Comparison of 21-gauge and 22-gauge Needles for Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Mediastinal and Hilar Lymph Nodes

Learning curves and association of pathologist's performance with the diagnostic accuracy of linear endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA): a cohort study in a tertiary care reference centre

OBJECTIVES

We aimed to assess the learning curves and the influence of the pathologist's performance on the endobronchial ultrasound transbronchial needle aspiration's (EBUS-TBNA's) diagnostic accuracy in a real-world study.

DESIGN/SETTING

Cohort study conducted in a tertiary care university hospital (single centre) with patients referred for EBUS-TBNA.

PARTICIPANTS/INTERVENTION

We initially evaluated 376 patients (673 lymph nodes), 368 (660 lymph nodes) of whom were recruited. The inclusion criterion was EBUS-TBNA indicated for the study of mediastinal or hilar lesions. The exclusion criteria were the absence of mediastinal and hilar lesions during EBUS confirmed by a normal mediastinum and hilum on chest CT (except in cases of mediastinal staging of cancer) and lost to follow-up.

PRIMARY AND SECONDARY OUTCOME MEASURES

Diagnostic accuracy and related outcomes.

METHODS

We included patients from a prospectively constructed database. We performed a logistic regression multivariate analysis to adjust for potential confounders of the association between pathologist performance and EBUS-TBNA accuracy. The Cumulative Summation (CUSUM) analysis was used to assess pathologists' performance and learning curves.

RESULTS

Most indications for EBUS were suspicion of malignancy, including intrathoracic tumours (68.3%), extrathoracic tumours (9.8%) and cancer staging (7.0%). The patients' mean age was 63.7 years, and 71.5% were male. Overall EBUS-TBNA accuracy was 80.8%. In the multivariate logistic regression model, the factors independently associated with EBUS-TBNA accuracy included certain pathologists (ORs ranging from 0.16 to 0.41; p<0.017), a lymph node short-axis diameter <1 cm (OR: 0.36; 95% CI 0.21 to 0.62; p<0.001), and the aetiology of lymph node enlargement (ORs ranging from 7 to 37; p<0.001). CUSUM analysis revealed four different learning curve patterns, ranging from almost immediate learning to a prolonged learning phase, as well as a pattern consistent with performance attrition.

CONCLUSIONS

Pathologists' proficiency conditioned EBUS-TBNA accuracy. This human factor is a potential source of error independent of factors conditioning tissue sample adequacy.

Endobronchial Ultrasound Transbronchial Needle Aspiration With a 19-Gauge Needle vs 21- and 22-Gauge Needles for Mediastinal Lymphadenopathy

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used to evaluate mediastinal lymphadenopathy. Studies focusing on malignant lymphadenopathy have compared 21- and 22-gauge (21G and 22G, respectively) needles and have not identified an advantage of one needle size over the other in terms of diagnostic yield.

RESEARCH QUESTION

Does the 19-gauge (19G) EBUS needle offer greater diagnostic yield and sensitivity vs the 21G and 22G EBUS needles for a diagnosis of sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed?

STUDY DESIGN AND METHODS

This study retrospectively examined records of 730 patients from the Stather Canadian Outcomes Registry for Chest Procedures (SCOPE) database who underwent EBUS-TBNA for a diagnosis of suspected sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed. A propensity score analysis of two groups was performed. One group comprised patients undergoing EBUS-TBNA with a 19G needle, the other with a 21G or 22G needle. Cases for analysis were selected with a 1:2 ratio of 19G vs 21/22G using logistic regression and random matching with all eligible 19G cases included.

RESULTS

There were 137 patients (312 targets) in the 19G group and 274 patients (631 targets) in the 21/22G group in the propensity score analysis. The diagnostic yield was 107 of 137 (78.1%) in the 19G group vs 194 of 274 (70.8%) in the 21/22G group (difference, 7.3%; 95% CI, -1.9 to 15.6; P = .116). The sensitivity of EBUS-TBNA for sarcoidosis was 80 of 84 (95.2%) in the 19G group vs 150 of 156 (96.2%) in the 21/22G group (difference, 1.0%; 95% CI, -4.2 to 8.2; P = .71). In patients with a final diagnosis of lymphoma, EBUS was diagnostic in 10 of 13 (76.9%) in the 19G group vs 12 of 12 (100%) in the 21/22G group (difference, 23.1%; 95% CI, -5.4 to 50.3; P = .08).

