introduction

Methods

Results

Conclusions

Utilization of High-pressure Suction for EBUS-TBNA Sampling in Suspected Lung Cancer

BACKGROUND

Sample adequacy for immediate molecular testing is paramount in lung cancer. To date, several endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) sampling setups have been evaluated, however, the utilization of high-pressure suction (HPS) has not yet been reported.The aim of this study was to evaluate the utilization of HPS onto the needle and its effect on sample volume and adequacy for molecular testing in patients with suspected lung cancer.

METHODS

We retrospectively analyzed 128 consecutive EBUS-TBNA performed for suspected lung cancer. This was confirmed in 109 patients. Other diagnoses confirmed in 12, and 7 referred for surgery. Sixty-three patients (89 targets) had HPS (May to September 2020), and compared with 46 (72 targets) who had standard vacuum syringe suction (October 2019 to March 2020). Several parameters and outcomes evaluated, such as number of needle passes, needle strokes, needle size, target size, positron emission tomography avidity, procedure time, blood content score, sample volume, adequacy for molecular testing, as well as baseline patient characteristics and complication rate.

RESULTS

There was no difference between the 2 groups in all baseline parameters and characteristics. In multivariable analysis, HPS was associated with significantly higher sample volume (11.2 vs. 9.1 mm3, P=0.036) and less additional procedures to achieve full molecular profiling (2/52 vs. 7/40, P=0.042), in necrotic targets of non-small cell lung cancer. Diagnostic yields were comparable.

CONCLUSION

HPS appears to be simple, no-cost, and safe, promising higher sample volume compared with vacuum syringe suction, and also appears to be associated with higher success of full molecular testing with less additional procedures, in non-small cell lung cancer necrotic targets.

The Value and Limitations of Cell Blocks in Endobronchial Ultrasound-Guided Fine-Needle Aspiration Cytology: Experience of a Tertiary Care Center in North India

Background:

Endobronchial ultrasound (EBUS)-guided fine-needle aspiration cytology (FNAC) is recommended for diagnosing bronchial neoplasms and evaluating mediastinal lymph nodes. However, it may not be possible to subtype or definitely categorize many bronchial neoplasms on FNAC smears alone. Obtaining adequate diagnostic material is often a problem. In such cases, cell blocks made from FNAC material may serve as a useful adjunct. Aim: To study the value and limitations of cell blocks in adding diagnostic information to EBUS guided FNAC smears.

Material and Methods:

One hundred and eighty-five cases of EBUS guided FNAC having concomitant cell blocks were reviewed. The cases were evaluated for the extent of adequacy, of definite benign/malignant categorization and of definite subtyping in malignant tumors in these cases. The proportion of cases in which cell blocks added information to FNAC smears alone for the above parameters were calculated.

Results:

Cell blocks provided additional information in 31 out of 185 cases. Cell blocks were necessary for subtyping 24/59 malignant tumors, definite categorization into benign and malignant in 10/140 adequate samples, and increasing adequacy in 6/185 total samples. A total of 45 samples were inadequate in spite of adding information from cell blocks to smears.

Conclusion:

Cell blocks added clinically significant information to EBUS guided FNAC and should be used routinely. To make it more useful, alternative methods of cell block preparation (including proprietary methods) may be evaluated.

Conventional Transbronchial Needle Aspiration (cTBNA) and EBUS-Guided Transbronchial Needle Aspiration (EBUS-TBNA): A Retrospective Study on the Comparison of the Two Methods for Diagnostic Adequacy in Molecular Analysis

Introduction: In recent years, there has been a growing development of molecularly targeted therapies for various types of solid tumors—in particular, in non-small-cell lung cancer (NSCLC). This has required the need for greater quantities of tissue that is able to support ancillary studies, alongside cyto-histological diagnoses for the assessment of molecular targets. Conventional TBNA (cTBNA) and EBUS-guided TBNA (EBUS-TBNA) have shown a high diagnostic yield for malignant mediastinal and/or hilar lymph node enlargement and peribronchial masses; however, few studies have compared these two procedures. We retrospectively compared TBNA patients (EBUS-TBNA and cTBNA) in order to determine the diagnostic yield and material adequacy for subsequent ancillary analyses. Materials and Methods: We retrospectively evaluated 318 patients with clinical suspicion of lung cancer or with disease recurrence. All of the patients underwent TBNA (either EBUS-TBNA or cTBNA) on enlarged mediastinal and/or hilar lymph nodes and peribronchial masses between January 2017 and June 2021 at the University Hospital of Pisa, Italy. After a definitive diagnosis, molecular analyses and an evaluation of PD-L1 expression were performed in the cases of adenocarcinoma, squamous cell carcinoma, and NSCLC, not otherwise specified (NOS). Results: EBUS-TBNA was performed in 199 patients and cTBNA was performed in 119 patients with 374 and 142 lymph nodes, respectively. The overall diagnostic yield for positive diagnoses was 59% (diagnostic rate of 61% in EBUS-TBNA, and 55% in cTBNA). Adenocarcinoma (ADC) was the most frequent diagnosis in both methods. EBUS-TBNA diagnostic adequacy was 72% for molecular analysis, while it was 55.5% for cTBNA, showing a statistical trend (p = 0.08) towards the significance of EBUS. The average percentage of neoplastic cells was also statistically different between the two methods (p = 0.05), reaching 51.19 ± 22.14 in EBUS-TBNA and 45.25 ± 22.84 in cTBNA. With regard to the PD-L1 protein expression, the percentage of positivity was similar in both procedures (86% in EBUS-TBNA, 85% in cTBNA). Conclusions: Conventional TBNA (cTBNA) and EBUS-guided TBNA (EBUS-TBNA) are minimally invasive diagnostic methods that are associated with a high diagnostic yield. However, EBUS-TBNA has an improved diagnostic adequacy for molecular analysis compared to cTBNA, and is associated with a higher average percentage of neoplastic cells.

Mediastinal lymphadenopathy: a practical approach

Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.

EBUS-TBNA Cytological Samples for Comprehensive Molecular Testing in Non-Small Cell Lung Cancer

Clinical guidelines promote the identification of several targetable biomarkers to drive treatment decisions in advanced non-small cell lung cancer (NSCLC), but half of all patients do not have a viable biopsy. Specimens from endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) are an alternative source of material for the initial diagnosis of NSCLC, however their usefulness for a complete molecular characterization remains controversial. EBUS-TBNA samples were prospectively tested for several biomarkers by next-generation sequencing (NGS), nCounter, and immunohistochemistry (PD-L1). The primary objectives were to assess the sensitivity of EBUS-TBNA samples for a comprehensive molecular characterization and to compare its performance to the reference standard of biopsy samples. Seventy-two EBUS-TBNA procedures were performed, and 42 NSCLC patients were diagnosed. Among all cytological samples, 92.9% were successfully genotyped by NGS, 95.2% by nCounter, and 100% by immunohistochemistry. There were 29 paired biopsy samples; 79.3% samples had enough tumor material for genomic genotyping, and 96.6% for PD-L1 immunohistochemistry. A good concordance was found between both sources of material: 88.9% for PD-L1, 100% for NGS and nCounter. EBUS-TBNA is a feasible alternative source of material for NSCLC genotyping and allows the identification of patient candidates for personalized therapies with high concordance when compared with biopsy.

