Diagnosis and subtyping of de novo and relapsed mediastinal lymphomas by endobronchial ultrasound needle aspiration

Diagnostic Yield of Endobronchial Ultrasound-Guided Mediastinal Lymph Node Transbronchial Forceps Biopsies (EBUS-TBFB)

OBJECTIVE

The diagnostic accuracy and yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is not well established in lymphoma and other mediastinal-related diseases. The objective of this study was to examine the yield of a combined technique of EBUS-TBNA and endobronchial ultrasound-guided transbronchial forceps biopsies (EBUS-TBFB) compared with each modality alone in lymphoma and other mediastinal-related diseases.

METHODS

This was a retrospective review of cases of mediastinal lymphadenopathy of unknown etiology accessed using TBNA and TBFB. The McNemar test was used to compare the diagnostic yield of TBNA, TBFB, and the combined technique.

RESULTS

The combined approach yielded a definitive diagnosis in 31/35 cases (88.6%). In 9/10 cases (90%), Hodgkin's and non-Hodgkin's lymphomas were diagnosed and subtyped without further need for invasive testing. All of the granulomatous inflammation cases were confirmed using the combined technique. Two cases led to adequate whole-genome sequencing of lung cancer, and one patient was diagnosed as having dedifferentiated liposarcoma despite a nondiagnostic preprocedural mediastinoscopy. There was only one procedure-related complication, a pneumomediastinum that required no further intervention. There were no significant adverse events.

CONCLUSIONS

The combination of EBUS-TBFB and EBUS-TBNA is safe and provides a high yield in the diagnosis of mediastinal adenopathy of unknown etiology, especially lymphoma. Furthermore, the larger samples obtained from TBFB increased its sensitivity to detect granulomatous disease and provided specimens for clinical trials of malignancy when needle aspirates were insufficient.

[The role of endoscopy in exploration of the mediastinum, indications and results]

Since 2005, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a standard pulmonological tool. The procedure is safe and well tolerated by patients, with minimal morbidity and almost no mortality. A previous review on the technique was published in 2012. However, over the last ten years, a number of new studies have been published on "benign" (sarcoidosis, tuberculosis…) as well as "malignant" diseases (lung cancer, metastases of extra-thoracic cancers, search for mutations and specific oncogenic markers…). These developments have led to expanded indications for EBUS-TBNA, with which it is indispensable to be familiar, in terms of "staging" as well as "diagnosis". In view of optimizing lymph node sampling, several publications have described and discussed EBUS exploration by means of newly available tools (biopsy forceps, larger needles…), and proposed interpretation of the images thereby produced. Given the ongoing evolution of linear EBUS, it seemed indispensable that information on this marvelous tool be updated. This review is aimed at summarizing the novel elements we have found the most important.

Roles of circulating tumor DNA in PD-1/PD-L1 immune checkpoint Inhibitors: Current evidence and future directions

Circulating tumor DNA (ctDNA) sequencing holds considerable promise for early diagnosis and detection of surveillance and minimal residual disease. Blood ctDNA monitors specific cancers by detecting the alterations found in cancer cells, such as apoptosis and necrosis. Due to the short half-life, ctDNA reflects the actual burden of other treatments on tumors. In addition, ctDNA might be preferable to monitor tumor development and treatment compared with invasive tissue biopsy. ctDNA-based liquid biopsy brings remarkable strength to targeted therapy and precision medicine. Notably, multiple ctDNA analysis platforms have been broadly applied in clinical immunotherapy. Through targeted sequencing, early variations in ctDNA could predict response to immune checkpoint inhibitor (ICI). Several studies have demonstrated a correlation between ctDNA kinetics and anti-PD1 antibodies. The need for further research and development remains, although this biomarker holds significant prospects for early cancer detection. This review focuses on describing the basis of ctDNA and its current utilities in oncology and immunotherapy, either for clinical management or early detection, highlighting its advantages and inherent limitations.

Endobronchial Ultrasound-Guided Transbronchial Forceps Biopsy: A Retrospective Bicentric Study Using the Olympus 1.5 mm Mini-Forceps

When evaluating mediastinal/hilar lymphadenopathy (LAD) or masses, guidelines recommend endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) as an initial technique for tissue analysis and diagnosis. However, owing to the small sample size obtained by needle aspiration, its diagnostic yield (DY) is limited. EBUS transbronchial forceps biopsy (TBFB) used as a complimentary technique to EBUS-TBNA might allow for better histopathological evaluation, thus improving DY. In this retrospective bicentric study, we assessed the DY and safety of an EBUS-guided 1.5 mm mini-forceps biopsy combined with EBUS-TBNA for the diagnosis of mediastinal/hilar LAD or masses compared to EBUS-TBNA alone. In total, 105 patients were enrolled. The overall DY was 61.9% and 85.7% for TBNA alone and EBUS-TBNA combined with EBUS-TBFB, respectively (p < 0.001). While the combined approach was associated with a significantly higher DY for lung cancer diagnosis (97.1% vs. 76.5%, p = 0.016) and sarcoidosis (85.2% vs. 44.4%, p = 0.001), no significant differences in DY were calculated for subgroups with smaller sample sizes such as lymphoma. No major adverse events were observed. Using a 1.5 mm mini-forceps is a safe and feasible technique for biopsy of mediastinal or hilar LAD or masses with superior overall DY compared to EBUS-TBNA as a standalone technique.

Endobronchial Ultrasound Transbronchial Needle Aspiration With a 19-Gauge Needle vs 21- and 22-Gauge Needles for Mediastinal Lymphadenopathy

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used to evaluate mediastinal lymphadenopathy. Studies focusing on malignant lymphadenopathy have compared 21- and 22-gauge (21G and 22G, respectively) needles and have not identified an advantage of one needle size over the other in terms of diagnostic yield.

RESEARCH QUESTION

Does the 19-gauge (19G) EBUS needle offer greater diagnostic yield and sensitivity vs the 21G and 22G EBUS needles for a diagnosis of sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed?

STUDY DESIGN AND METHODS

This study retrospectively examined records of 730 patients from the Stather Canadian Outcomes Registry for Chest Procedures (SCOPE) database who underwent EBUS-TBNA for a diagnosis of suspected sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed. A propensity score analysis of two groups was performed. One group comprised patients undergoing EBUS-TBNA with a 19G needle, the other with a 21G or 22G needle. Cases for analysis were selected with a 1:2 ratio of 19G vs 21/22G using logistic regression and random matching with all eligible 19G cases included.

