Linear EBUS in staging non-small cell lung cancer and diagnosing benign diseases

Does prior mediastinal lymph node aspiration contribute to false-positive positron emission tomography–computed tomography?

Background

Proper staging of the mediastinum is an essential component of lung cancer evaluation. Positron emission tomography–computed tomography (PETCT) and endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) are an integral part of this process. False-positive PETCT results can occur following surgical procedures but has not been demonstrated following EBUS-TBNA. We aimed to determine whether false-positive PETCT rates increase when EBUS-TBNA is performed prior to PETCT.

Study design and methods

A retrospective review was carried out of clinical cases that underwent both PETCT and EBUS-TBNA within 30 days for the suspected malignancy. The impact of test sequence on the PETCT false-positive rate (FPR) was determined using Generalised Estimating Equation logistic regression analysis.

Results

A total of 675 lymph node stations were sampled and imaged on PETCT. Overall, 332 (49.2%) nodes were sampled by EBUS-TBNA before PETCT, and 343 (50.8%) afterwards, with the interval between EBUS and subsequent PETCT being a mean±sd of 11.6±6.8 days (range 1–29). The FPR on qualitative PETCT for the EBUS first group was 41 (23.2%) out of 164, and for PETCT first it was 57 (29.0%) out of 193 for a difference of 5.8% (95% CI −3.4–14.7, p=0.22). In the regression model, EBUS as the first test was associated with a lower FPR when using the clinical PETCT interpretation.

Interpretation

The performance of EBUS-TBNA sampling did not influence the FPR of PETCT when bronchoscopy took place in the 30 days prior to testing. Test sequence should be selected based on other clinical considerations.

In patients with suspected malignancy undergoing endobronchial ultrasound transbronchial needle aspiration (TBNA) as well as PETCT scan, performing the TBNA prior to PETCT does not increase the rate of false-positive PET scan resultshttps://bit.ly/3gFy6Fi

Disease-specific haptoglobin-β chain N-glycosylation as biomarker to differentiate non-small cell lung cancer from benign lung diseases

Background: The association of pathological states with N-glycosylation of haptoglobin-β has attracted increasing attention.

Materials & Methods: In the present study, disease-specific haptoglobin-β (DSHp-β) was separated from serum immunoinflammation-related protein complexes (IIRPCs) of 600 participants including 300 patients with benign lung diseases (BLDs) and 300 patients with non-small cell lung cancer (NSCLC). The enriched glycopeptides of the tryptic digests of the DSHp-β were analyzed using matrix assisted laser desorption/ionization-Fourier transform ion cyclotron resonance mass spectrometry (MALDI-FTICR MS).

Results: 20 of glycopeptides were detected for each sample. The statistical analysis has indicated that significant changes in the sialylation of DSHp-β between BLDs and NSCLC patients were observed. The age- and sex-matched participants were randomly clarified into the training set and the validation set. Receiver operating characteristic (ROC) analysis has revealed that the level ratio of glycopeptides (G2G3/G2G3S4) at the sites of Asn207/211 has potential capability to distinguish BLDs from NSCLC, with the sensitivity of 74.4%, the specificity of 82.8%, and the area under curve (AUC) of 0.805.

Conclusion: The glycosylation of DSHp-β can distinguish NSCLC from BLDs with high diagnostic accuracy compared with current clinical available serum markers.

Minimally Invasive Methods for Staging in Lung Cancer: Systematic Review and Meta-Analysis

Introduction. Endobronchial ultrasound (EBUS) is a procedure that provides access to the mediastinal staging; however, EBUS cannot be used to stage all of the nodes in the mediastinum. In these cases, endoscopic ultrasound (EUS) is used for complete staging. Objective. To provide a synthesis of the evidence on the diagnostic performance of EBUS + EUS in patients undergoing mediastinal staging. Methods. Systematic review and meta-analysis to evaluate the diagnostic yield of EBUS + EUS compared with surgical staging. Two researchers performed the literature search, quality assessments, data extractions, and analyses. We produced a meta-analysis including sensitivity, specificity, and likelihood ratio analysis. Results. Twelve primary studies (1515 patients) were included; two were randomized controlled trials (RCTs) and ten were prospective trials. The pooled sensitivity for combined EBUS + EUS was 87% (CI 84-89%) and the specificity was 99% (CI 98-100%). For EBUS + EUS performed with a single bronchoscope group, the sensitivity improved to 88% (CI 83.1-91.4%) and specificity improved to 100% (CI 99-100%). Conclusion. EBUS + EUS is a highly accurate and safe procedure. The combined procedure should be considered in selected patients with lymphadenopathy noted at stations that are not traditionally accessible with conventional EBUS.

Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging in lung cancer

OBJECTIVE:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic test with a high diagnostic yield for suspicious central pulmonary lesions and for mediastinal lymph node staging. The main objective of this study was to describe the diagnostic yield of EBUS-TBNA for mediastinal lymph node staging in patients with suspected lung cancer.

METHODS:

Prospective study of patients undergoing EBUS-TBNA for diagnosis. Patients ≥ 18 years of age were recruited between July of 2010 and August of 2013. We recorded demographic variables, radiological characteristics provided by axial CT of the chest, location of the lesion in the mediastinum as per the International Association for the Study of Lung Cancer classification, and definitive diagnostic result (EBUS with a diagnostic biopsy or a definitive diagnostic method).

RESULTS:

Our analysis included 354 biopsies, from 145 patients. Of those 145 patients, 54.48% were male. The mean age was 63.75 years. The mean lymph node size was 15.03 mm, and 90 lymph nodes were smaller than 10.0 mm. The EBUS-TBNA method showed a sensitivity of 91.17%, a specificity of 100.0%, and a negative predictive value of 92.9%. The most common histological diagnosis was adenocarcinoma.