Oncogenic gene transcripts detection by FISH on liquid-based cytology slides of 338 advanced lung cancer patients

INTRODUCTION

Oncogenic gene transcripts in advanced lung cancer are a strong indication for targeted therapy. Cytology specimens are often the only materials available for oncogenic fusion analysis. This prospective study is to evaluate the feasibility of anaplastic lymphoma kinase (ALK) gene rearrangements, ROS oncogene 1 (ROS-1), and c-mesenchymal-epidermal transformation (c-MET) detected by fluorescence in situ hybridization (FISH) using liquid-based cytology (LBC) slides.

MATERIALS AND METHODS

Consecutive cytology specimens including fine-needle aspiration biopsy (FNAB) and serous effusions from 338 advanced lung cancer patients were collected between March 1, 2015, and July 6, 2016. The correlation between ALK, ROS-1, c-MET, and other common driver gene abnormalities and the therapeutic response to crizotinib in ALK-positive patients were also evaluated.

RESULTS

ALK fusion transcripts were detected in 31 of 338 patients (9.17%). Twenty-two of the 31 ALK-positive patients were treated with crizotinib at our institution (2 were lost to follow-up), and the overall response rate was 75.0 % (15 of 20); disease control rate was 90.0% (18 of 20). FISH analyses for ROS-1 and c-MET were performed on 75 and 73 patients, respectively, and showed 3 patients positive for ROS-1 and 3 positive for c-MET. These positive cases were all ALK-negative.

CONCLUSION

For patients with advanced lung cancer, LBC slides are suitable for detecting oncogenic gene transcripts, and the results can provide a reliable guideline for targeted therapy.

Molecular analysis in cytological samples obtained by endobronchial or oesophageal ultrasound guided needle aspiration in non-small cell lung cancer

INTRODUCTION

Cytological samples obtained by endobronchial ultrasound (EBUS) are capital for diagnosis, staging and molecular profile in non-small cell lung carcinoma (NSCLC).

OBJECTIVE

To assess the success rate of complete, partial and individual of molecular analysis in samples obtained by EBUS-guided transbronchial needle aspiration (TBNA) and/or by oesophageal ultrasound-guided fine needle aspiration with an echobronchoscope (EUS-B-FNA) in patients with NSCLC.

METHODS

Prospective study including 90 patients with non-squamous NSCLC, or non-smoking squamous. Cytological samples were classified into two groups. Group 1: PEN membrane slide and/or cell blocks for the determination of mutations of EGFR, KRAS, ERBB2 and BRAF. Group 2: silane coated slides or cell blocks for rearrangements of ALK, ROS1 and MET amplification.

RESULTS

The success rate was 78.6% for 4 molecular alterations (EGFR, KRAS, ALK and ROS1), and 44% for 7 determinations. The individual success rate for EGFR was 97%, KRAS 96.3%, ALK 85%, ROS1 82.3%, ERBB2 71.4%, BRAF 67.7% and MET 81.1%. There were no significant differences (p=0.489) in the number of molecular analyses (1-3 vs. 4) in group 1, depending on the types of samples (cell block vs. PEN membrane slide vs. cell block and PEN membrane slide).

CONCLUSIONS

In patients with NSCLC, the cytological material obtained by ultrasound-guided needle aspiration is sufficient for individual and partial molecular analysis in the vast majority of cases. Membrane slides such as cell blocks are valid samples for molecular analysis.

State of the Art: Toward Improving Outcomes of Lung and Liver Tumor Biopsies in Clinical Trials-A Multidisciplinary Approach

PURPOSE

National Cancer Institute (NCI)-sponsored clinical trial network studies frequently require biopsy specimens for pharmacodynamic and molecular biomarker analyses, including paired pre- and post-treatment samples. The purpose of this meeting of NCI-sponsored investigators was to identify local institutional standard procedures found to ensure quantitative and qualitative specimen adequacy.

METHODS

NCI convened a conference on best biopsy practices, focusing on the clinical research community. Topics discussed were (1) criteria for specimen adequacy in the personalized medicine era, (2) team-based approaches to ensure specimen adequacy and quality control, and (3) risk considerations relevant to academic and community practitioners and their patients.

RESULTS AND RECOMMENDATIONS

Key recommendations from the convened consensus panel included (1) establishment of infrastructure for multidisciplinary biopsy teams with a formalized information capture process, (2) maintenance of standard operating procedures with regular team review, (3) optimization of tissue collection and yield methodology, (4) incorporation of needle aspiration and other newer techniques, and (5) commitment of stakeholders to use of guideline documents to increase awareness of best biopsy practices, with the goal of universally improving tumor biopsy practices.

Novel ProCore 25-gauge needle for endobronchial ultrasound-guided transbronchial needle aspiration reduces the puncture time and frequency, with comparable diagnostic rate for mediastinal and hilar lymphadenopathy

Background

The ProCore 25‐gauge needle is a novel specifically designed puncture needle for endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA), which may improve the puncture efficiency of the procedure while ensuring the diagnostic rate. The aim of the present study was to evaluate the diagnostic accuracy, mRNA yield, and complication rate of 25‐gauge needles compared to those of 22‐gauge needles in the evaluation of mediastinal and hilar lymphadenopathy.

Methods

A total of 39 patients undergoing EBUS‐TBNA at our institution were evaluated. All the procedures were performed by an experienced endoscopist formally trained in interventional pulmonology. Both the traditional 22‐gauge and ProCore 25‐gauge needles were used at each lymph node station. For all specimens obtained via EBUS‐TBNA, 50 μL was used to extract mRNA and detect the RNA concentration, whereas the other part was sent to the pathological evaluation. χ² test and t‐test were performed to determine the differences between the two types of the needles. A P‐value of <0.05 was considered significant.

Results

A total of 88 lymph nodes were punctured by the two needles separately. The diagnostic accuracy for each puncture between the two needles did not show any significant difference (P > 0.05). No serious procedure‐related complications were reported. In addition, the mRNA concentration did not differ between the two types of needles (P > 0.05).

Conclusion

The ProCore 25‐gauge needle gained a similar diagnostic yield with less puncture time and frequency compared with the 22‐gauge needle.

Adequacy of Samples Obtained by Endobronchial Ultrasound with Transbronchial Needle Aspiration for Molecular Analysis in Patients with Non-Small Cell Lung Cancer. Systematic Review and Meta-Analysis

RATIONALE

Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) are commonly used for the diagnosis and mediastinal staging of lung cancer. Molecular markers are becoming increasingly important in patients with lung cancer to define targetable mutations suitable for personalized therapy, such as epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), reactive oxygen species proto-oncogene (ROS1), and programmed death-ligand 1 (PD-L1).

OBJECTIVES

To evaluate the adequacy of EBUS-TBNA-derived tissue for molecular analysis.

METHODS

We searched the MEDLINE, LILACS, www.clinicaltrials.gov , and Epistemonikos databases through January 2018.