RESULTS

There were 137 patients (312 targets) in the 19G group and 274 patients (631 targets) in the 21/22G group in the propensity score analysis. The diagnostic yield was 107 of 137 (78.1%) in the 19G group vs 194 of 274 (70.8%) in the 21/22G group (difference, 7.3%; 95% CI, -1.9 to 15.6; P = .116). The sensitivity of EBUS-TBNA for sarcoidosis was 80 of 84 (95.2%) in the 19G group vs 150 of 156 (96.2%) in the 21/22G group (difference, 1.0%; 95% CI, -4.2 to 8.2; P = .71). In patients with a final diagnosis of lymphoma, EBUS was diagnostic in 10 of 13 (76.9%) in the 19G group vs 12 of 12 (100%) in the 21/22G group (difference, 23.1%; 95% CI, -5.4 to 50.3; P = .08).

INTERPRETATION

The study did not identify an advantage of the 19G EBUS needle over the 21/22G EBUS needles for diagnostic yield nor sensitivity for sarcoidosis or lymphoma.

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.

Role of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and classification of lymphomas

BACKGROUND

endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe and effective technique in the diagnosis of mediastinal and abdominal masses. However, the usefulness of EUS-FNA in the diagnosis and classification of lymphomas is controversial. The aim of this study was to determine the yield of EUS-FNA in the diagnosis and classification of lymphomas.

METHODS

a retrospective case series was performed in a tertiary referral center. All consecutive patients referred for EUS-FNA with a suspected diagnosis of lymphoma from March 2013 to June 2019 were included.

RESULTS

thirty-five patients (54.3 % women, median age 72 years) were included. The most frequent location of the node was the abdomen (67.9 %). Nodes were punctured using a 22-gauge (85.7 %) and 19-gauge needle (14.3 %) with a slow-pull technique. The number of passes performed were three or more in 82.9 % of patients. The samples were processed by the cellblock method. Adequate samples for immunohistochemical and molecular biological study were obtained in 33 (94.3 %) patients. EUS-FNA correctly diagnosed lymphoma in 30 out of 35 patients (85.7 %), and subclassification was determined in 23 patients (65.7 %). The most frequent diagnosis was non-Hodgkin lymphoma (85.7 %). There was one moderate adverse event (bleeding), which was resolved during the procedure.

CONCLUSIONS

EUS-FNA may be a valuable technique in the evaluation of suspected lymphomas with an adequate diagnostic yield and a very low rate of adverse events.

Endosonography-Guided Biopsy as a First Test in the Diagnosis of Lymphoma

To evaluate the diagnostic accuracy of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) and Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-FNA) in the diagnosis of lymphoma. A retrospective analysis of patients with suspected mediastinal lymphoproliferative disorders who underwent EBUS-TBNA, EUS-FNA or combined procedures from 2009 to 2019 was conducted using a prospectively maintained interventional thoracic endoscopy database. Demographic data, imaging, needle size, surgical biopsy, complications rate and pathology reports were reviewed. Over a 10-year period, a total of 444 patients were investigated with endosonography as the first diagnostic procedure for mediastinal adenopathy suspicious for lymphoma. Lymphoma was diagnosed in 77 patients (17.3%). In total, 68 patients (88.3%) were diagnosed using endosonographic mediastinal tissue sampling. Four patients had both lymphoproliferative disorders and lung cancer. Nine patients (11.7%) required a surgical biopsy to confirm the lymphoma diagnosis (6 non-diagnostic; 3 inadequate samples from endosonographic biopsies). In patients with adequate biopsies via endosonography, the sensitivity for the diagnosis of lymphoma, was 91.9% (n = 68/74). The histopathologic subtype of lymphoma was determined by endosonographic biopsies in 61 patients (89.7%) with an increased sensitivity (92.6%) for low grade Non-Hodgkin lymphoma (NHL). No acute complication related to endosonography was observed. Endosonographic biopsy (EBUS and/or EUS) of mediastinal adenopathy in patients with suspected lymphoma is a highly sensitive and safe diagnostic test. Endosonography should be the first test in the diagnosis of suspicious mediastinal lymphoma and should be followed by surgical biopsy in cases of insufficient sampling or indefinite diagnosis.

Respiratory cytology in malignant lung disease - The thoracic oncologist's perspective

Respiratory cytology continues to play a central role in the diagnosis and staging of thoracic malignancy, although over time indications have changed. Historically, sputum cytology and endobronchial brushings and washings figured prominently, but with the advent of endobronchial and endoscopic ultrasound much greater emphasis is placed on fine needle aspirates from lymph nodes. The advent of targeted sequencing panels for genomic profiling to identify driver mutations and PD-L1 directed immunotherapy means that there is a need to extract increasing amounts of diagnostic and predictive information from ever smaller amounts of diagnostic material. Recent work has demonstrated that cytology samples are well suited to delivering the information required, but in order to understand the limitations of clinical and laboratory techniques, a close working relationship between pathologist and thoracic oncologist is needed to optimise sample procurement and utilisation.

Mediastinal lymphadenopathy: a practical approach

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

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.

Recent Advances in Interventional Pulmonology

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

Diagnostic performance of 19-gauge endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in suspected lymphoma: A prospective cohort study

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) represents a minimally invasive approach in the evaluation of mediastinal/hilar lymphadenopathy. Diagnostic performance of EBUS-TBNA in lymphoma using standard 22-gauge (22G) needle is limited by sample volumes that are often inadequate for histopathological assessment.

OBJECTIVES

To evaluate the diagnostic utility of 19-gauge (19G) EBUS-TBNA needle in the evaluation of suspected lymphoma.

METHODS

We prospectively collected clinical and procedural information for patients undergoing EBUS-TBNA with 19G needle at Royal Melbourne Hospital for investigation of mediastinal/hilar lymphadenopathy, where lymphoma was considered in the differential diagnosis. All consecutive patients between June 15, 2016 and July 10, 2019 were included. If definitive diagnosis was not achieved on EBUS-TBNA, final diagnosis was determined through subsequent investigation or a minimum of 6 months radiologic surveillance.

RESULTS

Thirty-nine patients underwent EBUS-TBNA using 19G needle for evaluation of suspected lymphoma. Thirteen patients had a prior diagnosis of lymphoma (33%). Lymphoma was ultimately diagnosed in 23 patients (59%). Of these, 10 had a prior diagnosis of lymphoma (43%). 19G EBUS-TBNA demonstrated lymphoma in 19 patients, with a sensitivity of 83% (95% CI 66-93) for detection of lymphoma. Four patients required surgical biopsy to definitively characterise lymphoma subtype. Therefore, sensitivity of 19G EBUS-TBNA for definitive diagnosis of lymphoma was 65% (95% CI 45-81). In patients with a prior diagnosis of lymphoma, sensitivity for definitive diagnosis of lymphoma was 80% (95% CI 48-95).

CONCLUSION

Diagnostic performance of 19G EBUS-TBNA appears similar to standard 22G needle in detection and definitive diagnosis of lymphoma. Further invasive testing remains necessary following non-diagnostic EBUS-TBNA procedures.

