New Technique for Endobronchial Ultrasound-guided Transbronchial Needle Aspiration to Improve Diagnostic Yield

Comparison of the harvest volume between maneuvers of endobronchial ultrasound-guided transbronchial needle aspiration including the "cross-fanning technique"

Recently, a certain volume of biopsy specimens has been required for genetic testing of tumors using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). This study aimed to verify the superiority of our newly devised EBUS-TBNA biopsy technique, the "cross-fanning technique," which combines rotation and up-down maneuvers, by comparing its harvest volume with that of other maneuvers. Using a bronchoscope simulator, ultrasonic bronchoscope, and 21-gauge puncture needle, we compared the weight of silicone biopsy specimens obtained by the following 4 procedures: Conventional maneuver; Up-down maneuver; Rotation maneuver, and; Cross-fanning technique. Each procedure was repeated 24 times in total, rotating the sequences of the maneuvers, and the operator/assistant pair to align the conditions. The means ± standard deviations of the sample volumes for each puncture technique were as follows: 2.8 ± 1.2 mg; 3.1 ± 1.6 mg; 3.7 ± 1.2 mg, and; 3.9 ± 1.2 mg. There was a significant difference between the 4 groups (P = .024). The post hoc test showed a statistically significant difference between techniques A and D (P = .019). This study showed that the cross-fanning technique might contribute to the increased volume of tissue samples obtained by EBUS-TBNA biopsy.

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.

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.

The Successful Removal of a Broken Needle as an Unusual Complication of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA): A Case Report and Literature Review

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is recommended for the diagnosis of mediastinal lymph nodes by the American College of Chest Physicians guidelines; however, the guidelines state that this procedure should only be performed by a trained bronchoscopist. Complications related to needle malfunction during the EBUS-TBNA procedure have recently been reported. We herein describe a rare case involving the successful management of a needle breakage that occurred as an unusual complication of EBUS-TBNA. An 81-year-old male patient with a medical history of myocardial infarction was introduced to our institution to undergo an evaluation for mediastinal and right hilar lymphadenopathy on chest computed tomography (CT). We performed EBUS-TBNA in a 14×10 mm subcarinal lymph node station using a 22 G aspiration needle (NA-201SX-4022, Vizishot®, Olympus, Japan) for diagnosing and staging of the patient's lung cancer. After the second aspiration, we noticed that the needle tip was broken and that it was stuck in the right main bronchus. We immediately removed the broken needle tip from the right main bronchus by flexible bronchoscopy using an ID 8.5 mm tracheal tube without cuff inflation. The length of the needle tip was 13 mm and it was considerably bent. The EBUS scope did not suffer any apparent damage. The patient did not have any other procedure-related complications. Needle breakage during EBUS-TBNA is rare; however, inhaling or swallowing of a broken needle tip has the potential to cause serious complications. Bronchoscopists should therefore be aware of the possibility of needle breakage, which is an important complication during EBUS-TBNA.

DNA topoisomerase 1 and 2A function as oncogenes in liver cancer and may be direct targets of nitidine chloride

The aim of the present study was to determine the role of topoisomerase 1 (TOP1) and topoisomerase 2A (TOP2A) in liver cancer (LC), and to investigate the inhibitory effect of nitidine chloride (NC) on these two topoisomerases. Immunohistochemistry (IHC) staining and microarray or RNA sequencing data mining showed markedly higher expression of TOP1 and TOP2A at the protein and mRNA levels in LC tissues compared with that in control non-tumor tissues. The prognostic values of TOP1 and TOP2A expression were also estimated based on data from The Cancer Genome Atlas. The elevated expression levels of TOP1 and TOP2A were closely associated with poorer overall survival and disease-free survival rates. When patients with LC were divided into high- and low-risk groups according to their prognostic index, TOP1 and TOP2A were highly expressed in the high-risk group. Bioinformatics analyses conducted on the co-expressed genes of TOP1 and TOP2A revealed that the topoisomerases were involved in several key cancer-related pathways, including the 'p53 pathway', 'pathway in cancer' and 'apoptosis signaling pathway'. Reverse transcription-quantitative polymerase chain reaction and IHC performed on triplicate tumor tissue samples from LC xenografts in control or NC-treated nude mice showed that NC treatment markedly reduced the protein and mRNA expression of TOP1 and TOP2A in LC tissues. Molecular docking studies further confirmed the direct binding of NC to TOP1 and TOP2A. In conclusion, the present findings indicate that TOP1 and TOP2A are oncogenes in LC and could serve as potential biomarkers for the prediction of the prognosis of patients with LC and for identification of high-risk cases, thereby optimizing individual treatment management. More importantly, the findings support TOP1 and TOP2A as potential drug targets of NC for the treatment of LC.

Usefulness of transesophageal bronchoscopic ultrasound-guided fine-needle aspiration in the pathologic and molecular diagnosis of lung cancer lesions adjacent to the esophagus

BACKGROUND

The discovery of driver oncogenes has increased the need to obtain a sufficient amount of tissue specimens for lung cancer diagnosis. Although endoscopic ultrasound (with bronchoscope)-guided fine-needle aspiration (EUS-B-FNA) is reportedly a feasible and well-tolerated modality, additional advantages of EUS-B-FNA are yet to be thoroughly investigated. The purpose of this study was to evaluate the ability of EUS-B-FNA to obtain sufficient tissue specimens for pathologic and molecular diagnoses of lung cancer.

METHODS

Among lung cancer patients who were diagnosed between December 2010 and December 2012 in our institute, patients who underwent EUS-B-FNA to diagnose lung cancer were enrolled (n=26). EUS-B-FNA was performed when bronchoscopic diagnosis was impossible or difficult to obtain sufficient samples. Epidermal growth factor receptor (EGFR) mutations and echinoderm microtubule-associated protein-like 4 and the anaplastic lymphoma kinase (EML4-ALK) fusion gene were evaluated using EUS-B-FNA samples of non-small cell lung cancer.

RESULTS

EUS-B-FNA was performed on 28 lesions in 26 patients. Among the target lesions, 23 were mediastinal lymph nodes including nodal stations 2L, 4L, 7, 8, and 10L. The remaining 5 were intrapulmonary lesions. EUS-B-FNAs were completed without complications in all the patients. The diagnostic yield of EUS-B-FNA in diagnosing lung cancer was 100% (26/26). Additional diagnostic gain of EUS-B-FNA was 69.2% (18/26) as compared to bronchoscopy alone. EGFR mutations and EML4-ALK fusion gene could be evaluated in all patients with non-small cell lung cancer (n=20) using EUS-B-FNA samples. One case with EGFR mutation and 1 case with ALK fusion gene were diagnosed. Six non-small cell carcinomas were also diagnosed by bronchoscopy, but all bronchoscopic samples were insufficient to evaluate mutation analyses.

CONCLUSIONS

EUS-B-FNA is a practical and feasible method to obtain abundant tumorous tissue samples for pathologic diagnosis and molecular analysis, particularly when the target lesions are inaccessible by other modalities because of their locations or because of the patient's poor physical condition.