DATA EXTRACTION

Two independent reviewers performed the data search, quality assessment, and data extraction. We included both prospective and retrospective studies; risk of bias was evaluated using the ROBINS-I tool. The primary outcome was the proportion of adequate samples obtained by EBUS-TBNA for molecular analysis. Data were pooled by using a binary random effects model. Finally, evidence was rated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

RESULTS

A total of 33 studies including 2,698 participants were analyzed. In 28 studies that evaluated EBUS-TBNA for the identification of EGFR mutations, the pooled probability of obtaining a sufficient sample was 94.5% (95% confidence interval CI], 93.2-96.4%). For identification of ALK mutations, the pooled probability was 94.9% (95% CI, 89.4-98.8%). Finally, the prevalence of EGFR mutation was 15.8% (95% CI, 12.1-19.4%), and the prevalence of ALK mutation was 2.77% (95% CI, 1.0-4.8%). Data for ROS1 and PD-L1 mutations were not suitable for meta-analysis.

CONCLUSIONS

EBUS-TBNA has a high yield for molecular analysis of both EGFR and ALK mutations. However, the suitability of TBNA samples for next-generation sequencing is uncertain and should be explored in further studies. Clinical trial registered with PROSPERO (CRD42017080008).

Adequacy of endosonography-derived samples from peribronchial or periesophageal intrapulmonary lesions for the molecular profiling of lung cancer

INTRODUCTION AND OBJECTIVES

Endosonography is increasingly used for the diagnosis of centrally located, bronchoscopically invisible intrapulmonary lesions, but data regarding its utility for molecular profiling are lacking. We aimed to assess the suitability of endosonography samples obtained from intrapulmonary lesions for cancer genotyping and programmed-death ligand 1 (PD-L1) testing.

METHODS

A prospectively collected database regarding 99 consecutive patients undergoing endosonography for the diagnosis of an intrapulmonary lesion was retrospectively reviewed. Genotyping ± PD-L1 testing was carried out in the 53 patients with advanced lung cancer and was classified as complete if all clinically indicated tests could be performed, incomplete if at least one test could not be carried out, and unsuccessful if the sample was unsuitable for molecular analysis.

RESULTS

All clinically indicated biomarkers could be tested in 44 (83%) patients, whereas the molecular profiling was classified as incomplete in 6 (11.3%), and unsuccessful in 3 (5.7%). Thirty-seven genetic alterations (KRAS mutation, 17; EGFR mutation, 17; ALK rearrangement, 3) and 2 cases of PD-L1 expression >50% were found in 31 (58%) patients. EGFR was successfully analysed in 94.1% of cases, KRAS in 93.9%, ALK in 89%, ROS1 in 90% and PD-L1 in 63.1%.

CONCLUSION

Endosonography-derived samples from intrapulmonary lesions were suitable for a thorough molecular profiling in most patients. The few cases of incomplete accomplishment of the testing algorithm were related to the failure of PD-L1 analysis due to the exhaustion of the sample or the lack of sufficient tumour cells in the paraffin-embedded material.

Adequacy of EBUS-TBNA specimen for mutation analysis of lung cancer

OBJECTIVE

Convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a minimally invasive technique with high sensitivity in the mediastinal staging of non-small cell carcinoma (NSCLC). In recent years, molecular testing has been developed to study genetic mutations in NSCLC. There are studies revealing improved survival in advanced NSCLC using targeted therapy as the first-line treatment in these patients. The aim of this study was to evaluate the adequacy of EBUS-TBNA in providing adequate size specimens for EGFR, ALK and ROS1 genetic mutation analysis in patients with adenocarcinoma or not otherwise specified (NOS) lung cancer.

MATERIALS AND METHODS

Charts of patients diagnosed with lung adenocarcinoma or NOS via EBUS-TBNA were retrospectively reviewed. Information on patient demographics, number of lymph nodes sampled, their size and location, targeted gene mutations and the adequacy of the material sampled for the molecular testing was recorded.

RESULTS

A total of 114 patients were included in the study, adenocarcinoma 86 (75%) and NOS 28 (25%). EGFR gene mutation was studied in all of the patients included in the study while ALK in 113 and ROS1 in 98. The material adequacy ratios for EGFR gene mutation, ALK and ROS1 rearrangements were found to be 88.6%, 93.8% and 91.8%, respectively. EGFR gene mutation, ALK and ROS1 rearrangements were found positive in 13 (11.4%), 9 (8%) and 1 (1%) patients, respectively.

CONCLUSION

The study demonstrated that EBUS-TBNA provides adequate material for mutation analysis in patients with newly diagnosed adenocarcinoma or NOS lung cancer.

PD-L1 testing on the EBUS-FNA cytology specimens of non-small cell lung cancer

OBJECTIVES

The FDA approved PD-L1 tests for anti-PD-L1 immunotherapy are for surgical or histology specimens. It is not clear if cytology specimens could be used for PD-L1 testing to guide immunotherapy. In this study, we assess the suitability of EBUS-FNA cytology specimens for the testing of PD-L1.

MATERIALS AND METHODS

Consecutive patients with Non-small cell lung cancer (NSCLC) underwent EBUS procedure between January 1, 2017 and March 31, 2018 for PD-L1 testing were included. The cell blocks of EBUS-FNA cytology specimens were used for PD-L1 testing using Dako 22C3 phamDx antibody according to the Dako protocol. PD-L1 protein expression in tumor cells is determined by using Tumor Proportion Score (TPS).

RESULTS AND CONCLUSION

Of the 265 EBUS-FNA specimens from 262 patients sent for testing, 230 (86.8%) were adequate for PD-L1 testing. Of the 34 NSCLC patients with both histology and EBUS-FNA cytology specimens tested for PD-L1, the results from different specimen types had a concordance of 91.3%. The PD-L1 results from 16 paired specimens from the same anatomic site had 100% agreement. The rates of PD-L1 TPS ≥ 50% were significantly higher in the metastatic tumors in the lymph nodes than in the lung primary lesions. Therefore, EBUS-FNA cytology specimen is suitable for PD-L1 testing in patients with advanced NSCLC. The metastatic tumors in mediastinal lymph nodes appear to have higher PD-L1 expression than primary lesions.

Heterogeneity analysis of PD-L1 expression and copy number status in EBUS-TBNA biopsy specimens of non-small cell lung cancer: Comparative assessment of primary and metastatic sites

OBJECTIVES

Most patients with non-small cell lung cancer (NSCLC) are diagnosed at advanced stages where small biopsy specimens obtained through endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are sometimes the only available samples for diagnosis. We aimed to determine whether EBUS-TBNA specimens are suitable for the evaluation of PD-L1 protein expression and copy number alterations (CNAs).

MATERIALS AND METHODS

PD-L1 protein expression and CNAs in 71 EBUS-TBNA specimens of NSCLC were assessed. Sixty-eight corresponding transbronchial biopsy (TBB) specimens from primary sites, thirteen resected primary tumors, and six resected metastases were comparatively analyzed. PD-L1 expression in tumor cells was assessed by immunohistochemistry (E1L3N). Positivity of ≥1% was used as the cutoff. PD-L1 CNAs were assessed with fluorescent in situ hybridization and were classified into three categories: amplification, polysomy, and disomy. Concordance between EBUS-TBNA and other specimens was calculated.

