Rapid on-site cytologic evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing lung cancer: a randomized study

Acquisition and Handling of Endobronchial Ultrasound Transbronchial Needle Samples: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

Endobronchial ultrasound-guided transbronchial aspiration (EBUS-TBNA) has become the standard for initial lung cancer diagnosis and staging. Previous guidelines have generally focused on the "when" and "how" of EBUS-TBNA; however, little guidance is available on handling and processing specimens during and after acquisition to help optimize both diagnostic yield and tissue integrity for ancillary studies. This document examines the available literature on EBUS-TBNA specimen processing and handling.

STUDY DESIGN AND METHODS

Rigorous methodology was applied to provide a trustworthy evidence-based guideline and expert panel report. Panelists developed key clinical questions utilizing the Population, Intervention, Comparator, and Outcome (PICO) format, addressing specific topics in EBUS-TBNA specimen processing. MEDLINE (via PubMed) and the Cochrane Library were systematically searched to identify relevant literature, supplemented by manual searches. References were screened for inclusion with document evaluation tools to assess the quality of included studies, extract meaningful data, and grade the level of evidence to support each recommendation or suggestion.

RESULTS

Our systematic review and critical analysis of the literature of the 9 PICO questions related to handling and processing EBUS-TBNA specimens resulted in 9 evidence-based statements.

INTERPRETATION

Evidence of the handling and processing of EBUS-TBNA specimens varies in strength but is satisfactory in some areas to guide clinicians in certain aspects of specimen handling. Additional research in many aspects of specimen handling and processing is needed to help improve our knowledge base.

Clinical utility of rapid on-site evaluation of brush cytology during bronchoscopy using endobronchial ultrasound with a guide sheath

Previous studies have shown that rapid on-site evaluation (ROSE) improves the diagnostic yield of bronchoscopy using endobronchial ultrasound with a guide sheath (EBUS-GS) for peripheral pulmonary lesions (PPL). While ROSE of imprint cytology from forceps biopsy has been widely discussed, there are few reports on ROSE of brush cytology. This study investigated the utility of ROSE of brush cytology during bronchoscopy. We retrospectively analyzed data from 214 patients who underwent bronchoscopy with EBUS-GS for PPL. The patients in the ROSE group had significantly higher diagnostic sensitivity through the entire bronchoscopy process than in the non-ROSE group (96.8% vs. 83.3%, P = 0.002). The use of ROSE significantly increased the sensitivity of brush cytology with Papanicolaou staining (92.9% vs. 75.0%, P < 0.001). When ROSE was sequentially repeated on brushing specimens, initially negative ROSE results converted to positive in 79.5% of cases, and the proportion of specimens with high tumor cell counts increased from 42.1 to 69.0%. This study concludes that ROSE of brush cytology improves the diagnostic accuracy of bronchoscopy and enhances specimen quality through repeated brushing.

A Multiscale Connected UNet for the Segmentation of Lung Cancer Cells in Pathology Sections Stained Using Rapid On-Site Cytopathological Evaluation

Lung cancer is an increasingly serious health problem worldwide, and early detection and diagnosis are crucial for successful treatment. With the development of artificial intelligence and the growth of data volume, machine learning techniques can play a significant role in improving the accuracy of early detection in lung cancer. This study proposes a deep learning-based segmentation algorithm for rapid on-site cytopathological evaluation (ROSE) to enhance the diagnostic efficiency of endobronchial ultrasound-guided transbronchial needle aspiration biopsy (EBUS-TBNA) during surgery. By utilizing the CUNet3+ network model, cell clusters, including cancer cell clusters, can be accurately segmented in ROSE-stained pathological sections. The model demonstrated high accuracy, with an F1-score of 0.9604, recall of 0.9609, precision of 0.9654, and accuracy of 0.9834 on the internal testing data set. It also achieved an area under the receiver-operating characteristic curve of 0.9972 for cancer identification. The proposed algorithm saved time for on-site diagnosis, improved EBUS-TBNA efficiency, and outperformed classical segmentation algorithms in accurately identifying lung cancer cell clusters in ROSE-stained images. It effectively reduced over-segmentation, decreased network parameters, and enhanced computational efficiency, making it suitable for real-time patient evaluation during surgical procedures.

Insufficient endobronchial ultrasound-guided transbronchial needle aspiration specimens. When and why? The analysis of criteria and reasons behind the insufficient specimens

BACKGROUND

The classification terminology systems for pulmonary cytology specimens have recently emerged. Inadequate samples, classified as "nondiagnostic," raise challenges in determining the threshold of cell numbers and the risk of malignancy (ROM).

METHODS

The study retrospectively reviewed 248 endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples: 46 insufficient samples, 60 low cellularity samples, and 142 adequate samples. Characteristics as cellularity, number of benign and malignant cells, and background features were assessed. Receiver operating characteristic curve analysis was performed to establish cell sufficiency thresholds for the diagnosis.

RESULTS

Out of the 248 samples analyzed, 108 were classified as benign, 94 as malignant, and 46 as insufficient. The study found that the cellularity thresholds for diagnosis in cell blocks and cytological samples were ≥50 cells and ≥100 cells, respectively. The thresholds for tumor cell counts were ≥1 - 10 cells for both types of cells, respectively. Considerably, some low cellularity samples were initially classified as insufficient despite meeting the diagnostic thresholds upon revision. The ROM varied across sample categories, with insufficient samples having a ROM of 10.9%, benign samples 15.7%, suspicious samples 92.0%, and malignant samples 100%.

CONCLUSION

Insufficient EBUS-TBNA samples raise challenges in diagnosis and management. This study identified the root cause of insufficient samples, including factors related to humans, diagnostic methods, sampling, and laboratory processing. By understanding the root causes, diagnostic recommendations can be developed to improve the diagnostic process. The findings emphasize the importance of standardized classification and terminology systems for clear communication among healthcare professionals and institutions, ultimately improving patient care and enabling quality assurance measures.

Comparison of the specimen quality of endobronchial ultrasound-guided intranodal forceps biopsy using standard-sized forceps versus mini forceps for lung cancer: A prospective study

BACKGROUND AND OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic procedure with adequate performance; however, its ability to provide specimens of sufficient quality and quantity for treatment decision-making in advanced-stage lung cancer may be limited, primarily due to blood contamination. The use of a 0.96-mm miniforceps biopsy (MFB) permits true histological sampling, but the resulting small specimens are unsuitable for the intended applications. Therefore, we introduced a 1.9-mm standard-sized forceps biopsy (SFB) and compared its utility to that of MFB.

METHODS

We prospectively enrolled patients from three institutions who presented with hilar/mediastinal lymphadenopathy and suspected advanced-stage lung cancer, or those who were already diagnosed but required additional tissue specimens for biomarker analysis. Each patient underwent MFB followed by SFB three or four times through the tract created by TBNA using a 22-gauge needle on the same lymph node (LN). Two pathologists assessed the quality and size of each specimen using a virtual slide system, and diagnostic performance was compared between the MFB and SFB groups.

RESULTS

Among the 60 enrolled patients, 70.0% were diagnosed with adenocarcinoma. The most frequently targeted sites were the lower paratracheal LNs, followed by the interlobar LNs. The diagnostic yields of TBNA, MFB and SFB were 91.7%, 93.3% and 96.7%, respectively. The sampling rate of high-quality specimens was significantly higher in the SFB group. Moreover, the mean specimen size for SFB was three times larger than for MFB.

CONCLUSION

SFB is useful for obtaining sufficient qualitative and quantitative specimens.

Pitfalls in Respiratory Tract Cytopathology

BACKGROUND

Cytopathology is integral to the investigation and diagnosis of respiratory disease, and, in the last decade or so, transbronchial needle aspiration by endobronchial ultrasound has made possible diagnosis and staging of malignant thoracic tumours at a single procedure. In addition, interventional teams increasingly include cytopathologists and cytotechnologists who, by providing rapid onsite evaluation, ensure efficient sampling of intrathoracic targets with the ultimate goal of accurate diagnosis as well as sufficient material for comprehensive predictive testing. Nonetheless, "traditional" cytological investigations such as bronchial washings, brushings, and lavages are still carried out for investigation of both suspected neoplastic and non-neoplastic conditions, and all these procedures still produce specimens in which florid benign cells mimic malignancy, while truly neoplastic cells lurk quietly in the background. Furthermore, even when neoplasia is not suspected, issues in preparation and interpretation may render a final assessment inaccurate and, therefore, clinically unhelpful or misleading. In this overview, we have tried to adopt a format partly modelled on the passage of a specimen from clinical acquisition to laboratory endpoint, thus taking in potential pitfalls in communication, clinical interaction, transport, and clinic-based preparation, as well as in morphology, immunocytochemistry, and suitability for predictive testing. It is not exhaustive but highlights areas that may frequently be encountered or are part of our personal experience.