INTERPRETATION

The study did not identify an advantage of the 19G EBUS needle over the 21/22G EBUS needles for diagnostic yield nor sensitivity for sarcoidosis or lymphoma.

Is endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) reliable and safe procedure in geriatric patients?

BACKGROUND

Even though studies have indicated the usefulness and safety of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), elderly patient data are limited due to the small sample sizes.

AIM

We aimed to evaluate usage and safety of EBUS-TBNA in elderly population.

METHODS

This single-center retrospective study was conducted with patients who underwent an EBUS-TBNA procedure between September 2011 and December 2019. The patients were categorized into two groups: those aged 65 years or older (elderly group) and those younger than 65 years (younger group).

RESULTS

2444 patient data, 1069 of which were in the elderly group, were analyzed. The cytological examination of EBUS-TBNA identified specimen adequacy in 96.8% of patients. One hundred and thirty patients (5.3%) experienced complications, with similar complication rates recorded in both the elderly and younger groups (5.4% vs 5.2%, p: 0.836). Logistic regression analyses revealed that age, and presence of hypertension, diabetes mellitus, coronary artery disease and malignancy are associated significantly with complication-related EBUS-TBNA. For the lymph nodes with a final diagnosis of malignancy, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EBUS-TBNA revealed a diagnostic performance in excess of 90% except for metastasis and lymphoma.

CONCLUSION

EBUS-TBNA can be considered a safe and effective technique in patients aged 65 years and over.

Linear Endobronchial Ultrasound in the Era of Personalized Lung Cancer Diagnostics-A Technical Review

Major advances in molecular profiling for available targeted treatments and immunotherapy for lung cancer have significantly increased the complexity of tissue-based diagnostics. Endobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNA) are commonly performed for diagnostic biopsies and lymph node staging. EBUS-TBNA has increasingly become one of the main sources of tumor cells for molecular analyses. As a result, there is a growing need for high quality EBUS-TBNA samples with adequate cellularity. This has increased the technical demands of the procedure and has created additional challenges, many of which are not addressed in the current EBUS guidelines. This review provides an overview of current evidence on the technical aspects of EBUS-TBNA in light of comprehensive sample processing for personalized lung cancer management. These include sonographic lymph node characterization, optimal needle choice, suction biopsy technique, and the role of rapid on-site evaluation. Attention to these technical details will be important to maximize the throughput of EBUS-TBNA biopsies for molecular testing.

Comparing diagnostic sensitivity of different needle sizes for lymph nodes suspected of lung cancer in endobronchial ultrasound transbronchial needle aspiration: Systematic review and meta-analysis

BACKGROUND

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a safe and minimally invasive procedure for evaluating hilar and mediastinal lymph nodes. The reported sensitivity and specificity of EBUS-TBNA are 95% and 97%, respectively. A comparison of diagnostic sensitivity for lymph nodes suspected of lung cancer according to needle size in EBUS-TBNA is needed.

OBJECTIVES

To compare the diagnostic sensitivity of the 19-G, 21-G, 22-G and 25-G needles for lymph nodes suspected of non-small cell lung cancer (NSCLC) using EBUS-TBNA.

METHODS

A literature search from PubMed, EMBASE, LILACS, DOAJ and CENTRAL through October 2020 was performed by two reviewers. The extracted data were evaluated using STATA® and Open Meta Analyst software for meta-analysis with a binary method model to compare sensitivity, specificity and summary receiver operating characteristic curve for each needle size.

