Defining expanded areas in EBUS sampling: EBUS guided trans- and intra-pulmonary artery needle aspiration, with review of transvascular EBUS

Assessment of effectiveness and safety of thrombolytic therapy to pulmonary emboli by endobronchial ultrasound-guided transbronchial needle injection

Objective

Endobronchial ultrasound-guided transbronchial needle injection (EBUS-TBNI) may effectively treat acute pulmonary embolisms (PEs). Here, we assessed the effectiveness of clot dissolution and safety of tissue plasminogen activator (t-PA) injection using EBUS-TBNI in a 1-week survival study of a porcine PE model.

Methods

Six pigs with bilateral PEs were used: 3 for t-PA injection using EBUS-TBNI (TBNI group) and 3 for systemic administration of t-PA (systemic group). Once bilateral PEs were created, each 25 mg of t-PA injection using EBUS-TBNI for bilateral PEs (a total of 50 mg t-PA) and 100 mg of t-PA systemic administration was performed on day 1. Hemodynamic parameters, blood tests, and contrast-enhanced computed tomography scans were carried out at several time points. On day 7, pigs were humanely killed to evaluate the residual clot volume in the pulmonary arteries.

Results

The average of percent change of residual clot volumes was significantly lower in the TBNI group than in the systemic group (%: systemic group 36.6 ± 22.6 vs TBNI group 9.6 ± 6.1, P < .01) on day 3. Considering the elapsed time, the average decrease of clot volume per hour at pre-t-PA to post t-PA was significantly greater in the TBNI group than in the systemic group (mm3/hour: systemic 68.1 ± 68.1 vs TBNI 256.8 ± 148.1, P < .05). No hemorrhage was observed intracranially, intrathoracically, or intraperitoneally on any contrast-enhanced computed tomography images.

Conclusions

This study revealed that t-PA injection using EBUS-TBNI is an effective and safe way to dissolve clots.

Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations

Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.

Efficacy and safety of endosonography-guided transvascular needle aspiration of thoracic and abdominal lesions: A systematic review and meta-analysis

BACKGROUND

The diagnosis of intrathoracic and abdominal masses is challenging when lesions are located behind major vessels. Endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS)-guided transvascular needle aspiration (TVNA) provides a potentially useful diagnostic tool for such lesions. Data with respect to the safety and outcome of E-TVNA are scarce. Hence, this meta-analysis was conducted to assess the critical role of E-TVNA for diagnosis of various lesions.

METHODS AND MATERIAL

A meta-analysis was performed by pooling the data from studies obtained from comprehensive search of Medline, Embase, and Scopus from January 2000 to September 2022. The outcomes analyzed included sample adequacy, diagnostic accuracy and adverse events including bleeding.

RESULTS

A total of 17 studies (n = 411) were included in the final analysis. The pooled rate of sample adequacy was 91.5% [95% confidence interval (CI): 86.8-96.2], while the pooled rate of diagnostic accuracy was 85.0% (95% CI: 78.9-91.2). The pooled rate of bleeding with E-TVNA was 1.4% (95% CI 0.0-3.1%). All the episodes of bleeding were mild and resolved without any further intervention. There was no significant heterogeneity with respect to various outcomes and results were comparable on sensitivity analysis.

CONCLUSIONS

E-TVNA offers a safe and accurate diagnostic modality for the diagnosis of mediastinal and abdominal lesions located on the other side of major vessels. Selection of potential candidates and close periprocedural observation are essential to improve the outcome.

Endobronchial ultrasound guided intracardiac needle aspiration (EBUS-ICNA)

Most cardiac tumours are secondary to metastasis from extracardiac tumours. Obtaining biopsy from intracardiac lesions, especially from the left heart, is challenging, and the conventionally used methods are invasive and involve significant risks such as arrhythmias, tamponade, valvular damage and tumour embolisation. Endobronchial ultrasound (EBUS) is a minimally invasive procedure used to biopsy lymph nodes or mass lesions adjacent to the airways. Its safety and usefulness have been well established. Use of EBUS has expanded to several novel indications over the last few years. Here we report a case of a young woman with suspected metastatic disease to the heart, in whom traditional methods of biopsy had failed to give a diagnosis. EBUS-guided transbronchial intracardiac needle aspiration was safely performed from the left atrial mass lesion to obtain tissue for histopathological diagnosis. A diagnosis of metastatic adenocarcinoma with tumour embolisation to the heart was established.

