EUS-B-FNA vs conventional EUS-FNA for left adrenal gland analysis in lung cancer patients

Added value of EUS-B-FNA to bronchoscopy and EBUS-TBNA in diagnosing and staging of lung cancer

Background

Bronchoscopy and EBUS are standard procedures in lung cancer work-up but have low diagnostic yield in lesions outside the central airways and hilar/mediastinal lymph nodes. Growing evidence on introducing the EBUS endoscope into the oesophagus (EUS-B) in the same session as bronchoscopy/EBUS gives access to new anatomical areas that can be safely biopsied.

Objective

To summarize the current evidence of the added value of EUS-B-FNA to bronchoscopy and EBUS-TBNA in lung cancer work-up.

Methods

A narrative review.

Results

Few randomized trials or prospective studies are available. Prospective studies show that add-on EUS-B-FNA increases diagnostic yield when sampling abnormal mediastinal lymph nodes, para-oesophageal lung and left adrenal gland. A large retrospective series on EUS-B-FNA from retroperitoneal lymph nodes suggests high diagnostic yield without safety concerns, as do casuistic reports on EUS-B-FNA from mediastinal pleural thickening, pancreatic lesions, ascites fluid and pericardial effusions. No study has systematically assessed both diagnostic yield, safety, patient reported outcomes, adverse events and costs.

Conclusion

The diagnostic value of add-on EUS-B to standard bronchoscopy and EBUS in lung cancer work-up appears very promising without safety concerns, giving the pulmonologist access to a variety of sites out of reach with other minimally invasive techniques. Little is known on patient-reported outcomes and costs. Future and prospective research should focus on effectiveness aspects to clarify whether overall benefits of add-on EUS-B sufficiently exceed overall downsides.

Endoscopic ultrasound-guided fine-needle aspiration using the bronchial ultrasound scope (EUS-B-FNA) for diagnosing pancreatic metastasis in a lung cancer patient case report

Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) of the pancreas is performed routinely in many endoscopic centers as part of the diagnostic set-up for suspected pancreatic cancer. The use of transesophageal bronchoscopic ultrasound-guided fine needle aspiration (EUS-B-FNA) by pulmonologists has expanded significantly, since it enables effective diagnosis of lesions in the mediastinum and upper abdomen. The following case demonstrates the safety and feasibility of EUS-B-FNA in a patient with non-small cell lung cancer (NSCLC) cancer and a pancreatic mass of unknown origin. A patient who was previously diagnosed with NSCLC was referred to the Department of Respiratory Medicine, Odense University Hospital due to suspected recurrence of NSCLC. The patient underwent endobronchial ultrasound guided (EBUS)-FNA from several suspected mediastinal lymph nodes and combined EUS-B-FNA from a pancreatic mass during the same procedure. Pathology results from the pancreatic mass and from the mediastinal lymph nodes showed squamous-cell carcinoma, metastasis from the previous NSCLC. We here by demonstrated that EUS-B-FNA is a feasible and safe technique to obtain tissue samples from pancreatic lesions in patients under investigation for lung cancer.

Performance of EUS-FNA and EUS-B-FNA for the diagnosis of left adrenal glands metastases in patients with lung cancer: A systematic review and meta-analysis

OBJECTIVES

For diagnosing left adrenal gland metastasis in lung cancer, clinical guidelines recommend to perform EUS, but EUS-B (EUS using an EBUS-scope) is increasingly being used. We evaluated the diagnostic performance of both procedures.

MATERIALS AND METHODS

We did a systematic review (PROSPERO, CRD42023416205) and searched MEDLINE and EMBASE on 04-July-2023 for studies evaluating EUS and/or EUS-B in diagnosing left adrenal gland metastases in adults with (suspected) lung cancer. Outcomes were: (1) ability to visualize the left adrenal gland, (2) ability to sample (in those with successful visualization and in whom sampling was attempted), (3) ability to obtain adequate material (in those with successful sampling), (4) malignancy detection rate (in those with successful sampling), and (5) remaining risk of malignancy (in those with a negative EUS(-B)-FNA and undergoing a reference standard). We performed random-effects meta-analyses.

