Analysis of cell cycle-related proteins in mediastinal lymph nodes of patients with N2-NSCLC obtained by EBUS-TBNA: relevance to chemotherapy response

Contemporary art of cell-block preparation: Overview

Cell blocks (CBs) are paraffin-embedded versions of cytology specimens. These versions are contrasted with tissues made from surgical pathology specimens of formalin-fixed paraffin-embedded (FFPE) tissue. CBs enable various elective ancillary studies of a range of specimens. These studies include the potential to perform molecular tests with the enhanced cytopathological interpretation. CBs are increasingly reported in cytology specimens. The enhanced role of CBs incorporates additives with new markers for immunohistochemistry (IHC), including the multicolored approach to IHC, and the subtractive coordinate immunoreactivity pattern. Even when archived material is retrospectively retrieved, CBs are a major tissue source for many supplementary studies. The CBs have been qualitatively and quantitatively improved. CBs are significant since they have increased molecular markers standardized on FFPE tissue. High-quality CBs can serve as useful additions to cytological smear preparations and touch imprint cytology. Most cytological specimens, such as fine-needle aspirations, cavitary effusion, washings, brushings, and gynecological and non-gynecological liquid specimens, may be used to produce CBs. This review deals with the CB-making process and discusses various historical limitations with an emphasis on recent advances.

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.

Clinical evaluation of the utility of a flexible 19-gauge EBUS-TBNA needle

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established modality for the assessment of mediastinal and hilar adenopathy. To overcome the sampling limitations of standard 21- and 22-gauge EBUS-TBNA needles, a new flexible 19-gauge (Flex 19G) needle was developed.

Methods

We performed a retrospective analysis of patients who underwent EBUS-TBNA sampling with the Flex 19G needle. A 22G needle was always used first for cytology, followed by a Flex 19G needle, either an early version (Oct/2014-Sep/2015) or a final version needle (May/2016-Jan/2017), for tissue sampling. The success rate of obtaining samples, specimen quantity, and safety were evaluated and compared.

Results

All sampling procedures in 45 patients and 82 targets were performed without complication and the overall diagnostic yield from cytology was 100%. Furthermore, 28% of Flex 19G samples were sufficient for histopathological diagnosis. Yield improved with an increased number of passes and if the target was larger. Compared to the early version evaluated in 52 targets, the final version of the Flex 19G needle evaluated in 30 targets provided significantly larger volume samples and more frequent diagnostic cores. Tissue obtained with the Flex 19G needle retained cohesiveness to a larger degree and was of higher cellularity compared to cytological samples processed as cell blocks.

Conclusions

The Flex 19G is safe and provides larger volumetric and cohesive tissue samples that are appropriate for histopathological processing. The final version of the Flex 19G could be a good choice in selected cases where greater tissue acquisition is required.

Learning curve and advantages of endobronchial ultrasound-guided transbronchial needle aspiration as a first-line diagnostic and staging procedure

Background

Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is now the standard for mediastinal lymph node staging of lung cancer. Training and maintenance of technical skills is very important in order to apply new techniques in clinical use.

Methods

A retrospective chart review was performed of patients who underwent EBUS‐TBNA from November 2009 to December 2015. We assessed the learning curve, accuracy (%), and whether this procedure shortened the duration of lung cancer staging.

Results

The EBUS‐TBNA learning curve continued to improve beyond 120 procedures. Diagnostic accuracy was similar between benign and malignant populations. There was no difference in the learning curve between the groups. Non‐small cell lung cancer patients who underwent EBUS‐TBNA as the first investigative procedure underwent fewer subsequent investigative procedures (1.47 vs. 2.05; P < 0.001), and had a shorter staging duration (4.52 vs. 11.05 days; P = 0.006) compared to those who underwent other procedures for the first investigation.

Conclusion

EBUS‐TBNA should be one of the preferred options for lung cancer diagnosis and staging because it reduces the staging duration compared to the use of other invasive procedures in initial investigation.