RESULTS

The cohort comprised 48 men (67.6%), 15 never-smokers (21.1%), and 39 adenocarcinomas (54.9%). The concordance of PD-L1 positivity between EBUS-TBNA and other specimens was moderate; κ = 0.63 for EBUS-TBNA vs. TBB, κ = 0.68 for EBUS-TBNA vs. resected primary tumors, and κ = 1.0 for EBUS-TBNA vs. resected metastases. The concordance of PD-L1 CNA status was comparable with that of PD-L1 expression: κ = 0.60 for EBUS-TBNA vs. TBB and κ = 0.74 for EBUS-TBNA vs. resected primary tumors. When PD-L1 copy number was assessed as a continuous variable, the correlation of PD-L1 CNAs was superior to that of PD-L1 expression. Intratumorally, PD-L1 copy number was less heterogeneous than protein expression in whole sections of resected tumors.

CONCLUSION

EBUS-TBNA specimens can be used to assess PD-L1 CNAs and protein expression. Although spatial heterogeneity should be considered for accurate interpretation, the evaluation of PD-L1 CNAs provides more reproducible results than that of protein expression levels especially with regard to intratumoral heterogeneity.

Diagnostic Performance of Radial Probe Endobronchial Ultrasound without a Guide-Sheath and the Feasibility of Molecular Analysis

BACKGROUND

Radial probe endobronchial ultrasound (R-EBUS), is effective for tissue diagnosis of lung lesions. We evaluated the diagnostic performance of R-EBUS both a guide-sheath and fluoroscopy and identified factors associated with accurate diagnosis. The feasibility of molecular and genetic testing, using specimens obtained by R-EBUS, was also investigated.

METHODS

The study retrospectively reviewed 211 patients undergoing R-EBUS without a guide-sheath and fluoroscopy, June 2016-May 2017. After excluding 27 patients of which the target lesion was not reached, 184 were finally included. Multivariate logistic regression was used, to identify factors associated with accurate diagnosis.

RESULTS

Among 184 patients, R-EBUS-guided biopsy diagnosed malignancy in 109 patients (59%). The remaining 75 patients (41%) with non-malignant results underwent additional work-ups, and 34 were diagnosed with malignancy. Based on final diagnosis, diagnostic accuracy was 80% (136/170), and sensitivity and specificity for malignancy were 76% (109/143) and 100% (27/27), respectively. In multivariate analysis, peripheral location (adjusted odds ratio [aOR], 3.925; 95% confidence interval [CI], 1.203-12.811; p=0.023), and central position of the probe (aOR, 2.435; 95% CI, 1.424-7.013; p=0.035), were associated with accurate diagnosis of malignancy. Molecular and genetic analyses were successful, in all but one case, with inadequate specimens.

CONCLUSION

R-EBUS-guided biopsy without equipment, is effective for tissue diagnosis. Peripheral location and central position of the radial probe, were crucial for accurate diagnosis. Performance of molecular and genetic testing, using samples obtained by R-EBUS, was satisfactory.

Next-Generation Sequencing for Genotyping of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Samples in Lung Cancer

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can obtain a small amount of specimen. This study aims to evaluate the feasibility and robustness of using EBUS-EBNA samples to perform capture-based targeted next-generation sequencing (NGS).

METHODS

Tissue samples from patients with advanced non-small cell lung cancer were collected by EBUS-TBNA and were formalin-fixed paraffin-embedded. Three representative genes, EGFR, ALK, and ROS1, were examined by amplification refractory mutation system polymerase chain reaction, immunohistochemistry, and quantitative reverse transcription polymerase chain reaction. The remaining samples were processed with NGS assay with a 56-gene panel. Classic driver mutations detected by NGS were verified by conventional methods.

RESULTS

Of the 85 samples from patients with advanced non-small cell lung cancer, 77 were performed successfully with all assays. Forty-one mutations in EGFR, ALK, and ROS1 were detected in both conventional methods and NGS, representing a 100% concordance. In contrast, four EGFR mutations detected by NGS were not covered in the targeted regions of amplification refractory mutation system polymerase chain reaction, leading to a negative call in these patients. Altogether, NGS detected 12 additional variants, including six KRAS mutations, one BRAF mutation, one RET fusion, one MET amplification concurrent with EGFR L858R, one KRAS amplification together with EGFR 19del, and one ERBB2 amplification. The mean number of needle passes per lymph node was 5.2 in samples successfully applied in all assays.

CONCLUSIONS

NGS assay can be successfully conducted with limited tissue samples obtained from EBUS-TBNA. Compared with conventional methods, NGS assay provides more comprehensive information on genetic alterations in tumors, which greatly assists therapeutic decision making for advanced lung cancer.

Molecular Testing in EBUS-TBNA Specimens of Lung Adenocarcinoma: A Study of Concordance Between Cell Block Method and Liquid-Based Cytology in Appraising Sample Cellularity and EGFR Mutations

PURPOSE

Cytological endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) specimens of mediastinal lymph node metastasis are frequently used to perform concomitant diagnosis, staging and genetic testing in non-small-cell lung cancer (NSCLC). The purposes of this single-center retrospective study were to evaluate EBUS-TBNA samples' adequacy for molecular testing of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK), and to analyze the concordance between the cell block method and liquid-based cytology (LBC) in appraising the sample cellularity and in detecting EGFR mutation.

MATERIALS AND METHODS

We retrospectively examined 82 patients who underwent EBUS-TBNA from October 2012 to September 2015 and received a confirmed diagnosis of lymph node metastasis of lung adenocarcinoma. Each sample was processed using both cell block and LBC to carry out DNA analysis (adequacy criterion: tumor cell percentage > 25%) and EGFR mutation testing.

RESULTS

Fifty-four patients were male, 66 were current or former-smokers, and the median age was 67 years. The median size of sampled lymph nodes was 14.8 mm. Seventy-one and 66 samples were adequate to perform cell block and LBC, respectively. The κ-statistic (0.78) showed an excellent concordance. EGFR mutation was detected in eight patients using cell block and in seven using LBC, with a simple percentage agreement of 87.5%. ALK translocation was found in two patients.

CONCLUSIONS

This study demonstrates the feasibility of EGFR mutation analysis with both cell block and LBC, with an excellent concordance between the two methods. Considering that the majority of advanced NSCLCs are diagnosed on cytology specimens, LBC is feasible and needs to be implemented for ancillary tests (immunocytochemistry, molecular analysis).

Determining factors of endobronchial ultrasound-guided transbronchial needle aspiration specimens for lung cancer subtyping and molecular testing

Objective:

This study is to explore the determining factors for testing epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) fusion after subtyping by immunohistochemistry (IHC) using samples obtained from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Materials and Methods:

Patients suspected with advanced lung cancer were performed EBUS-TBNA without rapid on-site evaluation(ROSE) from January 2015 to March 2016 in Shanghai Chest Hospital. All samples diagnosed as lung cancer by histopathology underwent IHC to identify subtypes. EGFR mutation and ALK fusion were tested in adenocarcinoma and non-small-cell lung cancer-not otherwise specified (NSCLC-NOS) using remnant tissue samples.

