Utility of transbronchial needle aspiration in the diagnosis of endobronchial lesions

Effectiveness and Safety of Argon Plasma Coagulation in Patients with Haemoptysis Caused by an Endobronchial Malignancy

INTRODUCTION

Patients with central neoplasms and haemoptysis show low survival rates. Symptom control without recurrence 48 h after bronchoscopic interventions may improve the prognosis of these patients. Bronchoscopic argon plasma coagulation (APC) is a useful technique for endobronchial management of haemoptysis in patients with central malignancies. Nevertheless, limited data are available in the literature on its efficacy and safety and the main predictors of success are still unclear.

METHODS

An observational, prospective, single-centre cohort study was carried out to assess the efficacy (i.e., immediate bleeding cessation without recurrence during the following 48 h) of bronchoscopic APC in the treatment of patients with haemoptysis caused by endobronchial malignancies and the main predictors of success.

RESULTS

A total of 76 patients with median age 75 years (interquartile range: 65-79) were enrolled. 67 (88.2%) patients had bleeding cessation without recurrence 48 h after bronchoscopic APC. A low rate of non-serious adverse events (5.3%) was recorded and a low (7.6%) recurrence rate of haemoptysis at 3.5 months after the procedure was also shown. No clinical, demographic and endoscopic variables related to a successful procedure at 48 h were found.

CONCLUSION

This study demonstrates that bronchoscopic APC is an effective procedure in the treatment of patients with haemoptysis caused by endobronchial malignancies, regardless of the clinical characteristics of the patients, the endoscopic and histological features of the neoplasm and the severity of the symptom. Furthermore, it shows a low rate of complications and long-term efficacy in bleeding control.

Bronchoscopic sampling techniques in the era of technological bronchoscopy

Flexible bronchoscopy is a key diagnostic and therapeutic tool. New endoscopes and technologically advanced navigational modalities have been recently introduced on the market and in clinical practice, mainly for the diagnosis of mediastinal lymph adenopathies and peripheral lung nodules. Bronchoscopic sampling tools have not changed significantly in the last three decades, with the sole exception of cryobiopsy. We carried out a non-systematic, narrative literature review aimed at summarizing the scientific evidence on the main indications/contraindications, diagnostic yield, and safety of the available bronchoscopic sampling techniques. Performance of bronchoalveolar lavage, bronchial washing, brushing, forceps biopsy, cryobiopsy and needle aspiration techniques are described, focusing on indications and diagnostic accuracy in the work-up of endobronchial lesions, peripheral pulmonary abnormalities, interstitial lung diseases, and/or hilar-mediastinal lymph adenopathies. Main factors affecting the diagnostic yield and the navigational methods are evaluated. Preliminary data on the utility of the newest sampling techniques (i.e., new needles, triple cytology needle brush, core biopsy system, and cautery-assisted transbronchial forceps biopsy) are shown. TAKE HOME MESSAGE: A deep knowledge of bronchoscopic sampling techniques is crucial in the era of technological bronchoscopy for an optimal management of respiratory diseases.

Risk factors for pulmonary infection after diagnostic bronchoscopy in patients with lung cancer

Pulmonary infection is a relatively rare but serious complication of flexible bronchoscopy. The aim of this study was to identify the risk factors for pulmonary infectious complications after diagnostic bronchoscopy in patients with lung cancer. We retrospectively analyzed the medical records of 636 patients who underwent bronchoscopic biopsy for lung cancer diagnosis between April 2011 and March 2016. We compared patients' characteristics, chest computed tomography and bronchoscopic findings, undertaken procedures, and final diagnoses between patients who developed the complication and those who did not. Pulmonary infection after the diagnostic bronchoscopy occurred in 19 patients (3.0%) and included pneumonia in 16 patients and lung abscess in 3. Patients with larger lesions, presence of endobronchial lesions, histology of small cell lung cancer, and advanced disease stage tended to develop pulmonary infectious complications more often. Our multivariate analysis revealed that a larger lesion size and the presence of endobronchial lesions were independently associated with post-bronchoscopy pulmonary infection. Although we found no mortality associated with the infections, two patients were left with significant performance status deterioration after the pulmonary infection and received no anticancer treatment. In conclusion, endobronchial lesions and a larger lesion size are independent risk factors for the incidence of infections following bronchoscopic biopsy in patients with lung cancer.

Advances in interventional diagnostic bronchoscopy for peripheral pulmonary lesions

Introduction: The incidence of peripheral pulmonary lesions (PPLs) is growing following the adoption of lung cancer screening by low-dose chest CT. Although CT-guided transthoracic needle aspiration has been the standard method to diagnose PPLs, the field of interventional bronchoscopy is rapidly advancing to overcome complications of the transthoracic approach yet maintain the yield. Areas covered: This article reviews the clinical evidence of recent emerging interventional bronchoscopic techniques for diagnosis of PPLs. Expert opinion: Recent advances in interventional bronchoscopy contribute to not only the safety of transbronchial approaches to PPLs but also the higher diagnostic yield. To perform accurate sampling of PPLs, bronchoscopists must select the correct airway, approach the target as close as possible, and confirm the location of the target before sampling. These key steps can be assisted by recently developed technologies. However, it is important for bronchoscopists to understand the strengths and limitations of these emerging technologies.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Basic Bronchoscopy: Technology, Techniques, and Professional Fees

Flexible bronchoscopy has evolved over the last few decades, allowing chest physicians to use advanced high-definition scopes to inspect the airways and perform various sampling techniques. Although the techniques of basic bronchoscopic sampling have not changed dramatically, documentation requirements, coding, and billing have become more complex and require a better understanding on the part of the proceduralists and practice administrators. Areas in need of attention include learning about the multiple endoscopy rule, appropriate use of modifiers, and recent changes to the Current Procedural Terminology codes, associated work relative value units for moderate sedation, and therapeutic aspiration of secretions. This article describes basic bronchoscopic procedures and the principles needed for their coding and billing.