Role of the pulmonologist in ordering post-procedure molecular markers in non-small-cell lung cancer: implications for personalized medicine

In the growing era of personalized medicine for the treatment of non-small-cell lung cancer (NSCLC), it is becoming increasingly important that sufficient quality and quantity of tumor tissue are available for morphologic diagnosis and molecular analysis. As new treatment options emerge that might require more frequent and possibly higher volume biopsies, the role of the pulmonologist will expand, and it will be important for pulmonologists to work within a multidisciplinary team to provide optimal therapeutic management for patients with NSCLC. In this review, we discuss the rationale for individualized treatment decisions for patients with NSCLC, molecular pathways and specific molecular predictors relevant to personalized NSCLC therapy, assay technologies for molecular marker analysis, and specifics regarding tumor specimen selection, acquisition, and handling. Moreover, we briefly address issues regarding racial and socioeconomic disparities as they relate to molecular testing and treatment decisions, and cost considerations for molecular testing and targeted therapies in NSCLC. We also propose a model for an institution-based multidisciplinary team, including oncologists, pathologists, pulmonologists, interventional radiologists, and thoracic surgeons, to ensure adequate material is available for cytological and histological studies and to standardize methods of tumor specimen handling and processing in an effort to provide beneficial, individualized therapy for patients with NSCLC.

Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of lung cancer depends on the type of lung cancer (small cell lung cancer or non-small cell lung cancer [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient. The objective of this study was to determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on techniques available for the initial diagnosis of lung cancer, a systematic search of the MEDLINE, Healthstar, and Cochrane Library databases covering material to July 2011 and print bibliographies was performed to identify studies comparing the results of sputum cytology, conventional bronchoscopy, flexible bronchoscopy (FB), electromagnetic navigation (EMN) bronchoscopy, radial endobronchial ultrasound (R-EBUS)-guided lung biopsy, transthoracic needle aspiration (TTNA) or biopsy, pleural fluid cytology, and pleural biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method (see the article "Methodology for Development of Guidelines for Lung Cancer" in this guideline), and reviewed by all members of the Lung Cancer Guideline Panel prior to approval by the Thoracic Oncology NetWork, the Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer, with a pooled sensitivity rate of 66% and a specificity rate of 99%. However, the sensitivity of sputum cytology varies according to the location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of FB for diagnosing lung cancer is 88%. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions &lt; 2 or &gt; 2 cm in diameter showed a sensitivity of 34% and 63%, respectively. R-EBUS and EMN are emerging technologies for the diagnosis of peripheral lung cancer, with diagnostic yields of 73% and 71%, respectively. The pooled sensitivity of TTNA for the diagnosis of lung cancer was 90%. A trend toward lower sensitivity was noted for lesions &lt; 2 cm in diameter. TTNA is associated with a higher rate of pneumothorax compared with bronchoscopic procedures. In a patient with a malignant pleural effusion, pleural fluid cytology is reported to have a mean sensitivity of about 72%. A definitive diagnosis of metastatic disease to the pleural space can be estalished with a pleural biopsy. The diagnostic yield for closed pleural biopsy ranges from 38% to 47% and from 75% to 88% for image-guided closed biopsy. Thoracoscopic biopsy of the pleura carries the highest diagnostic yield, 95% to 97%. The accuracy in differentiating between small cell and non-small cell cytology for the various diagnostic modalities was 98%, with individual studies ranging from 94% to 100%. The average false-positive and false-negative rates were 9% and 2%, respectively. Although the distinction between small cell and NSCLC by cytology appears to be accurate, NSCLCs are clinically, pathologically, and molecularly heterogeneous tumors. In the past decade, clinical trials have shown us that NSCLCs respond to different therapeutic agents based on histologic phenotypes and molecular characteristics. The physician performing diagnostic procedures on a patient suspected of having lung cancer must ensure that adequate tissue is acquired to perform accurate histologic and molecular characterization of NSCLCs.

