Transbronchial needle aspiration with endobronchial ultrasonography and ultrathin bronchoscopy for peripheral pulmonary lesions

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined.

AREAS COVERED

This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed.

EXPERT OPINION

The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Transbronchial cryobiopsy for small peripheral pulmonary lesions using endobronchial ultrasonography and an ultrathin bronchoscope

BACKGROUND

Transbronchial biopsy using an ultrathin bronchoscope (UTB) has a high diagnostic yield for peripheral pulmonary lesions (PPLs). When combined with peripheral transbronchial needle aspiration (pTBNA), it improves the diagnostic yield of "adjacent to" radial endobronchial ultrasonography (rEBUS) findings. However, pTBNA is a complicated technique, and the specimen volume is often inadequate for diagnostic and multiplex analyses. Recently, transbronchial cryobiopsy (TBCB) using a 1.1-mm cryoprobe that could be inserted into an UTB has been available. We investigated whether TBCB combined with forceps biopsy using a 1.1-mm cryoprobe with an UTB improved the diagnostic yield of "adjacent to" lesions.

METHODS

The data of 66 consecutive patients who underwent TBCB and forceps biopsy using UTB (hemostasis using two-scope method) under rEBUS for small PPLs (≤30 mm) were retrospectively analyzed. The histological diagnosis rate using TBCB and forceps biopsy, TBCB alone, or forceps biopsy alone was compared between cases where the rEBUS probe was "within" and "adjacent to" lesions.

RESULTS

The diagnosis rate using TBCB and forceps biopsy was 81.8 % for all lesions ("within" vs. "adjacent to" cases: 88.4 % vs. 69.6 %; p = 0.093). The corresponding rate using TBCB alone was 80.3 % (86.0 % vs. 69.6 %; p = 0.19), and that using forceps biopsy alone was 62.1 % (74.4 % vs. 39.1 %; p = 0.008). Bleeding leading to discontinuation of the examination occurred in four (6.1 %) patients; however, in all cases, bleeding could be controlled endoscopically.

CONCLUSION

Forceps biopsy with TBCB during ultrathin bronchoscopy for small PPLs improved the diagnostic yield when the lesions were adjacent to the rEBUS probe.

Ultrathin bronchoscopy for diagnosing peripheral pulmonary lesions

Bronchoscopes are continuously improving. Increasingly, thinner bronchoscopes with larger working channels and better imaging quality are becoming available for clinical use. Concurrently, useful ancillary devices have been developed, such as radial probe endobronchial ultrasound (rEBUS) and navigation devices. Randomized studies have demonstrated the diagnostic superiority of ultrathin bronchoscopy over thin bronchoscopy under rEBUS and virtual bronchoscopic navigation guidance for small, peripheral pulmonary lesions. Furthermore, biopsy needles and cryoprobes have been miniaturized and adapted to the working channel of the new ultrathin bronchoscopes. Multi-modality and multi-instrumental ultrathin bronchoscopy using such new technologies has facilitated high diagnostic yields.

Peripheral transbronchial needle aspiration-guided pinpoint cryobiopsy of lung nodule without bronchus sign: A case report

Peripheral transbronchial needle aspiration (pTBNA) allows the access of pulmonary nodules without bronchus sign but is limited to cytological examination. A 39-year-old man with left parotid carcinoma presented with an incidental lung nodule. Target localisation was performed with manual airway mapping, virtual bronchoscopic navigation, and pTBNA. Direct target validation using radial endobronchial ultrasound (rEBUS) was performed through the puncture defect. Targeted pinpoint biopsy with a 1.1 mm cryoprobe through the pTBNA puncture defect confirmed metastatic adenoid cystic carcinoma. Guided pTBNA with rEBUS validation followed by cryobiopsy of lung nodules without bronchus sign is potentially feasible for histological and molecular analyses.

Value of adding ultrathin bronchoscopy to thin bronchoscopy for peripheral pulmonary lesions: A multicentre prospective study

BACKGROUND AND OBJECTIVE

The diagnostic yield of thin bronchoscopy with radial probe endobronchial ultrasound (rEBUS) of peripheral pulmonary lesions into which the rEBUS probe cannot be inserted is unsatisfactory. In such cases, adding ultrathin bronchoscopy may be an option. We evaluated the efficacy of sequential ultrathin bronchoscopy for peripheral pulmonary lesions into which the rEBUS probe could not be inserted during thin bronchoscopy.