SUMMARY

The account highlights potential pitfalls in respiratory cytopathology at key stages of the process from acquisition to reporting and presents these in both flow diagram and tabular form. We hope this is useful for the increasingly collaborative roles of cytotechnologist and cytopathologist and their wider involvement in the clinical investigative teams.

KEY MESSAGES

Correct clinical and radiological information is crucially important and promotes the correct acquisition and processing of cytopathological specimens. Cross-discipline collaborative working ensures the most efficient use of the specimen such that diagnoses and predictive tests are performed on optimal material, reducing the potential for misinterpretation. Nonetheless, even with optimal material, morphological mimics and atypical antigen expression may mislead and render accurate diagnosis challenging.

Application of rapid on-site evaluation combined with flexible bronchoscopy in the diagnosis of lung lesions

BACKGROUND

Pathology is considered the gold standard for the diagnosis of lung lesions, but the pathological result is relatively lagging and cannot provide real-time guidance for the biopsy procedure.

OBJECTIVE

To investigate the potential application of rapid on-site evaluation (ROSE) during flexible bronchoscopy (FB) in the evaluation and diagnosis of lung lesions.

PATIENTS AND METHODS

Consecutive patients who underwent FB for the diagnosis of lung lesions between August 2022 and February 2023 were included in this retrospective study. 294 patients underwent FB with ROSE, while 304 patients underwent FB without ROSE. The final pathological results and the number of patients undergoing repeat biopsies were recorded in both groups. Specifically, we conducted separate statistical analysis for patients undergoing different biopsy methods, including the endobronchial biopsy (EBB), radial probe endobronchial ultrasound transbronchial lung biopsy with guide sheath (r-EBUS-GS-TBLB), and the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to study the detailed roles that ROSE plays under different biopsy methods.

RESULTS

The adequacy rate of biopsy specimens from the non-ROSE group was significantly lower than that of the ROSE group (259/281 = 92.17 % vs. 263/268 = 98.13 %, p = 0.001). Meanwhile, fewer patients underwent repeat biopsies in the ROSE group compared to the non-ROSE group (2/294 = 0.68 % vs. 10/304 = 3.29 %, p = 0.023). For the ROSE group, the consistency between ROSE diagnoses and final pathological diagnoses was 94.40 % (κ = 0.886), with 95.58 % for benign diseases and 93.55 % for malignant diseases.

CONCLUSION

The utility of ROSE during FB increases the adequacy rate of biopsy specimens and thus decreases the need for repeat biopsies in patients with lung lesions to get a definite diagnosis. Moreover, the high consistency between ROSE diagnoses and final pathological diagnoses suggests that ROSE is a reliable tool for optimizing the diagnosis of lung lesions.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): revolutionizing the landscape of lung disease diagnostics

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a revolutionary diagnostic tool for lung diseases, including lung cancer, sarcoidosis, and lymphoproliferative diseases. This minimally invasive procedure offers a superior diagnostic yield while ensuring maximum patient safety when compared to traditional invasive techniques such as mediastinoscopy and thoracoscopy. By enabling real-time imaging and sampling of mediastinal and hilar lymph nodes and masses directly from the bronchoscope, EBUS-TBNA has redefined the precision of diagnostic bronchoscopy. This comprehensive review explores the origins, development, and current status of EBUS-TBNA, highlighting its successes and identifying potential areas for improvement. Technological advancements have continuously enhanced the reliability and efficacy of EBUS-TBNA over time. The mechanisms underlying the superior diagnostic yield of EBUS-TBNA are thoroughly discussed, further solidifying its position as the gold standard for lung cancer staging and diagnosis. Furthermore, this review delves into the crucial role of EBUS-TBNA in lung cancer diagnosis, supported by studies comparing its accuracy, safety, and cost-effectiveness to other diagnostic tools. Looking ahead, ongoing research aims to expand the applications of EBUS-TBNA and improve its diagnostic performance. Notable advancements in needle design and sampling techniques hold promise for further enhancing its efficacy. Maximizing its potential through comprehensive training and continuous technological developments will enable broader clinical applications, ultimately leading to improved patient outcomes. As EBUS-TBNA continues to evolve, its diagnostic impact is expected to increase, solidifying its position as an indispensable tool in the diagnosis and management of lung diseases.

Early experience of endobronchial ultrasound-guided transbronchial nodal cryobiopsy: a case series from Sabah, Malaysia

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established minimally invasive method for the diagnosis of benign and malignant conditions. Continuous efforts are underway to improve the material adequacy of EBUS-TBNA, including the introduction of a new technique called EBUS-guided transbronchial nodal cryobiopsy (EBUS-TBNC). This method allows for the retrieval of larger and well-preserved histologic samples from the mediastinum. We present a case series of four patients who underwent combined EBUS-TBNA and EBUS-TBNC procedures in our centre. All procedures were performed under general anaesthesia using a convex probe EBUS scope (Pentax EB-1970UK). Two patients were diagnosed with malignancy and two with benign disorders (silicosis and tuberculosis). In the malignant cases, both EBUS-TBNA/cell block and cryobiopsy provided a diagnosis but cryobiopsy yielded more material for ancillary tests in one patient. However, in the benign cases, there was discordance between EBUS-TBNA/cell block and cryobiopsy. Only cryobiopsy detected granuloma in the patient with TB (tuberculosis), and in the patient with silicosis, TBNC provided a better overall histological evaluation, leading to a definitive diagnosis. No complications were observed. This case series supports the potential diagnostic value of combining EBUS-TBNA and EBUS-TBNC, particularly in benign mediastinal lesions (granulomatous diseases), and in cases requiring additional molecular tests in cancer diagnosis.

Artificial intelligence in interventional pulmonology

PURPOSE OF REVIEW

In recent years, there has been remarkable progress in the field of artificial intelligence technology. Artificial intelligence applications have been extensively researched and actively implemented across various domains within healthcare. This study reviews the current state of artificial intelligence research in interventional pulmonology and engages in a discussion to comprehend its capabilities and implications.

RECENT FINDINGS

Deep learning, a subset of artificial intelligence, has found extensive applications in recent years, enabling highly accurate identification and labeling of bronchial segments solely from intraluminal bronchial images. Furthermore, research has explored the use of artificial intelligence for the analysis of endobronchial ultrasound images, achieving a high degree of accuracy in distinguishing between benign and malignant targets within ultrasound images. These advancements have become possible due to the increased computational power of modern systems and the utilization of vast datasets, facilitating detections and predictions with greater precision and speed.

SUMMARY

Artificial intelligence integration into interventional pulmonology has the potential to enhance diagnostic accuracy and patient safety, ultimately leading to improved patient outcomes. However, the clinical impacts of artificial intelligence enhanced procedures remain unassessed. Additional research is necessary to evaluate both the advantages and disadvantages of artificial intelligence in the field of interventional pulmonology.

Endobronchial ultrasound in diagnosing and staging of lung cancer by Acquire 22G TBNB versus regular 22G TBNA needles: A randomized clinical trial

OBJECTIVES

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has an important role in the diagnosis and staging of lung cancer. Evaluation of programmed death ligand 1 (PD-L1) expression and molecular profiling has become standard of care but cytological samples frequently contain insufficient tumor cells. The 22G Acquire needle with Franseen needle tip was developed to perform transbronchial needle biopsy (TBNB) with improved tissue specimens. This study evaluated if the 22G Acquire TBNB needle results in enhanced PD-L1 suitability rate compared to the regular Expect 22G TBNA needle.

METHODS

in this multi-center randomized clinical trial (Netherlands Trial Register NL7701), patients with suspected (N)SCLC and an indication for mediastinal/hilar staging or lung tumor diagnosis were recruited in five university and general hospitals in the Netherlands, Poland, Italy and Czech Republic. Patients were randomized (1:1) between the two needles. Two blinded reference pathologists evaluated the samples. The primary outcome was PD-L1 suitability rate in patients with a final diagnosis of lung cancer. In case no malignancy was diagnosed, the reference standard was surgical verification or 6 month follow-up.