CONCLUSIONS

The sensitivity of bronchoscopy is high for endobronchial disease and poor for peripheral lesions &lt; 2 cm in diameter. The sensitivity of TTNA is excellent for malignant disease, but TTNA has a higher rate of pneumothorax than do bronchoscopic modalities. R-EBUS and EMN bronchoscopy show potential for increasing the diagnostic yield of FB for peripheral lung cancers. Thoracoscopic biopsy of the pleura has the highest diagnostic yield for diagnosis of metastatic pleural effusion in a patient with lung cancer. Adequate tissue acquisition for histologic and molecular characterization of NSCLCs is paramount.

Utilizing endobronchial ultrasound with fine-needle aspiration to obtain tissue for molecular analysis: a single-center experience

BACKGROUND

: Lung cancer is the leading cause of cancer deaths worldwide, with the majority of patients presenting with advanced disease for which surgery is not an option. Recently, a number of genetic mutations have been identified that predict response to chemotherapy, making the acquisition of tissue for molecular analysis important for treatment planning. It has previously been demonstrated that samples obtained using endobronchial ultrasound fine-needle aspiration (EBUS-FNA) are adequate for this analysis. This is the first report on the use of EBUS-FNA specimens for analysis of the epithelial mesenchymal transition (EMT) pathway.

METHODS

: A total of 74 consecutive patients with known or suspected lung cancer undergoing EBUS for diagnosis and/or staging were enrolled in this study. Total RNA was isolated from the FNA specimens, reverse transcribed, and analyzed for expression of a panel of genes associated with EMT using a probe-based real-time quantitative polymerase chain reaction.

RESULTS

: A total of 150 lymph nodes were sampled from the 74 patients who participated in the study. There was adequate tissue to perform real-time polymerase chain reaction in 130 (86%) of the nodes.

CONCLUSIONS

: EBUS-FNA samples are adequate for analysis of novel markers and pathways, including EMT, which may predict prognosis, responsiveness to therapy, and provide potential targets for new drug development. As the treatment of lung cancer shifts toward a more personalized approach, EBUS-FNA will likely play a central role in tissue acquisition for diagnosis, staging, and molecular analysis.

Bronchoscopic staging of lung cancer

Advances in bronchoscopy have contributed valuable tools to the diagnosis and staging of lung cancer. Detection of lesions at the premalignant microscopic stage has become possible with autofluorescence bronchoscopy and narrow band imaging. Bronchoscopy also allows for sampling of visible intra-bronchial lesions and for transbronchial needle aspiration of lesions in pulmonary parenchyma. With endobronchial ultrasound guidance, real-time evaluation and biopsy of mediastinal and pulmonary lesions can be achieved, enabling accurate clinical and pathological T-staging and N-staging without the need for surgery. In combination with advanced imaging techniques, Navigational bronchoscopy allows for the targeting and biopsy of the most peripheral lesions that are located in the smallest airways. For patients in whom tumor genetics are important, bronchoscopic-guided transbronchial biopsy can provide sufficient material for molecular analysis. As minimally invasive technology continues to evolve and improve, bronchoscopic techniques are poised to continue to be essential for the diagnosis and staging of lung cancer.

Clinical impact of ki-67 labeling index in non-small cell lung cancer

The ki-67 index is a marker of proliferation in malignant tumors. Studies from the period 2000 to 2012 on the prognostic and predictive value of ki-67 labeling index (LI) in non-small cell cancer (NSCLC) are reviewed. Twenty-eight studies reported on the prognostic value of ki-67 index with various endpoints. No consensus on the prognostic value of ki-67 LI was found among the published studies neither according to disease stage nor histological subtype. Comparison of studies is hampered by differences in patient populations, methodologies and cut-off values. Five studies explored the predictive value of ki-67 to chemotherapy and none revealed significant influence. Ki-67 index seems to be of prognostic influence in NSCLC although largely variable cut-off levels have been used in the various studies and standardization of methodology is required. The relative importance of ki-67 compared to newer biomarkers has not been explored. It is likely that a signature of several biomarkers in combination may be necessary to more sufficiently stratify patients to various treatment options than is currently possible, especially when it comes to the question of the optimal use of classical chemotherapy. A predictive impact of ki-67 to treatment in NSCLC remains unclear.