RESULTS

Fourteen studies including 1296 participants were considered for the analysis. The overall sensitivity of EBUS-TBNA was 88.2% (95% CI 84%, 91%) and 93% (95% CI 88%, 95%) for the 19-G needle, 87.6% (95% CI 79.6%, 92.8%) for the 21-G needle and 85% (95% CI 80%, 88%) for the 22-G needle. The overall sensitivity of EBUS-TBNA for diagnosing NSCLC was 88.3% (95% CI, 81%, 93%) and 92.9% (95% CI, 85%, 97%) for the 19-G needle, 89.4% (95% CI 79.4%, 94.8%) for the 21-G needle and 82.1% (95% CI 66%, 91%) for the 22-G needle.

CONCLUSION

The 19-G, 21-G and 22-G needles present a similarly high diagnostic sensitivity in EBUS-TBNA. The 19-G needle provided better sample adequacy for molecular and immunohistochemical testing, improving diagnostic yield in this subgroup.

Interventional Pulmonology: Diagnostic and Therapeutic Advances in Bronchoscopy

BACKGROUND

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

AREAS OF UNCERTAINTY

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

DATA SOURCES

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

THERAPEUTIC ADVANCES

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

CONCLUSIONS

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

Comparison of the 22-gauge and 25-gauge needles for endobronchial ultrasound-guided transbronchial needle aspiration

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive hilar mediastinal node sampling technique used for lung cancer staging and diagnosis of lesions. Besides the conventional 22-gauge (G) and 21G needles, a 25G needle is now available for this procedure. The objective of this study was to evaluate the efficacy of the 25G EBUS-TBNA needle.

METHODS

We retrospectively reviewed consecutive patients who underwent EBUS-TBNA using both 22G and 25G aspiration needles from January 2017 through December 2017 at St. Marianna University School of Medicine. We identified 10 patients and compared the diagnostic yield and the sample volume for each needle.

RESULTS

Six patients were diagnosed with lung cancer and four with sarcoidosis. Total diagnostic yield was 80% (8/10) for the 22G and 60% (6/10) for the 25G (P = 0.31). In patients with lung cancer, the diagnostic yield was 67% (4/6) for the 22G and 83% (5/6) for the 25G (P = 0.50). In patients with sarcoidosis, the diagnostic yield was 100% (4/4) for the 22G and 25% (1/4) for the 25G (P = 0.07). In patients with lung cancer, the median tissue area was comparable for each needle; however, in patients with sarcoidosis, the sample area was smaller for the 25G than for the 22G. We did not encounter any major complications or bleeding during EBUS-TBNA procedures.

CONCLUSIONS

Although histologic specimens obtained by the 25G needle are expected to be useful for the diagnosis of lung cancer, we found the 25G needle inadequate for diagnosing sarcoidosis due to insufficient sample size.

Evaluation of histological specimens obtained by two types of EBUS-TBNA needles: a comparative study

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration is a standard method for obtaining specimens of mediastinal and hilar lesions. Several types of needles of various sizes and materials are available. This study aimed to compare the quality of specimens collected using two needles, cobalt chromium and stainless steel for endobronchial ultrasound-guided transbronchial needle aspiration.

METHODS

This retrospective study included data of patients who underwent EBUS-TBNA with a 22-gauge needle made from either stainless steel (41 lesions, 121 punctures) or cobalt chromium (47 lesions, 145 punctures). Histological data per puncture, diagnostic yield per lesion, procedure time and complication rates were compared.

RESULTS

There were no significant differences between the groups in the baseline characteristics of the patients or lesions or in the complication rates. The rate of diagnostic histological specimens in each sample (71.0% vs. 58.7%, P = 0.039), fewer samples with cartilage alone (1.4% vs. 6.6%, P = 0.047) and fewer samples containing cartilage (7.6% vs. 16.5%, P = 0.034) were seen in the cobalt chromium needle group than in the stainless steel needle group. In both groups, the rate of specimens that only contained blood clots in each sample and diagnostic yield per lesion were similar, but the procedure time was significantly shorter (22 min vs. 26 min, P = 0.007) in the cobalt chromium needle group.