[Lung involvement in hematologic systemic diseases]

Pulmonary diseases can occur across the entire disease spectrum of malignant hematologic systemic diseases. Although infectious processes of the lungs are common in these immunosuppressed patient collectives, noninfectious causes account for up to half of the pulmonary manifestations found in hematologic malignancies. Besides the frequent infections including opportunistic pathogens, a broad differential diagnosis including drug-induced lung injury by cytostatic substances, cytokines, and innovative immunotherapeutic agents, rarer transfusion of blood products and intrathoracic manifestations of the hematologic malignancy itself, have to be kept in mind. Finally, vascular complications can also lead to pulmonary reactions. Early and consistent diagnostics and treatment of the bronchopulmonary, intrathoracic and vascular complications within the framwework of hematologic systemic diseases can be essential for the patient's prognosis.

Endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB)-technical review

Endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) have changed the landscape of pulmonology. Mediastinal structures beyond the confines of airway walls are visualized in real-time with EBUS, leading to improved accuracy of tissue sampling and diagnostic yield. With the development of various needle sizes ranging from 25-G to 19-G, the sampling of lymph nodes is becoming easier and more commonplace. Yet, certain conditions such as sarcoidosis and lymphoma may still be difficult to diagnose via EBUS-TBNA. Furthermore, in the age of targeted therapy, there are more demands on EBUS-TBNA samples for molecular marker testing and next-generation sequencing. Here, we present a complementary methodology, EBUS-guided intranodal forceps biopsy (EBUS-IFB), for tissue acquisition that may help address these deficiencies. Specifically, we aim to propose indications, contraindications, outline approaches in performing IFB, and provide an overview of the data for this complementary technique.

A pragmatic application of endobronchial ultrasound-guided transbronchial needle aspiration: a single institution experience

Background

Endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is minimally invasive technique used for diagnosis and/or staging of benign and malignant pulmonary and non-pulmonary disease. Previous studies have established the utility of EBUS-TBNA in narrowly defined indications and populations. In this pragmatic ‘real world’ study we have analysed the use of EBUS-TBNA for a variety of clinical presentations and its clinical application in conjunction with other invasive investigations.

Methods

All EBUS-TBNA procedures performed at Sir Charles Gardiner Hospital in 2012–2014 were reviewed retrospectively, using relevant hospital databases.

Results

A total of 327 patients underwent 337 EBUS-TBNA procedures. EBUS-TBNA procedures were used to diagnose a wide spectrum of benign and malignant conditions. The main application was in the diagnosis and staging of malignant conditions (70.6%), and in the diagnosis of benign conditions such as sarcoidosis 40 (12.2%), and silicoanthracosis 17 (5.2%). EBUS-TBNA was sufficient to diagnose and stage the disease as a single stand-alone invasive procedure in 191 (59.2%) patients. EBUS-TBNA was the final invasive procedure undertaken in 283 (87.6%) patients. Only 13.3% of non small cell lung cancer (NSCLC) patients who had EBUS-TBNA as a first investigation required multiple procedures compared to 51.1% of all NSCLC patients undergoing EBUS-TBNA. Overall sensitivity, specificity, NPV and diagnostic accuracy for EBUS-TBNA were 89.7, 100, 85.1 and 89.9%, respectively and three minor complications (0.9%) occurred as a result of the procedure.

Conclusions

EBUS-TBNA was undertaken for a wide variety of clinical conditions. Good diagnostic accuracy and safety profiles were demonstrated for the procedure, supporting its application as a first line investigation in the diagnosis and/or staging of a range of malignant and benign conditions. Our study was unique in its documentation of the use of EBUS-TBNA in a real-world setting in conjunction with other invasive modalities. EBUS-TBNA was utilised as a stand alone invasive procedure in more than half of the patients. Importantly, in NSCLC, when EBUS-TBNA was performed as primary diagnostic and staging investigation, less patients underwent subsequent invasive procedures.

[Next Steps after Negative Results Obtained by EBUS-TBNA from Patients Suspected Clinically Lung Cancer with Mediastinal Lymphnode Metastasis]

背景与目的

超声气管镜针吸活检（endobronchial ultrasound guided tranbronchial needle aspiration, EBUS-TBNA）是肺癌诊断和分期的重要手段，但经活检阴性结果的患者后续处理尚无标准流程。本文通过分析来自单中心的临床疑诊肺癌纵隔淋巴结转移但EBUS-TBNA病理结果阴性患者，以探讨此类患者处理方式。

方法

对北京协和医院2010年9月-2016年12月进行EBUS-TBNA的1, 412例患者资料进行分析，选取临床疑诊肺癌纵隔淋巴结转移但EBUS-TBNA病理诊断阴性的患者51例进行回顾性分析。

结果

入选51例患者按临床情况和后续处理方式分为以下5组：①经同一次气管镜下其他检查组（9例）：该组患者大多（8例）存在镜下异常表现，通过活检、毛刷、灌洗或经支气管镜肺活检（transbronchial lung biopsy, TBLB）取得明确诊断；②再次EBUS-TBNA组（11例）：该组患者气管粘膜及管腔大致正常，再次行EBUS-TBNA取得诊断；③手术治疗组（6例）：该组患者因EBUS结果除外纵隔淋巴结转移，接受手术治疗。其中5例术后确诊无淋巴结转移癌；④进行其他病理检查组（15例）：该组患者有其他部位转移，针对可能的转移灶进行计算机断层扫描（computed tomography, CT）引导下穿刺、淋巴结活检等确诊。⑤随访组（10例）：该组患者未进行其他有创检查，中位随访时间38个月，其中1例随访中诊断为淋巴瘤。

结论

对于经EBUS-TBNA未能确定诊断而临床怀疑肺癌的患者，应该根据患者的具体情况，综合多种方式进行诊断。对于暂时无法确诊的患者，仍需要长期随访。

A novel, stepwise approach combining conventional and endobronchial ultrasound needle aspiration for mediastinal lymph node sampling

Background and Objectives:

Since the introduction of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), most pulmonary centers use this technique exclusively for mediastinal lymph node (LN) sampling. Conventional “blind” TBNA (cTBNA), however, is cheaper, more accessible, provides more tissue, and requires less training. We evaluated whether sampling of mediastinal LN using EBUS-TBNA or cTBNA according to a predefined set of criteria provides acceptable diagnostic yield.

Materials and Methods:

Sampling method was determined prospectively according to a predefined set of criteria based on LN station, LN size, and presumed diagnosis. Sensitivity, specificity, positive, and negative predictive value were evaluated for each modality.

