Ultrasound guided fine-needle aspiration biopsy of metastases in nonpalpable supraclavicular lymph nodes in lung cancer patients

Thoracic ultrasound in guiding management of respiratory disease

INTRODUCTION

The use of ultrasound in respiratory disease has evolved substantially over the past two decades. From a test done to confirm the safe site of pleural fluid drainage, thoracic ultrasound has become a point-of-care test that guides the management of patients on respiratory wards, in clinics and endoscopy.

AREAS COVERED

This review overviews the process of ultrasound examination in the chest. It then delves into specific disease areas (pleural disease, lung disease, diaphragm disease, and invasive procedures) to highlight how thoracic ultrasound is being used to refine management. The review concludes with discussion on the training curricula and assessment tools for competency in thoracic ultrasound. Being a scoping review, literature searches were conducted on PubMed using relevant search terms.

EXPERT OPINION

In addition to its current uses, there are many avenues where thoracic ultrasound will soon be beneficial. Recent studies show promising roles in areas such as patient-tailored guidance of pleurodesis and non-invasively predicting lung re-expansion after pleural fluid drainage. In addition, auxiliary tools such as contrast-enhanced ultrasound and elastography are proving useful in identifying the etiology and directing the successful sampling of pleural and lung lesions. Studies are also exploring the utility of sonographic biomarkers such as echogenicity and septations to predict outcomes in pleural disease.

Conformity of Fine Needle Aspiration Biopsy (FNAB) and Core Needle Biopsy (CNB) in peripheral lung tumor patients: A cross-sectional study

Background

The problem of establishing lung tumor diagnostics is a challenge for clinicians, especially pulmonologists, in determining a definitive diagnosis of a lung tumor.

Objective

Analyzing the conformity of anatomical pathology results between fine-needle aspiration biopsy (FNAB) and core needle biopsy (CNB) materials in peripheral lung tumors.

Methods

A cross-sectional study was conducted from July 2019 to December 2020 with 66 participants. Participants were examined for CNB and FNAB, in which the results of these examinations were compared for conformity. Statistical analysis used the Kappa test with p < 0.05.

Result

Most participants' tumor size was >70 mm, with FNAB results showing malignant category (39.5%), non-malignant (40.0%), and undiagnosed (38.9%; p = 0.757). Meanwhile, CNB examination showed a tumor size of >70 mm that was categorized into malignant (40.4%) and non-malignant (33.3%; p = 0.510). Most tumors were located in the right superior lobe that had FNAB results in the malignant (39.5%), non-malignant (30.0%) and undiagnosed (27.8%; p = 0.306) categories. The CNB examination also showed that most tumors were located in the right superior lobe, which had resulted in the category of malignant (34.4%), non-malignant (26.7%), and undiagnosed (75.0%; p = 0.240). Conformity of anatomical pathology results from FNAB and CNB subject such as malignancy category of 35 participants (74.5%), non-malignancy of 7 participants (53.8%) and undiagnosed of 4 participants (16.7%) with an accuracy of 69.69% (Κ = 0.43; p = 0.001).

Conclusion

There is a conformity between the anatomical pathology results from FNAB and CNB materials for the diagnosis of lung tumors. CNB showed better results in the detection of anatomical malignancy and specimen adequacy.

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There is a conformity between the results of FNAB and CNB assisted by ultrasound.

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FNAB and CNB results in lung cancer are similar >70%.

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The use of FNAB followed by CNB minimizes misdiagnosis.

Focused Neck Ultrasound and Lymph Node Sampling by Respiratory Physicians in Suspected Lung Cancer

BACKGROUND

Malignant cervical lymphadenopathy in the setting of lung cancer represents N3 disease, and neck ultrasound (NUS) with sampling is described in the Royal College of Radiologists ultrasound training curriculum for the non-radiologists. This study reviews the incorporation of NUS +/- biopsy in the routine practice of a lung cancer fast-track clinic in the UK.

METHODS

We retrospectively assessed 29 months of activity of a lung cancer fast-track clinic. Systematic focused NUS was conducted in suspected thoracic malignancy, sampling nodes with a ≥5-mm short axis, under real-time US using a linear probe (5-12 Mhz). Fine-needle aspirations (FNAs) with or without 18 Ga core biopsies were taken.