Results:

A total of 453 patients were diagnosed with lung cancer, including 44.15% (200/453) with adenocarcinoma and 11.04% (50/453) with NSCLC-NOS. With the average passes of 3.41 ± 0.68, samples obtained from EBUS-TBNA were adequate for performing EGFR mutation and ALK fusion gene analysis in 80.4% (201/250) of specimens after routine IHC. On univariate analysis, successful molecular testing was associated with passes per lesion (P = 3.80E-05), long-axis diameters (P = 6.00E-06) and short-axis diameters (P = 4.77E-04), and pathology subtypes of lesions (P = 3.00E-03). Multivariate logistic regression revealed that passes per lesion (P = 1.00E-03), long-axis diameters (P = 3.50E-02), and pathology subtypes (P = 8.00E-03) were independent risk factors associated with successful molecular testing.

Conclusions:

With at least three passes of per lesion, EBUS-TBNA is an efficient method to provide adequate samples for testing of EGFR mutation and ALK gene arrangement following routine histopathology and IHC subtyping. Determining factors associated with successful pathology subtyping and molecular testing using samples obtained by EBUS-TBNA are passes of per lesion, long-axis diameter, and pathology subtypes. During the process of EBUS-TBNA, selecting larger lymph nodes and the puncturing at least 3 passes per lesion may result in higher success rate in lung cancer subtyping and molecular testing.

Protocol to Improve Genotyping of Non-Small-Cell Lung Cancer Diagnosed Using EBUS-TBNA

OBJECTIVES

Targeted therapies for non-small-cell lung cancers (NSCLCs) are based on the presence of driver mutations such as epidermal growth factor receptor (EGFR) and the echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) translocation. Endobronchial ultrasound-guided-transbronchial needle aspiration (EBUS-TBNA) is a first-line modality for diagnosing and staging NSCLC. A quality improvement protocol maximizing tissue acquisition for molecular analysis has not been previously described.

METHODS

We instituted a standardized protocol designed from a multidisciplinary meeting of the pulmonology, oncology, and pathology departments for the acquisition and on-site processing of samples obtained through EBUS-TBNA to improve the yield for genetic analysis of EGFR and ALK testing.

RESULTS

Preprotocol there were 50 NSCLCs (29 adenocarcinomas) and postprotocol there were 109 NSCLCs (52 adenocarcinomas). A statistically significant increase in yield for molecular analysis was seen in both EGFR (36% preprotocol and 80% postprotocol, P < 0.01) and ALK (41% preprotocol and 80% postprotocol, P < 0.01). There was no difference in complications preprotocol and postprotocol.

CONCLUSIONS

Implementation of a standardized protocol with EBUS-TBNA was associated with an increase in adequacy for molecular genetic analysis in NSCLC.

Safety and efficacy of diagnostic flexible bronchoscopy in very old patients with lung cancer

INTRODUCTION

Although there is a remarkable increase in diagnostic flexible bronchoscopy (FB) in old patients, safety and efficacy of FB in very old patients remain to be elucidated. In this study, we aimed to evaluate the complications and diagnostic yield of FB in patients aged ≥ 80 years with lung cancer compared with those aged < 80 years.

MATERIALS AND METHODS

We retrospectively analysed the medical records of 668 consecutive patients, which included 89 patients aged ≥ 80 years (older group) and 579 patients aged < 80 years (younger group) who underwent bronchoscopy for the diagnosis or staging of lung cancer between April 2011 and March 2016.

RESULTS

The median age of the patients was 82 and 69 years in the older and younger groups, respectively. Performance status and Charlson comorbidity index were comparable between the study groups. Diagnostic yield in the older and younger groups was equivalent, and stage distribution in both the groups was similar. Sixty-one patients (68.5%) received anticancer treatment including surgery, radiation and chemotherapy with cytotoxic or molecular-targeted agents in the older group. There were no statistical differences in the occurrence of overall complications between the two groups.

CONCLUSIONS

Safety and efficacy of FB in the diagnosis of lung cancer in very old patients are comparable with those of younger patients. Accurate diagnosis established by bronchoscopy leads to appropriate treatment decision in very old patients.

Molecular testing on endobronchial ultrasound (EBUS) fine needle aspirates (FNA): Impact of triage

BACKGROUND

Endobronchial ultrasound (EBUS)-guided fine needle aspiration (FNA) is performed to diagnose and stage lung cancer. Multiple studies have described the value of Rapid On-Site Evaluation (ROSE), but often the emphasis is upon diagnosis than adequacy for molecular testing (MT). The aim was to identify variable(s), especially cytology-related, that can improve MT.

METHODS

A search for EBUS-FNAs with ROSE was conducted for lung adenocarcinomas or when this diagnosis could not be excluded. All such cases underwent reflex MT on cell blocks. The impact of cytology-related variables [i.e., number of pass(es), dedicated pass(es) directly into media, cytotechnologist (CT), laboratory technician (LT) and triage with 1 or >1 cytologist] was evaluated. The latter category was divided into Group A [ROSE, triage and slide preparation by cytopathologist (CP) and CT at start of the procedure] and Group B (ROSE only by CT or by CT/CP after start of procedure; triage and slide preparation by CT or clinical staff). The impact of all these variables on MT was assessed.

RESULTS

A total of 100 cases were identified, and 79 had sufficient tissue for MT. Of all variables evaluated, MT was positively affected by performing a direct dedicated pass (P = 0.013) and ROSE by Group A (P = 0.033).

CONCLUSIONS

ROSE with appropriate triage, including performing a dedicated pass and proper slide preparation, improves MT, and this is enhanced by having >1 cytologist at the start of the procedure. In the era of personalized medicine, "adequate" should denote sufficient tissue for diagnosis and MT.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)-from morphology to molecular testing

In recent years, endobronchial ultrasound-guided TBNA (EBUS-TBNA) has emerged as an innovative technique for diagnosis and staging of lung cancer and has been successfully introduced into daily clinical practice with several advantages including minimally invasive approach, safe, cost-effective, real time image guidance, broad sampling capability, and rapid on-site evaluation (ROSE). Both cytological and histological approach could be useful to have material for diagnosis, immunohistochemical and molecular analyses which may be very important for targeted therapy with successful rate ranging from 89% to 98%. The utility of ROSE during EBUS-TBNA has been matter of debate. Indeed, although some evidence concluded that ROSE does not increase the diagnostic efficacy of EBUS-TBNA, other demonstrated that it improves the diagnostic yield of the procedure up to 30%, allows to avoid repetition of additional diagnostic procedures and reduces risk of complications. Furthermore the sample preparation by cytopathologist is optimized with the aid of direct macroscopic inspection, optimal smearing techniques, and triage of the sample permitting to obtain adequate tissue for diagnosis, ancillary techniques and molecular testing, when needed. Some pathological issues on EBUS-TBNA are reviewed and discussed with particular focus on ROSE and molecular testing.

Ten-year experience with endobronchial ultrasound-guided transbronchial needle aspiration: single center results in mediastinal diagnostic and staging

BACKGROUND

Endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) is recognized as an accurate and minimal invasive procedure for diagnosis and staging of lung cancer and lymph nodal malignancies. EBUS is recommended as the first choice procedure for mediastinal staging in lung cancer in international guidelines.