RESULTS

154 patients were randomized (n = 76 Acquire TBNB; n = 78 Expect TBNA) of which 92.9% (n = 143) had a final malignant diagnosis. Suitability for PD-L1 analysis was 80.0% (n = 56/70; 95 %CI 0.68-0.94) with the Acquire needle and 76.7% (n = 56/73; 95 %CI 0.65-0.85) with the Expect needle (p = 0.633). Acquire TBNB needle specimens provided more frequent superior quality (65.3% (95 %CI 0.57-0.73) vs 49.4% (95 %CI 0.41-0.57, p = 0.005) and contained more tissue cores (72.0% (95 %CI 0.60-0.81) vs 41.0% (95 %CI 0.31-0.54, p < 0.01). There were no statistically significant differences in tissue adequacy, suitability for molecular analysis and sensitivity for malignancy and N2/N3 disease.

CONCLUSION

The 22G Acquire TBNB needle procured improved quality tissue specimens compared to the Expect TBNA needle but this did not result in an improved the suitability rate for PD-L1 analysis.

Accuracy of Preliminary Pathology for Robotic Bronchoscopic Biopsy

BACKGROUND

Diagnosis and treatment of peripheral pulmonary lesions (PPLs) currently require at least 2 procedures. An all-in-1 approach would require diagnosing malignancy with preliminary cytology results. This study investigated the concordance between preliminary cytology and final pathology results in biopsies of PPLs obtained by shape-sensing robotic-assisted bronchoscopy (ssRAB).

METHODS

This study was a retrospective, consecutive, single-arm, single-center study of 110 ssRABs for PPLs. Concordance was defined as agreement between preliminary cytology and final pathology results. Accuracy, sensitivity, specificity, positive and negative predictive values, and safety outcomes were examined.

RESULTS

The concordance was 89% for needle biopsies, 85% for forceps biopsies, and 92% overall, with substantial agreement. There was no significant association of concordance with patients' demographics or lesion characteristics. Preliminary cytology resulted in a malignant diagnosis in 70%, a nonmalignant diagnosis in 4%, and a nondiagnostic result in 26%, with accuracy of 86% and sensitivity of 84%. The total complication rate was 3.6%, with a pneumothorax rate of 1.8%.

CONCLUSIONS

This study compared the concordance of preliminary pathology results with final pathology results for ssRAB biopsies in PPLs. The results showed that preliminary samples have a high concordance with final pathology results and may enable management of PPLs with a single anesthetic procedure including biopsy, staging, and treatment.

Clinical Applications of Endobronchial Ultrasound (EBUS) Scope: Challenges and Opportunities

Endobronchial Ultrasound (EBUS) has been widely used to stage lung tumors and to diagnose mediastinal diseases. In the last decade, this procedure has evolved in several technical aspects, with new tools available to optimize tissue sampling and to increase its diagnostic yield, like elastography, different types of needles and, most recently, miniforceps and cryobiopsy. Accordingly, the indications for the use of the EBUS scope into the airways to perform the Endobronchial Ultrasound-TransBronchial Needle Aspiration (EBUS-TBNA) has also extended beyond the endobronchial and thoracic boundaries to sample lesions from the liver, left adrenal gland and retroperitoneal lymph nodes via the gastroesophageal tract, performing the Endoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In this review, we summarize and critically discuss the main indication for the use of the EBUS scope, even the more uncommon, to underline its utility and versatility in clinical practice.

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.

Rapid on-site evaluation of touch imprints of medical thoracoscopy biopsy tissue for the management of pleural disease

Background and objective

Medical thoracoscopy (MT) plays an important role in the diagnosis and treatment of pleural diseases, and rapid on-site evaluation (ROSE) has long been used for transbronchial needle aspiration or fine-needle aspiration to evaluate the adequacy of biopsy materials for the diagnosis of peripheral lung lesions. However, research on ROSE combined with MT for the management of pleural disease has been rarely reported. We aimed to evaluate the diagnostic performance of ROSE for pleura biopsies and visual diagnosis by thoracoscopists for gross thoracoscopic appearance. The secondary objective was to assess the intermodality agreement between ROSE and the final histopathologic diagnosis.

Methods

A total of 579 patients with exudative pleural effusion (EPE) who underwent MT combined with ROSE from February 2017 to December 2020 at Taihe Hospital were included in the study. Thoracoscopists' visual diagnosis of gross thoracoscopic appearance, ROSE results, histopathologic findings, and the final diagnosis was recorded.

Results

Thoracoscopic pleural biopsies were performed in 565 patients (97.6%); 183 patients were confirmed to have malignant pleural effusion (MPE), and 382 patients were confirmed to have benign pleural effusion (BPE). The area under the curve of ROSE for the diagnosis of MPE was 0.96 (95% CI: 0.94-0.98, p < 0.001), with a sensitivity of 98.7%, a specificity of 97.2%, a diagnostic accuracy of 97.1%, a positive predictive value of 97.2%, and a negative predictive value of 97.2%. Diagnostic consistency between ROSE and histopathology was good (κ ± SE = 0.93 ± 0.02, p < 0.001). The area under the curve of the thoracoscopists' visual diagnosis of gross thoracoscopic appearance was 0.79 (95% CI: 0.75-0.83, p < 0.01), with a sensitivity of 76.7%, a specificity of 80.9%, a positive predictive value of 62.4%, and a negative predictive value of 89.3%.

Conclusion

ROSE of touch imprints of MT biopsy tissue during MT showed high accuracy for distinguishing between benign and malignant lesions. In addition, ROSE was in good agreement with the histopathological diagnosis, which may help thoracoscopists perform pleurodesis (talc poudrage) directly during the procedure, especially in patients with malignant results.

Evaluating Diff-Quik cytology smears for large-panel mutation testing in lung cancer-Predicting DNA content and success with low-malignant-cellularity samples

BACKGROUND

Cytology smears are commonly collected during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) procedures but are rarely used for molecular testing. Studies are needed to demonstrate their great potential, in particular for the prediction of malignant cell DNA content and for utility in molecular diagnostics using large gene panels.

METHODS

A prospective study was performed on samples from 66 patients with malignant lymph nodes who underwent EBUS TBNA. All patients had air-dried, Diff-Quik cytology smears and formalin-fixed, paraffin-embedded cell blocks collected for cytopathology and molecular testing. One hundred eighty-five smears were evaluated by microscopy to estimate malignant cell percentage and abundance and to calculate smear size and were subjected to DNA extraction. DNA from 56 smears from 27 patients was sequenced with the TruSight Oncology 500 assay (Illumina).

RESULTS

Each microscopy parameter had a significant effect on the DNA yield. An algorithm was developed that predicted a >50-ng DNA yield of a smear with an area under the curve of 0.86. Fifty DNA samples (89%) with varying malignant yields were successfully sequenced. Low-malignant-cell content (<25%) and smear area (<15%) were the main reasons for failure. All standard-of-care mutations were detected in replicate smears from individual patients, regardless of malignant cell content. Tier 1/2 mutations were discovered in two cases where standard-of-care specimens were inadequate for sequencing. Smears were scored for tumor mutation burden.

CONCLUSIONS

Microscopy of Diff-Quik smears can triage samples for comprehensive panel sequencing, which highlights smears as an excellent alternative to traditional testing with cell blocks.

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.

Validation of a Cytological Classification System for the Rapid On-Site Evaluation (Rose) of Pulmonary and Mediastinal Needle Aspirates

Rapid on-site evaluation (ROSE) is a procedure that allows immediate assessment of adequacy of cytological specimens obtained by fine needle aspiration (FNA). The application of ROSE diagnostic categories has been applied in various organs, but not in thoracic pathology. We aimed to retrospectively assess the concordance with the final diagnosis of a categorization from C1 (inadequate) to C5 (neoplastic) during ROSE performed with bronchoscopic or percutaneous sampling procedures of thoracic lesions in a large series of consecutive cases. This retrospective single-center study evaluated 2282 consecutive ROSEs performed on 1827 patients from January 2016 to December 2020 in 994 cases of transbronchial needle aspiration (TBNA) in peripheral pulmonary lesions, in 898 transthoracic FNAs, in 318 ultrasound-guided TBNAs, in 50 conventional TBNAs and in 22 endobronchial TBNAs. False positive and false negative cases of ROSE were 43 (1.88%) and 73 (3.2%), respectively, when compared with the definitive diagnosis. The sensitivity, specificity and the positive and negative prognostic values of ROSE were 94.84%, 95.05%, 96.89% and 91.87%, respectively. Overall concordance between ROSE and the final diagnosis was 0.8960 (Cohen's kappa). No significant differences were observed in terms of sampling procedures and type and location of the lesions. A tiered classification scheme of ROSE from C1 to C5 during bronchoscopic and percutaneous sampling procedures is helpful in effectively guiding clinical management of patients with thoracic lesions.