CONCLUSION

Compared with stainless steel needles, cobalt chromium needle for EBUS-TBNA showed lower cartilage contamination and a higher ratio of obtaining diagnostic specimens in each sample. Bronchoscopists should consider using the optimal needle gauges and materials for collecting adequate specimens.

Interventional Bronchoscopy

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Collection and Handling of Thoracic Small Biopsy and Cytology Specimens for Ancillary Studies: Guideline From the College of American Pathologists in Collaboration With the American College of Chest Physicians, Association for Molecular Pathology, American Society of Cytopathology, American Thoracic Society, Pulmonary Pathology Society, Papanicolaou Society of Cytopathology, Society of Interventional Radiology, and Society of Thoracic Radiology

CONTEXT.—

The need for appropriate specimen use for ancillary testing has become more commonplace in the practice of pathology. This, coupled with improvements in technology, often provides less invasive methods of testing, but presents new challenges to appropriate specimen collection and handling of these small specimens, including thoracic small biopsy and cytology samples.

OBJECTIVE.—

To develop a clinical practice guideline including recommendations on how to obtain, handle, and process thoracic small biopsy and cytology tissue specimens for diagnostic testing and ancillary studies.

METHODS.—

The College of American Pathologists convened an expert panel to perform a systematic review of the literature and develop recommendations. Core needle biopsy, touch preparation, fine-needle aspiration, and effusion specimens with thoracic diseases including malignancy, granulomatous process/sarcoidosis, and infection (eg, tuberculosis) were deemed within scope. Ancillary studies included immunohistochemistry and immunocytochemistry, fluorescence in situ hybridization, mutational analysis, flow cytometry, cytogenetics, and microbiologic studies routinely performed in the clinical pathology laboratory. The use of rapid on-site evaluation was also covered.

RESULTS.—

Sixteen guideline statements were developed to assist clinicians and pathologists in collecting and processing thoracic small biopsy and cytology tissue samples.

CONCLUSIONS.—

Based on the systematic review and expert panel consensus, thoracic small specimens can be handled and processed to perform downstream testing (eg, molecular markers, immunohistochemical biomarkers), core needle and fine-needle techniques can provide appropriate cytologic and histologic specimens for ancillary studies, and rapid on-site cytologic evaluation remains helpful in appropriate triage, handling, and processing of specimens.

Evaluating Yield of 19 Versus 21 G EBUS-TBNA Needles: A Prospective Study

BACKGROUND

Controversy remains regarding the effect of needle size on the diagnostic yield of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. We conducted a prospective study comparing the diagnostic yield of 19 and 21 G EBUS needles and hypothesized that the 19 G have a greater EBUS-guided transbronchial needle aspiration diagnostic yield as compared with the 21 G needle.

METHODS

A total of 60 patients undergoing EBUS-guided transbronchial needle aspiration were enrolled with informed consent. Both 19 and 21 G needles were used at each lymph node station in alternating fashion, we randomized which needle, to begin with. Two rapid on-site cytology evaluation stations were present and assigned to one of the 2 needles. They reported sample adequacy and prepared a separate cell block per lymph node sampled for their assigned needle.

RESULTS

A total of 141 lymph nodes were analyzed. Diagnosis included 69 benign lymph nodes, 47 malignant lymph nodes, 22 noncaseating granulomas, and 3 infected lymph nodes. Five hundred seventy-three passes (average: 4.1 passes/lymph node) were done with 19 G and 581 passes with 21 G needles (average: 4.1 passes/lymph node). Diagnostic yield was similar between 19 and 21 G needles overall (89.4% vs. 88.7%, P=0.71). The 19 G needles showed higher smear cellularity (32.6% vs. 13.0%, P=0.05), and rapid on-site cytology evaluation adequacy (84.8% vs. 63.0%, P=0.004) in lymph nodes with cancer diagnosis. In 7 of the 141 lymph nodes, samples from only one of the needles provided the final diagnosis.