Results:

One hundred and eighty-six biopsies were carried out over a 3-year period (86 cTBNA, 100 EBUS-TBNA). Seventy-seven percent of LN biopsied by EBUS-TBNA were <20 mm, while 83% of cTBNA biopsies were ≥20 mm. Most common sites of cTBNA sampling were station 7, 4R, and 11R as opposed to 7, 11R, 4R, and 4 L in the case of EBUS-TBNA. Most common EBUS-TBNA diagnosis was malignancy versus sarcoidosis in cTBNA. EBUS-TBNA and cTBNA both had a true positive yield of 65%, but EBUS-TBNA had a higher true negative rate (21% vs. 2% for cTBNA) and a lower false negative rate (7% vs. 28%). Sensitivity, specificity, positive predictive value, and negative predictive value for EBUS-TBNA were 90%, 100%, 100%, and 75%, respectively, and for cTBNA were 68%, 100%, 100%, and 7%, respectively.

Conclusion:

A stepwise approach based on LN size, station, and presumed diagnosis may be a reasonable, cost-effective approach in choosing between cTBNA and EBUS-TBNA.

Endobronchial ultrasound-guided transbronchial needle aspiration cytology in patients with known or suspected extra-pulmonary malignancies: A cytopathology-based study

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the primary modality for mediastinal lymph node staging in lung carcinoma. We aimed to evaluate its utility in extra-pulmonary malignancies (EPM).

METHODS

Database search of EBUS-TBNA aspirations (2013-2017) done in patients with known/suspected EPMs and mediastinal lymphadenopathy/masses was performed. All archived cytology/histology material was reviewed and categorised as positive, negative and unsatisfactory.

RESULTS

The selected 139 patients included 100 patients with known EPMs, 11 patients with known lymphoma, and 28 patients with suspected EPM of unknown primary. EBUS-TBNA was adequate in 110 patients (79%), including 21 patients who yielded only reactive lymphoid tissue. Satisfactory blood clot cores were obtained in 34 patients and contributed significantly to diagnosis and ancillary testing. Metastasis was detected in 45 patients with known EPM, predominantly originating from a known primary in the breast in females (56%) and squamous cell carcinomas of head and neck in males (60%). Granulomatous lymphadenopathy was identified in 16 patients with known EPM (16%). Lymphoma relapse and granulomatous lymphadenopathy were identified in three and four patients with known lymphoma, respectively. In patients with suspected EPM of unknown primary site, malignancy was confirmed in 21 patients, predominantly representing metastatic adenocarcinomas (n = 5) and neuroendocrine neoplasms (n = 5). Immunocytochemistry was performed in 16 of these cases and aided in characterisation of primary site/type of tumour in 12 cases.

CONCLUSION

EBUS-TBNA is efficient for screening mediastinal lymph nodes/masses for malignancy in EPMs. Procuring sufficient material for ancillary testing would improve diagnostic accuracy and reduce need for resampling.

Sampling Utility of the Convex Probe Endobronchial Ultrasound Visible Intrapulmonary Lesion

BACKGROUND

The value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the mediastinal staging of lung cancer has been well established. However, data regarding its utility in the diagnosis of intrapulmonary lesions has been sparse. This study assesses the sampling utility of convex probe EBUS-visible intrapulmonary lesions not visualized by the white-light bronchoscopy.

METHODS

A retrospective analysis of EBUS-TBNA of EBUS-visible intrapulmonary lesions was performed between January 2010 and March 2015. Patients with visible endobronchial lesions by white-light bronchoscopy were excluded from analysis.

RESULTS

Among 108 procedures, the diagnostic yield of EBUS-TBNA for EBUS-visible intrapulmonary lesions was 87%. Following diagnoses were established: lung cancer (73/67.6%), lung metastases (10/9.2%), infection (5/4.6%), lymphoma (1/<1%), sarcoma/spindle cell sarcoma or neoplasm (3/2.8%), unspecified malignancy (1<1%), and hamartoma (1/<1%). EBUS-TBNA was nondiagnostic in 14 (13%); among these, 9 turned out to have benign disease based on additional bronchoscopy samples or other testing and/or follow-up imaging. Five were ultimately diagnosed with a malignant condition: lymphoma (1), epithelioid hemangioendothelioma (1), and non-small cell lung cancer (3). The sensitivity and the negative predicted value of EBUS-TBNA for differentiating malignancy from benign disease was 94.7% and 75%, respectively, while the accuracy for diagnosing the neoplastic disease was 95.3%. There was one major bleeding requiring bronchial artery embolization and 1 pneumothorax requiring chest tube drainage.

CONCLUSION

EBUS-TBNA is safe and effective in the diagnosis of EBUS-visible intrapulmonary lesions. It should be considered as the diagnostic test of choice in patients with these lesions undergoing EBUS-TBNA for the staging of suspected lung cancer.

Endobronchial Ultrasound Transbronchial Needle Aspiration for the Diagnosis of Lymphoma

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) presents a minimally invasive way to evaluate abnormal mediastinal and hilar adenopathy. Although EBUS has been established as an effective modality to diagnose lung cancer, its sensitivity for the diagnosis of lymphoma has been demonstrated to be lower. Because of these lower yields uncertainty persists about the ability of EBUS-TBNA to reliably diagnose lymphoma and questions remain regarding the utility of EBUS-TBNA as a first-line biopsy modality for patients suspected of having lymphoma.

METHODS

We conducted a review of our database (n=806 EBUS-TBNAs) for patients undergoing EBUS-TBNA for mediastinal and/or hilar lymphadenopathy over an 8-year span to identify patients diagnosed with lymphoma.

RESULTS

Twenty patients (2.3%) who underwent EBUS-TBNA were ultimately diagnosed with lymphoma. In total, 17 of the 20 patients with lymphoma obtained a diagnosis using EBUS-TBNA. The overall sensitivity of EBUS-TBNA for lymphoma was 85%. The sensitivity for de novo diagnosis was 78% (7/9), and sensitivity for recurrence was 91% (10/11). All patients who achieved a diagnosis by EBUS-TBNA could be adequately subtyped, allowing treatment recommendations.

CONCLUSION

Although the sensitivity of EBUS-TBNA for the diagnosis of lymphoma did not reach values of published data for non-small cell lung cancer, EBUS-TBNA can be considered as a first-line diagnostic tool for patients with mediastinal and/or hilar lymphadenopathy suspected to be lymphoma. Because of the inherent limitations in small volume needle biopsies it is essential that negative samples obtained in the setting of high clinical suspicion warrant further evaluation.

[Endobronchial ultrasound with transbronchial needle aspiration: Evaluation of clinical practice]

INTRODUCTION

Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has undergone a large increase in France since 2007. The aim is to study the evolution of the indications for EBUS-TBNA in our region during the period 2008-2013.