The role of endobronchial ultrasound in lung cancer diagnosis and staging: a comprehensive review

Endobronchial ultrasound (EBUS) technology is a relatively new bronchoscopic method of visualizing the tracheobronchial tree, the surrounding pulmonary parenchyma, and the mediastinal structures, with a particular role in lung cancer diagnosis, staging, and treatment. There are 2 types of probes used in EBUS: the peripheral or radial probe (RP) and the linear or convex probe (CP) EBUS, which have technical differences and distinct diagnostic abilities. Both are used for EBUS-guided biopsies and transbronchial needle aspirations (TBNA), which increases the diagnostic yield over conventional bronchoscopic techniques, thus providing advanced information on staging, diagnosis, and treatment. Complications of EBUS are rare, and they are usually related to the underlying biopsy procedure and the operator's experience. EBUS examination duration is usually short, and it can be performed as an outpatient procedure. Interestingly, EBUS combinations with other current and evolving techniques, eg, electromagnetic navigation, are feasible and have a role in therapeutic interventions and molecular diagnostics. In conclusion, EBUS is a safe and accurate technique that is comparable with current criterion standard procedures, eg, mediastinoscopy. More training is required for the vast majority of respiratory physicians, and precise diagnostic algorithms are needed so that more patients benefit from this development.

Improvement of cellularity on cell block preparations using the so-called tissue coagulum clot method during endobronchial ultrasound-guided transbronchial fine-needle aspiration

BACKGROUND

Cell block (CB) preparation during the endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-TBNA) procedure plays an important role in the diagnosis of lung cancer and recovery of cellular material for molecular characterization of the tumor. However, the efficiency of the conventional method of CB preparation is suboptimal.

METHODS

In the current study, the "tissue coagulum clot" cell block (TCC-CB) method was used to prepare the CBs and its efficiency was compared with that of the conventional saline rinse cell block (NR-CB) method. A total of 84 consecutive TCC-CBs (106 lymph nodes [LNs] and 14 lung lesions) and 28 consecutive cases of NR-CB (39 LNs and 3 lung lesions) obtained within the same time period were included in the current study.

RESULTS

In the TCC-CB specimens, 94 of 106 LN cases (88.7%) yielded sufficient diagnostic material, as did 11 of 14 lung lesions (78.6%). In the NR-CB group, which was used as the control, 22 of 39 LN specimens (56.4%) and none of 3 lung specimens (0%) were found to provide sufficient diagnostic material. Although the average size of the LNs in the study group were not significantly different from those in the control group (1.76 cm vs 1.82 cm; P > .05), the overall nondiagnostic rates in the TCC-CB and NR-CB groups were 11.2% and 43.6%, respectively (P < .001). The nondiagnostic rates of the lung specimens were 15.4% in the TCC-CB group and 100% in the NR-CB group (P < .05). In addition, immunohistochemistry studies and epidermal growth factor receptor (EGFR)/KRAS mutational analyses were performed in 26 and 14 TCC-CB cases, respectively. With the exception of 1 case, all of them had satisfactory results.

CONCLUSIONS

The data from the current study demonstrate that the TCC-CB method significantly increases the cellular yield of CB preparations without compromising cytomorphological characterization of tumor cells.

An intronic polymorphism in GRP78 improves chemotherapeutic prediction in non-small cell lung cancer

BACKGROUND

Glucose-regulated protein 78 (GRP78) is involved in not only the progression of non-small cell lung cancer (NSCLC) but also chemotherapeutic effects. We hypothesized that an intronic polymorphism (rs430397G>A) in GRP78 affects survival among patients with NSCLC treated with platinum-based chemotherapy.

METHODS

Blood samples of patients with advanced NSCLC (IIIB/IV) were maintained in our specimen bank between 2001 and 2006. Genomic DNA was genotyped for rs430397. Associations between rs430397 and platinum-based treatment response, overall survival (OS), NSCLC-related survival, progression-free survival (PFS), and relapses were evaluated. GRP78 RNA and protein in NSCLC tissues were tested by real-time polymerase chain reaction and immunohistochemistry.