Diagnostic performance of convex probe EBUS-TBNA in patients with mediastinal and coexistent endobronchial or peripheral lesions

To compare the performance of convex probe endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) with conventional endobronchial biopsy (EBB) or transbronchial lung biopsy (TBLB) in patients with mediastinal, and coexisting endobronchial or peripheral lesions.Retrospective review of records of patients undergoing diagnostic EBUS-TBNA and conventional bronchoscopy in 2014.A total of 74 patients had mediastinal, and coexisting endobronchial or peripheral lesions. The detection rate of EBUS-TBNA for mediastinal lesion >1 cm in short axis, EBB for visible exophytic type of endobronchial lesion, and TBLB for peripheral lesion with bronchus sign were 71%, 75%, and 86%, respectively. In contrast, the detection rate of EBUS-TBNA for mediastinal lesion ≤1 cm in short axis, EBB for mucosal hyperemia type of endobronchial lesion, and TBLB for peripheral lesion without bronchus sign were 25%, 63%, and 38%, and improved to 63%, 88%, and 62% respectively by adding EBB or TBLB to EBUS-TBNA, and EBUS-TBNA to EBB or TBLB. Postprocedure bleeding was significantly more common in patients undergoing EBB and TBLB 8 (40%) versus convex probe EBUS-TBNA 2 patients (2.7%, P = 0.0004).EBUS-TBNA is a safer single diagnostic technique compared with EBB or TBLB in patients with mediastinal lesion of >1 cm in size, and coexisting exophytic type of endobronchial lesion, or peripheral lesion with bronchus sign. However, it requires combining with EBB or TBLB and vice versa to optimize yield when mediastinal lesion is ≤1 cm in size, and coexisting endobronchial and peripheral lesions lack exophytic nature, and bronchus sign, respectively.

Pre- and postoperative care for stage I-III NSCLC: Which quality of care indicators are evidence-based?

Identification of evidenced-based Quality of Care (QoC) indicators for lung cancer care is essential to quality improvement. The aim of this review was to identify evidence-based quality indicators for the pre- and postoperative care of stage I-III Non Small Cell Lung Cancer (NSCLC) provided by the lung physician. To obtain these indicators, a search in PubMed, Embase and the Cochrane library database was performed. English literature published between 1980 and 2012 was included and search terms regarding 'lung neoplasms', 'quality of care', 'pathology', 'diagnostic methods', 'preoperative and postoperative treatment' were used. The potential indicators were categorized as structure, process or outcome measures and the indicators supported by literature with high evidence level were selected. Five QoC indicators were identified. The use of the positron emission tomography-computed tomography (PET-CT) results in more accurate mediastinal staging compared to the CT scan. Endoscopic Ultrasound-Fine Needle Aspiration and Endobronchial Ultrasound-Fine Needle Aspiration are sensitive diagnostic tools for mediastinal staging and reduce futile thoracotomies. Pathological conformation of lung cancer can best be obtained by a combination of cytological and histological diagnostics used during bronchoscopy. For patients with clinical stage III NSCLC, preoperative multimodality treatment (i.e. preoperative chemoradiation) results in superior survival and increased mediastinal downstaging compared to single modality treatment (i.e. preoperative chemotherapy or radiotherapy). After surgery, the addition of chemotherapy results in a significant survival benefit for patients with pathological stage II and III NSCLC. These five QoC indicators can be used for benchmarking and ultimately quality improvement of lung cancer care.

Conventional transbronchial needle aspiration in community practice

Conventional transbronchial needle aspiration (C-TBNA) provides an opportunity to diagnose mediastinal lesions and stage bronchogenic carcinoma in a minimally invasive fashion. The procedure is easy to learn and requires zero upfront cost. Any community pulmonologist can acquire and maintain the skills of C-TBNA without undergoing formal interventional pulmonary fellowship training. Besides being used for the diagnosis and staging of lung cancer, C-TBNA can be used in patients suspected to have benign conditions such as sarcoidosis and tuberculosis. It also contributes in improving the diagnostic yield of flexible bronchoscopy while dealing with endobronchial, submucosal, peribronchial, or peripheral lesions. C-TBNA may be the only diagnostic modality that can be performed in patients in whom mediastinoscopy is contraindicated due to a bleeding diathesis. The procedure is safe and has great potential to augment the welfare of patients with pulmonary ailments. The learning curve of the procedure is short and steep. Every community pulmonologist should be able to perform C-TBNA.

Additional transbronchial needle aspiration through a guide sheath for peripheral pulmonary lesions that cannot be detected by radial EBUS

BACKGROUND

Endobronchial ultrasound with a guide sheath (EBUS-GS) has resulted to better diagnostic outcome for peripheral pulmonary lesions (PPLs), although the yield is not satisfactory for lesions that cannot be located by EBUS. We aimed to evaluate whether the addition of a new technique, transbronchial needle aspiration through a guide sheath (GS-TBNA), can increase the yield for these cases.

METHODS

This was a retrospective review of cases that were not located by EBUS during EBUS-GS for PPL diagnosis. From September 2012 to August 2014, 67 PPLs had 'invisible' EBUS-GS location prior to transbronchial sampling. The patients were divided into two groups according to the use of additional GS-TBNA: GS-TBNA group (n=22) and non-GS-TBNA group (n=45). Diagnostic yields were compared and multivariate analysis was performed to determine the factors associated with increased diagnostic yield.

