Diagnostic yield and safety of endoscopic ultrasound guided fine needle aspiration of central mediastinal lung masses

Endoscopic Diagnosis of Extra-Luminal Cancers

The last 2 decades have seen an emergence of endoscopic technologies and techniques allowing for minimally invasive modalities for assessing and sampling lesions outside of the gastrointestinal lumen, including the chest, abdomen, and pelvis. Incorporating these new endoscopic approaches has revolutionized the diagnosis and staging of extra-luminal malignancies and has enabled more accessible and safer tissue acquisition.

Transesophageal endoscopic ultrasound-guided tissue acquisition of lung masses: a case series with systematic review and meta-analysis

Background

The diagnosis of intraparenchymal lung masses is challenging when lesions are located at sites inaccessible through bronchoscopy or endobronchial ultrasound. Endoscopic ultrasound (EUS)-guided tissue acquisition (TA)-fine-needle aspiration (FNA) or fine-needle biopsy-provides a potentially useful diagnostic tool for lesions located adjacent to the esophagus. This study was conducted to analyze the diagnostic outcome and safety of EUS-guided tissue sampling of lung masses.

Methods

Data were retrieved for patients who underwent transesophageal EUS-guided TA between May 2020 and July 2022 at 2 tertiary care centers. A meta-analysis was performed after pooling these data with studies obtained from a comprehensive search of Medline, Embase, and ScienceDirect from January 2000 to May 2022. Pooled event rates across studies were expressed with summative statistics.

Results

After screening, 19 studies were identified and, after their data had been combined with those of 14 patients from our centers, a total of 640 patients were included in the analysis. The pooled rate of sample adequacy was 95.4% (95% confidence interval [CI] 93.1-97.8), while the pooled rate of diagnostic accuracy was 93.4% (95%CI 90.7-96.1). The pooled rate of adverse events with transesophageal EUS-guided TA from lung masses was 0.7% (95%CI 0.0-1.6%). There was no significant heterogeneity with respect to various outcomes and results were comparable on sensitivity analysis.

Conclusions

EUS-FNA offers a safe and accurate diagnostic modality for the diagnosis of paraesophageal lung masses. Future studies are needed to determine the needle type and techniques for improving outcomes.

Neuroendocrine Tumor Diagnosed Through Endoscopic Ultrasound-Guided Fine-Needle Biopsy of a Lung Mass

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is an excellent modality for tissue acquisition and has been shown to be superior to EUS-fine-needle aspiration in several studies. Although tissue sampling of lung nodules using EUS-fine-needle aspiration has been reported in the literature, the use of EUS-FNB for tissue acquisition of parenchymal lung mass has rarely been reported in the literature. Our report highlights that EUS-FNB is safe and effective for lung lesions that are near the esophageal wall.

Clinical application of endoscopic ultrasonography in evaluation of colorectal and peri-colorectal lesions

BACKGROUND

Endoscopic ultrasonography (EUS) has the functions of both endoscopy and ultrasound. Due to the complex anatomical structure of the intestine, there are few studies on EUS in colorectal lesions.

AIM

To explore the clinical application value of EUS in the diagnosis of colorectal and peri-colorectal lesions.

METHODS

We retrospectively analyzed the examination results of 95 patients detected by endoscopic miniprobe sonography (MPS) and linear EUS from September 2018 to July 2021, which were then compared to postoperative pathology. The kappa test was used in statistical analysis.

RESULTS

Using postoperative pathology as the golden standard, the accuracy of linear EUS in diagnosing the depth of rectal cancer invasion (T stage) was 73.9% (17/23 cases), including T1 (2/4 cases), T2 (4/6 cases), T3 (6/7 cases) , and T4 (5/ 5 cases) stages. The accuracy of linear EUS in diagnosing regional lymph node metastasis (N stage) was 91.3% (21/23 cases), including N0 (14/15 cases) and N1 (7/8 cases) stages. The consistency was high (kappa value = 0.782, P < 0.01). During preoperative evaluation of colorectal adenoma or early cancer before endoscopic submucosal dissection (ESD), the accuracy of MPS in diagnosing the depth of tumor invasion was 87.1% (27/31 cases), and the consistency was moderate (kappa value = 0.665, P < 0.01). The accuracy of MPS in diagnosing the origin and type of colorectal submucosal lesions was 95.5% (21/22 cases), and the consistency was high (kappa value = 0.919, P < 0.01). The accuracy of endoscopic ultrasonography-guided fine-needle aspiration in determining rectal and peri-rectal lesions was 70.0% (7/10 cases), and the consistency was moderate (kappa value = 0.565, P < 0.01).