RESULTS

The AA genotype is significantly associated with platinum-based chemoresistance (P = .019) and NSCLC-related death (P = .022). OS, NSCLC-related survival, and PFS of the AA genotype group are decreased compared with the GG and AG genotype groups (log-rank P < .05, respectively). The AA group showed a higher prevalence of early NSCLC relapses than the AG and GG group (P = .030). In addition, the AA genotype showed a significantly increased risk for OS (hazard ratio, 1.95) and PFS (hazard ratio, 1.80) compared with the GG group. Functional analysis showed that NSCLC tissues with genotype AA have higher GRP78 RNA and protein expression compared with those carrying GG at rs430397.

CONCLUSIONS

The rs430397 AA genotype of GRP78 is associated with reduced survival and higher prevalence of early relapses in patients with advanced NSCLC treated with platinum-based chemotherapy.

Sarcoidal reactions in regional lymph nodes of patients with early stage non-small cell lung cancer predict improved disease-free survival: a pilot case-control study

Sarcoidal reactions occurring in regional lymph nodes of patients with non-small cell lung carcinoma appear to be limited to patients with stage I disease. The prognostic significance of this remains unknown. Such reactions are thought to represent a cell-mediated antitumor response and have been associated with improved outcomes in other solid organ malignancies. We performed a retrospective chart review of all patients undergoing lobectomy with curative intent for non-small cell lung carcinoma. Eligible cases were selected based on pathologic reports, with matched controls then drawn from the same surgical cohort. One hundred fifty-seven patients underwent lobectomy and lymph node dissection. Eight patients with sarcoidal granulomas present in regional lymph nodes were identified as cases and matched to 16 control subjects. All subjects were staged pN0. Disease recurrence was noted in no case subjects but in 7 (44%) of control subjects (P = .044, χ(2) = 4.051). The presence of sarcoidal reactions within regional lymph nodes of patients with non-small cell lung carcinoma predicts a lower rate of disease recurrence after definitive surgical resection. The exact mechanism by which antitumor immunity is achieved remains to be elucidated.

Increased expression of transcription factor TFAP2α correlates with chemosensitivity in advanced bladder cancer

BACKGROUND

The standard treatment for patients with advanced transitional cell carcinoma of the bladder is platin based chemotherapy. Only approximately 50% of the patients respond to chemotherapy. Therefore, molecular predictive markers for identification of chemotherapy sensitive subgroups of patients are highly needed. We selected the transcription factor TFAP2α from a previously identified gene expression signature for chemotherapy response.

METHODS

TFAP2α expression and localization was assessed by immunohistochemistry using a tissue microarray (TMA) containing 282 bladder cancer tumors from patients with locally advanced (pT2-T4(b) and N(1-3)) or metastatic (M(1)) disease. All patients had received cisplatin containing chemotherapy. Furthermore, QPCR analysis of three TFAP2α isoforms was performed on tumor specimens of advanced muscle invasive bladder cancers (T2-4). Using the bladder cell lines T24 and SW780 the relation of TFAP2α and cisplatin and gemcitabine sensitivity as well as cell proliferation was examined using siRNA directed TFAP2α knockdown.

RESULTS

TFAP2α protein expression was analyzed on a TMA with cores from 282 advanced bladder cancer tumors from patients treated with cisplatin based combinational chemotherapy. TFAP2α was identified as a strong independent predictive marker for a good response and survival after cisplatin-containing chemotherapy in patients with advanced bladder cancer. Strong TFAP2α nuclear and cytoplasmic staining predicted good response to chemotherapy in patients with lymph node metastasis, whereas weak TFAP2α nuclear staining predicted good response in patients without lymph node metastasis. In vitro studies showed that siRNA mediated knockdown of TFAP2α increased the proliferation of SW780 cells and rendered the cells less sensitive to cisplatin and gemcitabine. In contrast to that T24 bladder cells with mutated p53 showed to be more drug sensitive upon TFAP2α depletion.