RESULTS

The diagnostic yield was significantly higher in the GS-TBNA group than in the non-GS-TBNA group (54.5% vs 17.8%, P<0.01). The complication rate was not significantly different between the GS-TBNA group and the non-GS-TBNA group (0% vs 4.4%, P=1.0). Multivariate analysis showed that only performing GS-TBNA was significantly associated with increased diagnostic yield (odds ratio 3.99, P=0.03).

CONCLUSION

GS-TBNA is a safe technique for PPL diagnosis and may be useful when the EBUS probe cannot reach the lesion.

Timeliness of Diagnosing Lung Cancer: Number of Procedures and Time Needed to Establish Diagnosis: Being Right the First Time

To study number of procedures and time to diagnose lung cancer and factors affecting the timeliness of clinching this diagnosis. Retrospective cohort study of lung cancer patients who consecutively underwent diagnostic bronchoscopy in 1 year (October 2013 to September 2014). Out of 101 patients diagnosed with lung cancer from bronchoscopy, average time interval between first abnormal computed tomogram (CT) scan-to-1st procedure, 1st procedure-to-diagnosis, and 1st abnormal CT scan-to-diagnosis was 16 ± 26, 11 ± 19, and 27 ± 33 days, respectively. These intervals were significantly longer in those requiring repeat procedures. Multivariate analysis revealed inconclusive 1st procedure to be the predictor of prolonged (>30 days) CT scan to diagnosis time (P = 0.04). Twenty-nine patients (28.7%) required repeat procedures (n = 63). Reasons behind repeating the procedures were inadequate procedure (n = 14), inaccessibility of lesion (n = 9), inappropriate procedure (n = 5), mutation analysis (n = 2), and others (n = 2). Fifty had visible endo-bronchial lesion, 20 had positive bronchus sign, and 83 had enlarged mediastinal/hilar lymph-nodes or central masses adjacent to the airways. Fewer procedures, and shorter procedure to diagnosis time, were observed in those undergoing convex probe endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) (P = 0.04). Most patients exhibit enlarged mediastinal lymph node or mass adjacent to the central airway accessible by convex probe EBUS-TBNA. Hence, combining it with conventional bronchoscopic techniques such as bronchoalveolar lavage, brush, and forceps biopsy increases detection rate, and reduces number of procedures and time to establish diagnosis. This may translate into cost and resource savings, timeliness of diagnosis, greater patient satisfaction, and conceivably better outcomes.

From tissue to molecular phenotyping: pre-analytical requirements heidelberg experience

Lung cancer is a leading cause of tumor-related death worldwide through years. Efforts to individualize lung cancer therapy to improve prognosis nowadays employ molecular analyses besides routine histopathological examination of tissue samples. In general, tissues are provided by bronchoscopy, CT-guided procedures or surgery. The sequence of tissue removal, storage, and processing has a considerable impact on the success and reliability of subsequent molecular biological analyses and will supposedly also influence therapeutic decisions. There is still an ongoing need for updated statements about the minimal requirements of tissue sampling for molecular diagnosis at international level and for certified/accredited quality control programs of the sampling procedures. Several of these issues may have to be adjusted to the individual local conditions. We will present several aspects of experiences gained in Thoraxklinik at the University Hospital of Heidelberg (TK-HD) with pre-analytical tissue requirements.

Teaching conventional transbronchial needle aspiration. A continuum

Proponents of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) propose that in this era of EBUS-TBNA, training for conventional transbronchial needle aspiration (C-TBNA) should be abandoned. The authors of this editorial provide the opposing view. C-TBNA has a short and a steep learning curve and adds to the diagnostic yield of flexible bronchoscopy in a cost-effective fashion. Considering its simplicity, availability, affordability, safety, and several unique indications, C-TBNA continues to contribute to the welfare of patients worldwide. It should remain as an integral part of pulmonary fellowship training programs.

Diagnostic utility of conventional transbronchial needle aspiration without rapid on-site evaluation in patients with lung cancer

BACKGROUND

Endobronchial involvement is frequently absent in many patients with bronchogenic carcinoma. Malignant involvement may be confined to lymph nodes/peribronchial locations only or may be present along with endobronchial lesions. Transbronchial needle aspiration (TBNA) is a flexible bronchoscopic technique which can be employed to obtain tissue samples from mediastinal lymph nodes or peribronchial locations. Although a safe and cost effective bronchoscopic modality, it is frequently underutilized owing to concerns regarding its diagnostic utility and safety. Herein, we describe our experience over 1 year on the diagnostic utility of TBNA without rapid on-site evaluation (ROSE) in patients with suspected diagnosis of lung cancer.

MATERIALS AND METHODS

We retrospectively reviewed the cases in which conventional TBNA-without ROSE was performed for suspected lung cancer, between January 2012 and December 2012. Each lymph node station from which aspiration was performed was sampled thrice and smears were prepared on slides which were later examined by a cytopathologist.

RESULTS

Twenty-six cases were retrieved in which conventional TBNA without ROSE for suspected lung cancer with mediastinal involvement was performed during the study period. Adequate lymph node sampling could be achieved in 57.7% cases. Conventional TBNA was diagnostic in 11 out of the 26 (42.3%) patients. The diagnostic yield improved to 73.3% in patients in whom an adequate lymph nodal sample could be obtained. TBNA was the sole diagnostic sample in six (54.5%) patients. Alternative diagnoses (sarcoidosis and tuberculosis) were obtained in two patients.

CONCLUSION

Conventional TBNA without ROSE is a safe and efficacious flexible bronchoscopic procedure which should be performed routinely from bronchoscopically accessible locations in patients with a suspected diagnosis of lung cancer.