Ultrasound-Guided Needle Aspiration Biopsy of Superficial Metastasis of Lung Cancer with and without Rapid On-Site Evaluation: A Randomized Trial

Simple Summary

Pulmonologist-performed US-NAB of “superficial” metastatic lesions is safe and has an excellent diagnostic yield for both tissue diagnosis and molecular profiling regardless of the use of rapid on-site evaluation. These findings have important implications for costs, hospital resource allocation, and the globally widespread utilization of US-NAB.

Abstract

Background and Objective: Studies which evaluated the role of an ultrasound-guided needle aspiration biopsy (US-NAB) of metastases from lung cancer located in “superficial” organs/tissues are scant, and none of them assessed the possible impact of rapid on-site evaluation (ROSE) on diagnostic accuracy and safety outcomes. Methods: Consecutive patients with suspected superficial metastases from lung cancer were randomized 1:1 to US-NAB without (US-NAB group) or with ROSE (ROSE group). The diagnostic yield for a tissue diagnosis was the primary outcome. Secondary outcomes included the diagnostic yield for cancer genotyping, the diagnostic yield for PD-L1 testing, and safety. Results: During the study period, 136 patients were randomized to receive an US-NAB with (n = 68) or without ROSE (n = 68). We found no significant differences between the ROSE group and the US-NAB group in terms of the diagnostic yields for tissue diagnosis (94.1% vs. 97%, respectively; p = 0.68), cancer genotyping (88% vs. 91.8%, respectively; p = 0.56), and PD-L1 testing (93.5% vs. 90.6%, respectively; p = 0.60). Compared to the diagnostic US-NAB procedures, the non-diagnostic procedures were characterized by less common use of a cutting needle (66.6% vs. 96.9%, respectively; p = 0.0004) and less common retrieval of a tissue core (37.5% vs. 98.5%; p = 0.0001). Only one adverse event (vasovagal syncope) was recorded. Conclusion: US-NAB of superficial metastases is safe and has an excellent diagnostic success regardless of the availability of ROSE. These findings provide a strong rationale for using US-NAB as the first-step method for tissue acquisition whenever a suspected superficial metastatic lesion is identified in patients with suspected lung cancer.

Value of transbronchial needle aspiration combined with a rapid on-site evaluation of cytology in the diagnosis of pulmonary lesions

Background

The diagnostic value of rapid on-site evaluation (ROSE) of cytology during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) remains controversial. The purpose of this study was to validate the value of ROSE during the EUBS-TBNA procedure in the diagnosis of pulmonary lesions (PLs).

Methods

Enrolled in this study were 260 patients with nodules, masses, cavities, or inflammatory lesions on pulmonary CT images. They were assigned to undergo EBUS-TBNA with ROSE (n = 134) or without ROSE (n = 126). The diagnostic results of ROSE during EBUS-TBNA and the final pathologic reports were analyzed and compared by utilizing SPSS21.0 software to evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). In addition, we further explored whether the ROSE method during EBUS-TBNA would improve the diagnostic yield and reduce the incidence of complications.

Results

The overall diagnostic yield of EBUS-TBNA for malignant diseases in the ROSE and the non-ROSE group were 29.9 and 11.1%, respectively. The sensitivity, specificity, PPV and NPV of the ROSE method during EBUS-TBNA were 97.4, 96.9, 92.5, and 98.90%, respectively. The result of the chi-square test effectively proved that ROSE operation during EBUS-TBNA contributes to the diagnosis of malignancy compared with the non-ROSE group (χ² = 13.858, P < 0.001). The number of punctures in the ROSE group was significantly lower than that in the non-ROSE group (P < 0.001).

Conclusion

ROSE examination during EBUS-TBNA could effectively improve the diagnostic yield of malignant diseases compared with the non-ROSE group and reduce the number of intraoperative punctures, which is a clinical application worth popularizing.

Evaluation of the Utility of Liquid-based Cytology, Cell-blocks, and Flow Cytometric Immunophenotyping on Endobronchial Ultrasound-guided Transbronchial Needle Aspiration Samples in the Diagnosis of Sarcoidosis

BACKGROUND

There is little information on the value of different processing methods for samples obtained during endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) in suspected sarcoidosis. We evaluated the role of conventional smears, liquid-based cytology (LBC), cell-blocks and flow cytometric immunophenotyping in the diagnosis of sarcoidosis using EBUS-TBNA samples.

METHODS

This was a prospective study of consecutive EBUS-TBNA samples from clinically suspected cases of sarcoidosis. In addition to conventional smears, we prepared LBC smears, cell-blocks, and performed flow cytometric evaluation of the CD4:CD8 ratio. The final diagnosis of sarcoidosis was made based on the relevant clinical details and laboratory investigations including the results of transbronchial and endobronchial biopsies (TBLB and endobronchial biopsy).

RESULTS

We included 60 subjects [mean age: 45.2 y; 29 (48.3%) men]. The sensitivity of conventional smears, LBC, and cell-blocks for diagnosing sarcoidosis was found to be 75.5%, 37.8%, 35%, respectively, when used alone. However, on combining conventional and LBC smears, the sensitivity increased to 84.4% and on combining all three techniques, the sensitivity was 86.7%. The CD4:CD8 ratio on flow cytometric immunophenotyping of EBUS-TBNA samples ranged from 0 to 11.5 with a mean of 3.17±2.78 in confirmed cases of sarcoidosis and 70% of these cases had CD4:CD8 ratio of more than 2.

CONCLUSION

Cell-blocks and liquid-based preparations add to the yield of conventional preparation of EBUS-TBNA samples in the diagnosis of sarcoidosis. A combination of conventional and LBC works well in detecting almost 85% of the cases of sarcoidosis. Higher CD4:CD8 ratio favors a diagnosis of sarcoidosis.

Clinical Utility of Rapid On-Site Evaluation of Touch Imprint Cytology during Cryobiopsy for Peripheral Pulmonary Lesions

Simple Summary

With increasing interest in precision medicine for lung cancer, cryobiopsy is expected to improve the success rate not only for histological diagnosis, but also for next-generation sequencing. Rapid on-site evaluation (ROSE) is an immediate cytological evaluation performed during bronchoscopy. However, little is known about its clinical utility during cryobiopsy. We retrospectively reviewed the data of 63 consecutive patients who underwent cryobiopsy with ROSE of touch imprint cytology (ROSE-TIC) for solid peripheral pulmonary lesions. When the results of ROSE-TIC of each patient were compared directly with the histological findings of the corresponding specimen, the sensitivity, specificity, and positive and negative predictive values were 69.8%, 90.0%, 93.8%, and 58.1%, respectively. The concordance rate was 76.2%. Therefore, we believe that ROSE-TIC, due to its high specificity and positive predictive value, may be a potential tool in deciding whether cryobiopsy sampling could be finished during bronchoscopy.

Abstract

Cryobiopsy enables us to obtain larger specimens than conventional forceps biopsy despite the caution regarding complications. This study aimed to evaluate the clinical utility of rapid on-site evaluation of touch imprint cytology (ROSE-TIC) during cryobiopsy of peripheral pulmonary lesions (PPLs). We retrospectively reviewed the data of consecutive patients who underwent cryobiopsy for solid PPLs between June 2020 and December 2021. ROSE-TIC was performed on the first specimen obtained via cryobiopsy and assessed using Diff-Quik staining. The results of ROSE-TIC for each patient were compared with the histological findings of the first cryobiopsy specimen. Sixty-three patients were enrolled in this study. Overall, 57 (90.5%) lesions were ≤30 mm in size and 37 (58.7%) had positive bronchus signs. The radial endobronchial ultrasound findings were located within and adjacent to the lesion in 46.0% and 54.0% of the cases, respectively. The sensitivity, specificity, and positive and negative predictive values of the ROSE results for histological findings of the corresponding specimens were 69.8%, 90.0%, 93.8%, and 58.1%, respectively. The concordance rate was 76.2%. In conclusion, ROSE-TIC, due to its high specificity and positive predictive value, may be a potential tool in deciding whether cryobiopsy sampling could be finished during bronchoscopy.