RESULTS

Between August 2017 and December 2019, of 152 peripheral lymph nodes (LNs)/deposits sampled, 98 (64.5%) were supraclavicular fossa LNs with median [IQR] size 12 [8-18] mm. Core biopsies were performed in 54/98 (55%) patients, while all patients had FNAs. No complications occurred. The representative yield was 90/95 (94.7%) in cases with suspected cancer. No difference was seen between FNA versus core biopsy (p = 0.44). Of the 5 non-diagnostic samples, one was FNA only. The commonest diagnosis was lung cancer in 66/98 (67.3%). PDL-1 was sufficient in 35/36 tested (97.2%). ALK-FISH was successful in 24/25 (96%) cases. EGFR mutation analysis was successful in 28/31 (90.3%) cases. Median time from clinic to initial diagnosis was 7 [5-10] days. Computed tomography (CT) scans reported no significant lymphadenopathy in 18/96 (18.7%) cases, yet 10/18 (55.5%) cases were positive for malignancy.

CONCLUSION

Neck nodal sampling by respiratory physicians was safe, timely, with a high diagnostic yield and suitability for molecular testing. Neck US can provide a timely diagnosis in cases that may be missed by CT alone.

Diagnostic value of NSE factor combined with ultrasound hemodynamic indexes in cervical lymph node metastasis of lung cancer

Value of neuron-specific enolase (NSE) factor combined with ultrasound hemodynamic parameters in the diagnosis of cervical lymph node metastasis of lung cancer was explored. The clinical data of 85 patients with lung cancer, admitted to Qingdao Municipal Hospital (Group) from January 2015 to December 2016, were retrospectively analyzed. According to the results of pathological examination, 47 patients with cervical lymph node metastasis were enrolled in the metastatic group and 38 patients without lymph node metastasis were enrolled in the non-metastatic group. The expression level of NSE in serum and the hemodynamic indicators of blood flow resistance index (RI) and pulsatility index (PI) were compared between the two groups. ROC curve analysis was used to analyze the diagnostic efficacy of NSE, RI, PI, and their combination in lymph node metastasis of lung cancer. The NSE, RI and PI indexes in the metastatic group were significantly higher than those in the non-metastatic group (P<0.05). The sensitivity and specificity of NSE in the diagnosis of cervical lymph node metastasis of lung cancer were 73.68 and 72.34%, respectively; the sensitivity and specificity of RI were 78.95 and 80.85%, respectively; the sensitivity and specificity of PI were 81.58 and 68.09%, respectively. Also, the sensitivity and specificity of NSE combined with RI were 89.47 and 61.70%, respectively, and the diagnostic AUC was 0.881. The sensitivity and specificity of NSE combined with PI were 92.11 and 74.47%, respectively, and the diagnostic AUC was 0.905. NSE, RI, and PI have certain diagnostic value for cervical lymph node metastasis of lung cancer, however, the combined diagnosis is more valuable, and can be used as the auxiliary diagnosis of cervical lymph node metastasis of lung cancer.

Ultrasound-Guided Cervical Lymph Node Sampling Performed by Respiratory Physicians

Background

A variety of disease processes investigated by respiratory physicians can lead to cervical lymphadenopathy. Ultrasound (US) has revolutionised respiratory investigations, and neck ultrasound (NUS) is increasingly recognised as an additional important skill for respiratory physicians.

Objectives

We aimed to assess the feasibility of NUS performed by respiratory physicians in the workup of patients with mediastinal lymphadenopathy.

Methods

This is a single-centre retrospective cohort study. All patients that underwent US-guided cervical lymph node sampling were included. The diagnostic yield is reported, and specimen adequacy is compared for respiratory physicians and radiologists.

Results

Over 5 years, 106 patients underwent NUS-guided lymph node sampling by respiratory physicians compared to 35 cases performed by radiologists. There was no significant difference in the adequacy of sampling between the two groups (respiratory physicians 91.5% [95% CI 84.5-96%] compared to 82.9% [95% CI 66.4-93.4%] for radiologists [p = 0.2]). In the respiratory physician group, a diagnosis was achieved based on lymph node sampling in 89 cases (84%). Neck lymph node sampling was the only procedure performed to obtain tissue in 48 cases (45.3%).