RESULTS

We included 19 studies (EUS: n = 11, EUS-B: n = 6, both: n = 2), covering 1712 patients. All studies had high (n = 18) or unclear (n = 1) risk of bias (QUADAS-2). Average ability to visualize the left adrenal gland was 0.94 (95 %CI 0.82-0.98; n = 7 studies). Average ability to sample was 1.00 (95 %CI 0.99-1.00; n = 9). Average ability to obtain adequate material was 0.96 (95 %CI 0.93-0.98; n = 18). Average malignancy detection rate was 0.42 (95 %CI 0.34-0.49; n = 18). Remaining risk of malignancy was 0.07 (95 %CI 0.04-0.12; n = 8). Ability to visualize was slightly higher for EUS (0.99; 95 %CI 0.90-1.00) than EUS-B (0.84; 95 %CI 0.70-0.92; p = 0.025), but the other performance characteristics were similar. No major complications were reported.

CONCLUSION

Both EUS and EUS-B have good performance and are safe for left adrenal gland analysis in patients with lung cancer, but the number of high-quality studies is limited and further well-constructed prospective studies are needed.

Transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) for left adrenal gland (LAG) sampling: A report of three cases with a review of the literature

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard-of-care modality for evaluating mediastinal lymph nodes and masses. The EBUS bronchoscope may also be introduced through the oesophageal route to perform sampling of accessible lesions, a technique described as transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA). Because of the central oesophageal approach, EUS-B-FNA provides easy access to the left para-tracheal, subcarinal and para-oesophageal lymph nodes. In addition, the left adrenal gland (LAG) can also be imaged and sampled during the EUS-B-FNA procedure. In patients with suspected lung cancer, accurate staging is essential. Adrenal metastasis is relatively common and may often be a solitary metastatic site. We describe three cases where EUS-B-FNA was performed to safely sample the enlarged LAG in suspected lung cancer. We also review the literature on the performance characteristics of EUS-B-FNA for LAG aspiration.

The yield and impact of pulmonologist-performed EUS-B-FNA of subdiaphragmatic lesions-an institutional experience

INTRODUCTION

Pulmonologists can biopsy structures below the diaphragm using the convex curvilinear ultrasound bronchoscope via the esophagus (EUS-B). The literature with respect to the value of EUS-B, rapid on-site evaluation, and final diagnostic yield for structures below the diaphragm is limited. We review our institutional experience.

MATERIALS AND METHODS

Our database was queried retrospectively for EUS-B fine needle aspirations (FNAs) from 2013 to 2021. All procedures involving EUS-B-FNA of subdiaphragmatic structures were selected for analysis. The following data elements were collected for each patient: age, gender, clinical indication, sample site, on-site adequacy (OSA), preliminary and final diagnoses, and sufficiency of cell block for ancillary studies.

RESULTS

A total of 75 subdiaphragmatic sites were biopsied in 74 patients. Of which, 87% of samples subjected to rapid on-site evaluation were deemed to contain adequate material (OSA+). There were no false-positive OSAs. Six cases remained nondiagnostic at the final diagnosis. The final diagnostic yield (with cell block) was 92% (69/75 cases). Cell block was sufficient for immunohistochemistry or special stains in all applicable cases (n = 36). Molecular testing was requested for 11 cases and successful in 10 (91%). Sampling of subdiaphragmatic sites changed the stage in 67% (38/57) of lung cancer patients.

CONCLUSIONS

Pulmonologists can perform EUS-B-FNA of subdiaphragmatic sites with high OSA and final diagnostic yield when assisted by cytopathologists. Strong correlations exist between OSA, cell block adequacy, and subsequent capacity to perform ancillary testing. EUS-B below the diaphragm can make an important contribution to the diagnosis of lung cancer, nonpulmonary malignancies, and other diseases.

One-stop-shop: Lung cancer and pheochromocytoma diagnosed by robotic-assisted bronchoscopy and EBUS scope on a single endoscopic event

Lung cancer is the deadliest cancer worldwide, therefore, early and prompt diagnosis is essential for better patient outcomes. It is known to have a high predilection for metastasis to the adrenal glands; however, two-thirds of adrenal masses in patients with lung cancer will turn out to be benign, so timely detection is crucial. We present a case of a lung squamous cell carcinoma diagnosed by shape-sensing robotic-assisted bronchoscopy (ssRAB), negative mediastinal and hilar staging with endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA), and a pheochromocytoma diagnosed through endoscopic ultrasound with bronchoscope (EUS-B) fine needle aspiration (FNA) all in the same endoscopic procedure.