METHODS

A retrospective evaluation was performed on single center experience with EBUS-TBNA in our thoracic surgery department in a 10-year time frame. Main indication for the procedure was suspected non-lymphomatous malignancy in intrathoracic lymph-nodes on computed tomography (CT) or positron emission tomography (PET) scan. All procedures were performed under conscious sedation in a day-hospital setting. All the aspirated specimens were obtained with a 22-gauge needle and were fixed in 10% formalin and paraffin embedded. Sections of 3 micron in thickness were cut and hematoxylin-eosin stained.

RESULTS

From October 2005 to August 2016, 496 patients were submitted to EBUS-TBNA. Number of nodal stations punctured was 592 with a mean of 2.25 punctures per patient. Diagnosis of malignancy was obtained in 291 patients (58.6%). In 25 cases a nodal metastasis from an extrathoracic primary tumor was diagnosed. Sensitivity, specificity and diagnostic accuracy were 95%, 100% and 96% respectively. Negative predictive value was 90% and positive predictive value (PPV) was 100%. When molecular tests were requested, mutational analysis was successfully performed on cell block derived material in 55 out of 56 cases (98.2%), and fluorescence in situ hybridization (FISH) analysis in 26 out of 27 cases (96.2%).

CONCLUSIONS

EBUS-TBNA in our setting was an accurate and safe tool to diagnose non-lymphomatous nodal malignancies. Interestingly, in our series EBUS-TBNA has demonstrated to yield sufficient tissue for molecular analysis.

Next-generation sequencing of non-small cell lung cancer using a customized, targeted sequencing panel: Emphasis on small biopsy and cytology

Background:

Next-generation sequencing (NGS) with a multi-gene panel is now available for patients with lung adenocarcinoma, but the performance characteristics and clinical utility of this testing are not well-described. We present the results of an extended 467 gene panel in a series of advanced, highly selected nonsmall cell lung cancer (NSCLC) patients using a range of specimens, including predominantly small biopsy and cytology specimens.

Materials and Methods:

A retrospective review of 22 NSCLC biopsies sent for NGS using an extended gene panel from January 2014 to July 2015. The customized NGS panel sequences 467 cancer-associated genes with exonic and intronic sequences obtained from purified tumor DNA. Genomic alterations, patient characteristics, and success of testing were determined.

Results:

The majority of samples tested were metastatic lung adenocarcinoma on final pathology. Of the 22 specimens tested, 5 (22.7%) were surgical resections and 17 (77.3%) were small biopsy and cytology specimens. Twenty-one (95%) of the specimens were adequate for full sequencing and yielded a total of 204 genomic alterations (average 8.9 per tumor), of which 17 (average 0.81 per tumor) were actionable and/or clinically relevant. Genomic alterations were found most commonly in the TP53, EGFR, EPHB1, MLL3, APC, SETD2, KRAS, DNMT3A, RB1, CDKN2A, ARID1A, EP300, KDM6B, RAD50, STK11, and BRCA2 genes.

Conclusions:

NGS using a comprehensive gene panel was performed successfully in 95% of all NSCLC cases in this series, including 94% small biopsy and cytology specimens and 100% surgical resections. This custom assay was performed on a range of tumor specimens and demonstrates that small specimens are able to provide a similar depth of information as larger ones. As many patients present at an advanced stage and only small specimens are obtained, the information these provide has the potential for guiding treatment in highly selected patients with advanced lung adenocarcinoma.

Impact of Cytological Sampling on EGFR Mutation Testing in Stage III-IV Lung Adenocarcinoma

Objectives. There have been advances in the identification and understanding of molecular subsets of lung cancer, defined by specific oncogenic aberrations. A number of actionable genetic alterations have been identified, such as the epidermal growth factor receptor (EGFR) mutation. We aimed to establish the reasons why patients were not undergoing EGFR mutation testing at the time of histological diagnosis. Methods. The records of 70 patients with advanced adenocarcinoma of the lung managed through a single multidisciplinary team at a single institution were reviewed. Data were collected on method of tumour sample collection, whether this was sent for EGFR testing, and the result. Results. Seventy patients were identified. In 21/25 (84%) cases, cytological sampling was sufficient for EGFR mutation analysis, compared with 40/45 (89%) cases with histological sampling. EGFR mutation testing was not carried out in 22/70 (31.4%) patients. There was insufficient tumour sample for EGFR testing in 9/22 (40.9%) patients. Other reasons for not testing included poor patient fitness and problems in the diagnostic pathway. Conclusions. In this series, cytological tumour sampling was not the predominant reason why cancers failed to have EGFR mutation status established.

Shifted focus of bronchoalveolar lavage in patients with suspected thoracic malignancy: an analysis of 224 patients

BACKGROUND

Bronchoscopies are extensively adopted for diagnosing and staging thoracic malignancies, but studies are missing as how to keep the process streamlined and more efficient. To evaluate current role of bronchoalveolar lavage (BAL) for cancer and possible infection diagnosis when practicing comprehensive bronchoscopy for patients suspected with thoracic malignancy, and provide foundation for possible practice modification.

METHODS

We retrospectively analyzed a prospectively kept database of immunocompetent patients undergoing bronchoscopy for suspected non-hematologic malignancies. Clinical, radiographic data, bronchoscopic sampling techniques and diagnostic results were recorded. Initially undiagnostic patients were followed up for 2 years for a definitive diagnosis.

RESULTS

Of 224 patients included, 179 (79.9%) were confirmed with active thoracic malignancies. BAL diagnostic yield of cancer based on different radiographic characters of target lesion are as follow: isolated lymphadenopathies 0%, central lesions 45.5%, peripheral masses (diameter ≥3 cm) 21.4%, peripheral large nodules (2≤ diameter <3 cm) 15.8%, and peripheral small nodules (diameter <2 cm) 7.1%, while composite bronchoscopy achieved diagnostic yield of 93.3%, 95.5%, 91.7%, 76.9%, and 66.7% in corresponding lesion types. No cancer was diagnosed solely by BAL-cytology. Proportions of patients with positive BAL culture did not differ significantly between patients with and without pre-test suspicion for infections (P=0.199). In multivariable analysis, infections were associated with age ≥75 (OR 3.0; 95% CI: 1.29-7.06), chronic obstructive pulmonary disease (COPD) (OR 2.7; 95% CI: 1.14-6.26) and diabetes mellitus (DM) (OR 4.5; 95% CI: 1.90-10.44).

CONCLUSIONS

Omitting BAL cytology in settings of comprehensive bronchoscopy may not compromise cancer diagnosis. For patients primarily suspected with thoracic malignancy, performing BAL culture only based on clinical suspicion could miss important infectious etiology.

Cell block samples from endobronchial ultrasound transbronchial needle aspiration provide sufficient material for ancillary testing in lung cancer-a quaternary referral centre experience

BACKGROUND

Rapid on site examination (ROSE) is encouraged at endobronchial ultrasound transbronchial needles aspiration (EBUS-TBNA) to improve diagnostic yield. Due to new therapeutic options in lung cancer, it is not sufficient to merely distinguish between non-small cell lung carcinoma (NSCLC) and small cell lung carcinoma (SCLC). Immunohistochemistry (IHC) distinction is now standard practice, as well as additional molecular testing where clinically indicated. We investigated the diagnostic yield of on-site smears vs. cell block and the provision of cellular material for ancillary testing at our centre.