MATERIAL AND METHODS

We conducted a retrospective observational study including all the patients who underwent an EBUS-TBNA procedure in Picardie from 2008 to 2013. The respective proportion for each indication was noted.

RESULTS

During the study period, 1036 EBUS-TBNA procedures were performed with a continuous increase in number (86 in 2008 versus 275 in 2013). We observed an increase in the proportion of procedures performed for a suspected diagnosis of sarcoidosis (OR=1.31; IC 95% [1.09-1.58]; P=0.005) and for the simultaneous diagnosis and staging of lung cancer (OR=1.12; IC 95% [1.02-1.24]; P=0.022). For the diagnosis of sarcoidosis, we observed an improvement in the diagnostic yield between the periods [2008-2010] and [2011-2013] (42.9% versus 72.5%).

CONCLUSION

A continuous increase in the number of EBUS-TBNA procedures was observed during the period 2008-2013. It was associated with a modification in practice with an increased proportion of procedures performed for the diagnosis of sarcoidosis.

Performance of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Isolated Mediastinal and Hilar Lymphadenopathy

BACKGROUND

Although many studies have assessed the diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the context of a specific disease, few studies have assessed the overall diagnostic yield, sensitivity, and negative predictive value in patients with isolated mediastinal and hilar lymphadenopathy (IMHL).

OBJECTIVE

We evaluated the performance of EBUS-TBNA for diagnosing IMHL in a population with a high prevalence of concurrent or preexisting non-pulmonary malignancy.

METHODS

A retrospective chart review of patients who underwent EBUS-TBNA from October 2008 to April 2014 was performed to identify patients with IMHL. Patients with known or suspected primary pulmonary malignancy were excluded. When available, EBUS-TBNA results were cross-referenced with further diagnostic investigation or clinical diagnosis based on follow-up.

RESULTS

EBUS-TBNA was used to sample 765 lymph nodes from 350 patients. One hundred and fourteen (33.3%) patients had a concurrent or preexisting non-pulmonary malignancy. The overall yield of EBUS-TBNA for specific diagnosis was 300/350 (86%). The diagnostic yield for sarcoidosis, lymphoproliferative disease, metastatic lymphadenopathy from extrathoracic malignancy, and necrotizing granuloma was 123/149 (83%), 27/33 (82%), 20/25 (80%), and 13/19 (68%), respectively. Amongst 50 patients with non-diagnostic EBUS-TBNA, 25 yielded an insufficient sample and another 25 yielded only benign lymphoid material which was not representative of the underlying pathology. Overall, EBUS-TBNA had a sensitivity of 89%, a diagnostic yield of 86%, and a negative predictive value of 79%.

CONCLUSION

For patients with isolated hilar or mediastinal lymphadenopathy and a high background prevalence of concurrent and preexisting non-pulmonary malignancy, EBUS-TBNA is a reliable first-line diagnostic investigation.

Interstitial lung disease: the diagnostic role of bronchoscopy

Interstitial lung diseases (ILDs) form one of the most fascinating fields in pulmonary medicine. They also pose one of the greatest challenges for accurate diagnosis and proper treatment. Even within the recommended and warranted multidisciplinary approach, differentiating between one disease and another may lead to frustration, especially when proper lung tissue is not available for adequate pathological review. A surgical lung biopsy (SLB) might render enough tissue for histopathology, but this could come at the expense of high morbidity and even mortality, as in the case of usual interstitial pneumonia (UIP). Could bronchoscopy and its various techniques offer a safer and higher yield alternative? Since the very late 19th century, efforts have been made to better examine the airways, obtain tissue and treat various conditions. This resulted in the successive emergence of bronchoalveolar lavage (BAL), endobronchial and transbronchial forceps biopsies, until recently when transbronchial cryobiopsy surfaced as a nascent technique with much promise. The use of endobronchial ultrasound revolutionized the diagnosis and staging of lung cancer, while adding to the yield of other conditions such as sarcoidosis. Ongoing research, efforts and studies have continuously scrutinized the roles of various techniques in the approach to ILDs. For example, BAL seems to serve mostly to eliminate infection as an etiology or a complicating factor in the acute worsening of a fibrotic lung disease, while a predominant cellular component might be diagnostic, such as eosinophilia in eosinophilic lung disease, or lymphocytosis in hypersensitivity pneumonitis (HP). On the other hand, endobronchial biopsy's (EBB) role appears limited to sarcoidosis. As for transbronchial biopsy by forceps, the small sample size and related artifact appear to be limiting factors in making an accurate diagnosis. Recently, however, the use of cryotherapy via employing a cryoprobe in obtaining transbronchial lung biopsies is unfolding into a refined interventional method which might transform indefinitely our approach to the pathological diagnosis of the various ILDs.

Diagnosing Hodgkin Lymphoma From an Endobronchial Ultrasound Core Needle Biopsy

Hodgkin lymphoma (HL) commonly presents as isolated mediastinal adenopathy. Although there is evidence to support minimally invasive techniques such as endobronchial ultrasound (EBUS) fine-needle aspiration as the initial diagnostic test for suspected lymphoma involving the mediastinum, it consistently performs the poorest at definitively diagnosing HL for a variety of reasons, and therefore histology specimens are usually required. We present a case of HL presenting as isolated mediastinal adenopathy that was definitively diagnosed on EBUS using a 22 G coring needle in which cellular and histologic specimens were obtained, allowing the core biopsy to be fixed in formalin and treated as a surgical specimen. The patient started treatment soon after the procedure without requiring any further invasive tests. Although it seems intuitive that a coring EBUS needle would be advantageous in diseases such as HL, further studies are needed before definitive recommendations can be made.

Understanding local performance data for EBUS-TBNA: insights from an unselected case series at a high volume UK center

BACKGROUND

We reviewed the diagnostic performance of endobronchial ultrasound transbronchial aspiration (EBUS-TBNA) on an unselected large cohort of patients who underwent the procedure in our institution in the past 3 years and to compare against published standards and existing literature.

METHODS

All consecutive patients who underwent EBUS from January 2013 to December 2015 were included in the retrospective analysis, with a minimum of 6 months of clinico-radiological follow up. For assessing EBUS-TBNA performance, patients were analysed in three subgroups based on the indication for the EBUS-TBNA: in investigation of isolated mediastinal and/or hilar lymphadenopathy (IMHL), in staging of suspected or confirmed non-small cell lung cancer (NSCLC) and in making a tissue diagnosis in suspected thoracic or extrathoracic cancer. For patients subjected to EBUS-TBNA for staging in suspected lung cancer, accuracy of EBUS was measured by its ability to determine the true N2 stage.