Bronchoscopic intratumoral injection of tranexamic acid to prevent excessive bleeding during multiple forceps biopsies of lesions with a high risk of bleeding: a prospective case series

BACKGROUND

Significant bleeding may occur following endobronchial forceps biopsy or brushing of necrotic or hypervascular tumors in the airways. In some cases, methods such as endobronchial instillation of iced saline lavage and epinephrine may fail to control bleeding. The present study evaluated the efficacy and safety of a new bronchoscopic technique using intratumoral injection of tranexamic acid (IIT) for control of bleeding during forceps biopsy in patients with endobronchial tumors with a high risk of bleeding.

METHODS

The study was a prospective case series carried out in a single center. Bronchoscopic IIT was performed in those patients who had endoscopically visible tumoral lesions with persistent active bleeding following the first attempt at bronchoscopic sampling. Tranexamic acid (TEA) was injected through a 22-gauge Wang cytology needle into the lesion in nominal doses of 250-500 mg. After 2-3 minutes, multiple forceps biopsy specimens were obtained from the lesion.

RESULTS

Of the 57 consecutive patients included in the study, 20 patients (35.1%) underwent bronchoscopic IIT. The first attempt in 18 patients was endobronchial forceps biopsy (EBB), and because of a high risk of bleeding, the first attempt for the remaining two patients, who were on continuous dual antiplatelet therapy (aspirin and clopidogrel), employed endobronchial needle aspiration (EBNA) as a precautionary measure. Following IIT, subsequent specimens were obtained using EBB in all patients. Multiple forceps biopsy specimens (3-10) were obtained from the lesions (8 necrotic and 12 hypervascular) without incurring active bleeding. The following histopathologic diagnoses were made: squamous cell carcinoma (n = 14), adenocarcinoma (n = 2), small-cell lung cancer (n = 3), and malignant mesenchymal tumor (n = 1). No side effects of TEA were observed.

CONCLUSIONS

Bronchoscopic IIT is a useful and safe technique for controlling significant bleeding from a forceps biopsy procedure and can be considered as a pre-biopsy injection for lesions with a high risk of bleeding.

TRIAL REGISTRATION

ISRCTN23323895.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transbronchial needle aspiration: a tool for a community bronchoscopist

BACKGROUND

Conventional transbronchial needle aspiration (C-TBNA) has been proven to be a safe, minimally invasive, and cost-effective technique in establishing the diagnosis of mediastinal pathologies. We studied the success of C-TBNA in our community practice, in patients with mediastinal lymphadenopathies.

MATERIALS AND METHODS

The technique of C-TBNA was learned solely from the literature, videos, and by practicing on inanimate models during "hands-on" courses. Conventional TBNA with 21- and/or 19-gauge Smooth Shot Needles was performed on consecutive patients with undiagnosed mediastinal lymphadenopathy.

RESULTS

Fifty-four patients (38 men), mean age 56.9±11.8 years, underwent C-TBNA. Thirty-three patients had nodes >20 mm. The final diagnoses were malignancy, 29; sarcoidosis, 9; reactive lymph nodes, 15; and tuberculosis, 1. The final diagnosis was established by C-TBNA in 27. The exclusive diagnostic yield of TBNA was 42.5% (n: 23). Nodal size had an impact on outcome (P=0.002), whereas location did not (P=0.82). C-TBNA was positive in 22/34 when malignancy was suspected (yield 64.7%) and positive in 5/20 when benign diagnoses were also included in the differential (yield 25%) (P=0.005). The sensitivity, specificity, positive predicted value, negative predicted value, and diagnostic accuracy were 79.4%, 100%, 100%, 73%, and 81.5%, respectively.

CONCLUSIONS

C-TBNA can be successfully learned without formal training and can be easily applied in the community practice.

Diagnosis of lung cancer: a bronchoscopist's perspective

BACKGROUND

Guidelines recommend multiple types of cytologic and tissue samplings in the diagnosis of lung cancer by bronchoscopy, but differences of opinion exist as to the relative value of bronchial brushings and endobronchial or transbronchial biopsies. Our objective was to determine concordance of these procedures by a test of symmetry in a historical cohort referred to the pulmonary diagnostic laboratory.

METHODS

From 1988 to 2001, patients with pathologic confirmation of primary lung cancer were examined by standard bronchoscopic techniques of that period. An electronic medical record system was used, with statistical analysis of symmetry between brushings and biopsies establishing the diagnosis.

RESULTS

Of 968 patients, 98% had bronchoscopy for 624 central and 322 peripheral suspect lesions. Bronchial brushings from 915 patients confirmed pulmonary malignancy in 811 (89%) patients. Endobronchial or transbronchial biopsies from 739 patients showed lung cancer in 603 (82%) cases. Bronchial washings in 16 patients and transthoracic needle biopsies in 30 patients established diagnosis. Transbronchial needle aspiration of mediastinal nodes identified metastases in 94 patients. Only 14 patients required a surgical procedure for diagnosis, but 188 received surgical excision as primary treatment. Statistical evaluation used only patients with both bronchial brushings and endobronchial or transbronchial biopsies. Analysis by a test of symmetry showed a significant difference (P<0.0001).

CONCLUSIONS

Positive, suspicious, and negative specimens were consistent, with bronchial brushings being more sensitive with a lower false-negative rate than endobronchial or transbronchial biopsies. Multiple techniques are recommended for bronchoscopic confirmation of lung cancer, but bronchial brushings should be collected initially, as technical or patient limitations might preclude diagnostic tissue biopsies.