METHODS

A retrospective audit of all EBUS-TBNA procedures performed until July 2012 was undertaken. Diagnostic yield on smears versus cell block was recorded. Cell blocks were reviewed by an experienced pathologist to determine diagnostic accuracy and whether IHC and molecular testing were possible.

RESULTS

In total, 234 procedures were recorded with 101 (43.2%) malignant cases, 107 (45.7%) benign cases and an initial 26/234 (11.1%) insufficient for diagnosis of which 11/234 (4.7%) were false negatives for malignancy after further follow up. The average number of passes was 4.5. For malignancies, smear diagnosis was possible in 95% (96/101) of cases and cell block diagnosis in 93.5% (87/93) of cases. There was sufficient material for IHC in 97.7% (85/87) of malignant cases. In 79.3% (69/87) of NSCLCs molecular testing for epidermal growth factor receptor (EGFR) mutation analysis was theoretically possible on samples obtained.

CONCLUSIONS

Cell blocks are not inferior to smears for diagnostic accuracy and provide sufficient samples for histology. However, ROSE assists the physician on how best to manage samples for ancillary testing.

The feasibility of molecular testing on cell blocks created from brush tip washings in the assessment of peripheral lung lesions

BACKGROUND

With the rapid development of genotype-guided therapies, molecular testing is becoming important in the management of lung cancer. Bronchoscopy is one of the most common investigations performed to diagnose and investigate lung cancer. Given the limited samples often produced by bronchoscopy, this study aims to evaluate the feasibility of performing molecular testing on cell blocks created from bronchoscope cytology brush tip washings (BTW).

METHODS

Patients with positive brush cytology for tumour cells had cell blocks created from the BTW. Mutations were detected using amplicon-based massively parallel sequencing of targeted regions of EGFR, KRAS, and BRAF genes.

RESULTS

A total of 45 patients were included in this study. Of those, 91% had adequate specimens for molecular analysis and 66% of patients with adenocarcinoma had mutations detected. Bronchial brush tip wash cell blocks were the sole specimen available for molecular testing in 27 (60%) patients.

CONCLUSIONS

The findings of this study demonstrate that molecular testing can be performed on cell blocks created from BTW and this technique may allow for an increase in bronchoscope specimens amenable to molecular testing without further increasing morbidity and mortality.

Recent advances in endobronchial ultrasound-guided transbronchial needle aspiration

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

High concordance of ALK rearrangement between primary tumor and paired metastatic lymph node in patients with lung adenocarcinoma

BACKGROUND

Lung cancer has heterogeneous features. It remains unclear whether ALK rearrangement was distributed heterogeneously in tumor from different anatomic sites. To address this issue, we investigate the concordance of ALK rearrangement between primary tumors and paired metastatic lymph nodes in pulmonary adenocarcinoma patients.

METHODS

From Sep 2013 to May 2014, resectable lung adenocarcinoma patients with EGFR wildtype and paired metastatic lymph nodes from Tongji University affiliated Shanghai pulmonary hospital were selected into this study. An auto-mated Ventana ALK with clone D5F3 antibody immunohistochemistry (IHC) and reverse transcriptase-polymerase chain reaction (RT-PCR) were used to detected ALK rearrangement. Discordant cases between IHC and RT-PCR were further validated by fluorescence in situ hybridization (FISH).

RESULTS

A total of 101 patients were enrolled into this study with a median age of 60 years old (range, 35-78 years). ALK rearrangement was found in 20 primary lesions, while in 18 paired metastatic lymph nodes. ALK rearrangement was more frequently happened in younger (P<0.001), Nonsmokers (P=0.012), high-stage disease (P=0.021) and predominantly solid growth pattern (P=0.024). The concordance rate between primary tumor and paired metastatic lymph nodes was 98%. Two patients with ALK rearrangement on primary tumor didn't show ALK gene fusion on paired metastatic lymph nodes. Sixty-eight cases had more than two stations of metastatic lymph nodes. ALK rearrangement in the different station of metastatic lymph nodes of the same patient was consistent.

CONCLUSIONS

High concordant rate of ALK rearrangement between primary tumors and paired metastatic lymph nodes were found in this study. The authors concluded that specimens from metastatic lesions and primary tumors are equally suitable for detection ALK rearrangement.

[Endobronchial ultrasound transbronchial needle aspiration initiation into the Lyon Sud hospital center: Experience of the first three years]

INTRODUCTION

Endobronchial ultrasound is a recent technique for the diagnosis and the lymph node staging in lung cancer. It also showed interest in non tumoral mediastinal lymph nodes diagnosis. This work relates the CHLS first three years' experience in terms of EEB practical use as a new diagnostic tool in this field.

METHODS

Retrospective study of consecutive cases patients having undergone endobronchial ultrasound from November 2008 till June 2011 in the CHLS.

RESULTS

On 65 endobronchial ultrasound, general anesthesia was practiced in 89 % of the cases, with a good tolerance in 81 % of the cases. In 77 % cases, EEB allowed diagnosis and avoided mediastinoscopy in 60.5 % of the cases. The respective sensibility, specificity, positive and negative predictive values were 74 %, 100 %, 100 % and 48 %.

CONCLUSION

These data, reflect of a novice team experience, illustrate the results obtained in the current practice in terms of etiologic diagnosis. Endobronchial ultrasound seems destined to a bright future but requires the development of dedicated centers allowing pulmonologists training and specialized pathologists in this field.

Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report

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.

Adequacy of endobronchial ultrasound-guided transbronchial needle aspiration samples processed as histopathological samples for genetic mutation analysis in lung adenocarcinoma

Phenotyping non-small-cell lung cancer is becoming increasingly important with the advent of molecular testing. Tumours harbouring somatic mutations in the gene that encodes for the tyrosine kinase domain of the epidermal growth factor receptor (EGFR) have been found to increase responsiveness to tyrosine kinase inhibitors. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique for mediastinal node sampling. The available prospective data on EBUS-TBNA sample suitability for molecular profiling are currently limited. The aim of this prospective study was to evaluate the adequacy of EBUS-TBNA samples for EGFR and anaplastic lymphoma kinase (ALK) genetic mutation analysis in confirmed primary lung adenocarcinomas. We conducted a prospective analysis of 410 consecutive patients referred for EBUS-TBNA between 2010 and 2014. Rapid on-site cytological evaluation was not used. The samples were obtained using 21-gauge (21G) or 22G needles and were prepared as histopathological samples. A total of 91 samples were confirmed as lung adenocarcinomas and 80 of these samples were sent for EGFR mutation analysis. EBUS-TBNA had a diagnostic accuracy of 98.3% for malignancy. EGFR mutation testing was possible in 79/80 cases (98.75%). EGFR mutations were detected in 5/80 (6.3%) samples. ALK gene analysis, which became available during the study period, was requested and successfully performed in 21/21 samples (100%). The total combined genotyping success rate was 100/101 (99.0%). This UK study confirmed the high clinical utility of EBUS-TBNA samples processed as histopathological specimens for EGFR and ALK genotyping in primary lung adenocarcinoma. The needle gauge did not affect genotyping efficacy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRY

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

EGFR mutation testing of lung cancer patients - Experiences from Vestfold Hospital Trust

BACKGROUND

Patients with advanced stage lung cancer and somatic mutations in the epithelial growth factor receptor (EGFR) gene are currently treated with tyrosine-kinase inhibitors. The Norwegian Lung Cancer Group (NLCG) recommended EGFR testing of all patients with non-small cell lung carcinoma (NSCLC) from June 2010. From March 2013, testing of squamous cell carcinomas was terminated. We have analysed how these recommendation were followed at a medium-sized Norwegian hospital and we present data on mutation frequency, retesting and possible explanations for missing test results.