RESULTS

A total of 1,656 lymph nodes and 138 peribronchial/peritracheal masses were sampled in 940 patients over the study period. The prevalence of reactive lymphadenopathy was 34%. The overall sensitivity to detect pathological disease was 81.6% (95% CI: 74.2-87.6%) whilst NPV was 74.8% (95% CI: 65.2-82.8%). Amongst patients who underwent EBUS-TBNA for staging purposes, the sensitivity for N2 staging was 83.7% (95% CI: 76.2-89.6%) and NPV was 81.6% (95% CI: 73.2-88.2%). The prevalence of N2 disease was 58%. In the subgroup of patients who proceeded to surgical sampling, the sensitivity was higher with the N2/N3 disease prevalence of 67.4%. The sensitivity of EBUS-TBNA to make a tissue diagnosis of thoracic or extrathoracic cancer was 88% (95% CI: 85.1-90.5%) and a NPV of 62% (95% CI: 54.7-69.0%). The disease prevalence was 83.6%.

CONCLUSIONS

This retrospective study of a large volume of patients represents real life practice and provides an accurate representation of the typical cohort of patients referred in for EBUS-TBNA to the general respiratory physician in UK. Our study highlights the pitfalls in collecting and analyzing data but also demonstrates how they can be used to improve service performance.

FNA diagnosis of deep-seated lymphoma: an institutional experience

INTRODUCTION

Controversy remains as to whether image-guided fine-needle aspiration (FNA) biopsy coupled with appropriate ancillary techniques has clinical utility in the diagnosis of deep-seated lymphomas.

MATERIALS AND METHODS

A retrospective search (20 years) was performed to identify FNA cases with a definitive or indeterminate lymphoma diagnosis for deep-seated locations. The FNA diagnosis was compared with corresponding surgical pathology (SP) and clinical follow-up. The application of ancillary tests was also evaluated.

RESULTS

A total of 121 cases from 118 patients were recovered. Among 95 of 121 (79%) aspirates that had a definitive lymphoma diagnosis, 50 lacked SP follow-up. Most (82%) represented possible recurrent lymphoma, and thus therapy proceeded based on the FNA results alone. Additionally, 44 of 95 (46%) had an FNA diagnosis concordant with corresponding SP and 1 case was discordant. Of 44 with concordant SP diagnosis, 25 had further lymphoma subtyping that was concordant with SP. There were 26 of 121 (21%) with indeterminate diagnosis on FNAs. Of these, SP confirmed a diagnosis of lymphoma in 81%. Indeterminate cytologic diagnoses were due either to absent/inconclusive flow cytometry (FC) (11 of 21) or Hodgkin lymphoma (10 of 21). Of 121 cases, 93 utilized FC, 53 utilized cell-block immunohistochemical stains, and 29 utilized molecular testing as part of FNA work-up.

CONCLUSIONS

FNA plays an important role in the diagnosis/clinical management of deep-seated non-Hodgkin B cell lymphoma (NHL), particularly for recurrence. The addition of ancillary techniques, particularly FC, markedly increases NHL diagnostic accuracy and subclassification. Our study is one of the few large series examining the clinical utility of FNA in the setting of deep-seated lymphomas.

Diagnostic yield of EBUS-TBNA for lymphoma and review of the literature

Aim:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which enables cytological examination of mediastinal lymph node (LN) aspiration samples, is a safe and minimally invasive method for diagnosis and staging of lung cancer and diagnosis of diseases affecting mediastinal LNs. In this study, we investigated the yield of EBUS-TBNA for diagnosis of lymphoma and reviewed the literature since the British Thoracic Society (BTS) guidelines were published.

Materials and Methods:

We retrospectively evaluated our database for patients who underwent EBUS between March 2011 and December 2014. One hundred eighty-nine patients with isolated mediastinal lymphadenopathy were included in the study. Patients with other causes of lymphadenopathy, such as lung cancer or extrathoracic malignancy, and those with pulmonary lesions accompanying mediastinal lymphadenopathy were excluded from the study. Patients with final diagnosed lymphoma were included in the study on the basis of a history of lymphoma or newly evaluated mediastinal lymphadenopathy. The sensitivity and negative predictive value (NPV) of EBUS-TBNA were calculated.

Results:

There were 13 patients with the final diagnosis of lymphoma. Eleven of them were new diagnoses and 2 patients were known chronic lymphocytic leukemia (CLL), and underwent EBUS-TBNA for determination of recurrence. Twelve EBUS-TBNA procedures were performed for suspected new cases. Three (25%) were diagnostic, 2 (16.7%) were suspicious for lymphoma and underwent further interventions for definite diagnosis, and 7 (58.3%) were false negative. All 3 patients diagnosed with EBUS-TBNA were non-Hodgkin lymphoma (NHL). None of the Hodgkin lymphoma (HL) cases could be diagnosed with EBUS-TBNA. The overall diagnostic sensitivity and NPV of EBUS-TBNA in detecting lymphoma was 65% and 96.1%, respectively. For the newly diagnosed lymphoma cases, EBUS-TBNA had a sensitivity of 61.1%.

Conclusion:

In conclusion, we believe that since the publication of the BTS guidelines, the value of EBUS-TBNA in the diagnosis of lymphoma still remains controversial. EBUS-TBNA can be the first diagnostic modality in diagnosis of recurrent lymphomas. However, for suspected new cases, especially for HL, the diagnostic yield of EBUS-TBNA is low and negative results do not exclude lymphoma. Further interventions such as mediastinoscopy should be performed for high-suspicion patients.

Recent advances in diagnostic bronchoscopy

The field of diagnostic bronchoscopy has been revolutionized in the last decade primarily with the advent of endobronchial ultrasound (EBUS) but also with the addition of multiple different techniques for "guided-bronchoscopy". These advances have had a substantial impact in the management of lung cancer with bronchoscopy now providing both diagnosis and mediastinal staging in a single procedure. EBUS has, in fact, become the first choice for staging of the mediastinum over cervical mediastinoscopy (CM). Although EBUS is now a well-established technique, there are continuous efforts from the scientific community to improve its diagnostic performance, and these will be reviewed in this manuscript. The term "guided-bronchoscopy" was recently coined to describe a myriad of techniques that guide our bronchoscopes or bronchoscopic tools into the periphery of the lungs in addition to our conventional fluoroscopy. Electromagnetic and non-electromagnetic navigation, thin and ultrathin scopes, as well as radial-probe EBUS have collectively increased our yield for smaller peripheral lung lesions and continue to evolve. Despite this improved diagnostic yield, there is still ample room for improvement and newer techniques are under way. With new therapies available for patients with interstitial lung disease, achieving a specific histologic diagnosis is now of paramount importance. Given the high morbidity and mortality of surgical biopsies, bronchoscopic cryobiopsy is being rapidly adopted as a safer and effective alternative, and it is likely going to play a major role in the management of these diseases in the near future. This manuscript we will focus on recent advances in EBUS, guided-bronchoscopy, and the use of cryobiopsy.