Rapid on-site evaluation improves needle aspiration sensitivity in the diagnosis of central lung cancers: a randomized trial

BACKGROUND

Few prospective studies have evaluated the role of endobronchial needle aspiration in diagnosing central airways neoplasms. Rapid on-site evaluation has long been used in transbronchial needle aspiration of adenopathies and peripheral lesions, but its role in sampling central malignancies has not been substantiated yet.

OBJECTIVES

In this study we evaluated if endobronchial needle aspiration may increase the sensitivity of bronchoscopy for diagnosing central airways neoplasms when added to conventional diagnostic methods (forceps biopsy, brushing and bronchial washing), and if rapid on-site evaluation may be beneficial in patients undergoing endobronchial needle aspiration.

METHODS

125 patients (77% males, aged 70 ± 7 years; mean ± SD) with central lung cancers were randomized to undergo bronchoscopy including conventional diagnostic methods and needle aspiration, with or without rapid on-site evaluation, stratifying the patients on the basis of the neoplasm growth pattern (exophytic and submucosal/peribronchial disease).

RESULTS

Needle aspiration significantly increased the sensitivity of bronchoscopy when added to conventional methods (from 76 to 91%; p < 0.001), primarily resulting from differences in submucosal/peribronchial diseases (68 vs. 90%; p < 0.001) and independently from the presence of rapid on-site evaluation; needle aspiration guided by rapid on-site evaluation guaranteed a higher improvement in bronchoscopy sensitivity than conventional needle aspiration (98 vs. 84%, respectively; p = 0.004). Needle aspiration guided by rapid on-site evaluation showed a significantly higher sensitivity than the conventional method (97 vs. 76%, respectively; p = 0.001).

CONCLUSIONS

Needle aspiration increases the sensitivity of bronchoscopy in diagnosing central airways malignancies when added to conventional diagnostic methods, with a further significant improvement when guided by rapid on-site evaluation.

Autoaspiration versus manual aspiration in transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy

BACKGROUND

Traditionally, aspiration with high negative pressure is recommended to obtain a specimen in transbronchial needle aspiration (TBNA). Undeniably, however, the assistant experiences difficulty in the generation of the negative pressure and precise control of the syringe while performing the procedure.

OBJECTIVE

To evaluate the effectiveness of the autoaspiration method created by our plunger lock in comparison with the conventional manual aspiration in the diagnosis of intrathoracic lymphadenopathy by TBNA.

METHODS

A prospective study was conducted on all patients referred for diagnostic TBNA of enlarged intrathoracic lymph nodes. Both automatic and manual aspiration techniques were performed after the needle had been completely inserted into the nodes. The diagnostic yield and the numbers of diagnostic cells or benign lymphoid cells obtained by each technique were compared in the same node.

RESULTS

A total of 31 intrathoracic lymph nodes in 24 patients were prospectively studied. Twenty-four nodes (77.4%) were malignancies whereas 7 nodes (22.6%) were benign disease. Adequate lymph node samples were obtained in 30 targets (96.8%), and TBNA revealed definite diagnosis for 25 nodes (80.6%). Both aspiration techniques showed exactly the same diagnostic yield. However, the autoaspiration technique provided significantly more adequate samples than manual aspiration techniques did (P=0.003).

CONCLUSION

The autoaspiration method using our plunger lock was superior to the manual method in obtaining the numbers of adequate samples in TBNA procedures.

Clinical and Radiological Manifestations of Primary Tracheobronchial Tumours: A Single Centre Experience

Introduction: Tracheobronchial tumours usually cause an airway obstruction and secondary pulmonary infections. Although rare, they are an important differential diagnosis as they may mimic other conditions and diseases. This paper aims to analyse clinical, radiological and histological characteristics of the patients with tracheobronchial tumours diagnosed for a period of 7 years. Materials and Methods: In this retrospective, observational study, we carefully reviewed 65 patients who were diagnosed with tracheal and endobronchial tumours, and performed statistical analysis on the results. Results: Among these 65 patients (36 men and 29 women) with a mean age of 48.8 years (range, 15 to 75), 50 had malignant tumours while 15 had benign ones. The most common symptoms were cough, chest pain and haemoptysis. Cough was a more frequent symptom in patients with benign tumours (P <0.0014). Only 2 patients were asymptomatic. Tumours were predominantly localised in the large airways (46 in large bronchi and 2 in trachea). The most common radiological manifestation of malignant tumours was tumour mass (46%) followed by atelectasis. One third benign tumour caused atelectasis, while tumour mass and consolidation were found in 3 patients each. Computerised tomography revealed endoluminal tumour mass in 29.2% of the cases, which was more frequently found in benign than malignant tumours (47% vs 24%, respectively). On bronchoscopy, tumours were visible in 73% and 70% benign and malignant cases respectively. Conclusion: Tracheobronchial tumours should be ruled as a possible diagnosis in patients with cough, haemoptysis, dyspnoea and chest pain. The imaging techniques and histological examination of the tissue would subsequently lead to correct diagnosis and proper treatment can be administered. Key words: Bronchus, Computerised tomography, Trachea, Tumour, X-ray

Diagnostic flexible bronchoscopy and accessory techniques

We reviewed the most important diagnostic procedures implemented by means of flexible bronchoscopy, including bronchoalveolar lavage, bronchial brushing and biopsy, transbronchial lung biopsy and transbronchial needle aspiration. We reviewed the tools, techniques and potential complications of this examination.

Clinical value of detection of metastasis of carina in patients with non-small cell lung cancer

BACKGROUND

Although the utility of blind biopsy in the detection of metastasis in the carina has been reported, submucosal fine needle aspiration (SMFNA) has not been evaluated. We investigated how SMFNA of the main carina and upper-lobe carina in addition to blind biopsy affect management of patients with NSCLC.

