Endobronchial ultrasound transbronchial needle aspiration in older people

Interventional pulmonology in elderly in tuberculosis and respiratory diseases-challenges

With the increasing number of the elderly population, the number of people with respiratory diseases along with other comorbidities is also increasing. With the good number of available evidence, the use of interventional pulmonary procedures is also increasing. However, the studies on the safety and therapeutic benefit of these procedures in the elderly population are limited. Because of the paucity of data, we decided to do a systematic review of the scientific literature that is currently available, to boost confidence to do these procedures by clinicians. This review deals with the procedures that are commonly performed in elderly respiratory patients, their indications, safety and the diagnostic and therapeutic yield, and compares them with the results in the younger population. It also focuses on the safety of anaesthetic techniques used for these procedures in the elderly. The bottom line of this review is that there is no significant difference between the older and younger age groups with regard to the above parameters and that age alone is not a criterion to decide whether the patients may undergo interventional pulmonary procedures.

Safety and efficacy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for patients aged 80 years and older

Background

The safety and efficacy of endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) in patients aged 70 years and older has been established. However, few studies have evaluated the safety, usefulness, and significance of EBUS‐TBNA in patients aged 80 years and older.

Methods

We retrospectively investigated patients aged 80 years and older who underwent EBUS‐TBNA under local anesthesia. The study period was 10 years; from November 1, 2010 to October 31, 2020. The primary endpoint was the safety of EBUS‐TBNA, which was measured as the incidence of complications associated with the procedure. The secondary endpoints were the overall diagnostic rate, malignant disease diagnosis rate, and malignant disease treatment rate.

Results

A total of 111 patients were enrolled in the study, and the median age was 82 years (range: 80–89 years). The incidence of complications (the primary endpoint) was 5% (5/111) and comprised oversedation in one case, chest pain in one case, hypoxemia in two cases, and arrhythmia in one case. Regarding the secondary endpoints, the diagnostic rate for all patients was 75% (83/111), and the diagnostic rate of malignant disease was 89% (75/84). Of the 75 patients with malignant disease diagnosed with EBUS‐TBNA, 61 (81%) received tumor‐specific therapy in accordance with their diagnoses.

Conclusion

EBUS‐TBNA can be considered safe and effective even in patients aged 80 years and older.

Flexible bronchoscopy for lung cancer diagnosis in patients aged ≥85 years

AIM

Flexible bronchoscopy (FB) is a common modality for the diagnosis of lung cancer. Recently, the number of older patients with lung cancer is increasing, and FB is being utilized more for these patients.

METHODS

FB carried out in patients aged ≥85 years at St. Marianna University Hospital, Kawasaki, Japan, were reviewed. The indication of FB was decided on a case-by-case basis, taking into consideration the condition of the patient, which included mental status and accessibility of the lesion. Outcomes included complications, diagnostic yields, treatment options and survival after FB evaluation.

RESULTS

From April 2015 to March 2019, 1604 diagnostic FBs were carried out. A total of 28 were carried out for the diagnosis of lung cancer (19 transbronchial lung biopsy, 9 transbronchial needle aspiration) in patients aged ≥85 years. Although there were three complications reported (pneumonia, fever, asthma exacerbation), they were successfully treated. A total of 19 cases were diagnosed with malignancy; five were treated with stereotactic body radiation therapy, five were prescribed targeted therapy, two underwent surgery and one was treated by cytotoxic monotherapy. Six patients were not included for active treatment. A total of 12 patients who received active treatment for lung cancer reported a 2-year survival rate of >60%.

CONCLUSIONS

FB for lung cancer diagnosis in patients aged ≥85 years were carried out with acceptable safety and diagnostic yield. Considering the development of less invasive therapeutic measures for lung cancer, FB is safe and valuable in individuals aged ≥85 years suspected of lung cancer with therapeutic indications. Geriatr Gerontol Int 2021; ••: ••-••.

Endobronchial ultrasound transbronchial needle aspiration in elderly patients: safety and performance outcomes EBUS-TBNA in elderly

AIM

Complication rates are low and endobronchial ultrasound guided needle aspiration (EBUS-TBNA) is generally regarded as a safe procedure, but there is a very limited number of studies evaluating the efficacy and safety of the procedure in advanced ages. The aim of this study is to assess the safety and performance outcomes of EBUS-TBNA in elderly.