The role of bronchoscopy in the diagnosis of airway disease

Endoscopy of the airway is a valuable tool for the evaluation and management of airway disease. It can be used to evaluate many different bronchopulmonary diseases including airway foreign bodies, tumors, infectious and inflammatory conditions, airway stenosis, and bronchopulmonary hemorrhage. Traditionally, options for evaluation were limited to flexible and rigid bronchoscopy. Recently, more sophisticated technology has led to the development of endobronchial ultrasound (EBUS) and electromagnetic navigational bronchoscopy (ENB). These technological advances, combined with increasing provider experience have resulted in a higher diagnostic yield with endoscopic biopsies. This review will focus on the role of bronchoscopy, including EBUS, ENB, and rigid bronchoscopy in the diagnosis of bronchopulmonary diseases. In addition, it will cover the anesthetic considerations, equipment, diagnostic yield, and potential complications.

Invasive diagnostic techniques in idiopathic interstitial pneumonias

Fibrosing interstitial lung diseases (f-ILDs) represent a heterogeneous group of disorders in which the aetiology may be identified or, not infrequently, remain unknown. Establishing a correct diagnosis of a distinct f-ILD requires a multidisciplinary approach, integrating clinical profile, physiological and laboratory data, radiological appearance and, when appropriate, histological findings. Surgical lung biopsy is still considered the most important diagnostic tool as it is able to provide lung samples large enough for identification of complex patterns such as usual interstitial pneumonitis (UIP) and nonspecific interstitial pneumonitis. However, this procedure is accompanied by significant morbidity and mortality. Bronchoalveolar lavage is still a popular diagnostic tool allowing identification of alternative diagnoses in patients with suspected idiopathic pulmonary fibrosis (IPF) when an increase in lymphocytes is detected. Conventional transbronchial lung biopsy has a very low sensitivity in detecting the UIP pattern and its role in this clinical-radiological context is marginal. The introduction of less invasive methods such as transbronchial cryobiopsy show great promise to clinical practice as they can be used to obtain samples large enough to morphologically support a diagnosis of IPF or other idiopathic interstitial pneumonias, along with fewer complications. Recent advances in the field suggest that less invasive methods of lung sampling, without significant side effects, in combination with other diagnostic methods could replace the need for surgical lung biopsy in the future. Indeed, these new multidisciplinary procedures may become the main diagnostic work-up method for patients with suspected idiopathic interstitial pneumonia.

Endoscopic/Endobronchial Ultrasound-Guided Fine Needle Aspiration and Ancillary Techniques, Particularly Flow Cytometry, in Diagnosing Deep-Seated Lymphomas

Evaluation of deep-seated lymphomas by fine-needle aspiration (FNA) can be challenging due to their reduced accessibility. Controversy remains as to whether FNA and ancillary techniques can be used to diagnose deep-seated lymphomas reliably and sufficiently for clinical management. Most published studies are favorable that endobronchial ultrasound (EBUS)/endoscopic ultrasound (EUS)-FNA plays an important role in the diagnosis of deep-seated lymphomas. The addition of ancillary techniques, particularly flow cytometry, increases diagnostic yield. While subclassification is possible in a reasonable proportion of cases, the reported rates of successful subclassification are lower than those for lymphoma detection/diagnosis. The diagnostic limitation exists for Hodgkin's lymphoma, grading of follicular lymphoma, and some T-cell lymphomas. The role of FNA in deep-seated lymphomas is much better established for recurrent than primary disease. It remains unclear whether the use of large-sized-needle FNA or a combination of core needle biopsy and FNA improves subclassification. It is important for cytopathologists to have considerable understanding of the WHO lymphoma classification and develop a collaborative working relationship with hematopathologists and oncologists. As EUS/EBUS-FNA techniques advance and sophisticated molecular techniques such as next- generation sequencing become possible, the role of FNA in the diagnosis of deep-seated lymphomas will possibly increase.

Recent advances in endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality for sampling of mediastinal and hilar lymph nodes as well as pulmonary lesions adjacent to the airway. Guidelines for staging of lung cancer suggest that EBUS-TBNA should be considered the best first test of nodal staging for radiologically abnormal lymph nodes that are accessible by this approach. The application of EBUS-TBNA in pulmonary medicine and thoracic oncology is expanding with its role in the diagnosis of sarcoidosis, lymphoma, and tuberculosis. Especially for patients with early-stage sarcoidosis with adenopathy and minimal changes in the lung parenchyma, EBUS-TBNA has a significantly higher diagnostic yield compared to the conventional bronchoscopic modalities. Multidirectional analysis of samples obtained by EBUS-TBNA has allowed assessment of lymphoma and molecular analysis in lung cancer. Histological evaluation with immunohistochemistry, flow cytometry, fluorescence in situ hybridization, and chromosome analysis can be performed if good-quality samples can be obtained. Molecular analyses such as identification of epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) fusion gene detection now are being performed routinely with good sampling. One of the advantages of EBUS-TBNA is the ability to perform repeat procedures in a minimally invasive way. Restaging of the mediastinum after induction therapy can be done safely and with ease compared to repeat surgical procedures. With improvement in molecular analysis technology, comprehensive gene expression analysis will become important in the management of patients with lung cancer. Further advances in EBUS technology and needles for tissue sampling likely will help bronchoscopists to acquire ideal tissue.

[Endobronchial ultrasonography (EBUS) for the internist]

Endobronchial ultrasonography (EBUS) is a recent mini-invasive technique allowing transbronchial needle aspiration (TBNA) of mediastinal lymph nodes as well as peribronchial lesions. EBUS was initially developed for lung cancer mediastinal staging. Over the years, indications for EBUS have been progressively extended to the scope of inflammatory disorders, mediastinal lymphomas, and infectious diseases. Particularly in immunosuppressed patients, including HIV-infected patients, EBUS allows the diagnosis of several diseases that involve the mediastinum, avoiding invasive surgical explorations such as mediastinoscopy or thoracoscopy. This review aims at discussing the technical aspects, and specifies indications, results, and limits of EBUS for the internist.

Diagnosis of mediastinal lesions unassociated with lung carcinoma diagnosed by endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)

INTRODUCTION

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a safe, cost-effective, and accurate diagnostic modality for the lung/mediastinum. Although some studies have been published on EBUS-TBNA of isolated mediastinal lesions, none have been reported from the United States. This study examines EBUS-TBNA for diagnosis of isolated mediastinal lesions.

MATERIALS AND METHODS

All cases of mediastinal EBUS-TBNA (defined in radioanatomic terms) during a 7-year period (July 2007-September 2014) were obtained from the anatomic pathology database. Pathologic reports, clinical notes, bronchoscopy notes, and imaging studies were reviewed. Only patients with a mediastinal lesion or non-pulmonary parenchyma-based lesions sampled by EBUS-TBNA without a prior or synchronous lung carcinoma were included in this study.