Interventional Pulmonology and Esophagus: Combined Endobronchial Ultrasound and Endoscopic Ultrasound for Mediastinal Staging

Endoscopic ultrasound (EUS) techniques in addition to endobronchial ultrasound (EBUS) can lead to diagnosis and complete accurate staging of the mediastinum in a single session. This allows for decreased health care costs, less delay in diagnosis and treatment, reduced patient discomfort, and decreased morbidity compared with invasive surgical staging techniques. In comparison to conventional mediastinoscopy, the cost-effectiveness and reduced complication profile of the endoscopic approach has made this a superior initial step in the staging and diagnosis of lung cancer. Moreover, compared with EBUS alone, combined EUS and EBUS has significantly increased yield, as well as diagnostic sensitivity making a combined approach preferable as the emerging gold-standard technique for initial minimally invasive mediastinal staging. We discuss the advantage of using EUS in combination with EBUS and highlight techniques, lymph node landmarks, utility in staging and restaging of the mediastinum, roles in diagnosing mediastinal infections and granulomatous lesions, and future directions in endosonography.

Left Adrenal Gland Sampling Through Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-B FNA): A New Route and a New Challenge

Metastasis to adrenal glands from primary pulmonary carcinoma is quite a common occurrence. In most cases, the diagnosis is made based on an imaging evaluation done because of chronic non-specific pulmonary symptoms. Further evaluation to determine the type of carcinoma is done using histopathological evaluation of the primary lung lesion. Here, we have described a case of a 60-year-old man who presented with chest pain and was incidentally detected with a lower lung mass and a bulky left adrenal gland in the upper abdominal cuts on a CT of the thorax. As the evaluation of the fine needle aspiration (FNA) sample from lung lesion couldn't be successfully performed, sampling from the left adrenal gland was attempted under the guidance of conventional endoscopic ultrasound using an endobronchial ultrasound probe (EUS-B). When the technique failed to localise the left adrenal gland, a modification was made and the gland was localised using the spleen as a marker. This case further presented a challenge, when due to the unfolding of rugae, the FNA needle wasn’t able to reach up to the left adrenal gland. Further adjustment was made and the maximum depth of the gland from the margin was measured and the needle was fully freed. Multiple jabs were made and sampling was successfully done. Cellblock confirmed the presence of adenocarcinoma of pulmonary origin, positive for thyroid transcription factor 1 (TTF-1). The patient remained stable and did not present with any early or late post-procedural complications. The patient was started on appropriate chemotherapy for the disease. He has received three cycles of carboplatin and pemetrexed till now and is doing well. 

Mediastinal Lymph Node Metastasis of Esophageal Cancer with Esophageal Stenosis Diagnosed via Transesophageal Endoscopic Ultrasound with Bronchoscope-guided Fine-needle Aspiration

An 80-year-old man underwent follow-up examinations after endoscopic submucosal dissection (ESD) for esophageal cancer. Computed tomography showed enlarged lymph nodes of the right recurrent nerve. The patient had esophageal stenosis due to repeated ESD for multiple esophageal tumors. The stenosis made the passage of an endoscopic ultrasound (EUS) scope through the esophagus difficult. Thus, an endobronchial ultrasound bronchoscope, which had a thinner diameter than that of the EUS scope, was used for transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration. This technique led to the diagnosis of mediastinal lymph node metastasis of esophageal cancer.

Thoracic endosonography (EBUS/EUS-b) in the diagnosis of different intrathoracic diseases: A 4-year experience at a single-centre in Greece

BACKGROUND

In the last decade, the advent of thoracic endosonography has revolutionised the field of diagnostic bronchoscopy.

METHODS

We conducted a single-centre prospective study in "Sotiria" Chest diseases hospital between January 2016 and December 2019. The study aimed to evaluate the efficacy and diagnostic value of combined EBUS/EUS-b in comparison with EBUS-TBNA and EUS-b FNA in different intrathoracic diseases.