Mediastinal lymphadenopathy: a practical approach

Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.

Endoscopic ultrasound-guided transvascular needle biopsy of thoracic and abdominal lesions: a multicenter experience

Background and study aims  Traditionally in the case of a vascular interposition, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been contraindicated. A transvascular route (TV) is feasible and probably a safe alternative approach in selected patients, but data are scarce. The primary aim of this study was to analyze the diagnostic yield and safety of EUS-TV-FNA in thoracic and abdominal lesions. Secondary aims included evaluation of the clinical impact and technical aspects. Patients and methods  A retrospective multicenter study was conducted with inclusion of all consecutive patients that underwent EUS-TV-FNA from July 2007 to January 2020. Feasibility, cytopathology, procedure details, and safety were evaluated. Univariate analysis was performed to identify variables associated with incidents, cytopathological diagnosis, and clinical impact. Results  Data were collected from a total of 49 cases and 50 EUS-TV-FNAs. The aorta (n = 19) and portal system (n = 17) were the most frequently punctured. The most frequent lesions were mediastinal lymph nodes (n = 13) and pancreatic tumors (n = 11). The diagnostic yield was 86 %, and there were nondiagnostic samples in seven cases. Overall sensitivity, specificity, and accuracy were 88 % (95 %CI,0.74-0.96), 100 % (95 %CI,0.59-1), and 90 % (95 %CI,0.78-0.96), respectively. Only three incidents were detected: two mural hematomas and a self-limited bleeding of gastroduodenal artery. In most patients, there was a significant impact on clinical management (88 %). Arterial vessel and ASA-III had a trend with incidents (both, P  < 0.08). Rapid on-site evlauation was found to be an independent predictor for obtaining a conclusive sample (OR 6.2; 95 %CI, 1.06-36.73, P  < 0.04). Conclusions  EUS-TV-FNA is feasible, seems to be safe, and can be recommended when no other targets are available, and the information obtained would impact on the clinical plan.

Cost-effectiveness of endoscopic mediastinal staging

Lung cancer is the first cause of cancer-related mortality. Mediastinal staging has a main role in the definition of the therapeutic strategy in early-stage and locally-advanced non-small cell lung cancer (NSCLC). Non-invasive mediastinal staging with CT or PET imaging has relatively limited accuracy, and nodal biopsy may be required to reach adequate staging results. In the last two decades endoscopic techniques have been increasingly used in the field of mediastinal staging thanks to a reduced invasiveness and to the possibility of obtaining a more thorough assessment in comparison with surgical techniques. However, the ideal staging strategy is still a matter for debate, particularly considering the cost-effectiveness of the different approaches. Complication-rate, costs, impact on quality of life, time delay to treatment and survival of the different staging techniques still have to be analyzed in detail. Other issues to be discussed are the optimal combination of staging approaches and the influence of factors as the prevalence of nodal disease on the cost-effectiveness of the different methods. Future issues of invasive staging concern the possibility of extending the definition of nodal status to N1 intrapulmonary nodes, in the light of the development of new oncological and surgical therapeutic approaches.

Role of EBUS TBNA in Staging of Lung Cancer: A Clinician's Perspective

The treatment of non-small cell lung cancer (NSCLC) includes surgical resection with curative intent in early-stage disease and chemoradiation in the advanced stage disease. Therefore, an accurate preoperative mediastinal lymph node staging is required not only to offer the appropriate treatment but also to avoid unnecessary invasive procedures including thoracotomy. The mediastinal lymph nodes can be sampled using several techniques including mediastinoscopy, surgery (open or video-assisted thoracoscopic surgery), endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA), or endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). Currently, EBUS-TBNA/EUS-FNA is the preferred modality for sampling mediastinal lymph nodes because of its minimally invasive nature and high diagnostic yield. In this review, we discuss the utility of endosonographic procedures in mediastinal lymph node staging of NSCLC.

Esophageal ultrasound with ultrasound bronchoscope (EUS-B) guided transvascular needle aspiration (TVNA)

We have described a 67-year-old man, diagnosed to have adenocarcinoma of lung by transvascular approach with esophageal ultrasound using ultrasound bronchoscope (EUS-B). To the best of our knowledge this is the first case where EUS-B has been used for transvascular fine needle aspiration cytology to diagnose lung carcinoma.