CONCLUSION

There is no difference in the overall diagnostic yield between 19 and 21 G needles. Further studies are needed to confirm the trend of the superiority of 19 G in cancerous lymph nodes.

Tissue Acquisition During EBUS-TBNA: Comparison of Cell Blocks Obtained From a 19G Versus 21G Needle

BACKGROUND

Previous studies have shown that needle gauge size has no significant impact on diagnostic yield during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Our objective was to determine whether cell blocks obtained via the new Flex 19G EBUS-TBNA needle would contain more cellular material based on cell area compared with those obtained from a 21G needle.

METHODS

A prospective analysis of patients undergoing EBUS-TBNA at our institutions was performed. Sampling of the same lesion(s) with both the Flex 19G and 21G needles was performed in an alternating manner. In total, 47 patients with suspected lung cancer or mediastinal/hilar lymphadenopathy were included with a total of 83 lesions biopsied. Cell block area was calculated using the Aperio ImageScope software.

RESULTS

Mean cell area in the Flex 19G group was 7.34±12.46 mm compared with 5.23±10.73 mm in the 21G group (P=0.02). In the malignant subgroup, the average cell area was 16.16±16.30 mm in the Flex 19G group versus 11.09±15.55 mm in the 21G group (P=0.02). No significant difference was noted in the mean cell area within the nonmalignant subgroup, 1.80±3.01 mm in the 19G group versus 1.56±1.79 mm in the 21G group (P=0.60).

CONCLUSION

The cell area obtained via the 19G needle was significantly larger than that obtained with the 21G needle. Further multicenter randomized studies are needed to identify the utility of the Flex 19G needle in diagnosing/subtyping lymphoproliferative disorders and adequacy for molecular testing in non-small cell lung cancer.

Optimal route planning for image-guided EBUS bronchoscopy

The staging of the central-chest lymph nodes is a major lung-cancer management procedure. To perform a staging procedure, the physician first uses a patient's 3D X-ray computed-tomography (CT) chest scan to interactively plan airway routes leading to selected target lymph nodes. Next, using an integrated EBUS bronchoscope (EBUS = endobronchial ultrasound), the physician uses videobronchoscopy to navigate through the airways toward a target node's general vicinity and then invokes EBUS to localize the node for biopsy. Unfortunately, during the procedure, the physician has difficulty in translating the preplanned airway routes into safe, effective biopsy sites. We propose an automatic route-planning method for EBUS bronchoscopy that gives optimal localization of safe, effective nodal biopsy sites. To run the method, a 3D chest model is first computed from a patient's chest CT scan. Next, an optimization method derives feasible airway routes that enables maximal tissue sampling of target lymph nodes while safely avoiding major blood vessels. In a lung-cancer patient study entailing 31 nodes (long axis range: [9.0 mm, 44.5 mm]), 25/31 nodes yielded safe airway routes having an optimal tissue sample size = 8.4 mm (range: [1.0 mm, 18.6 mm]) and sample adequacy = 0.42 (range: [0.05, 0.93]). Quantitative results indicate that the method potentially enables successful biopsies in essentially 100% of selected lymph nodes versus the 70-94% success rate of other approaches. The method also potentially facilitates adequate tissue biopsies for nearly 100% of selected nodes, as opposed to the 55-77% tissue adequacy rates of standard methods. The remaining nodes did not yield a safe route within the preset safety-margin constraints, with 3 nodes never yielding a route even under the most lenient safety-margin conditions. Thus, the method not only helps determine effective airway routes and expected sample quality for nodal biopsy, but it also helps point out situations where biopsy may not be advisable. We also demonstrate the methodology in an image-guided EBUS bronchoscopy system, used successfully in live lung-cancer patient studies. During a live procedure, the method provides dynamic real-time sample size visualization in an enhanced virtual bronchoscopy viewer. In this way, the physician vividly sees the most promising biopsy sites along the airway walls as the bronchoscope moves through the airways.