RESULTS

A total of 266 patients were enrolled (70.7% males, 85.7% smokers, mean age ± SD: 62.8 ± 11.8). Diagnosis and staging of suspected lung cancer (LC) were the main indications for EBUS/EUS-b in 56.7% of patients, followed by lymphadenopathy of unknown origin in 27%, lymphadenopathy in previous malignancy in 10.9%, and staging of proven LC in 5.3%. EUS-b FNA alone or combined with EBUS-TBNA was performed in 14.7% of patients. A total of 512 lymph nodes was sampled (481 through EBUS-TBNA and 31 through EUS-b FNA). EBUS/EUS-b led to a definitive diagnosis in 68.4% of the patients. Most cases (50.4%) were malignancies, while 18% represented benign diseases (83.3% sarcoidosis). Sensitivity of combined EBUS/EUS-b was higher in comparison with sensitivity of both procedures alone (100% vs 89.4% vs 88.9%). Accordingly, the overall sensitivity of EBUS/EUS-b for the detection of malignancy and sarcoidosis was 93% and 95.2%, respectively. No severe complications were observed.

CONCLUSION

Thoracic endosonography is an efficient, safe, minimally invasive tool yielding high sensitivity and diagnostic accuracy in patients with suspected malignancy and mediastinal lymphadenopathy. Experienced pulmonologists in EBUS-TBNA should more routinely perform EUS-b FNA to avoid unnecessary surgical interventions.

Endoscopic transoesophageal fine-needle aspiration with convex probe bronchoscope for diagnosis of coeliac lymphadenopathy

Endoscopic transoesophageal fine-needle aspiration with a convex probe bronchoscope (EUS-B-FNA) is a complementary technique to endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) for the staging of mediastinal lymph nodes [1]. The safety and feasibility of EUS-B-FNA for sampling pulmonary parenchymal lesions and adrenal lesions has been reported [2, 3]. Recent literature also suggest a role for EUS-B-FNA in the diagnosis of infective lymphadenitis [4]. Here we present two cases of successful sampling of coeliac lymph nodes to further extend the utility of EUS-B-FNA in the assessment of patients with suspected or confirmed lung cancer. Localisation of nodes during the procedure did not involve fluoroscopy and relied upon linear EBUS guidance. Sampling was successfully performed with a 22-G TBNA needle.

EUS-B-FNA is a feasible and accurate technique for diagnosis of extrathoracic lesionshttps://bit.ly/34TFMR8

EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial

BACKGROUND

Endobronchial Ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard of care modality for the evaluation of mediastinal lymphadenopathy. Transesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-B-FNA), wherein one introduces the EBUS bronchoscope through the esophageal route, is also a safe and efficacious diagnostic modality for sampling the mediastinal lymph nodes. The objective of this study was to compare the diagnostic yield and patient comfort with these two available approaches.

METHODS

We randomized subjects with predominant subcarinal or lower left paratracheal mediastinal lymph node enlargement to either EBUS-TBNA or EUS-B-FNA (50 to each group). Co-Primary objectives were the comparison of adequate and diagnostic aspirates between groups. Key secondary objectives were a comparison of Operator rated cough and Operator rated procedural comfort on Visual Analog scale (VAS), procedure duration and complications between the groups.

RESULTS

Baseline characteristics were comparable between the groups. The proportion of adequate (EBUS-TBNA 46/50; 92% and EUS-B-FNA 48/50;96%, P = 0.4) and diagnostic aspirates (EBUS-TBNA 38/50; 76% and EUS-B-FNA 36/50;74%, P = 0.4) were similar between the two groups. Operator rated cough was significantly less, and Operator rated patient comfort significantly higher with the EUS-B-FNA approach. Procedure duration was significantly shorter with EUS-B-FNA [18.1(14.4) minutes versus 16.4 (49.6) minutes, P < 0.001]. Minor complications occurred in one patient in the EBUS-TBNA group and none in the EUS-B-FNA group.

CONCLUSION

During the endosonographic evaluation for undiagnosed mediastinal lymphadenopathy located at predominantly the subcarinal or lower left paratracheal stations, EUS-B-FNA as compared with EBUS-TBNA provides greater patient comfort with a similar diagnostic yield.