CONCLUSION

According to the specific location and size of colorectal and peri-colorectal lesions, selective use of the MPS and linear EUS is of great value with regard to T/N staging of rectal cancer, preoperative evaluation of ESD, determination of the characteristics of colorectal-submucosal bulging lesions, and acquisition of lesion tissue of rectal and peri-rectal lesions.

Characterization of Lung Tumors that the Pulmonologist can Biopsy from the Esophagus with Endosonography (EUS-B-FNA)

BACKGROUND

According to guidelines, it is possible to biopsy lung tumors "immediately adjacent to the esophagus" with EUS-B-FNA. However, it is unknown what "immediately adjacent" exactly means.

OBJECTIVE

to investigate the possibility of achieving EUS-B-FNA biopsies from a lung tumor depending on the distance from the esophagus and to establish the maximal allowable distance between the tumor and the esophagus.

METHODS

In a prospective observational study, we included patients with a lung tumor located maximum 6 cm from the esophagus and indication of EUS-B-FNA from the tumor. The tumors were of different sizes. In a plot presenting the tumor size-distance relationship in cases with (biopsy) versus without (non-biopsy) successful EUS-B-FNA, a separation line representing the threshold between the groups were identified and a biopsy-index equation established. The maximal tumor-size corrected distance (TSCD) was calculated using the residuals to the separation line.

RESULTS

In total, 70 patients were included. EUS-B-FNA from the lung tumor was possible in 46 patients. All tumors with a distance from the esophagus below 19 mm could be biopsied. The maximal allowable esophagus-tumor distance depended on tumor size. From the separation line, a biopsy-index equation was established with the sensitivity of 93.5%, a specificity of 100%, and total accuracy of 95.7%. The TSCD was 31 mm (sensitivity: 95.7%, specificity 75.0%, and accuracy: 88.6%).

CONCLUSION

We established a biopsy-index equation to predict the achievability of a lung tumor using EUS-B-FNA depending on distance to esophagus and tumor size. A general maximal TSCD was 31 mm.

Contribution of endobronchial ultrasound elastography to the characterization of mediastinal lymphadenopathy: A single-center, prospective, observational study

BACKGROUND

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a reliable technique providing high diagnostic yield in mediastinal lymphadenopathy. However, mediastinoscopy is sometimes necessary to eliminate false-negative results. Elastography is a recent technique that can be combined with EBUS to evaluate the elasticity and consequently the nature of a tissue. The primary objective was to evaluate the diagnostic performance of EBUS-TBNA combined with elastography for the assessment of mediastinal lymph nodes.

METHODS

Single-center, prospective study in patients with mediastinal lymphadenopathy. EBUS-TBNA combined with elastography was performed in each patient. Several elastographic parameters were studied: colorimetric score, average elasticity, elasticity ratio, percentage of hard areas. The final diagnosis was that obtained by TBNA cytology, histology of a surgical biopsy, when performed, or follow-up CT and PET-CT at 6 months.

RESULTS

Overall, 110 lymph nodes were examined in 87 patients: 44 were malignant according to TBNA. These nodes had significantly higher elasticity ratio, percentage of hard areas and colorimetric score and significantly lower average elasticity compared to benign nodes (P<0.001). With a negative predictive value of 100%, the cut-offs defined by receiver operating characteristic curves were 1.4 for elasticity ratio, 84.8 for average elasticity, 32.6 for percentage of hard areas and 3 for colorimetric score. No adverse events were observed.

CONCLUSION

Endobronchial ultrasound elastography is a non-invasive technique that can contribute to prediction of the nature of lymph nodes by distinguishing malignant from benign nodes. Although EBUS cannot replace histological examination, elastography can provide reliable complementary information when combined with EBUS.

Diagnosis of Aelurostrongylus abstrusus verminous pneumonia via sonography-guided fine-needle pulmonary parenchymal aspiration in a cat

Case summary A 9-year-old, male neutered, indoor–outdoor domestic shorthair cat from the northern Alabama countryside presented for a 3 week history of coughing, lethargy and an episode of self-resolving dyspnea that occurred 1 week prior to presentation. Three-view thoracic radiographs revealed a moderate-to-severe, diffuse, mixed bronchial to structured interstitial (miliary-to-nodular) pulmonary pattern in all lung lobes with peribronchial cuffing and multifocal areas of mild patchy alveolar opacity. Ultrasound-guided evaluation and fine-needle aspiration of the caudodorsal lung parenchyma was performed with sedation. Cytology revealed many widely scattered Aelurostrongylus abstrusus larvae and ova. Upon the confirmed diagnosis of A abstrusus verminous pneumonia, treatment with fenbendazole and selamectin resulted in complete resolution of clinical signs within 6 weeks of the initial diagnosis.

Relevance and novel information We report herein the first documented case in the Americas of A abstrusus verminous pneumonia diagnosed via cytologic evaluation of an in vivo, percutaneous ultrasound-guided fine-needle aspirate of affected lung. Additionally, to our knowledge, we offer the first account of the sonographic (pulmonary) features of the disease.