METHODS

It was a retrospective observational study; patients who received EBUS-TBNA between September 2016 and January 2018 were evaluated. We analyzed patient's characteristics, doses of midazolam, and lidocaine used, regions of lymph node biopsies, and complications. Also, functionality and general physical status of patients over 65 years of age were evaluated.

RESULTS

During study period 132 cases of EBUS-TBNA were evaluated. 39 (29.5%) cases were aged 70 years, and over. There were more comorbidities in older group. Performance status of older group was worse. Furthermore, when evaluated according to American College of Cardiology (ACC)/American Heart Association (AHA) and American Society of Anesthesiologists (ASA), the older group was found to be composed of the riskier patients. When patients aged between 65 and 69, and over 70 compared, older patient's Barthel, EQ 5-D, SGA, and G8 scores were found to be worse. Despite that, there was no difference in the frequency, and types of complications between both groups. Diagnostic performance was not different between age groups.

CONCLUSIONS

Independent from comorbidities, general health status, and functionality EBUS-TBNA procedure in 70-year-old and over patients is a safe minimally invasive procedure.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for PD-L1 Testing in Non-small Cell Lung Cancer

BACKGROUND

Programmed death-ligand 1 (PD-L1) expression on cancer cells is a clinically important biomarker to select patients with non-small cell lung cancer (NSCLC) for treatment with programmed death-1/PD-L1 inhibitors. Clinical trials of immunotherapy in patients with NSCLC have required histologic evidence for PD-L1 testing; in clinical practice, cytologic samples commonly are acquired in patients with advanced disease.

RESEARCH QUESTION

This study aims to investigate whether endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples are adequate for PD-L1 testing in NSCLC.

STUDY DESIGN AND METHODS

This study investigates the sampling adequacy of EBUS-TBNA for PD-L1 testing when compared with other methods. Furthermore, the relationship between clinicopathologic characteristics and PD-L1 expression in the study population have been examined. Five hundred seventy-seven NSCLC specimens were analyzed from consecutive patients with NSCLC across six centers in the United Kingdom and one center in the United States between January 2015 and December 2016.

RESULTS

In the EBUS-TBNA group (189 specimens), the overall percentage of patients with successful PD-L1 testing was 94.7%. There was no significant difference in sampling adequacy with other methods of tissue acquisition. Older patients had higher failure rates of PD-L1 testing (OR, 1.06; P = .008). In multivariate analysis, advanced N-stage (P = .048) and presence of brain metastasis (P < .001) were associated with high PD-L1 expression.

INTERPRETATION

This large multicenter study shows that EBUS-TBNA provides samples adequate for PD-L1 testing and that advanced N stage and the presence of brain metastasis are associated with high PD-L1 expression.

Risk factors for pulmonary infection after diagnostic bronchoscopy in patients with lung cancer

Pulmonary infection is a relatively rare but serious complication of flexible bronchoscopy. The aim of this study was to identify the risk factors for pulmonary infectious complications after diagnostic bronchoscopy in patients with lung cancer. We retrospectively analyzed the medical records of 636 patients who underwent bronchoscopic biopsy for lung cancer diagnosis between April 2011 and March 2016. We compared patients' characteristics, chest computed tomography and bronchoscopic findings, undertaken procedures, and final diagnoses between patients who developed the complication and those who did not. Pulmonary infection after the diagnostic bronchoscopy occurred in 19 patients (3.0%) and included pneumonia in 16 patients and lung abscess in 3. Patients with larger lesions, presence of endobronchial lesions, histology of small cell lung cancer, and advanced disease stage tended to develop pulmonary infectious complications more often. Our multivariate analysis revealed that a larger lesion size and the presence of endobronchial lesions were independently associated with post-bronchoscopy pulmonary infection. Although we found no mortality associated with the infections, two patients were left with significant performance status deterioration after the pulmonary infection and received no anticancer treatment. In conclusion, endobronchial lesions and a larger lesion size are independent risk factors for the incidence of infections following bronchoscopic biopsy in patients with lung cancer.