Aspiration of Pericardial Effusion Performed with EUS-B-FNA in Suspected Lung Cancer

Ultrasound-guided needle aspiration via the esophagus using the endobronchial endoscope (EUS-B-FNA) is increasingly being performed by the pulmonologist for the diagnosis of lung cancer, but we have little experience and data available in the literature especially with respect to staging of the disease. We present 2 cases of EUS-B-guided aspiration of malignant pericardial effusion performed in the same setting as bronchoscopy and endobronchial ultrasound. No complications were observed. We conclude that EUS-B-FNA may be safe and efficacious in the evaluation of pericardial effusion during lung cancer workup. Thus, EUS-B-FNA may save time in the diagnostic workup, improve cancer staging, and prevent transthoracic pericardiocentesis.

EUS-B for suspected left adrenal metastasis in lung cancer

Background

Several studies have reported the efficacy of esophageal ultrasound-guided fine needle aspiration (EUS-FNA) for the detection of metastases in the left adrenal gland (LAG) in patients with lung cancer. Currently we have only limited evidence based on small studies on the usefulness of EUS-B [endobronchial ultrasound (EBUS) scope into the esophagus] to provide tissue proof of suspected LAG metastases. The objectives of this study are to investigate feasibility, safety and diagnostic yield of EUS-B-FNA in LAG analysis in patients with proven or suspected lung cancer.

Methods

In two Danish hospitals, a systematic search in the electronic database for patients who underwent EUS-B-FNA of the LAG for suspected or proven lung cancer was performed retrospectively between January 1st, 2015 and December 31st, 2017. Computed tomography (CT), positron emission tomography-CT, endoscopy, pathology and follow-up data were acquired.

Results

One hundred and thirty-five patients were included; the prevalence of biopsy proven LAG malignancy was 30% (40/135). A total of 87% (117/135) of EUS-B-FNA samples were adequate (i.e., containing adrenal or malignant cells). No complications were observed.

Conclusions

We present the largest cohort of patients ever reported showing that EUS-B-FNA of the LAG is a safe and feasible procedure and should therefore be used for staging purposes in patients with lung cancer and a suspicious LAG.

Endoscopic ultrasound-guided pleural biopsy in the hands of the pulmonologist

The use of the endobronchial ultrasound (EBUS) endoscope in the oesophagus, the so-called EUS-B procedure, for the diagnosis and staging of thoracic malignancy is quickly gaining ground. Pleural lesions located close to the oesophagus can be inaccessible to transthoracic biopsy and endoscopic procedures can be the only option. We here present two cases demonstrating that EUS-B-guided fine needle aspiration (EUS-B-FNA) of pleural lesions is possible. The first case demonstrates a EUS-B-FNA with malignant mesothelioma of a pleural lesion in a 70-year-old patient. In the second case, EUS-B-FNA diagnosed a pleural metastasis from adenoid cystic adenocarcinoma in a 75-year-old-patient. In conclusion, we hereby demonstrate that EUS-B-FNA from pleural lesions is feasible and appears to be safe.

EUS-B-FNA for Left Adrenal Lesions in Non-Small Cell Lung Cancer Patients: Report of Cases and Literature Review

The left adrenal gland (LAG) is a common metastatic site in patients with non-small-cell lung cancer. In practice, staging mainly relies on radiologic studies and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Recently, a new technique using convex probe-endobronchial ultrasound (CP-EBUS) scope through the esophagus (EUS-B) has been introduced. A complete mediastinal staging and a reach for upper-abdominal structures in a single session naturally attract attention. However, scientific data are not sufficient to clearly judge the role of this technique in the cytological diagnosis of left adrenal lesions. Therefore, we present cases in which our patients have undergone EUS-B for LAG lesions to increase the data in the literature with regard to accessibility, diagnostic performance, and rate of complications.

Integration of Bronchoscopic Transesophageal Ultrasound Examination of the Left Adrenal Gland into Routine Lung Cancer Staging Workup: A Prospective Trial

BACKGROUND

Endobronchial ultrasound (EBUS) with transbronchial needle aspiration increases the diagnostic yield of lung cancer staging. The left adrenal gland (LAG) is a common site for lung cancer metastasis. The modality of transesophageal examination with an EBUS bronchoscope (EUS-B) routinely for LAG has not been assessed.