METHODS

In this multicentre prospective study, patients with peripheral pulmonary lesions ≤30 mm in diameter underwent rEBUS-guided transbronchial biopsy using a 4.0 mm diameter thin bronchoscope. In patients with lesions into which a rEBUS probe could not be inserted using that bronchoscope, bronchoscopy using a 3.0 mm diameter ultrathin bronchoscope was performed.

RESULTS

A total of 342 patients were enrolled and 340 were analysed. Among them, 87 patients with lesions of a median longest diameter of 17.5 mm underwent thin bronchoscopy followed by ultrathin bronchoscopy. Of the 87 patients, the rEBUS probe was successfully inserted into the lesions via the ultrathin bronchoscope in 50 patients (57.5%). Of the 87 patients, the diagnostic yields of thin bronchoscopy and ultrathin bronchoscopy were 12.6% (11 of 87) and 41.4% (36 of 87), respectively (p < 0.001).

CONCLUSION

Ultrathin bronchoscopy affords a higher diagnostic yield for lesions into which a rEBUS probe cannot be inserted via a thin bronchoscope.

Endobronchial ultrasound-guided transbronchial needle aspiration in peripheral pulmonary lesions: a systematic review and meta-analysis

The diagnosis of peripheral pulmonary lesions (PPLs) remains a challenge for physicians. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been applied in the diagnosis of PPLs, but its diagnostic rate varies widely. The systematic review and meta-analysis was conducted to figure out the accuracy and safety of EBUS-TBNA in the diagnosis of PPLs. We searched the PubMed and Embase databases for relevant studies published from January 1, 2000 to December 30, 2021 and used PICO (Participants, Intervention, Comparison, and Outcome) to worked out the diagnostic rate of EBUS-TBNA in PPLs. Two reviewers independently performed the data extraction and assessed study quality. Statistical analysis was carried out via R software. In 7 studies of totally 510 patients of PPLs, the overall EBUS-TBNA diagnosis yield is 0.75 (95% CI 0.67-0.84) by the random effect model. EBUS-TBNA showed a higher accuracy of 0.64 (95% CI 0.53-0.74) compared to 0.46 (95% CI 0.19-0.72) of endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) when EBUS probe is adjacent to lesions. In the case of malignant lesions, the diagnostic rate of EBUS-TBNA is 0.79 (95% CI 0.72-0.88). Combined EBUS-TBNA with conventional bronchoscopy procedures showed the highest diagnostic yield (0.83 (95% CI 0.79-0.87)). Collectively, EBUS-TBNA should be performed firstly in patients with PPLs suspected to lung cancer especially when the EBUS probe was adjacent to the lesions. No serious procedure-related complications were observed.

Inheritance and innovation of the diagnosis of peripheral pulmonary lesions

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.

Endoscopic Technologies for Peripheral Pulmonary Lesions: From Diagnosis to Therapy

Peripheral pulmonary lesions (PPLs) are frequent incidental findings in subjects when performing chest radiographs or chest computed tomography (CT) scans. When a PPL is identified, it is necessary to proceed with a risk stratification based on the patient profile and the characteristics found on chest CT. In order to proceed with a diagnostic procedure, the first-line examination is often a bronchoscopy with tissue sampling. Many guidance technologies have recently been developed to facilitate PPLs sampling. Through bronchoscopy, it is currently possible to ascertain the PPL's benign or malignant nature, delaying the therapy's second phase with radical, supportive, or palliative intent. In this review, we describe all the new tools available: from the innovation of bronchoscopic instrumentation (e.g., ultrathin bronchoscopy and robotic bronchoscopy) to the advances in navigation technology (e.g., radial-probe endobronchial ultrasound, virtual navigation, electromagnetic navigation, shape-sensing navigation, cone-beam computed tomography). In addition, we summarize all the PPLs ablation techniques currently under experimentation. Interventional pulmonology may be a discipline aiming at adopting increasingly innovative and disruptive technologies.

Radial-EBUS and virtual bronchoscopy planner for peripheral lung cancer diagnosis: How it became the first-line endoscopic procedure

Background

Various advanced bronchoscopy methods have been developed to reach peripheral lung lesions (PLL). In a large cohort, we aimed to assess a standardized procedure of first‐line radial‐endobronchial ultrasound (r‐EBUS) and virtual bronchoscopy planner for the diagnosis of peripheral lung cancer.

Methods

This retrospective, single center study included patients who had r‐EBUS‐guided bronchoscopy for the diagnosis of a PLL between 2008 and 2019. Cases without a final diagnosis of cancer or follow‐up were excluded.