Assessing ROSE for adequacy of EBUS-TBNA compared with a direct-to-cell block approach as a response to the COVID-19 pandemic

Introduction:

Rapid on-site evaluation (ROSE) has been used during the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) procedure as standard practice. Because of the COVID-19 (coronavirus disease 2019) pandemic, our institute had had to discontinue ROSE and adopt a direct-to-cell block approach. In the present study, we aimed to determine whether this change has had significant effects on the cytopathology quality.

Materials and methods:

A total of 1903 EBUS-TBNA cases from 734 patients were collected (1097 cases with ROSE for 452 patients; 806 cases without ROSE but with direct-to-cell block for 282 patients). The clinical and cytology data were analyzed using SAS, version 9.4, software to render calculated standardized residuals and a fitted multivariate generalized linear model.

Results:

On average, a biopsy from a patient with ROSE was 0.936 (=exp −0.066) times less likely to be reported as satisfactory compared with a biopsy from a patient without ROSE, although the difference was not statistically significant (P = 0.785). The inadequacy rate of EBUS-TBNA was 6.4% higher on average for cases with ROSE compared with a direct-to-cell block approach. However, this difference was also not statistically significant. The proportions of biopsies reported as diagnostic for malignancy and other were significantly different between the ROSE and no-ROSE groups with a standardized residual of 1.80 (P = 0.036) and −2.27 (P = 0.012), respectively.

Conclusions

Discontinuing ROSE and using a direct-to-cell block approach had no negative effects on cytopathology quality. This practice can be considered acceptable during the COVID-19 pandemic when social distancing and the shortage of staff and supplies have resulted in challenges to delivering quality care to cancer patients whose treatment cannot be postponed.

Comparison of the Detection Rates of Different Diagnostic Methods for Primary Peripheral Lung Cancer

Objective

The present study aims to compare the detection rates of different diagnostic methods for primary peripheral lung cancer (PPLC).

Methods

The detection rate and patient information were collected from a total of 359 cases of PPLC or a suspected diagnosis of lung cancer; among these, 186 cases were simultaneously treated with fibreoptic bronchoscopy, brush inspection and flush inspection, and 173 cases underwent a computed tomography (CT)-guided percutaneous lung biopsy (PNB). The positive detection rates of the different methods were compared.

Results

In the detection of peripheral lesions (diameter of <5 cm), the CT-PNB had the significantly highest detection rate, followed by the combined basic method (fibreoptic bronchoscopy + brushing + flushing). The independent use of the three basic sampling methods showed a significantly lower detection rate compared with the combined use.

Conclusion

In the diagnosis of peripheral lung cancer, the CT-PNB had the best detection rate; hence, it could be used in clinical practice for the diagnosis of such lesions.

Role of EBUS-TBNA in Non-Neoplastic Mediastinal Lymphadenopathy: Review of Literature

Mediastinal lymphadenopathy is a condition in which one or more mediastinal lymph nodes are enlarged for malignant or benign causes, generally more than 10 mm. For a long time, the only way to approach the mediastinum was surgery, while in last decades endoscopic techniques gained their role in neoplastic diseases. At the present time, EBUS is the technique of choice for studying the mediastinum in the suspicion of cancer, while there are not strong indications in guidelines for the study of benign mediastinal lymphadenopathy. We reviewed the literature, looking for evidence of the role of EBUS in the diagnostics of non-neoplastic mediastinal lymphadenopathy, with special regard for granulomatous disease, both infectious and non-infectious. EBUS is a reliable alternative to surgery in non-neoplastic mediastinal lymphadenopathy, even if more evidence is needed for granulomatous diseases other than tuberculosis and sarcoidosis.

Controversies in Mediastinal Staging for Nonsmall Cell Lung Cancer

Mediastinal lymph nodal involvement in nonsmall cell lung cancer plays a crucial role in deciding treatment strategy. Survival falls markedly with increasing involvement of mediastinal nodal stations. Hence, accurate staging of the mediastinum with lowest morbidity is of utmost importance. A wide array of invasive and noninvasive modalities that complement each other in assessing the nodes are available at our disposal. Guidelines recommend noninvasive imaging as the initial step in the staging algorithm for all tumors, followed by invasive staging. No single modality has proven to be the ideal method to stage the mediastinum when used alone. In the present decade, minimally invasive endobronchial ultrasound (EBUS) has challenged the position of surgical mediastinoscopy, which has been the gold standard, historically. However, a negative EBUS needs to be confirmed by surgical mediastinoscopy. Video-assisted mediastinoscopic lymphadenectomy has also come to the forefront in last two decades and has shown exceptional results, when performed in experienced centers. This review details the various modalities of mediastinal staging and the controversies surrounding the optimal method of staging, restaging after neoadjuvant therapy, and the most cost-effective strategy.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA): Technical Updates and Pathological Yield

Since the endobronchial ultrasound bronchoscope was introduced to clinical practice, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become the procedure of choice to sample hilar and mediastinal adenopathy. Multiple studies have been conducted in the last two decades to look at the different technical aspects of the procedure and their effects on the final cytopathological yield. In addition, newer modes of ultrasound scanning and newer tools with the potential to optimize the selection and sampling of the target lymph node have been introduced. These have the potential to reduce the number of passes, reduce the procedure time, and increase the diagnostic yield, especially in rare tumors and benign diseases. Herein, we review the latest updates related to the technical aspects of EBUS-TBNA and their effects on the final cytopathological yield in malignant and benign diseases.

Rapid on-site evaluation (ROSE) during endobronchial ultrasound bronchoscopy (EBUS) in the diagnosis of granulomatous diseases

AIM

We aimed to evaluate the role of Rapid On-Site Evaluation (ROSE) in improving the diagnostic contribution of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of granulomatous lymphadenitis.

METHODS

We retrospectively included all patients in the study who underwent EBUS-TBNA (n = 405) from September 2013 to September 2017. All cases who underwent EBUS-TBNA and were found to have "granuloma" in the final pathological diagnosis (n = 143) were included in the research.

RESULTS

One hundred forty-three cases who underwent EBUS and whose final pathological diagnosis was granuloma were included in the study. A total of 231 lymph nodes were sampled. The final diagnosis was found to be compatible with the examination during the procedure for 55 (85.9%) out of 64 patients for whom ROSE was performed. In addition, while 79.7% of the 64 patients who underwent ROSE were tested positive for granuloma, 9.4% were suspected to have granuloma, and no diagnostic result was obtained for 10.9%. The number of lymph node needle aspirations was statistically significantly lower in patients for whom ROSE was performed (P < .001). The final diagnosis was found to be compatible with the examination during the procedure for 55 (85.9%) out of 64 patients for whom ROSE was performed. According to the evaluation made on the duration, the procedure was completed in the first 15 minutes in 95.4% of the patients for whom ROSE was performed, while the procedure took longer than 15 minutes in 93.6% of the patients for whom ROSE was not performed.

CONCLUSION

We found a high incidence of congruence between ROSE and the final cytological diagnosis if granulomas were identified in the final cytology. Performing ROSE shortens the duration of the procedure and reduced sampling thus preventing complications that may occur due to prolongation of the procedure.

Linear Endobronchial Ultrasound in the Era of Personalized Lung Cancer Diagnostics-A Technical Review

Major advances in molecular profiling for available targeted treatments and immunotherapy for lung cancer have significantly increased the complexity of tissue-based diagnostics. Endobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNA) are commonly performed for diagnostic biopsies and lymph node staging. EBUS-TBNA has increasingly become one of the main sources of tumor cells for molecular analyses. As a result, there is a growing need for high quality EBUS-TBNA samples with adequate cellularity. This has increased the technical demands of the procedure and has created additional challenges, many of which are not addressed in the current EBUS guidelines. This review provides an overview of current evidence on the technical aspects of EBUS-TBNA in light of comprehensive sample processing for personalized lung cancer management. These include sonographic lymph node characterization, optimal needle choice, suction biopsy technique, and the role of rapid on-site evaluation. Attention to these technical details will be important to maximize the throughput of EBUS-TBNA biopsies for molecular testing.