MATERIAL AND METHODS

All pathology reports for patients diagnosed with NSCLC at Vestfold Hospital Trust were examined for the period June 2010 to December 2013. Mutation analyses were done at the Department of Pathology, Oslo University Hospital.

RESULTS

Material was sent for EGFR analysis for 256 of the 304 eligible patients diagnosed in the period. Material from 48 patients was never sent for EGFR testing, of which five samples consisted of too few tumour cells. For the rest, no obvious reason for omitting EGFR mutation analyses was identified. During the first six months of our study period, material from 25 of 66 NSCLC patients (38%) was not tested, whereas only six of the 118 patients (5%) in 2013 were not tested. For 34 patients, the first tissue specimen contained too few tumour cells and a new sample was sent for EGFR analyses for 11 of these. EGFR mutation was detected in 7.1% of the analysed NSCLC and in 9.4% of adenocarcinomas.

DISCUSSION

Especially for patients with advanced stages of NSCLC, EGFR mutation status is necessary for treatment stratification. Our results show that the guidelines were followed increasingly over time for patients diagnosed with NSCLC at the Vestfold Hospital Trust. The establishment of interdisciplinary meetings has improved the diagnostic routines.

Endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing mediastinal lymphadenectasis: a cohort study from a single center

OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used for clinical diagnosis of mediastinal lymphadenectasis. This study aimed to evaluate the diagnostic significance of EBUS-TBNA for mediastinal lymphadenectasis in a large single center.

METHODS

A total of 846 patients who were not definitively diagnosed with mediastinal lymphadenectasis underwent EBUS-TBNA were retrospectively analyzed in this study.

RESULTS

In total, 842 patients underwent EBUS-TBNA successfully. There were 589 patients with malignancy, including squamous carcinoma (118 cases; 20.6%), adenocarcinoma (187 cases; 32.7%) and small cell carcinoma (88 cases; 15.4%). A total of 253 patients were diagnosed with benign disease, including tuberculosis (111 cases; 43.9%) and sarcoidosis (93 cases; 36.7%). The diagnostic sensitivity of lung cancer, tuberculosis and sarcoidosis were 94.4%, 81.1% and 51.6%, respectively. The overall sensitivity of EBUS-TBNA was 92.0%. N2 stage in lung cancer patients who were diagnosed by EBUS-TBNA was significantly higher than other stages. The positive rate of targeted puncture is high for the lymph nodes whose short-axis diameters were larger than 1 cm.

CONCLUSION

The operation risk of EBUS-TBNA is relatively small. In diseases complicated by mediastinal lymphadenectasis, malignant diseases are most, and benign diseases mainly are granulomatous. EBUS-TBNA is a valuable diagnostic technique in patients with mediastinal lymphadenectasis whose diagnosis have not been determined.

Efficacy of bronchoscopic biopsy for the detection of epidermal growth factor receptor mutations and anaplastic lymphoma kinase gene rearrangement in lung adenocarcinoma

Background

To explore the efficacy of bronchoscopic biopsy for the detection of epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) gene rearrangement in lung adenocarcinoma.

Methods

All patients with bronchoscopic biopsy-proven lung adenocarcinoma at the Peking Union Medical College Hospital from January 2009 to November 2011 were enrolled. Scorpion amplification refractory mutation system (ARMS) was used to detect EGFR gene mutations and fluorescence in situ hybridization (FISH) to detect ALK rearrangement. The correlation of immunohistochemistry (IHC) results with standard methods for EGFR mutation status and ALK rearrangement were checked.

Results

Bronchoscopic specimens were successfully used to detect EGFR mutation and ALK rearrangement with success rates of 85.2% and 71.3%, respectively, in non-small cell lung cancer patients. EGFR analysis by ARMS yielded a positive result in 35.8% (33/92) and positive ALK rearrangement was detected by FISH in 7.8% (6/77) of cases. It was more likely to be unsuccessful in patients with tumor cells less than 100/high power field and the ratio tumor numbers in 0–10%. In EGFR-IHC, the sensitivity and specificity of E746-A750 deletions were 73.3% (11/15) and 93.3% (70/75), respectively, and those of L858R were 93.3% (14/15) and 93.2% (69/74), respectively. In ALK-IHC, the sensitivity and specificity were 50% (3/6) and 100% (71/71), respectively.

Conclusions

Small bronchoscopic specimens could achieve higher successful detection rates via EGFR mutation and ALK gene rearrangement.

A novel point-of-care system for high-speed real-time polymerase chain reaction testing for epidermal growth factor receptor mutations in bronchial lavage fluids after transbronchial biopsy in patients with non-small cell lung cancer

Epidermal growth factor receptor (EGFR) gene mutation testing is essential for choosing appropriate treatment options in patients with advanced non-small cell lung cancer (NSCLC). However, a time delay occurs between histological diagnosis and molecular diagnosis in clinical situations. To minimize this delay, we developed a novel point-of-care test for EGFR mutations, based on a high-speed real-time polymerase chain reaction (PCR) system designated here as ultrarapid PCR combined with highly accurate bronchoscopic sampling. We investigated whether our system for detecting EGFR mutations was valid by comparing test results with those obtained using a commercialized EGFR mutation test. We obtained small amounts of bronchial lavage fluids after transbronchial biopsies (TBBs) were performed on enrolled patients (n=168) who underwent endobronchial ultrasonography using a guide sheath (EBUS-GS). EGFR mutation analysis was performed by ultrarapid PCR immediately after EBUS-GS-TBBs were obtained (on the same day). After pathological diagnoses of NSCLC, EGFR mutation status in formalin-fixed, paraffin- embedded samples was confirmed by the PCR-invader method, and the concordance rates between the PCR methods were compared. The total diagnostic yield of EBUS-GS-TBB was 91.0%. The positive concordance rates for detecting 19del and L858R with the ultrarapid PCR and PCR-invader methods were both 100%. Negative concordance rates were 97.2 and 98.1%, respectively. We also demonstrated a dramatic effect of early erlotinib administration, based on ultrarapid PCR results, for a 52-year-old woman suffering from respiratory failure due to severe intrapulmonary metastases with poor performance status. In conclusion, ultrarapid PCR combined with EBUS-GS-TBB enabled rapid and reliable point-of-care testing for EGFR mutations.