Diagnostic Utility and Safety of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in the Elderly

BACKGROUND

There is limited evidence regarding the effect of age on the specimen adequacy, positivity rate of specimen on cytology (PR), and safety of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA). The aim of this study was to investigate the utility of EBUS-TBNA in the elderly.

METHODS

This was a retrospective study of subjects who underwent EBUS-TBNA. We compare the specimen adequacy, PR, and the incidence of complications in the elderly (age 65 y and above) versus the younger subjects (age younger than 65 y). A multivariate logistic regression analysis was performed to identify the factors affecting the diagnostic yield.

RESULTS

Of the 1816 subjects, 258 (14.2%) were elderly. The specimen adequacy was similar between the old and the young (93.5% vs. 96.3%, P=0.053). The PR in the elderly (48.8%) was lower (P<0.001) than the younger subjects (66.7%). Among those with a definite diagnosis made on EBUS-TBNA, 55.4% of the older subjects had malignancy, while 82.4% of the young had granulomatous disorders. The incidence of complications was similar in the 2 groups (3.9% vs. 4.4%, P=0.87). The specimen adequacy, PR and complications were also similar among the different age groups within the older population (65 to 69, 70 to 74, 75 to 79, and 80 y and above). On multivariate logistic regression analysis, older age, the number of lymph nodes sampled, the lymph node size, and needle reuse influenced the PR.

CONCLUSION

EBUS-TBNA appears to have a similar specimen adequacy and safety but a lower PR in the elderly as compared with the younger individuals.

Safety and efficacy of diagnostic flexible bronchoscopy in very old patients with lung cancer

INTRODUCTION

Although there is a remarkable increase in diagnostic flexible bronchoscopy (FB) in old patients, safety and efficacy of FB in very old patients remain to be elucidated. In this study, we aimed to evaluate the complications and diagnostic yield of FB in patients aged ≥ 80 years with lung cancer compared with those aged < 80 years.

MATERIALS AND METHODS

We retrospectively analysed the medical records of 668 consecutive patients, which included 89 patients aged ≥ 80 years (older group) and 579 patients aged < 80 years (younger group) who underwent bronchoscopy for the diagnosis or staging of lung cancer between April 2011 and March 2016.

RESULTS

The median age of the patients was 82 and 69 years in the older and younger groups, respectively. Performance status and Charlson comorbidity index were comparable between the study groups. Diagnostic yield in the older and younger groups was equivalent, and stage distribution in both the groups was similar. Sixty-one patients (68.5%) received anticancer treatment including surgery, radiation and chemotherapy with cytotoxic or molecular-targeted agents in the older group. There were no statistical differences in the occurrence of overall complications between the two groups.

CONCLUSIONS

Safety and efficacy of FB in the diagnosis of lung cancer in very old patients are comparable with those of younger patients. Accurate diagnosis established by bronchoscopy leads to appropriate treatment decision in very old patients.

Thin-section computed tomography-determined usual interstitial pneumonia pattern affects the decision-making process for resection in newly diagnosed lung cancer patients: a retrospective study

BACKGROUND

There is only limited information on the impact of thin-section computed tomography (TSCT)-determined usual interstitial pneumonia (UIP) pattern in the decision-making for resection in newly diagnosed lung cancer patients.

METHODS

In this retrospective analysis, data were reviewed from 499 newly diagnosed lung cancer patients who received bronchoscopy between 2010 and 2014. The clinical impact of TSCT-determined UIP pattern on the decision-making process for resection in this cohort was evaluated.

RESULTS

The prevalence rate of TSCT-determined fibrosis was 14.8% (74/499 cases), 86.5% (64/74 cases) of which also had TSCT-determined emphysema. The fibrosis group comprised 40 patients with possible UIP and 34 patients with the UIP pattern. Among surgical candidates, the number of surgeries performed was lower in the fibrosis group (60.8%) than in the normal and emphysema groups (84.7 and 77.3%, respectively). Although the proportion of possible UIP did not differ between surgical candidates and patients with resected lung cancer, the proportion of UIP pattern in patients with resected lung cancer was decreased by 8.5%, compared to the surgical candidates. Although measurement of diffusing capacity of the lung for carbon monoxide (DLCO) was performed in more than 97% of patients with thoracic surgery, only 58% of patients without thoracic surgery had DLCO measurement. Multivariate analysis showed that the finding of UIP pattern independently affects the decision-making process for thoracic surgery. The adjusted odds ratios for the comparison between the patients without fibrosis and the patients with UIP pattern was 0.266 (95% confidence intervals: 0.087-0.812).