Technical aspects of the use of cytopathological specimens for diagnosis and predictive testing in malignant epithelial neoplasms of the lung

Lung cancer is a leading cause of cancer mortality worldwide but recent years have seen a rapidly rising proportion of cases of advanced non-small cell carcinoma amenable to increasingly targeted therapy, initially based on the differential response to systemic treatment of tumours of squamous or glandular differentiation. In two-thirds of the cases, where patients present with advanced disease, both primary pathological diagnosis and biomarker testing is based on small biopsies and cytopathological specimens. The framework of this article is an overview of the technical aspect of each stage of the specimen pathway with emphasis on maximising potential for success when using small cytology samples. It brings together the current literature addressing pre-analytical and analytical aspects of specimen acquisition, performing rapid onsite evaluation, and undertaking diagnostic and predictive testing using immunocytochemistry and molecular platforms. The advantages and drawbacks of performing analysis on cell block and non-cell block specimen preparations is discussed.

The Value of Additional Conventional Transbronchial Biopsy in the Negative Results of Rapid On-site Evaluation During Endobronchial Ultrasound With Guide Sheath to Diagnose Small Peripheral Lung Cancer

Objective: The accuracy of rapid on-site evaluation (ROSE) during endobronchial ultrasonography with guide sheath (EBUS-GS) was reported to be approximately 90% for diagnosing small peripheral pulmonary lesions (PPLs). When ROSE during EBUS-GS for diagnosing small peripheral lung cancer is carried out and does not include malignant cells in a position whereby the probe was located within or adjacent to the lesion, the best technique for overcoming the lower diagnostic yield remains unknown. This study aimed to evaluate factors affecting positive results of ROSE during EBUS-GS in such a probe position. Moreover, when the results of ROSE were consistently negative, we evaluated the effectiveness of conventional transbronchial biopsy (TBB) in addition to EBUS-GS alone. Methods: We performed a retrospective analysis of consecutive patients who underwent EBUS-GS combined with ROSE for diagnosing small peripheral lung cancer (≤30 mm). We classified the results of ROSE into two groups based on the presence of malignant cells: the ROSE positive group (included malignant cells) and the ROSE negative group (did not include malignant cells). The significant predictors of positive ROSE results during EBUS-GS were analyzed using multivariate logistic regression analyses. Results: We identified 67 lesions (43 lesions in the ROSE positive group and 24 lesions in the ROSE negative group, respectively). Multivariate logistic analysis revealed that the significant factor affecting positive ROSE results was lesion size (>15 mm) (OR = 9.901). The diagnostic yield of additional conventional TBB to EBUS-GS was significantly higher than that of EBUS-GS alone (75.0% vs 33.3%, P = .041). Conclusion: The positive results of ROSE during EBUS-GS were significantly influenced by lesion size (>15 mm). When the results of ROSE during EBUS-GS were consistently negative in a position whereby the probe was located within or adjacent to the lesion, additional conventional TBB was effective to improve the diagnostic yield compared with EBUS-GS alone.

The Association of "GOOP" on Gross Examination of Fine Needle Aspiration Samples and On-Site Adequacy

BACKGROUND

Rapid on-site cytologic evaluation (ROSE) is not always available for fine needle aspiration (FNA) specimens. We have examined the relationships between the presence of "GOOP" (defined as gooey white material) on FNA aspirates, on-site adequacy (OSA), and diagnosis.

METHODS

Consecutive FNA samples obtained over the study interval were included. Samples were assessed macroscopically for the presence or absence of GOOP (GOOP+ or GOOP-). GOOP+ samples were further characterized as shiny (G+S) or cheesy (G+C). Gross descriptors were correlated with OSA and final diagnoses.

RESULTS

Of the 204 sites biopsied, 102 were malignant, 94 benign, and 8 nondiagnostic. The presence of GOOP was highly predictive for adequacy (positive predictive value 98%). While these correlations for GOOP positivity were significant, the absence of GOOP did not rule out adequacy or malignancy. The presence of GOOP was also significantly correlated with a malignant diagnosis.

CONCLUSIONS

We have prospectively demonstrated that the presence of GOOP correlates strongly with adequacy. This may be of value for those for whom ROSE is not available and, when available, may help prioritize specimens for on-site review.

Optimizing Diagnostic and Staging Pathways for Suspected Lung Cancer: A Decision Analysis

BACKGROUND

The optimal diagnostic and staging strategy for patients with suspected lung cancer is not known.

RESEARCH QUESTION

What diagnostic and staging strategies are most cost-effective for lung cancer?

STUDY DESIGN AND METHODS

A decision model was developed by using a hypothetical patient with a high probability of lung cancer. Sixteen unique permutations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound, electromagnetic navigation, convex endobronchial ultrasound with or without rapid-onsite evaluation (ROSE), CT-guided biopsy (CTBx), and surgery were evaluated. Outcomes included cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio, and willingness-to-pay thresholds. Sensitivity analyses were performed on primary outcomes.

RESULTS

For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy costs $1,694 more than the best CTBx strategy but resulted in fewer complications (risk difference, 14%). The additional cost of bronchoscopy to avoid one complication from a CTBx strategy was $12,037. The cost and cumulative complications of bronchoscopy strategies increased compared with CTBx strategies for small lesions. The cost and cumulative complications of bronchoscopy strategies decreased compared with CTBx strategies when a bronchus sign was present, but bronchoscopy remained more costly overall. For a central lesion and/or radiographic N1-3 disease, convex endobronchial ultrasound with ROSE followed by lung biopsy with incremental cost-effectiveness ratio, if required, was more cost-effective than any CTBx strategy across all outcomes. Strategies with ROSE were always more cost-effective than those without, irrespective of scenario. Trade-offs also exist between different bronchoscopy strategies, and optimal choices depend on the value placed on individual outcomes and willingness-to-pay.

INTERPRETATION

The most cost-effective strategies depend on nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of ROSE. For most clinical scenarios, many strategies can be eliminated, and trade-offs between the remaining competitive strategies can be quantified.

Transbronchial mediastinal cryobiopsy in the diagnosis of mediastinal lesions: a randomised trial

BACKGROUND

Guidelines recommend endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) as an initial investigation technique for mediastinal nodal staging in lung cancer. However, EBUS-TBNA can be limited by the inadequacy of intact tissues, which might restrict its diagnostic yield in mediastinal lesions of certain etiologies. We have previously shown that EBUS-guided transbronchial mediastinal cryobiopsy can provide intact samples with greater volume.

METHODS

This randomised study determined the diagnostic yield and safety of transbronchial mediastinal cryobiopsy monitored by endosonography for the diagnosis of mediastinal lesions. Patients with mediastinal lesion of 1 cm or more in the short axis were recruited. Following identification of the mediastinal lesion by linear EBUS, fine-needle aspiration and cryobiopsy were sequently performed in a randomised order. Primary endpoints were diagnostic yield defined as the percentage of patients for whom mediastinal biopsy provided a definite diagnosis, and procedure-related adverse events.

RESULTS

One hundred and ninety-seven patients were enrolled and randomly allocated. The overall diagnostic yield was 79.9% and 91.8% for TBNA and transbronchial mediastinal cryobiopsy, respectively (p=0.001). Diagnostic yields were similar for metastatic lymphadenopathy (94.1% versus 95.6%, p=0.58), while cryobiopsy was more sensitive than TBNA in uncommon tumors (91.7% versus 25.0%, p=0.001) and benign disorders (80.9% versus 53.2%, p=0.004). No significant differences in diagnostic yield were detected between TBNA first and cryobiopsy first groups. We observed 2 cases of pneumothorax and 1 case of pneumomediastinum.

CONCLUSIONS

Transbronchial cryobiopsy performed under EBUS guidance is a safe and useful approach that offers diagnostic histological samples of mediastinal lesions.

