Endosonography for the Diagnosis of Malignant Lymphoma Presenting With Mediastinal Lymphadenopathy

Present status and perspectives of endosonography 2017 in gastroenterology

Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.

Performance of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Isolated Mediastinal and Hilar Lymphadenopathy

BACKGROUND

Although many studies have assessed the diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the context of a specific disease, few studies have assessed the overall diagnostic yield, sensitivity, and negative predictive value in patients with isolated mediastinal and hilar lymphadenopathy (IMHL).

OBJECTIVE

We evaluated the performance of EBUS-TBNA for diagnosing IMHL in a population with a high prevalence of concurrent or preexisting non-pulmonary malignancy.

METHODS

A retrospective chart review of patients who underwent EBUS-TBNA from October 2008 to April 2014 was performed to identify patients with IMHL. Patients with known or suspected primary pulmonary malignancy were excluded. When available, EBUS-TBNA results were cross-referenced with further diagnostic investigation or clinical diagnosis based on follow-up.

RESULTS

EBUS-TBNA was used to sample 765 lymph nodes from 350 patients. One hundred and fourteen (33.3%) patients had a concurrent or preexisting non-pulmonary malignancy. The overall yield of EBUS-TBNA for specific diagnosis was 300/350 (86%). The diagnostic yield for sarcoidosis, lymphoproliferative disease, metastatic lymphadenopathy from extrathoracic malignancy, and necrotizing granuloma was 123/149 (83%), 27/33 (82%), 20/25 (80%), and 13/19 (68%), respectively. Amongst 50 patients with non-diagnostic EBUS-TBNA, 25 yielded an insufficient sample and another 25 yielded only benign lymphoid material which was not representative of the underlying pathology. Overall, EBUS-TBNA had a sensitivity of 89%, a diagnostic yield of 86%, and a negative predictive value of 79%.

CONCLUSION

For patients with isolated hilar or mediastinal lymphadenopathy and a high background prevalence of concurrent and preexisting non-pulmonary malignancy, EBUS-TBNA is a reliable first-line diagnostic investigation.

Understanding local performance data for EBUS-TBNA: insights from an unselected case series at a high volume UK center

BACKGROUND

We reviewed the diagnostic performance of endobronchial ultrasound transbronchial aspiration (EBUS-TBNA) on an unselected large cohort of patients who underwent the procedure in our institution in the past 3 years and to compare against published standards and existing literature.

METHODS

All consecutive patients who underwent EBUS from January 2013 to December 2015 were included in the retrospective analysis, with a minimum of 6 months of clinico-radiological follow up. For assessing EBUS-TBNA performance, patients were analysed in three subgroups based on the indication for the EBUS-TBNA: in investigation of isolated mediastinal and/or hilar lymphadenopathy (IMHL), in staging of suspected or confirmed non-small cell lung cancer (NSCLC) and in making a tissue diagnosis in suspected thoracic or extrathoracic cancer. For patients subjected to EBUS-TBNA for staging in suspected lung cancer, accuracy of EBUS was measured by its ability to determine the true N2 stage.

RESULTS

A total of 1,656 lymph nodes and 138 peribronchial/peritracheal masses were sampled in 940 patients over the study period. The prevalence of reactive lymphadenopathy was 34%. The overall sensitivity to detect pathological disease was 81.6% (95% CI: 74.2-87.6%) whilst NPV was 74.8% (95% CI: 65.2-82.8%). Amongst patients who underwent EBUS-TBNA for staging purposes, the sensitivity for N2 staging was 83.7% (95% CI: 76.2-89.6%) and NPV was 81.6% (95% CI: 73.2-88.2%). The prevalence of N2 disease was 58%. In the subgroup of patients who proceeded to surgical sampling, the sensitivity was higher with the N2/N3 disease prevalence of 67.4%. The sensitivity of EBUS-TBNA to make a tissue diagnosis of thoracic or extrathoracic cancer was 88% (95% CI: 85.1-90.5%) and a NPV of 62% (95% CI: 54.7-69.0%). The disease prevalence was 83.6%.

CONCLUSIONS

This retrospective study of a large volume of patients represents real life practice and provides an accurate representation of the typical cohort of patients referred in for EBUS-TBNA to the general respiratory physician in UK. Our study highlights the pitfalls in collecting and analyzing data but also demonstrates how they can be used to improve service performance.

Linear endobronchial and endoesophageal ultrasound: a practice change in thoracic medicine

PURPOSE OF REVIEW

Linear endosonography, including intrathoracic lymph nodal sampling by endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) and endoesophageal ultrasound fine-needle aspiration (EUS-FNA), has an important role in the diagnosing and staging of lung cancer. Furthermore, endosonography is applied in the mediastinal evaluation of sarcoidosis, lymphoma, cysts, and nodal metastases of extrathoracic malignancies. Endosonography-related complications as well as sedation and training strategies are discussed. The purpose of this review is to summarize current practice, recent advances, and future directions.

RECENT FINDINGS

Lung cancer guidelines recommend endosonography - above mediastinoscopy - as the initial test for mediastinal nodal tissue staging. By introducing the EBUS-scope into the esophagus (EUS-B) - following an EBUS procedure - the complete mediastinum and the left adrenal gland can be investigated in a single scope procedure by one operator. In patients with suspected stage I/II sarcoidosis, EBUS-TBNA/EUS-FNA is the test with the highest granuloma detection rate. Diagnosing (recurrent) lymphoma is an increasingly accepted indication for endosonography. Systematic surveys showed that endosonography has a low complication rate. Simulator-based training and assessment tools measuring competency are important instruments to provide standardized and optimal implementation.

SUMMARY

Endosonography is generally accepted as a powerful and safe diagnostic test for various diseases affecting the mediastinum. Large-scale implementation is needed.

Ten Years of Linear Endobronchial Ultrasound: Evidence of Efficacy, Safety and Cost-effectiveness

Real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is one of the major landmarks in the history of bronchoscopy. In the 10 years since it was introduced, a vast body of literature on the procedure and its results support the use of this technique in the study of various mediastinal and pulmonary lesions. This article is a comprehensive, systematic review of all the available scientific evidence on the more general indications for this technique. Results of specific studies on efficacy, safety and cost-effectiveness available to date are examined. The analysis shows that EBUS-TBNA is a safe, cost-effective technique with a high grade of evidence that is a valuable tool in the diagnosis and mediastinal staging of patients with suspected or confirmed lung cancer. However, more studies are needed to guide decision-making in the case of a negative result. Evidence on the role of EBUS-TBNA in the diagnosis of sarcoidosis and extrathoracic malignancies is also high, but much lower when used in the study of tuberculosis, lymphoma and for the re-staging of lung cancer after neoadjuvant chemotherapy. Nevertheless, due to its good safety record and lack of invasiveness compared to surgical techniques, the grade of evidence for recommending EBUS-TBNA as the initial diagnostic test in patients with these diseases is very high in most cases.