Waste not, want not: diagnostic material found in suction syringe aspirate during endobronchial ultrasound guided transbronchial needle aspiration

Background

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a frequently performed procedure. Suction is utilized during this procedure and may occasionally result in the collection of aspirated material, the diagnostic utility of which is uncertain. This study aims to determine the contents of the suction syringe aspirate and its diagnostic value.

Methods

The suction syringe aspirate was pooled in a container and sent for analysis. We retrospectively reviewed the cytological outcomes of these specimens in comparison to the diagnosis determined by EBUS-TBNA between 2015-2018. The primary outcome was the percent agreement between the diagnostic material found in the suction syringe aspirate, and the final diagnosis established by EBUS-TBNA.

Results

Forty-four patients were included. Percent agreement was calculated as the percent in which the suction syringe aspirate diagnosis agreed with the EBUS-TBNA diagnosis. The percent agreement of any diagnosis was 90.9% (95% CI: 78.7-97.2%). Two of the 44 diagnoses (4.5%) were established based solely on the suction syringe aspirate, both cases of granulomatous inflammation.

Conclusions

Our results suggest that material collected in the suction syringe has a very high percent agreement with the final diagnosis established by EBUS-TBNA. Furthermore, the suction syringe aspirate may represent the sole diagnostic material in nearly 5% of cases. Given the additional diagnostic material in the suction syringe aspirate, it is reasonable to pool the aspirate with the primary specimen in an effort to enrich the overall diagnostic specimen. This practice may improve the likelihood that the specimen will be sufficient for additional molecular analysis, although further study is necessary. Care must be taken when more than one needle is involved to ensure that a new suction syringe is also used to avoid inadvertent upstaging by specimen contamination.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Diagnosis and Staging of Lung Cancer

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) is fundamental to the diagnosis of lung cancer, as many patients present with more advanced stages of lung cancer, with enlarged hilar and mediastinal lymph nodes. It also represents a way to sample pulmonary masses directly to make the diagnosis, whereby no other accessible tissue is present and the mass sits adjacent to a large central airway. Very importantly also, EBUS TBNA is the widely accepted first procedure in lung cancer staging. A combined procedure of EUS TBNA can be performed to improve diagnostic accuracy.

Use of an Additional 19-G EBUS-TBNA Needle Increases the Diagnostic Yield of EBUS-TBNA

BACKGROUND

Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has an excellent diagnostic yield, there remain cases where the diagnosis is not obtained. We hypothesized that additional sampling with a 19-G EBUS-TBNA needle may increase diagnostic yield in a subset of cases where additional tissue sampling was required.

METHODS

Indications for use of the 19-G needle following 22-G sampling with rapid on-site cytologic examination were: (1) diagnostic uncertainty of the on-site cytopathologist (eg, nondiagnostic, probable lymphoma, etc.), (2) non-small cell lung cancer with probable need for molecular genetic and/or PD-L1 testing, or (3) need for a larger tissue sample for consideration of inclusion in a research protocol.

RESULTS

A 19-G EBUS-TBNA needle was utilized following standard sampling with a 22-G needle in 48 patients (50 sites) during the same procedure. Although the diagnostic yield between the needles was equivalent, the concordance rate was only 83%. The 19-G determined a diagnosis in 4 additional patients (8%) and provided additional histopathologic information in 6 other cases (12%). Conversely, in 3 cases (6%) diagnostic information was provided only by the 22-G needle. Compared with 22-G EBUS-TBNA alone, sampling with both the 22- and 19-G EBUS needles resulted in an increase in diagnostic yield from 92% to 99% (P=0.045) and a number needed to sample of 13 patients to provide one additional diagnosis. There were no significant complications.

CONCLUSION

In select cases where additional tissue may be needed, sampling with a 19-G EBUS needle following standard aspiration with a 22-G needle results in an increase in diagnostic yield.