OBJECTIVE

The aim of this study was to prospectively assess if evaluation and tissue sampling of the LAG could routinely be implemented in an EBUS procedure.

METHODS

Patients referred for EBUS between March and August 2017 had assessment of the LAG via EUS-B. Fine-needle aspiration (FNA) was performed in cases with a suspicious LAG. The detection rate, procedure time, and learning curve of four experienced EBUS-bronchoscopists was assessed, plus the diagnostic accuracy and complication rate of FNA.

RESULTS

In total, 313 consecutive patients were included. The overall LAG detection rate was 87.5%. After the initial learning curve, the detection rate for all four bronchoscopists was >93%. The detection rate did not correlate with any patient characteristics. EUS-B-FNA revealed nine LAG metastases, with a sensitivity, specificity, and accuracy of 75%, 100%, and 99%, respectively. The mean EUS-B operation time was 194.4 s, with 594.8 s for FNA. There were no FNA-associated complications.

CONCLUSIONS

Evaluation of the LAG with EUS-B could routinely be included in an EBUS procedure if necessary. A high detection rate can be achieved after an initial learning period. FNA of the LAG was feasible and safe. EUS-B of the LAG could be integrated into the usual EBUS/EUS-B procedure in lung cancer staging workup.

EUS-B-FNA for Diagnosing Liver and Celiac Metastases in Lung Cancer Patients

BACKGROUND

In patients with suspected or proven lung cancer, assessment of regional nodal and distant metastases is key before treatment planning. By introducing the endobronchial ultrasound (EBUS)-guided scope into the esophagus and stomach (EUS-B), liver lesions and celiac nodes can be visualized. To date, the utility of EUS-B in diagnosing liver lesions and retroperitoneal lymph nodes is unknown.

OBJECTIVES

To assess the feasibility, safety, and diagnostic yield of sampling of liver lesions and retroperitoneal nodes by EUS-B fine-needle aspiration (FNA) in a lung cancer staging setting.

METHOD

Consecutive patients suspected of lung cancer in 2 Danish centers between 1 January 2015 and 31 December 2017 were included retrospectively when a lesion in the liver or a retroperitoneal lymph node was visualized and biopsied with EUS-B-FNA.

RESULTS

23 left liver lobe lesions and 19 retroperitoneal lymph nodes were sampled by EUS-B-FNA. Sensitivity and diagnostic yield of sampled liver lesions were 86 and 83%, respectively. In 19/23 patients, there was a cytopathological diagnosis of malignancy. Sensitivity and diagnostic yield from retroperitoneal lymph node samples were 83 and 63%, respectively. In 10/19 patients, the diagnosis was malignancy. No complications were observed.

CONCLUSION

EUS-B-FNA enables safe sampling of left liver lobe lesions and retroperitoneal lymph nodes. EUS-B should be considered as a minimally invasive technique to provide tissue proof of distant metastases lung cancer patients.

Endosonography with lymph node sampling for restaging the mediastinum in lung cancer: A systematic review and pooled data analysis

BACKGROUND

Mediastinal restaging after induction treatment is still a difficult and controversial issue. We aimed to investigate the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration for restaging the mediastinum after induction treatment in patients with lung cancer.

METHODS

Embase and PubMed databases were searched from conception to March 2019. Data from relevant studies were analyzed to assess sensitivity and specificity of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration, and to fit the hierarchical summary receiver operating characteristic curves.

RESULTS

A total of 10 studies consisting of 558 patients fulfilled the inclusion criteria. All patients were restaged by endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound-guided fine-needle aspiration, or both. Negative results were confirmed by subsequent surgical approaches. There were no complications reported during any endosonography approaches reviewed. The pooled sensitivities of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration were 65% (95% confidence interval [CI], 52-76) and 73% (95% CI, 52-87), respectively, and specificities were 99% (95% CI, 78-100) and 99% (95% CI, 90-100), respectively. The area under the hierarchical summary receiver operating characteristic curves were 0.85 (95% CI, 0.81-0.88) for endobronchial ultrasound-guided transbronchial needle aspiration and 0.99 (95% CI, 0.98-1) for endoscopic ultrasound-guided fine-needle aspiration. Moreover, for patients who received chemotherapy alone, the pooled sensitivity of endosonography with lymph node sampling for restaging was 66% (95% CI, 56-75), and specificity was 100% (95% CI, 34-100); for patients who received chemoradiotherapy, the results seemed similar with a sensitivity of 77% (95% CI, 47-92) and specificity of 99% (95% CI, 48-100).