RESULTS

Of the 3005 EBUS-TBNA cases accessioned during this time period at our institute, 47 fulfilled the inclusion criteria. The median patient age was 61 years (range: 27-84 years). Both genders were nearly equally represented. A definitive cytologic interpretation was rendered in 40 out of 47 cases (85.1%). Malignancies included non-pulmonary carcinomas (8), sarcomas (5), hematolymphoid malignancies (5), neuroendocrine neoplasm (1), melanoma (1), and undifferentiated malignancy (1). Surgical follow-up was available in 18 of 47 cases (38.3%). There was cytologic-histologic correlation in 16 of 18 cases (88.9%). Surgical follow-up of all cysts diagnosed by cytology were benign cysts. Over the 7-year period, an increasing proportion of all EBUS-TBNAs performed were for mediastinal lesions unassociated with lung carcinoma.

CONCLUSIONS

EBUS-TBNA has a high accuracy rate when used to diagnose mediastinal lesions unassociated with lung carcinoma. Its utility as a primary diagnostic modality in this setting needs to be explored further.

The utility of endobronchial ultrasound-transbronchial needle aspiration in lymphoma

BACKGROUND AND OBJECTIVES

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has a well-established role in the diagnosis and staging of lung cancer. This technology is also widely used for the diagnosis of mediastinal masses and cysts as well as other inflammatory disorders such as sarcoidosis. However, the utility of this procedure in the diagnosis and subclassification of lymphoproliferative disorders (LPDs) is not clear. We performed a systematic review to evaluate EBUS-TBNA use in LPDs.

MATERIALS AND METHODS

PubMed, EMBASE, MEDLINE, Cochrane Library Plus, and ISI Web of Knowledge were searched for studies of clinical trials in English reporting diagnostic performance of EBUS-TBNA in lymphoma until September 2014. The overall sensitivity, negative predictive value (NPV), and diagnostic accuracy were evaluated.

RESULTS

Six trials involving 346 patients with suspected lymphoma were included. The overall sensitivity, NPV, and diagnostic accuracy ranged 38%-91%, 83%-96.4%, and 91%-97%, respectively. Further invasive surgery was needed only in 13-43% of the patients. None of the studies included in the present review reported important complications.

CONCLUSION

Current evidence suggests that EBUS-TBNA can be used as an initial evaluation for patients with suspected lymphoma. Additional surgical procedures may be necessary if a sample is inadequate or negative with high suspicion of lymphoma. Further multicenter trials are needed to evaluate the diagnostic yield of EBUS-TBNA in lymphoma patients.

[Endobronchial ultrasound transbronchial needle aspiration initiation into the Lyon Sud hospital center: Experience of the first three years]

INTRODUCTION

Endobronchial ultrasound is a recent technique for the diagnosis and the lymph node staging in lung cancer. It also showed interest in non tumoral mediastinal lymph nodes diagnosis. This work relates the CHLS first three years' experience in terms of EEB practical use as a new diagnostic tool in this field.

METHODS

Retrospective study of consecutive cases patients having undergone endobronchial ultrasound from November 2008 till June 2011 in the CHLS.

RESULTS

On 65 endobronchial ultrasound, general anesthesia was practiced in 89 % of the cases, with a good tolerance in 81 % of the cases. In 77 % cases, EEB allowed diagnosis and avoided mediastinoscopy in 60.5 % of the cases. The respective sensibility, specificity, positive and negative predictive values were 74 %, 100 %, 100 % and 48 %.

CONCLUSION

These data, reflect of a novice team experience, illustrate the results obtained in the current practice in terms of etiologic diagnosis. Endobronchial ultrasound seems destined to a bright future but requires the development of dedicated centers allowing pulmonologists training and specialized pathologists in this field.

Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report

BACKGROUND

Endobronchial ultrasound (EBUS) was introduced in the last decade, enabling real-time guidance of transbronchial needle aspiration (TBNA) of mediastinal and hilar structures and parabronchial lung masses. The many publications produced about EBUS-TBNA have led to a better understanding of the performance characteristics of this procedure. The goal of this document was to examine the current literature on the technical aspects of EBUS-TBNA as they relate to patient, technology, and proceduralist factors to provide evidence-based and expert guidance to clinicians.

METHODS

Rigorous methodology has been applied to provide a trustworthy evidence-based guideline and expert panel report. A group of approved panelists developed key clinical questions by using the PICO (population, intervention, comparator, and outcome) format that addressed specific topics on the technical aspects of EBUS-TBNA. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and well-recognized document evaluation tools were used to assess the quality of included studies, to extract meaningful data, and to grade the level of evidence to support each recommendation or suggestion.

RESULTS

Our systematic review and critical analysis of the literature on 15 PICO questions related to the technical aspects of EBUS-TBNA resulted in 12 statements: 7 evidence-based graded recommendations and 5 ungraded consensus-based statements. Three questions did not have sufficient evidence to generate a statement.

CONCLUSIONS

Evidence on the technical aspects of EBUS-TBNA varies in strength but is satisfactory in certain areas to guide clinicians on the best conditions to perform EBUS-guided tissue sampling. Additional research is needed to enhance our knowledge regarding the optimal performance of this effective procedure.

Endobronchial ultrasound-guided transbronchial needle aspiration is useful as an initial procedure for the diagnosis of lymphoma

BACKGROUND

The usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for evaluating hilar, mediastinal and central parenchymal lesions has been well established. However, its utility for diagnosing lymphoma is controversial. The aim of this study was to evaluate the diagnostic utility of EBUS-TBNA for the definitive diagnosis of de novo lymphoma with subtype classification.

METHODS

Patients with lymphoma who underwent EBUS-TBNA for diagnostic purposes at a single institution between March 2004 and May 2013 were retrospectively reviewed.

RESULTS

Of the 971 patients who underwent EBUS-TBNA during the study period, 19 patients, who did not have a previous history of lymphoma, had a final diagnosis of lymphoma. EBUS-TBNA provided a diagnosis accompanied with subtype classification in 6 patients (32%), a suspicious but not definitive classification in 10 patients (53%), and a negative classification in 3 patients (16%). Immunohistochemical staining for definitive diagnosis was performed in 15 of 16 patients (94%), with suspicious results from routine hematoxylin and eosin staining. No procedure-related complications occurred.

CONCLUSIONS

EBUS-TBNA is a useful initial diagnostic procedure, aiding decisions for the management of patients with suspected lymphoma, even though the sensitivity of EBUS-TBNA for diagnosing lymphoma with subtype classification was lower than previously reported.