CONCLUSIONS

High levels of nuclear and cytoplasmic TFAP2α protein were a predictor of increased overall survival and progression free survival in patients with advanced bladder cancer treated with cisplatin based chemotherapy. TFAP2α knockdown increased the proliferation of the SW780 bladder cells and reduced cisplatin and gemcitabine induced cell death. The inverse effect was observed in the TP53 mutated T24 cell line where TFAP2α silencing augmented cisplatin and gemcitabine sensitivity and did not stimulate proliferation.

[Endobronchial ultrasound]

Endobronchial ultrasound (EBUS), one of the most important advances in pneumology in recent years, provides visualization of bronchial walls and parabronchial structures, extending the diagnostic spectrum of bronchoscopic techniques. Two different techniques are available: radial endobronchial ultrasound and the technique of ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Due to a high diagnostic informative value, low effort and low risk, EBUS has become incorporated into routine practice in pulmonary centers. Thus endobronchial ultrasound has proved to be of increasing importance in the diagnosis of mediastinal mass and staging of lung cancer. EBUS-TBNA is particularly useful for the evaluation of hilar and mediastinal lymph nodes in cases of lung neoplasms with a sensitivity of 88% and specificity of 100%. EBUS therefore plays an important role in the new interdisciplinary guidelines on "prevention, diagnostics, therapy and aftercare of lung cancer".

The Techniques of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for mediastinal lymph node staging in lung cancer patients as well as for the diagnosis of mediastinal and hilar adenopathy. The high diagnostic yield of EBUS-TBNA for lymph node staging has been shown in systematic reviews and meta-analysis. It has attracted physicians and surgeons as an alternative modality to surgical biopsy for the assessment of patients with enlarged mediastinal and/or hilar lymph nodes. Cell blocks obtained by EBUS-TBNA can be applicable not only for pathologic diagnosis but also for further investigations such as immunohistochemistry and fluorescence in situ hybridization. In addition, samples obtained by EBUS-TBNA can also be used for molecular analysis. Unlike regular bronchoscopy, EBUS-TBNA uses the convex probe EBUS with an ultrasound probe on the tip of a flexible bronchoscope. It is important for the bronchoscopist to fully understand the mediastinal anatomy and be able to correlate it with the ultrasound images for a successful EBUS-TBNA. The dedicated transbronchial needle used for EBUS-TBNA is somewhat different from an ordinary transbronchial biopsy forceps. Training is mandatory for achieving high diagnostic yield without complications. The learning curve of EBUS-TBNA is different from each physician, and continuous training program will be needed for impartiality. This article explains the detailed techniques of EBUS-TBNA to master this innovative procedure.

Relevance of endobronchial ultrasonography to thoracic surgeons

The relevance of endobronchial ultrasonography (EBUS) to thoracic surgeons is 2-fold: first, EBUS is an accurate and versatile diagnostic tool; second, EBUS is of importance to our specialty. The diagnostic performance of endobronchial ultrasonography (EBUS) is similar to that of mediastinoscopy, except for a lower negative predictive value for EBUS. Consequently, EBUS does not replace mediastinoscopy, but instead EBUS and mediastinoscopy are complementary. A thoracic surgeon proficient in EBUS has the ability to decide which tool or combination of tools to use to optimize patient care. The relevance of EBUS can be described in evolutionary terms: proficiency in EBUS exemplifies a new trait that can enhance our adaptability to the current environment. An indirect measure of the acquisition of this new skill by our specialty can be gleaned from an overview of original EBUS publications: nearly one-half are authored or coauthored by thoracic surgeons. EBUS is an excellent diagnostic tool available to thoracic surgeons to optimize patient care and an example of a skill that may enhance our survival as a surgical specialty.