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

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

Committee II: Guidelines for cytologic sampling techniques of lung and mediastinal lymph nodes

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pulmonary cytology including indications for bronchial brushings, washings, and endobronchial ultrasound guided transbronchial fine-needle aspiration (EBUS-TBNA), technical recommendations for cytological sampling, recommended terminology and classification schemes, recommendations for ancillary testing and recommendations for post-cytological management and follow-up. All recommendations are based on the expertise of the authors, an extensive literature review and feedback from presentations at national and international conferences. This document selectively presents the results of these discussions. The present document summarizes recommendations regarding techniques used to obtain cytological and small histologic specimens from the lung and mediastinal lymph nodes including rapid on-site evaluation (ROSE), and the triage of specimens for immunocytochemical and molecular studies.

Loss of flexion during bronchoscopy: a physical experiment and case study of commercially available systems

During routine endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) procedures, especially with biopsy of lymph nodes in or around the left upper lobe, frequent reports have noted the loss of ultrasound image and needle angulation leading to an inability to biopsy nodes visualised by EBUS. The aim of this research was to investigate and compare this loss of angulation with commercially available scopes. Bench-top experiments and a clinical case study demonstrated the varying loss of scope angulation, flexibility and manoeuvrability with different scopes and biopsy instruments leading to procedural implications. Improvements in both the EBUS scope and needle characteristics are required to overcome this limitation which has implications in bronchoscope navigation and the diagnostic yield of EBUS-TBNA.

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.

Endobronchial ultrasound-guided transbronchial needle aspiration for diagnosis of sarcoidosis in clinically unselected study populations

Literature suggests that ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has excellent performance characteristics for diagnosis of sarcoidosis. However, many authors challenge the external validity of EBUS-TBNA results, as most studies were performed in referral centres by highly experienced investigators, and included populations with very high sarcoidosis prevalence. We performed a systematic review and meta-analysis to estimate the role of EBUS-TBNA for diagnosis of sarcoidosis in studies enrolling consecutive patients with lymphadenopathy detected at imaging studies, regardless of the suspected underlying clinical aetiology. The Pubmed, Embase, Cinahl, Web of Science and Cochrane Library databases were screened to identify the pertinent literature. Quality of eligible studies was assessed by Quality Assessment, Data Abstraction and Synthesis-2 criteria. Pooled diagnostic yield, sensitivity and specificity were calculated, and a summary receiver operating characteristic curve was constructed. Subgroup analysis was planned to identify possible sources of study heterogeneity. Fourteen studies, collectively involving 2097 patients, fulfilled eligibility criteria. The median prevalence of sarcoidosis was 15%. EBUS-TBNA had a pooled diagnostic yield of 0.79 (standard deviation, 0.24), a pooled sensitivity of 0.84 (95% confidence interval (CI), 0.79-0.88) and a pooled specificity of 1.00 (95% CI, 0.99-1.00). Only subgroup analysis exploring the influence of study design seemed to influence the observed inter-study heterogeneity for sensitivity, retrospective studies showing worst sensitivity than prospective ones. The results of EBUS-TBNA for diagnosis of sarcoidosis in clinically unselected populations are excellent and compare favourably with published results from studies conducted in selected populations. High-quality trials would be needed to evaluate factors possibly explaining the observed heterogeneity in sensitivity.

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

RATIONALE

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

OBJECTIVES

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

METHODS

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

MAIN RESULTS

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

Impact of needle gauge on characterization of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) histology samples

BACKGROUND AND OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal node sampling technique used for lung cancer staging and diagnosis of mediastinal lesions. The four published studies assessing sampling with 21-G or 22-G needles conflict. The study objective is to evaluate the diagnostic utility of 21-G versus 22-G EBUS-TBNA needles, and the ability to subcharacterize both benign and malignant lesions using histopathological assessment only.

METHODS

A retrospective analysis was performed from 303 patients referred for EBUS-TBNA between January 2011 and July 2013. Sampling needle gauge was selected at the discretion of the operator. Samples were assessed by histopathologists blinded to the needle gauge without rapid on-site evaluation for cytology. Contingency table analysis was performed to compare diagnostic utility and ability to subcharacterize malignant and benign lesions.