Esophageal Endosonography for the Diagnosis of Intrapulmonary Tumors: A Systematic Review and Meta-Analysis

BACKGROUND

Biopsy-based diagnosis in patients with paraesophageal intrapulmonary tumors suspected of lung cancer is crucial for adequate treatment planning.

OBJECTIVE

To evaluate the performance of transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in the diagnosis of intrapulmonary tumors located near or adjacent to the esophagus.

METHODS

We performed a systematic review (PROSPERO, CRD42016033737) and searched MEDLINE, Embase, BIOSIS Previews, and Web of Science on September 22, 2016, without date or language restrictions. We included studies that evaluated the yield and/or sensitivity of EUS-FNA for diagnosing intrapulmonary tumors. Yield was defined as the number of patients in whom EUS-FNA made a biopsy-proven diagnosis (malignant or nonmalignant) relative to the total number of patients on whom EUS-FNA was performed. Sensitivity was defined as the number of patients in whom EUS-FNA made a biopsy-proven diagnosis of malignancy relative to the total number of patients in whom the tumor was found to be malignant. We performed a random-effects meta-analysis.

RESULTS

Of 3,320 search results, 11 studies were included. Ten had a high risk of bias. The total number of patients was 313; the proportion of patients with malignancy ranged from 87 to 100% across these studies. The average yield was 0.90 (95% CI 0.82-0.95) and the average sensitivity was 0.92 (0.83-0.96). In the subgroup of prospective studies (n = 3), the average yield was 0.80 (0.56-0.93) and the average sensitivity was 0.83 (0.58-0.95). EUS-FNA-induced complications were reported for 5/256 patients (2.0%) for whom this information was available.

CONCLUSIONS

Although the number of high-quality studies is limited, these findings suggest that EUS-FNA is safe and has a high yield for diagnosing intrapulmonary tumors.

Endoscopic Ultrasonography-Guided Biopsy for Differentiation of Benign and Malignant Pelvic Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Preoperative diagnosis of pelvic lesions remains challenging despite advances in imaging technologies. Endoscopic ultrasonography (EUS)-guided biopsy is an effective diagnostic modality for sampling the digestive tract and surrounding areas. However, a meta-analysis summarizing the diagnostic efficacy of EUS-guided biopsy for pelvic lesions has not been published.

AIMS

We aimed to evaluate the utility of EUS-guided biopsy in the diagnosis of pelvic lesions.

METHODS

Articles were identified via structured database search; only studies where pelvic lesions were confirmed by surgery or clinical follow-up were included. Data extracted were selected with strict criteria. A fixed-effects model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A summary receiver operating characteristic curve (SROC) was also constructed.

RESULTS

Ten studies containing a total of 246 patients were included. The pooled sensitivity of EUS-guided biopsy for differential diagnosis of pelvic masses was 0.89 (95% CI 0.83-0.94), and the specificity was 0.93 (95% CI 0.86-0.97). The area under the SROC was 0.9631. The combined PLR, NLR, and DOR were 11.75 (95% CI 5.90-23.43), 0.12 (95% CI 0.07-0.20), and 100.06 (95% CI 37.48-267.10) respectively. There is potential presence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis shows that EUS-guided biopsy is a powerful tool for differentiating pelvic masses with a high sensitivity and specificity. Furthermore, it is a safe procedure with low rate of complication, although more high-quality prospective studies are required to be done.

Endoscopic ultrasound in the diagnosis and staging of lung cancer

We reviewed the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound guided fine needle aspiration (EUS-FNA) in the pretherapeutic assessment of patients with proven or suspected lung cancer. EUS-FNA and EBUS-TBNA have been shown to have a good diagnostic accuracy in the diagnosis and staging of lung cancer. In the future, these techniques in combination with positron emission tomography/computed tomographic may replace surgical staging in patients with suspected and proven lung cancer, but until then surgical staging remains the gold standard for adequate preoperative evaluation.

Expanding the horizons of endoscopic ultrasound: diagnosis of non-digestive pathologies

Endoscopic ultrasound (EUS) is mainly used for the evaluation and sampling of mediastinal and abdominal lymph nodes, luminal and submucosal lesions of the upper and lower gastrointestinal tract, as well as in the diagnostic approach for pancreatic, biliary and liver disease. However, several non-digestive pathologies may be encountered as well, expanding the diagnostic potential of EUS. In this article, we present nine examples of extra-digestive abnormalities detected by means of EUS, including pathologies of the thyroid gland, mediastinal and abdominal vessels, lungs, kidney and the urinary bladder. The purpose of this article is to review the capabilities of EUS beyond routine evaluation of gastrointestinal organs.