Conclusion

NUS and sampling performed by respiratory physicians are feasible and associated with an adequacy rate comparable to that of radiologists. It can reduce the number of invasive procedures performed in a selected group of patients. Guidelines for training and competency assessment are required.

Clinical value of the VTIQ technology in the differential diagnosis of superficially enlarged lymph nodes

Background Lymph node enlargement is a common clinical finding in clinical practice with different treatment strategies. Purpose To investigate the application of Virtual Touch Image Quantification (VTIQ) to diagnose benign and malignant superficial enlarged lymph nodes. Material and Methods Between December 2015 and August 2016, 116 superficial enlarged lymph nodes were examined by VTIQ. Maximum (V_max), minimum (V_min), and average (V_mean) shear wave velocities (SWV) were obtained from the lymph nodes and from normal muscular tissues (V_n) located at the same level and within 5 mm from the target lymph node. The pathological results were used as the gold standard to evaluate VTIQ. Results All 116 patients underwent fine-needle aspiration biopsy for pathological examination. Forty patients had malignant lymph nodes and 76 patients had benign lymph nodes. Lymph node characteristics on B-mode ultrasound showed no differences between malignant and benign lymph nodes, but there were differences in VTIQ parameters (all P < 0.001). Compared with pathological diagnosis as the gold standard, the area under the ROC curves of V_max, V_min, and V_mean were 0.815, 0.746, and 0.795. The V_max cutoff value to diagnose benign from malignant lymph nodes was 3.045 m/s. The sensitivity, specificity, and positive and negative predictive values were 70%, 78.9%, 63.6%, and 83.3%. Conclusion VTIQ has a clinical application in the differential diagnosis of superficial enlarged lymph nodes.

Ultrasound-Guided Needle Biopsy of Neck Lymph Nodes in Patients With Suspected Lung Cancer: Are the Specimens Sufficient for Complete Pathologic Evaluation to Guide Patient Management?

BACKGROUND

The purpose of this study is to determine the ability of ultrasound guided needle biopsy of a neck lymph node to provide adequate tissue for complete pathologic evaluation of suspected metastatic lung cancer, including molecular testing for epidermal growth factor receptor gene mutations by pyrosequencing and anaplastic lymphoma kinase gene rearrangement by fluorescence in situ hybridization.

METHODS

Institutional review board approval was obtained and the requirement for informed consent was waived. All ultrasound guided neck biopsies performed July 1, 2011, to June 30, 2015, were retrospectively reviewed, and all biopsies performed for suspected lung cancer metastatic to supraclavicular and cervical lymph nodes were included.

RESULTS

Forty patients with suspected lung cancer underwent ultrasound-guided needle biopsy of an abnormal appearing neck lymph node identified on preprocedure computed tomography or positron emission tomography/computed tomography. Thirty-seven patients were subsequently diagnosed with lung cancer and 3 were diagnosed with lymphoma. A definitive pathologic diagnosis was rendered in 95% of neck node biopsies (38/40; 95% confidence interval, 84%-99%). Of the 36 specimens diagnostic for lung cancer, 16 were considered for further molecular testing and the specimen was adequate for molecular testing in 15 (94%; 73%-100%) cases. Therefore, the neck node biopsy specimens were adequate for complete pathologic workup in 93% (37/40; 81%-98%). No complications related to the biopsies were observed.

CONCLUSIONS

In patients presenting with suspected lung cancer and suspicious neck lymph nodes, ultrasound-guided needle biopsy frequently provides adequate tissue for complete pathologic evaluation and eliminates the need for more invasive procedures.