RESULTS

No difference in diagnostic ability was seen for malignancy (96.6% vs. 95.3% accuracy, 21-G vs. 22-G). Subgroup analysis of benign 21-G tissue samples revealed superior characterization compared with 22-G samples (63/76, 83%, vs. 31/52, 60%, P < 0.01). Characterization of non-small cell lung cancer (NSCLC) was also significantly better with samples obtained with 21-G needles versus 22-G needles (57/65, 88% vs. 34/52, 65%, P < 0.01).

CONCLUSIONS

This large UK single-centre study suggests 21-G EBUS-TBNA needles are superior to 22-G in characterizing benign lesions (especially sarcoidosis) and NSCLC when using histopathological assessment. Making a positive benign diagnosis may avoid the need to perform mediastinoscopy. Obtaining sufficient histological material to subcharacterize NSCLC and particularly lung adenocarcinoma allows appropriate testing for genetic mutations facilitating targeted oncological therapy.

Diagnostic concordance rate between histologic and cytologic specimens of endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer: A single institution experience

BACKGROUND

The aspirates from endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) were examined using the tissue core and cytology. We assessed that the tissue core was a more reliable specimen and attempted to analyze how many discrepancies were found between the two specimens. We investigated diagnostic concordance rate between histology and cytology.

METHODS

From January 2011 to December 2011, a total of 267 consecutive patients with lung cancer, who underwent EBUS-TBNA, were included in this retrospective study.

RESULTS

Of the 267 lung cancer patients, 207 (77.5%) were men. The median age was 65 years old. The most common pathologic type was adenocarcinoma (120, 44.9%), followed by squamous cell carcinoma (79, 29.6%). Among the 267 patients, 579 mediastinal and hilar lymph nodes were punctured. The right lower paratracheal (204, 35.2%) and subcarinal (172, 29.7%) lymph nodes were the most common nodal stations. Among the 579 lymph nodes, malignant cells were observed in 267 (46.1%) nodes, in either the histologic, cytologic or both slides: 209 in both histology and cytology, 37 in histology only, and 21 in cytology only slides. The diagnostic concordance rate between the tissue core and cytology was 90.0% (95% confidence interval CI, 87.1-92.2) (κ = 0.79).

CONCLUSIONS

The diagnostic concordance rate between the histology and cytology of EBUS-TBNA in lung cancer was 90.0% (95% CI, 87.1-92.2) (κ = 0.79).

Comparison of 21-gauge and 22-gauge aspiration needle in endobronchial ultrasound-guided transbronchial needle aspiration: results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit.

METHODS

We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge.

RESULTS

A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P &lt; .001).

CONCLUSIONS

There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.

Acquisition and processing of endobronchial ultrasound-guided transbronchial needle aspiration specimens in the era of targeted lung cancer chemotherapy

Recent advances in therapy for non-small cell lung carcinoma have shown that a personalized approach to treatment has the potential to significantly reduce lung cancer mortality. Concurrently, endoscopic ultrasound transbronchial needle aspiration has emerged as an accurate and sensitive tool for the diagnosis and staging of this disease. As knowledge of the molecular mechanisms that drive lung cancer progression increases, the amount of information that must be derived from a tumor specimen will also increase. Recent clinical studies have demonstrated that small specimens acquired by endoscopic ultrasound transbronchial needle aspiration are sufficient for molecular testing if specimen acquisition and processing are done with these needs in mind. Optimum use of this procedure requires a coordinated effort between the bronchoscopist and the cytopathologist to collect and triage specimens for diagnostic testing. When feasible, rapid onsite evaluation should be performed to assess the specimen for both diagnostic quality and quantity and to allocate the specimen for cell-block and possible immunohistochemistry and molecular studies. It is necessary for pulmonologists and bronchoscopists to understand the rationale for histologic and molecular testing of lung cancer diagnostic specimens and to ensure that specimens are acquired and processed in a fashion that provides information from small cytologic specimens that is sufficient to guide treatment in this era of targeted therapy.