METHODS

Thirty-five patients were evaluated. During fiberoptic bronchoscopy (FOB), five blind biopsy and three SMFNA specimens were collected from normal-appearing main carina (n = 35) and/or upper-lobe carina (n = 18). Subjects were staged for operability using traditional staging system, without knowing the blind biopsy or SMFNA results. Then, patients were staged again after results were made known.

RESULTS

Thirty-five NSCLC patients were analyzed. The management of 12 patients (34%) was changed according to our results. Out of the patients, 8, 5 and one had microscopic metastasis in the main carina, ipsilateral upper-lobe carina and both, respectively. Although SMFNA were more diagnostic compared to blind forceps biopsy, there was no statistically difference between them. These procedures increased the success of detection of microscopic metastasis and the results changed management of those cases.

CONCLUSION

SMFNA adds valuable information to blind biopsy, and their combination changed the management in one quarter of our NSCLC patients.

A randomized controlled trial of electrocoagulation-enabled biopsy versus conventional biopsy in the diagnosis of endobronchial lesions

BACKGROUND

Although electrocoagulation at time of endobronchial biopsy can potentially reduce procedure-related bleeding during fiberoptic bronchoscopy (FOB), it can also impair quality of tissue specimen; credible data for either are lacking.

OBJECTIVE

To evaluate the impact of hot biopsy on the quality of tissue samples and to quantify the amount of procedure-related bleeding during endobronchial biopsy.

METHODS

In this single-center, prospective, single-blind, randomized controlled study we included adult patients referred for FOB and having endobronchial lesions. Patients were randomized to bronchial biopsy using an electrocoagulation-enabled biopsy forceps, with (EC+ group) or without (EC- group) application of electrocoagulation current (40 W for 10 s in a monopolar mode). Procedure-related bleeding was semi-quantified by observer description, as well as through a visual analogue scale. Overall quality of biopsy specimen and tissue damage were assessed and graded by a pulmonary pathologist blinded to FOB details.

RESULT

160 patients were randomized to endobronchial biopsy with (n = 81) or without (n = 79) the application of electrocoagulation. There were no severe bleeding episodes in either group, and severity of bleeding in the EC+ and EC- groups was similar (median visual analogue scale scores of 14 and 16, respectively). Histopathological diagnosis was similar in the EC+ and EC- groups (77.8% and 82.3%, respectively). There was no significant difference in tissue quality between the two groups.

CONCLUSION

Use of electrocoagulation-enabled endobronchial biopsy does not alter specimen quality and does not result in any significant reduction in procedure-related bleeding.

[The role of TBNA in diagnosis and treatment of lung diseases]

经支气管针吸活检（transbronchial needle aspiration, TBNA）在其临床应用的三十余年里，以其高效、准确、创伤小等特点得到了临床医师们的青睐。支气管内超声（endobronchial ultrasound, EBUS）的应用更增加了TBNA的准确性。EBUS-TBNA更比TBNA和其它传统的检查方法（如CT、PET、纵隔镜等）的敏感性、特异性和准确性高并有较高的安全性。TBNA可获得组织学标本，对于肺癌的诊断和分期有重要意义。同时对肺部其它疾病（如结节病、纵隔淋巴瘤、肺结核）的诊断，TBNA也有帮助。TBNA联合应用常规检查方法可提高肺部疾病的诊断率和阴性预测值，在临床工作中应大力推广TBNA的使用。

Flexible bronchoscopy and its role in the staging of non-small cell lung cancer

Technologic advances in bronchoscopy continue to improve the ability to perform minimally invasive, accurate evaluations of the tracheobronchial tree and to perform an ever-increasing array of diagnostic, staging, therapeutic, and palliative interventions. The role of both old and new diagnostic bronchoscopy will continue to evolve as further improvements are made in bronchoscopes, accessory equipment, and imaging technologies. The major challenge is the adoption of the many new bronchoscopic techniques into routine clinical practice. There is a need for well-designed studies to delineate the appropriate use of these interventions and to better define their limitations and cost effectiveness.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer

PURPOSE

We performed this study to evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the pathologic diagnosis of lung cancer including lung masses as well as lymph nodes as targets.

METHODS

We retrospectively reviewed 126 patients who underwent EBUS-TBNA to diagnose radiologically suspected lung cancer. The patients had masses or lymph nodes that were highly suspicious for malignancy and accessible by EBUS-TBNA.

RESULTS

EBUS-TBNA was performed on 195 lesions (lymph nodes, n=151; lung masses, n=44). In 61 cases, other diagnostic methods had failed previous to EBUS-TBNA. In 118 patients, no definite endobronchial mucosal tumor invasion was observed. In eight patients with endobronchial tumor invasion, EBUS-TBNA was chosen due to tumor bleeding, necrosis, or difficult location for endobronchial biopsy. EBUS-TBNA confirmed 105 lung cancers, five other malignancies and six specific benign cases, demonstrating a diagnostic yield of 92.1% (116/126). Nine cases were diagnosed by other methods (lung cancer, n=2; other malignancies, n=2; benign cases, n=5). One case that was not confirmed by any diagnostic method was considered false negative. The sensitivity and diagnostic accuracy of EBUS-TBNA in the diagnosis of lung cancer were 97.2% (105/108) and 97.6% (123/126), respectively.

CONCLUSIONS

EBUS-TBNA targeting lymph nodes or masses highly suspicious for malignancy demonstrated high diagnostic value in the diagnosis of lung cancer. EBUS-TBNA is recommended for these cases, especially when other diagnostic methods have failed or are difficult.