EBUS in optimizing non-small cell lung cancer diagnosis and treatment

Background

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a commonly used minimally invasive method for the diagnosis and staging of lung cancer. In order to improve its diagnostic accuracy, rapid on-site cytologic evaluation (ROSE) is being utilized in some institutions. ROSE, performed by a cytopathologist in the examination room, allows the assessment of the adequacy of the collected samples, identifies malignant cells and sometimes establishes diagnosis on the spot, thus improving diagnostic sensitivity. As non-small cell lung carcinomas (NSCLC) require not only pathological subtyping, but also molecular characterization, obtaining the adequate amount of tissue is crucial. Only a limited number of studies have analyzed the suitability of EBUS-TBNA samples for assessment of epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK) and programmed death-ligand 1 (PD-L1) status.

Aim

We intended to examine the diagnostic yield of ROSE in NSCLC and the results and feasibility of molecular analysis performed on EBUS-TBNA small samples.

Methods

100 patients with lung tumors and hilar and/or mediastinal lymphadenopathy on CT or PET/CT scans were retrospectively identified over a 3-year period, from a prospectively maintained EBUS-TBNA database. All examinations were accompanied by on-site cytological exam - ROSE, histopathological exam (HPE) and, in the case of NSCLC, molecular testing. After the sampling of the lymph nodes, specimens were Diff-Quik stained and a rapid preliminary diagnosis was established. Immunohistochemistry and mutational testing were performed using cell blocks.

Results

Adenocarcinoma was the most frequent diagnosis in both ROSE (34%) and histopathology (53%). Overall sensitivity and positive predictive value of ROSE in NSCLC, considering HPE the gold standard, were 92.18% and 93.65%, respectively, with a specificity and negative predictive value of 75% and 70.58%, respectively. All samples that were tested for EGFR mutation and ALK rearrangement were adequate for analysis. The adequacy ratio for PD-L1 was 91.66%; 37.5% of patients showed a high PD-L1 expression level, with a tumor proportion score TPS ≥50%.

Conclusion

EBUS-TBNA is a valuable method for lung cancer diagnosis. ROSE proved to have a moderate prediction of the final diagnosis in NSCLC. Molecular analysis of EGFR, ALK and PD-L1 can be successfully accomplished on EBUS-TBNA small tissue samples.

The role of rapid on site evaluation on touch imprint cytology and brushing during conventional bronchoscopy

BACKGROUND

The increase in immunohistochemical and molecular predictive tests in lung cancer requires new strategies for managing small samples taken during bronchoscopic procedures. The value of Rapid On Site Evaluation (ROSE) during conventional bronchoscopic procedures on endobronchial neoplasms in optimizing small biopsies and cytologlogical tissue specimens for diagnostic testing, and ancillary studies was evaluated.

METHOD

ROSE on touch imprint cytology (TIC) and brushing was performed on 690 consecutive cases of patients undergoing biopsies, using fiber optic bronchoscopy. Immunohistochemical assay for PD-L1, ALK, and ROS1 and molecular testing, via next generation technique for EGFR, KRAS, and BRAF, were performed.

RESULTS

The concordance between ROSE and final diagnoses was almost perfect for brushing (sensitivity: 0.84; specificity: 0.96), and less so for touch preparations (sensitivity: 0.77; specificity: 0.89). Immunohistochemical assay for PD-L1 was evaluated on 256 bioptic cases with only six unsuitable samples. Material available for immunohistochemistry for ALK was sufficient in 151 biopsies with no inadequate cases. ROS1 was evaluated in 132 biopsies, with only two unsuitable samples. Molecular analysis was performed on 128 biopsies, 29 TIC, and 17 brushing. Out of these, only ten were considered to be unsuitable.

CONCLUSIONS

ROSE is an effective procedure for monitoring the quality and quantity of material taken during conventional bronchoscopic procedures for evaluating the suitability of small samples that must undergo immunohistochemical and molecular assay.

Rapid onsite evaluation uses a very small proportion of total material aspirated at endobronchial or endoscopic ultrasound in the investigation of suspected thoracic malignancy

INTRODUCTION

The objectives were: to measure the proportion of aspirated material used to make direct slides for rapid onsite evaluation (ROSE) at endobronchial (EBUS) and endoscopic ultrasound (EUS) in suspected thoracic malignancy; and to correlate pass weights with ROSE category and needle size.

METHOD

All EBUS and EUS cases for possible thoracic malignancy October 2018-May 2019 were included. All material from each pass was expelled into a Petri dish. One drop of material was placed on each of two slides; one used for ROSE, the other fixed and remaining material processed to cell block. Dish and slides were weighed before and after this procedure on a sensitive balance and weight of aspirate and slide material calculated. When ROSE identified malignancy, slide production ceased but target sampling for ancillary studies continued.

RESULTS

ROSE accuracy was 96.8%. Mean percentage by target of aspirated material used to make direct slides for ROSE was 1.9% in malignant cases and 3.6% in non-malignant cases (P = .027 for difference). Mean percentage by pass was 5.9%. Mean weight of a single aspirate was 128.8 mg. Mean weight of aspirates insufficient on ROSE (175.7 mg) was significantly higher than the mean weight of benign or malignant aspirates (117.1 and 114.0 mg, respectively). Mean weight of aspirates using 22G needles (132.6 mg) was significantly higher than that for 25G needles (87.1 mg).

CONCLUSION

Material made into direct slides at EBUS and EUS and used in part for ROSE uses a tiny proportion of aspirated material with over 98% processed to cell block and available for ancillary testing in malignant cases.

Advanced Diagnostic and Therapeutic Bronchoscopy: Technology and Reimbursement

Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.

[Masterplan 2025 of the Austrian Society of Pneumology (ASP)-the expected burden and management of respiratory diseases in Austria]

Scientific Members of the Austrian Society of Pneumology describe the expected development in respiratory health and provide guidance towards patient-oriented and cost-efficient respiratory care in Austria.Methods: In November 2017, respiratory care providers (physicians, nurses, physiotherapists) together with patient's advocacy groups and experts in health development, collaborated in workshops on: respiratory health and the environment, bronchial asthma and allergy, COPD, pediatric respiratory disease, respiratory infections, sleep disorders, interventional pneumology, thoracic oncology and orphan diseases.Results: Respiratory disease is extremely prevalent and driven by ill-health behavior, i.e. cigarette smoking, over-eating and physical inactivity. For the majority of respiratory diseases increased prevalence, but decreased hospitalizations are expected.The following measures should be implemented to deal with future challenges:1. Screening and case-finding should be implemented for lung cancer and COPD.2. E-health solutions (telemedicine, personal apps) should be used to facilitate patient management.3. Regional differences in respiratory care should be reduced through E‑health and harmonization of health insurance benefits across Austria.4. Patient education and awareness, to reduce respiratory health illiteracy should be increased, which is essential for sleep disorders but relevant also for other respiratory diseases.5. Respiratory care should be inter-professional, provided via disease-specific boards beyond lung cancer (for ILDs, sleep, allergy)6. Programs for outpatient's pulmonary rehabilitation can have a major impact on respiratory health.7. Increased understanding of molecular pathways will drive personalized medicine, targeted therapy (for asthma, lung cancer) and subsequently health care costs.

Results from the 2019 American Society of Cytopathology survey on rapid onsite evaluation (ROSE)-part 2: subjective views among the cytopathology community

INTRODUCTION

This study aims to improve understanding of the cytopathology community's perspective regarding the value of rapid onsite evaluation (ROSE) in clinical practice.

MATERIALS AND METHODS

The American Society of Cytopathology membership was surveyed in 2019 to obtain subjective data on the cytopathology community's perceptions regarding ROSE. Comments were categorized by major themes and attitudes and analyzed by respondent's role in laboratory, practice size, and practice setting (Fisher's exact and χ² tests).

RESULTS

A total of 541 responses were received from 255 cytopathologists/pathologists, 261 cytotechnologists, 19 trainees, and 6 others (as previously reported). Reasons for which cytopathology personnel provide this service aligned with their perceptions of why clinicians request ROSE. A minority of respondents, disproportionally from high volume centers, felt ROSE is unnecessary. Overall attitude regarding ROSE was generally positive. There were no significant differences in attitude regarding ROSE according to role in laboratory or practice size, but respondents from academic centers provided a significantly higher percentage of positive comments than those in private or community practice. Although survey respondents generally felt that ROSE is valuable to patient care, they also highlighted several challenges, including staffing, time commitment, and inadequate reimbursement. Implementation of telecytology was felt to potentially alleviate some of these challenges.