Results

Between 2008 and 2019, 2735 patients had a r‐EBUS procedure, among whom 1627 had a final diagnosis of cancer and were included in the present study. Over the 12‐year study period, r‐EBUS became the first‐line endoscopic procedure to assess PLL (25% as first‐line bronchoscopy in 2008 vs. 92% in 2019). The frequency of the bronchus sign decreased from 2009 to 2019 (100% to 80%; p = 0.001), whereas US visualization of the lesion remained stable (88%). The median number of biopsies increased from two (2008 to 2014) to four (2015 to 2019) (p < 0.0001), with the same diagnostic efficiency (74% total and 80% when a bronchus sign was present). Of the 651 adenocarcinomas, molecular analysis was possible in 86%. PD‐L1 expression analysis was possible in 81% of cases. During the study period, the lifetime of the radial probe increased from 57 procedures to 77 procedures/probe.

Conclusion

Because r‐EBUS and VB planner is easy to perform under local anesthesia, inexpensive and efficient it can be used as a first‐line procedure to assess peripheral lung cancer.

Endobronchial Ultrasonography with a Guide Sheath Transbronchial Biopsy for Diagnosing Peripheral Pulmonary Lesions within or near Fibrotic Lesions in Patients with Interstitial Lung Disease

Simple Summary

Lung cancer often occurs around fibrotic lesions in patients with interstitial lung disease (ILD). In patients with ILD, several methods are available for diagnosing peripheral pulmonary lesions (PPLs), such as bronchoscopy with radial endobronchial ultrasound (R-EBUS), transthoracic needle biopsy, and surgical lung biopsy. As well as previous reports, in patients with ILD, bronchoscopy with R-EBUS might be an option as the primary procedure for diagnosing PPLs with fewer complications. However, the utility and safety of bronchoscopy with R-EBUS for PPLs in patients with ILD remain unknown. In this study, we assessed the efficacy and complications as the initial diagnostic procedure of bronchoscopy with R-EBUS according to the proximity of PPLs to fibrotic lesions. Our study might make a contribution to physicians who treat PPLs in patients with underlying ILD.

Abstract

In patients with interstitial lung disease (ILD), the most frequent locations of lung cancer are within or near fibrotic lesions. However, the diagnostic yield for peripheral pulmonary lesions (PPLs) within or near fibrotic lesions using endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) may be unsatisfactory compared to that for PPLs distant from fibrotic lesions because of the difficulty in reaching the lesions. Our objectives were to evaluate the yield for PPLs using EBUS-GS TBB according to the proximity of PPLs to fibrotic lesions and to determine factors affecting the yield for PPLs. We retrospectively investigated 323 consecutive lesions using EBUS-GS TBB between 1 November 2014 and 31 December 2016. We identified PPLs with ILD in such lesions. PPLs with ILD were divided into PPLs within or near fibrotic lesions which met the criterion of PPLs, and of fibrotic lesions overlapping each other (PPLs-FL) and those distant from fibrotic lesions, which met the criterion of PPLs and the area of fibrotic lesion not overlapping each other (PPLs-NFL). Of the 323 lesions, 55 were included (31 PPLs-FL and 24 PPLs-NFL). The diagnostic yield for PPLs-FL was significantly lower than for PPLs-NFL (45.2% vs. 83.3%, p = 0.004). Multivariate analysis revealed that PPLs-NFL (odds ratio (OR) = 7.509) and a probe position within the lesion (OR = 4.172) were significant factors affecting diagnostic yield. Lesion’s positional relation to fibrotic lesions and the probe position were important factors affecting the successful diagnosis via EBUS-GS TBB in these patients.

Effective early diagnosis for NSCLC: an algorithm

INTRODUCTION

Lung cancer still remains undiagnosed for most patients until the disease is inoperable.

AREAS COVERED

We performed search on PubMed with the keywords: EBUS, radial-EBUS, bronchoscopy, lung cancer, electromagnetic navigation, ct-biopsy, transthoracic biopsy. We present diagnostic equipment and imaging techniques such as positron emission tomography, endoscopical navigation systems, endobronchial ultrasound, radial-endobronchial ultrasound, transthoracic ultrasound biopsy, and computed tomography guided biopsies.

EXPERT OPINION

However, lack of early disease symptoms remains the most important issue and therefore we should direct our efforts to screening and early disease diagnosis. An algorithm is proposed for biopsy upon initial disease diagnosis.