CONCLUSIONS:

EBUS-TBNA is a diagnostic tool that yields satisfactory results in the staging of neoplastic mediastinal lesions.

Enhancement of conventional TBNA outcome after EBUS Training

BACKGROUND

Conventional transbronchial needle aspiration (C-TBNA) is a well-established technique for the diagnosis and staging of bronchogenic carcinoma. Because of the implementation of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), the C-TBNA is being used less frequently. Despite its proven diagnostic utility some of the pulmonary fellowship programs have chosen to eliminate training for C-TBNA from their curriculum. The objective our study was to compare the outcomes of C-TBNA before and after the implementation of EBUS in our unit.

METHODS

We compared the diagnostic performance of C-TBNA in 2 groups of non-small cell lung cancer patients with mediastinal lymph nodes >10 mm in short axis as seen on the computed tomography scan of the chest. Patients underwent C-TBNA before (group A, N=147) or after (group B, N=67) implementing EBUS technology in our unit. C-TBNA technique was performed by the same bronchoscopists before and after being proficient in EBUS.

RESULTS

The overall accuracy in group B was higher than in group A (23.9% vs. 9.5%, respectively; P=0.0001). Overall test accuracy and sensitivity of C-TBNA was 66% versus 86% and 63% versus 86% in groups A and B, respectively. The negative predictive values of C-TBNA improved after EBUS training (19% vs. 33%, P<0.001). Inadequate samples were less frequent in group B than in group A (31.1% vs. 49.7%, respectively; P=0.00001).

CONCLUSIONS

Diagnostic performance of C-TBNA improves after EBUS training. C-TBNA should remain in the armamentarium of every bronchoscopist and on the curriculum of all pulmonary fellowship training programs even if EBUS technology is available.

Imaging of the central airways with bronchoscopic correlation: pictorial essay

A wide variety of pathologic processes, both benign and malignant, affect the central airways. These processes may be classified into 4 distinct groups: anatomic variants, lesions that result in focal or diffuse airway narrowing, and those that result in multinodular airway disorder. Key to the accurate assessment of the central airways is meticulous imaging technique, especially the routine acquisition of contiguous high-resolution, 1-mm to 1.5-mm images. These images enable high-definition axial, coronal, and sagittal reconstructions, as well as advanced imaging techniques, including minimum intensity projection images and virtual bronchoscopy. Current indications most commonly include patients presenting with signs and symptoms of possible central airway obstruction, with or without hemoptysis. In addition to diagnosing airway abnormalities, computed tomography (CT) also serves a critical complementary role to current bronchoscopic techniques for both diagnosing and treating airway lesions. Advantages of CT include noninvasive visualization of the extraluminal extent of lesions, as well as visualization of airways distal to central airways obstructions. As discussed and illustrated later, thorough knowledge of current bronchoscopic approaches to central airway disease is essential for optimal correlative CT interpretation.

A case report on the diagnosis of a rare pleural tumor with endobronchial ultrasound: breaking new boundaries

Convex endobronchial ultrasound (C-EBUS)-guided transbronchial needle aspiration (TBNA) is an effective tool for the diagnosis of hilar, mediastinal, and central parenchymal lung lesions. However, it has a limited utility for pleural-based masses. We report a unique case of a pleural synovial sarcoma recurrence that was diagnosed by C-EBUS. The patient had a history of inguinal synovial sarcoma. He presented with cough and chest pain. Imaging of chest revealed large right pleural mass. Bronchoscopy with EBUS-TBNA diagnosed pleural recurrence of synovial sarcoma. He underwent radical resection and pathological examination confirmed the diagnosis of pleural synovial sarcoma. He experienced complete recovery and resolution of symptoms. Synovial sarcoma should be included in the differential diagnosis of pleural masses. Convex EBUS-guided biopsies can provide adequate diagnosis of large pleural tumors adjacent to the central airways without need for more invasive diagnostic procedures.

Teaching conventional transbronchial needle aspiration. A continuum

Proponents of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) propose that in this era of EBUS-TBNA, training for conventional transbronchial needle aspiration (C-TBNA) should be abandoned. The authors of this editorial provide the opposing view. C-TBNA has a short and a steep learning curve and adds to the diagnostic yield of flexible bronchoscopy in a cost-effective fashion. Considering its simplicity, availability, affordability, safety, and several unique indications, C-TBNA continues to contribute to the welfare of patients worldwide. It should remain as an integral part of pulmonary fellowship training programs.

Advanced bronchoscopic techniques in diagnosis and staging of lung cancer

The role of advanced brochoscopic diagnostic techniques in detection and staging of lung cancer has steeply increased in recent years. Bronchoscopic imaging techniques became widely available and easy to use. Technical improvement led to merging in technologies making autofluorescence or narrow band imaging incorporated into one bronchoscope. New tools, such as autofluorescence imagining (AFI), narrow band imaging (NBI) or fuji intelligent chromo endoscopy (FICE), found their place in respiratory endoscopy suites. Development of endobronchial ultrasound (EBUS) improved minimally invasive mediastinal staging and diagnosis of peripheral lung lesions. Linear EBUS proven to be complementary to mediastinoscopy. This technique is now available in almost all high volume centers performing bronchoscopy. Radial EBUS with mini-probes and guiding sheaths provides accurate diagnosis of peripheral pulmonary lesions. Combining EBUS guided procedures with rapid on site cytology (ROSE) increases diagnostic yield even more. Electromagnetic navigation technology (EMN) is also widely used for diagnosis of peripheral lesions. Future development will certainly lead to new improvements in technology and creation of new sophisticated tools for research in respiratory endoscopy. Broncho-microscopy, alveoloscopy, optical coherence tomography are some of the new research techniques emerging for rapid technological development.