CONCLUSIONS

Survey results show that the cytology community views ROSE favorably, practices vary considerably, and there is a perceived need for improved reimbursement. Data from this study may be used to identify areas that warrant additional research to clarify the clinical value of ROSE.

Detailed procedure and clinical application overview of rapid on-site evaluation in diagnostic interventional pulmonology

Diagnostic interventional pulmonology is widely accepted as a minimally invasive, highly accurate procedure for diagnosing lung cancer, more drug-resistant pathogen infections of lower respiratory tract, and critical respiratory diseases. The efficiency of interventional diagnostics depends on quite a few factors, including size and the anatomic location of lymph nodes, number of biopsy sites and complications rate, characteristics of the lesion, and underlying disease. Specifically, the application of rapid on-site evaluation (ROSE) may avoid additional sampling without compromising diagnostic yield with a preliminary evaluation for adequate diagnostic material and thus reduce the complication rate. In this review article we aimed at elaborate the technical details, clinical roles, and technological progress of ROSE in diagnostic interventional pulmonology, highlighting the importance of ROSE in diagnostic interventional pulmonology. We finally pointed out that it will be a tendency for a pulmonologist, to undergo a short yet intensive training and perform ROSE in diagnostic interventional pulmonology.

Feasibility and accuracy of rapid on-site evaluation of touch imprint cytology during transbronchial biopsy

Background

Rapid on-site evaluation (ROSE) of cytologic material is widely performed because it provides clinicians with instant diagnostic information. However, the utility of ROSE of touch imprint cytology (ROSE-TIC) during transbronchial biopsy (TBB) remains unclear. The aim of this study was to evaluate the feasibility and accuracy of ROSE-TIC for TBB.

Methods

A retrospective study was performed on patients who underwent diagnostic bronchoscopy combined with ROSE-TIC. The results of ROSE-TIC, diagnosed as either positive or negative for malignancy, were compared with the histological findings and final diagnosis. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated. The success rate of molecular testing on TBB specimens was also assessed.

Results

Overall, 460 patients underwent bronchoscopy with ROSE-TIC. Of these, 377 cases (82.0%) were malignant and 83 cases (18.0%) were non-malignant in the final diagnosis. Compared with the histological findings, ROSE-TIC showed sensitivity, specificity, PPV, NPV, and diagnostic accuracy values of 91.1%, 90.4%, 94.8%, 84.0%, and 90.9%, respectively. Compared with the final diagnosis, ROSE-TIC showed sensitivity, specificity, PPV, NPV, and diagnostic accuracy values of 75.3%, 91.6%, 97.6%, 45.0%, and 78.3%, respectively. Seven discordant cases (1.5%) were positive on ROSE-TIC and negative on final diagnosis. The success rates for molecular analysis from TBB samples were 96.6% for EGFR mutation, 87.3% for ALK rearrangement, 93.1% for ROS1 rearrangement, and 96.2% for PD-L1 expression.

Conclusions

The accuracy of ROSE-TIC is high. It can be useful for obtaining instant diagnosis, contributing to a high success rate of molecular analysis for targeted therapy.

State of the Art: Toward Improving Outcomes of Lung and Liver Tumor Biopsies in Clinical Trials-A Multidisciplinary Approach

PURPOSE

National Cancer Institute (NCI)-sponsored clinical trial network studies frequently require biopsy specimens for pharmacodynamic and molecular biomarker analyses, including paired pre- and post-treatment samples. The purpose of this meeting of NCI-sponsored investigators was to identify local institutional standard procedures found to ensure quantitative and qualitative specimen adequacy.

METHODS

NCI convened a conference on best biopsy practices, focusing on the clinical research community. Topics discussed were (1) criteria for specimen adequacy in the personalized medicine era, (2) team-based approaches to ensure specimen adequacy and quality control, and (3) risk considerations relevant to academic and community practitioners and their patients.

RESULTS AND RECOMMENDATIONS

Key recommendations from the convened consensus panel included (1) establishment of infrastructure for multidisciplinary biopsy teams with a formalized information capture process, (2) maintenance of standard operating procedures with regular team review, (3) optimization of tissue collection and yield methodology, (4) incorporation of needle aspiration and other newer techniques, and (5) commitment of stakeholders to use of guideline documents to increase awareness of best biopsy practices, with the goal of universally improving tumor biopsy practices.

Rapid on-site cytologic evaluation by pulmonologist improved diagnostic accuracy of endobronchial ultrasound-guided transbronchial biopsy

BACKGROUND/PURPOSE

Rapid on-site cytologic evaluation (ROSE) has been shown to improve the diagnostic accuracy of endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB). However, ROSE by a cytopathologist or cytotechnologist is not always available during the procedure. The purposes of this study were to verify that a pulmonologist, after receiving training in cytology, could accurately assess an EBUS-TBB specimen on-site, and to evaluate the contribution of ROSE to EBUS-TBB.

METHODS

A retrospective chart review of patients who underwent EBUS-TBB for diagnosis of peripheral pulmonary lesions (PPLs) from January 2014 to June 2017 was performed. PPLs without a malignant diagnosis were excluded. The ROSE result determined by a pulmonologist was compared to the formal imprint cytologic report and pathologic report. The diagnostic accuracy of EBUS-TBB was also compared between those with and without ROSE.

RESULTS

Two hundred ninety-three patients who underwent 336 EBUS-TBB procedures for PPL diagnosis and were found to have proven malignancy were enrolled. Eighty-six procedures were performed with ROSE. With the formal imprint cytologic diagnosis as the standard, ROSE had 96.9% sensitivity, 68.2% specificity, 89.9% positive predictive value (PPV), 88.2% negative predictive value (NPV), and 89.5% diagnostic accuracy. With the formal pathologic result as the standard, ROSE had 88.2% sensitivity, 80% specificity, 97.1% PPV, 47.1% NPV, and 87.2% diagnostic accuracy, respectively. The diagnostic accuracy was significantly higher when ROSE was performed during EBUS-TBB (88.4% vs 68.0%, P < 0.001).

CONCLUSION

A trained pulmonologist can interpret adequately cytologic smears on-site and effectively improve the accuracy of EBUS-TBB in the diagnosis of PPLs.

Concordance Between Rapid On-Site Evaluation and Final Cytologic Diagnosis in Patients Undergoing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Non-Small Cell Lung Cancer Staging

OBJECTIVES

In patients with lung cancer undergoing mediastinal staging through endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), decisions are based on rapid on-site evaluation (ROSE) findings. We aimed to analyze the concordance rate between ROSE diagnosis and final diagnosis.

METHODS

A prospective study was carried out in patients undergoing EBUS-TBNA for lung cancer staging. Diagnosis concordance was defined as cases where lymph nodes (LNs) presented the same diagnosis in ROSE and final diagnosis. Determinants of concordance were analyzed.

RESULTS

Sixty-four patients were included and 637 LNs sampled. ROSE diagnosis was concordant with final diagnosis in 612 (96.1%) LNs and nonconcordant in 25 (3.9%). Differences in the concordance rate were found between pathologists, ROSE diagnoses, presence of cell block, number of passes, and number of slides. The staging status was changed between ROSE and the final diagnosis in three (4.6%) patients.

CONCLUSIONS

ROSE diagnosis has a high concordance with the final diagnosis.

Diagnostic value of rapid on-site evaluation during endobronchial ultrasound with a guide sheath for peripheral pulmonary lesions

OBJECTIVE

To evaluate the applied value of rapid on-site evaluation during endobronchial ultrasound (EBUS) with a guide sheath for peripheral pulmonary lesions (PPLs).

METHODS

Consecutive patients who underwent EBUS with a guide sheath for PPLs at our hospital from December 2015 to June 2017 in this retrospective study. The samples obtained from each operation were made rapid on-site evaluation at the same time. The results of rapid on-site evaluation were compared with the pathological diagnosis.

RESULTS

A total of 127 PPLs in 124 patients were included in the study. 70 lesions were malignancy in the final pathological diagnosis. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of rapid on-site evaluation for malignancy during EBUS with a guide sheath for PPLs was 88.6%, 98.2%, 98.4%, 87.5% and 92.9%, respectively.

CONCLUSIONS

Rapid on-site evaluation during EBUS with a guide sheath has a high diagnostic value for malignant PPLs.