[Initial experience on endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and staging of lung cancer]

背景与目的

经支气管超声引导针吸活检（endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA）是近年来新的纵隔淋巴结定性诊断方法。本研究旨在探讨其应用于肺癌诊断及分期中的价值。

方法

2009年4月1日-2010年2月8日，75例本院胸部增强CT提示肺内占位伴多发纵隔淋巴结肿大患者接受EBUS-TBNA检查。以最终病理诊断为金标准，检验EBUS-TBNA诊断肺癌纵隔淋巴结转移的准确性、敏感性、特异性、阳性及阴性预测值，并判断其用于非小细胞肺癌N分期的准确率。

结果

75例患者共计穿刺177组病灶区域，平均穿刺2.4组/例。75例患者，组织病理标本送检率为49.33%。以177组穿刺区域计算，组织病理标本送检率为28.81%。75例患者EBUS-TBNA诊断准确率为98.66%，敏感性为98.43%，特异性为100.00%，阳性预测值为100.00%，阴性预测值为91.67%。以177组穿刺区域计算EBUS-TBNA诊断准确率为96.05%，敏感性为95.10%，特异性为100.00%，阳性预测值为100.00%，阴性预测值为82.93%。上述指标除敏感性（P=0.435）外，均高于CT检查（P < 0.05）。73例可行N分期患者中，19例（26.03%）患者EBUS-TBNA检查后出现分期改变。

结论

EBUS-TBNA准确率较高，创伤小，是用于肺癌诊断及分期的较好方法。

Advances in diagnostic bronchoscopy

Diagnostic bronchoscopy has undergone two major paradigm shifts in the last 40 years. First, the advent of flexible bronchoscopy gave chest physicians improved access to the tracheobronchial tree with a rapid learning curve and greater patient comfort compared with rigid bronchoscopy. The second paradigm shift has evolved over the last 5 years with the proliferation of new technologies that have significantly enhanced the diagnostic capabilities of flexible bronchoscopy compared with traditional methods. At the forefront of these new technologies is endobronchial ultrasound. In its various forms, endobronchial ultrasound has improved diagnostic yield for pulmonary masses, nodules, intrathoracic adenopathy, and disease extent, thereby reducing the need for more invasive surgical interventions. Various navigational bronchoscopy systems have become available to increase flexible bronchoscope access to small peripheral pulmonary lesions. Furthermore, various modalities of airway assessment, including optical microscopic imaging technologies, may play significant roles in the diagnosis of a variety of pulmonary diseases in the future. Finally, the combination of new diagnostic bronchoscopy technologies and novel approaches in molecular analysis and biomarker assessment hold promise for enhanced diagnosis and personalized management of many pulmonary disorders. In this review, we provide a contemporary review of diagnostic bronchoscopy developments over the past decade.

Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy

PURPOSE OF REVIEW

There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative.

RECENT FINDINGS

EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses.

SUMMARY

Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.

Endobronchial ultrasound in pediatric pulmonology

Endobronchial ultrasound (EBUS) is a recently introduced technique that has significantly advanced bronchoscopic techniques in adult medicine. Use of ultrasound allows far more accurate localization and sampling of both peripheral pulmonary, as well as mediastinal and hilar lesions. This has led to greater diagnostic success, with a reduced rate of complications. Its performance characteristics in adult populations are equivalent to surgical procedures previously considered gold standard, but it has dramatically reduced morbidity and mortality among patients requiring invasive diagnostic procedures, when compared to surgical approaches. We describe the types of EBUS in clinical use, the method of use, the clinical indications for each procedure, and the potential role for EBUS in pediatric pulmonology. Radial probe EBUS is used in the investigation of peripheral lung lesions and could be adopted in children to achieve accurate biopsy of such lesions. Linear probe EBUS allows minimally invasive biopsy of mediastinal and hilar lesions. It has potentially greater performance characteristics than current biopsy techniques, with no significant complications reported to date. It may be useful in the diagnosis of lymphoma, or neurogenic tumors, as well as many other diseases resulting in mediastinal or hilar lymphadenopathy. EBUS is a minimally invasive technique that allows tissue sampling of peripheral lung lesions, or mediastinal/hilar masses, with a high diagnostic accuracy, and a significantly lower morbidity and mortality than alternative approaches. The indications for and the use of EBUS in pediatric patients is certain to increase in the future.