Cryoprobe biopsy increases the diagnostic yield in endobronchial tumor lesions

OBJECTIVE

Forceps biopsy is the standard method to obtain specimens in endoscopically visible lesions. It is common to combine forceps biopsy with cytology methods to increase the diagnostic yield. Although the flexible cryoprobe has been established for bronchoscopic interventions in malignant stenosis, the obtained biopsies, called "cryobiopsies," have not been investigated in a large cohort of patients. The aim of this feasibility study was to prospectively evaluate the diagnostic yield and safety of cryobiopsy and forceps biopsy.

METHODS

During a 6-year period, 296 patients with visible endoluminal tumor lesions were included in the study at the bronchoscopy unit of a university hospital. In the first consecutively conducted 55 cases, both techniques, forceps biopsy and cryobiopsy, were applied simultaneously. Pathologic and quantitative image analyses were performed to evaluate the size and quality of the obtained specimens. We evaluated the safety and diagnostic yield to describe the feasibility of cryobiopsy.

RESULTS

Comparative analysis of the first conducted and randomly assigned 55 cases revealed a significantly higher diagnostic yield for cryobiopsy compared with forceps biopsy (89.1% vs 65.5%, P < .05). In this cohort, quantitative image analysis showed significantly larger biopsies regarding size and artifact-free tissue sections for cryobiopsy compared with forceps biopsy (P < .0001). The overall diagnostic yield of cryobiopsy was 89.5%. Mild bleeding occurred in 11 cases (3.7%), moderate bleeding occurred in 3 cases (1.0%), and severe bleeding occurred in 1 case (0.3%).

CONCLUSION

Cryobiopsy is safe and increases the diagnostic yield in endobronchial tumor lesions. The method also is feasible under routine conditions.

Management of complications from diagnostic and interventional bronchoscopy

From the humble beginnings as a mere curiosity, the art of bronchoscopy has progressed at a rapid pace. The millennium ushers in new technologies and refinements in established techniques to facilitate early detection of cancer, precise targeting of pulmonary nodules and infiltrates, near-total staging of the mediastinum with combined endoscopic modalities and more effective palliation of inoperable tumours. Bronchoscopists are faced with an increasing myriad of tools and equipment, each promising to carry out better than the previous. It is opportune to review the complications of established bronchoscopic techniques and how to manage them as well as new complications associated with novel technologies. In this article, we provide a concise overview of diagnostic and therapeutic bronchoscopic modalities, discussion of associated complications and their management strategies.

A novel needle-type sampling device for flexible ultrathin bronchoscopy

Diagnosis of suspected cancer in the periphery of the lung is difficult. A flexible ultrathin bronchoscope has been developed for the diagnosis of peripherally located pulmonary lesions that cannot be reached with the sampling devices for standard flexible bronchoscopes. The diagnostic yield with forceps and a brush for ultrathin bronchoscopes, however, is not adequate, especially when a lesion is not exposed to the bronchial lumen. We have thus developed a novel needle-type sampling device and tested its yield in transbronchial cytology. The device consists of an elongated dental H-file (0.4 mm in diameter and 110 cm in length), a housing sheath (1.0 mm in outer diameter), and a novel handle, which enables rapid out-and-in motion of the needle. Ten consecutive patients with a peripheral pulmonary lesion who had an indication for diagnostic procedure with a flexible ultrathin bronchoscope were enrolled. The optimal bronchial route to the lesion was analyzed with virtual bronchoscopy in a data set obtained with high-resolution computed tomography, and a novel bronchial route labeling system (prior-ridge-based relative orientation nomenclature) was employed to guide insertion of the bronchoscope. Sampling with the novel needle was performed prior to use of the forceps and brush under conventional fluoroscopy. In all the cases, sampling with the needle was successful and the amount of the specimen was sufficient for cytology. Our novel sampling system with flexible ultrathin bronchoscopes may contribute to accurate and minimally invasive diagnosis of peripheral pulmonary lesions.

[Transbronchial needle aspiration of hilar and mediastinal lymph nodes]

BACKGROUND

Besides clarifying the etiology of unidentified lymphadenomegaly, puncturing hilar and mediastinal lymph nodes by a flexible bronchoscopic needle is an aid in diagnosing and staging broncho- genic cancer or other metastatic cancers.

OBJECTIVE

Our study had the principal objective to evaluate the positivity of transbronchial needle aspiration (TBNA).

METHOD

We evaluated retrospectively the effectiveness of all TBNA done in 74 consecutive patients. Forty-nine patients were male and the median age was 59. We used Wang-needles, 21-gauge (Bard, USA), and the same technique described for different authors. Of the 74 patients evaluated, 11(15%) showed mediastinal mass and 65 (85%) hilar mass. We observed 76 endoscopic abnormalities.

RESULTS

According to the classification of the specimens, we had 32/74 (43%) unsatisfactory specimens, 34/74 (46%) satisfactory and diagnostic specimens, and 8/74(11%) satisfactory and non-diagnostic specimens. Thirty four (46%) of the examinations were found to be positive out of the total amount of specimens. Of the positive results, 30/34 specimens (88%) contained malignant disease. Small-cell carcinoma was the most frequent finding, with 10/34 cases (29%); squamous cell carcinoma 7/34 (21%); adenocarcinoma 7/34 (21%), non- -small cell carcinoma 6/34 (17%); sarcoidosis 2/34 (6%) and tuberculosis 2/34 (6%).

CONCLUSION

Our study indicated that this method is safe, easy to per- form, with a minimum of complications and useful for the diagnosis and staging of pulmonary neoplasms.