The value of ultrasound-guided biopsy of fluorodeoxy-glucose positron emission tomography (FDG-PET)-positive supraclavicular lymph nodes in patients with suspected lung cancer

Background

Accurate lymph node staging is essential for adequate prognostication and therapy planning in patients with non-small cell lung cancer (NSCLC). FDG-PET/CT is a sensitive tool for the detection of metastases, including non-palpable supraclavicular lymph node (SCLN) metastases. Histological proof of metastatic spread and mutation analysis is crucial for optimal staging and therapy. The aim of this study was to investigate the value of ultrasound-guided fine needle aspiration cytology (FNAC) and core biopsy (CB) of FDG active, non-palpable SCLN’s in patients with suspicion for lung cancer.

Methods

Twelve consecutive patients with suspected lung cancer and FDG-positive SCLN underwent FNAC (n = 11) and/or CB (n = 10) and were included and evaluated retrospectively in this study. Cytologic and/or histologic evaluation was performed to confirm initially suspected diagnosis (lung cancer), to confirm N3 stage, and to screen for driver mutations in lung adenocarcinoma.

Results

FNAC alone showed diagnostic success in 11/11 cases (100%), CB alone in 9/10 patients (90%), and the combination of both procedures was successful in 12/12 cases (100%). Lymph node metastases from NSCLC (7 adenocarcinoma, 2 squamous cell carcinoma) could be confirmed in 9 patients. Other diagnoses were small cell lung cancer (SCLC), breast cancer and sarcoidosis. There was enough material for immunhistochemistry in all patients. For molecular testing, material from this lymph node biopsies and lung biopsy was used. In two patients with adenocarcinoma of the lung driver mutations were detected (EGFR Exon 19 deletion and ALK rearrangement) out of the lymph node metastasis.

Conclusions

US-guided combined FNAC and CB of FDG positive supraclavicular lymph nodes in patients with suspected lung cancer is a safe and effective procedure to confirm N3-stage and to obtain representative material for molecular testing.

Cervical lymph node metastases from remote primary tumor sites

Although most malignant lymphadenopathy in the neck represent lymphomas or metastases from head and neck primary tumors, occasionally, metastatic disease from remote, usually infraclavicular, sites presents as cervical lymphadenopathy with or without an obvious primary tumor. In general, these tumors metastasize to supraclavicular lymph nodes, but occasionally may present at an isolated higher neck level. A search for the primary tumor includes information gained by histology, immunohistochemistry, and evaluation of molecular markers that may be unique to the primary tumor site. In addition, 18F-fluoro-2-deoxyglocose positron emission tomography combined with CT (FDG-PET/CT) has greatly improved the ability to detect the location of an unknown primary tumor, particularly when in a remote location. Although cervical metastatic disease from a remote primary site is often incurable, there are situations in which meaningful survival can be achieved with appropriate local treatment. Management is quite complex and requires a truly multidisciplinary approach. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2374-E2385, 2016.

[Clinical value of ultrasound in the diagnosis of supraclavicular lymph node metastasis of primary lung cancer]

背景与目的

原发性肺癌是常见的恶性肿瘤之一，术前准确的局部淋巴结（N）分期可避免不必要的手术创伤，N3期已非手术治疗指征。本研究旨在探讨超声在诊断原发性肺癌锁骨上淋巴结转移及确定其分期中的应用价值。

方法

回顾性分析2012年10月-2013年11月经病理确诊为肺癌患者131例，所有患者均在术前行锁骨上区域的超声和增强计算机断层扫描（computed tomography, CT），对检查结果为阳性的患者行超声引导下穿刺活检，将组织病理学诊断作为淋巴结转移的诊断标准，对比两种检查方法与病理结果的一致性。

结果

131例肺癌患者中经病理证实共有50例为锁骨上淋巴结转移，经超声检查阳性者54例，转移者50例；增强CT检查阳性者41例，其中36例为恶性。超声的灵敏度、特异度、正确指数、阳性预测值及阴性预测值（分别为100%、95.06%、95.06%、92.59%、100%）明显高于增强CT（分别为72%、93.83%、65.83%、87.80%、84.44%）。两种方法在确定肺癌TNM分期准确性的差异存在统计学意义（P < 0.01）。

结论

与增强CT相比，超声在原发性肺癌锁骨上淋巴结转移方面具有较高的准确性、敏感性和特异性，并且能够更加准确地确定原发性肺癌的TNM分期。