CONCLUSIONS

The presence of TSCT-determined UIP pattern might independently affect the decision-making process for proposing thoracic surgery with curative intent.

Factors Affecting the Diagnostic Yield of Transbronchial Biopsy Using Endobronchial Ultrasonography with a Guide Sheath in Peripheral Lung Cancer

Objective Endobronchial ultrasonography with a guide sheath (EBUS-GS) and virtual bronchoscopic navigation (VBN) improves the diagnostic yield in patients with peripheral pulmonary lesions (PPLs). Most previous reports on EBUS-GS-guided transbronchial biopsy (TBB) have included patients with benign and malignant diseases. We aimed to determine the factors that predicted a successful diagnosis by EBUS-GS-guided TBB diagnostic in patients with small peripheral lung cancer, with a focus on the high-resolution computed tomography (HRCT) findings before bronchoscopy. Methods We retrospectively reviewed the medical records of 173 consecutive patients with 175 small (≤30 mm) PPLs who were diagnosed with primary lung cancer between June 2010 and October 2013 at Nagoya University Hospital. All patients underwent EBUS-GS-guided TBB with VBN using a ZioStation computer workstation (Ziosoft, Osaka, Japan). We analyzed the patient characteristics, HRCT findings, diagnostic yield, and the diagnostic factors in small peripheral lung carcinoma. Results The EBUS probe position was within the PPL in 83 of the 175 lesions (47%) and 112 (64.0%) cases were successfully diagnosed by EBUS-GS-guided TBB. A univariate analysis revealed that the following factors were associated with a significantly higher diagnostic yield: CT bronchus sign positivity, a lesion of >20 mm in diameter, a solid nodule, and a probe position that was within the lesion. The following factors were not significant: the lesion location, the number of biopsies, and the lung cancer histology. A multivariate analysis revealed that the following factors significantly affected the diagnostic yield: CT bronchus sign positivity [odds ratio (OR) =2.479]; a probe position that was within the lesion (OR=2.542); and a solid nodule (OR=2.304). Conclusion The significant factors that were significantly associated with a successful diagnosis using EBUS-GS-guided TBB in small peripheral lung carcinoma were as follows: CT bronchus sign positivity, a solid nodule, and a probe position that was within the lesion.

Endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing mediastinal lymphadenectasis: a cohort study from a single center

OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used for clinical diagnosis of mediastinal lymphadenectasis. This study aimed to evaluate the diagnostic significance of EBUS-TBNA for mediastinal lymphadenectasis in a large single center.

METHODS

A total of 846 patients who were not definitively diagnosed with mediastinal lymphadenectasis underwent EBUS-TBNA were retrospectively analyzed in this study.

RESULTS

In total, 842 patients underwent EBUS-TBNA successfully. There were 589 patients with malignancy, including squamous carcinoma (118 cases; 20.6%), adenocarcinoma (187 cases; 32.7%) and small cell carcinoma (88 cases; 15.4%). A total of 253 patients were diagnosed with benign disease, including tuberculosis (111 cases; 43.9%) and sarcoidosis (93 cases; 36.7%). The diagnostic sensitivity of lung cancer, tuberculosis and sarcoidosis were 94.4%, 81.1% and 51.6%, respectively. The overall sensitivity of EBUS-TBNA was 92.0%. N2 stage in lung cancer patients who were diagnosed by EBUS-TBNA was significantly higher than other stages. The positive rate of targeted puncture is high for the lymph nodes whose short-axis diameters were larger than 1 cm.

CONCLUSION

The operation risk of EBUS-TBNA is relatively small. In diseases complicated by mediastinal lymphadenectasis, malignant diseases are most, and benign diseases mainly are granulomatous. EBUS-TBNA is a valuable diagnostic technique in patients with mediastinal lymphadenectasis whose diagnosis have not been determined.