CONCLUSIONS

Endosonography with lymph node sampling is an accurate and safe technique for mediastinal restaging of lung cancer.

Advances in Interventional Pulmonology

Much has changed since the last review of interventional pulmonology (IP) published in this Clinics series. The rate of development of new techniques and their complexities require IP physicians to be constantly maintaining and updating their skill set. International agreed training pathways help ensure that the interventionalists of the present and future have the required knowledge of anatomy, manual dexterity, and clinical judgment to keep up with the continuing advances that are constantly expanding IP's diagnostic and therapeutic boundaries. IP remains one of the most desirable subspecialities in pulmonology, and the technologic advances make the future an exciting one.

What should be known prior to performing EUS exams? (Part II)

In “What should be known prior to performing EUS exams, Part I,” the authors discussed the need for clinical information and whether other imaging modalities are required before embarking EUS examinations. Herewith, we present part II which addresses some (technical) controversies how EUS is performed and discuss from different points of view providing the relevant evidence as available. (1) Does equipment design influence the complication rate? (2) Should we have a standardized screen orientation? (3) Radial EUS versus longitudinal (linear) EUS. (4) Should we search for incidental findings using EUS?

EBUS: Faster, cheaper and most effective in lung cancer staging

The use of endobronchial ultrasound trans-bronchial needle aspiration (EBUS-TBNA) as the initial diagnostic and staging procedure in patients with suspected, non-metastatic lung cancer has gained substantial support, and is now recommended by numerous guidelines. Whereas considerable attention has been pointed to the reductions in costs achieved by EBUS-TBNA, that has not been the case for some of its more significant benefits, namely the reduction of the diagnostic work-up time and its ability to accurately assess and restage lymph nodes, which were previously stated incorrectly by CT or PET scan. Both these benefits translate into improved outcomes for patients, as delays are reduced, futile surgeries are prevented and curable operations can be performed on patients previously excluded by CT or PET scan. Indeed, the use of EBUS as the initial diagnostic and staging procedure has been proven to significantly increase survival, compared with conventional diagnostic and staging procedures, in a pragmatic, randomised controlled trial (Navani N. et al, 2015). The instalment of EBUS will have the greatest effect on overwhelmed, suboptimally functioning national healthcare systems, by decreasing the number of required diagnostic and staging procedures, therefore reducing both treatment delays and costs. The improved selection of surgical candidates by EBUS will result in improved patient outcomes. The latest findings regarding the benefits of EBUS are outlined in this review, which, to the best of our knowledge, is the first to emphasise the impact of the procedure, both on timing and costs of lung cancer staging, as well as on survival.

Initial report of transesophageal EUS-guided intraparenchymal lung mass core biopsy: Findings and outcomes in two cases

EUS is most commonly used to evaluate and sample lesions of the abdomen but has only been used on rare occasions to evaluate and sample lung lesions. Prior reported cases of EUS sampling of lung lesions were performed by fine-needle aspiration. We present what is believed to be the first reported cases of EUS-guided core biopsy of intraparenchymal lung lesions through two separate case reports. Both patients had the upper lobe lesions not amenable to bronchoscopy or endobronchial ultrasound, and both patients underwent core biopsy without adverse event. This report of two cases shows that EUS-guided core biopsy of intraparenchymal lung lesions is technically possible and may not necessarily result in adverse events such as hemorrhage, pneumothorax, or infection.

Trans-esophageal endobronchial ultrasound-guided needle aspiration (EUS-B-NA): A road map for the chest physician

The endobronchial ultrasound (EBUS) scope has been increasingly used in the gastrointestinal tract (EUS-B). Scientific data proves its efficacy and safety to provide a complete lung cancer staging, when combined with EBUS-TBNA, and in the diagnosis of para-esophageal lesions. There are multiple barriers to start performing EUS-B but probably the most important ones are related to knowledge and training, so new operators should follow a structured training curriculum. This review aims to reflect the best current knowledge regarding EUS-B and provide a road map to assist those who are incorporating the technique into their clinical practice.