Initial Diagnosis of Lung Cancer

BACKGROUND

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph finding or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer [SCLC] or non-SCLC [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient.

OBJECTIVES

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

METHODS

To update previous recommendations on the initial diagnosis of lung cancer, a systematic search of MEDLINE, Healthstar, and Cochrane Library databases to July 2004, and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspiration (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the lung cancer panel prior to approval by the Thoracic Oncology Network, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physician.

RESULTS

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer with a pooled sensitivity rate of 0.66 and specificity rate of 0.99. However, the sensitivity of sputum cytology varies by location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of flexible bronchoscopy (FB) for diagnosing lung cancer is 0.88. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions smaller or larger than 2 cm in diameter showed a sensitivity of 0.34 and 0.63, respectively. In recent years, endobronchial ultrasound (EBUS) has shown potential in increasing the diagnostic yield of FB while dealing with peripheral lesions without adding to the risk of the procedure. In appropriate situations, its use can be considered before moving on to more invasive tests. The pooled sensitivity for TTNA for the diagnosis of lung cancer is 0.90. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. The accuracy in differentiating between SCLC and NSCLC cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive rate and FN rate were 0.09 and 0.02, respectively.

CONCLUSIONS

The sensitivity of bronchoscopy is high for the detection of endobronchial disease and poor for peripheral lesions < 2 cm in diameter. Detection of the latter can be aided with the use of EBUS in the appropriate clinical setting. The sensitivity of TTNA is excellent for malignant disease. The distinction between SCLC and NSCLC by cytology appears to be accurate.

Detection of epidermal growth factor receptor mutation in transbronchial needle aspirates of non-small cell lung cancer

BACKGROUND

Somatic mutations of epidermal growth factor receptor (EGFR) are closely associated with an objective response to EGFR tyrosine kinase inhibitors. However, it is difficult to obtain sufficient tumor samples from patients with non-small cell lung cancer (NSCLC), so these diagnoses are often made using cytology procedures alone. The aim of this study was to detect EGFR mutations in transbronchial needle aspiration (TBNA) samples using both direct sequencing and a highly sensitive assay (Scorpions Amplified Refractory Mutation System; DxS; Manchester, UK) [ARMS], and to compare the sensitivity of these methods.

METHODS

We enrolled 94 patients (63 men and 31 women) with NSCLC in this study. Cytologic diagnoses were adenocarcinoma (n = 58), squamous cell carcinoma (n = 24), and other types of NSCLC (n = 12). We extracted DNA from the TBNA samples, and EGFR mutations were analyzed using both direct sequencing (exons 19 and 21) and the Scorpions ARMS method (E746 A750del and L858R).

RESULTS

Mutations were detected in 31 patients (33%; 14 women and 17 men). Of these, 23 patients had adenocarcinoma, 4 had squamous cell carcinoma, and 4 had other types of NSCLC. Direct sequencing detected 13 mutations (14%) in 13 patients (E746-A750del, n = 6; L858R, n = 7), and the Scorpions ARMS method detected 27 mutations (29%) in 27 patients (E746 A750del, n = 16; L858R, n = 11 patients).

CONCLUSIONS

Both methods detected EGFR mutations in TBNA samples, but Scorpions ARMS is more sensitive than direct sequencing.

Bronchial washing yield before and after forceps biopsy in patients with endoscopically visible lung cancers

BACKGROUND AND OBJECTIVE

The need for routine use of bronchial washing in addition to forceps biopsy has been debated in the diagnosis of endoscopically visible lung tumours. Moreover, the optimal sequence for obtaining bronchial washing and forceps biopsy specimens from endoscopically visible tumours through a flexible bronchoscope has not been well established.

METHODS

A multicentre 13-month prospective randomized study was performed. Two hundred and thirty consecutive patients with endoscopically visible tumours were randomly assigned into a bronchial washing before forceps biopsy (pre-biopsy) group and a bronchial washing after forceps biopsy (post-biopsy) group. Bronchial washing and forceps biopsy were performed according to the assigned sequence.

RESULTS

Two hundred and seven patients with a definite cytological or histological diagnosis of lung cancer were included in the analyses. One hundred and three were in the pre-biopsy group and 104 were in the post-biopsy group. The diagnostic yield of bronchial washing was 57.3% (59/103) in the pre-biopsy group and 55.8% (58/104) in the post-biopsy group (P = 0.88). In addition, bronchial washing provided the diagnosis in six patients without definite diagnosis from forceps biopsy, and its addition to forceps biopsy significantly increased the overall diagnostic yield of bronchoscopy from 93.7% to 96.6% (P = 0.03).

CONCLUSION

The sequence for performing bronchial washing before or after forceps biopsy did not affect the diagnostic yield of bronchial washing in patients with endoscopically visible lung cancers. However, bronchial washing led to a significant increase in the overall diagnostic yield of bronchoscopy in patients with lung cancers.

Measuring the success of transbronchial needle aspiration in everyday clinical practice

BACKGROUND

Trans-bronchial needle aspiration (TBNA) is a simple, safe technique that can be performed without additional resources in any centre with a bronchoscopy service. It provides rapid diagnostic information in malignant and benign conditions and staging information in non-small cell lung cancer (NSCLC) and may avoid the delays, risks, in-patient stay and financial implications associated with surgical exploration of the mediastinum. Despite this, centres have been slow to adopt the technique. This may be due to the lack of clarity about the clinical success of TBNA in everyday clinical practice and the absence of a single valid measurement of clinical utility for TBNA against which to audit.

METHODS

We undertook a retrospective analysis of all TBNA carried out at Nottingham City Hospital since the service began. "Success" was carefully and strictly defined. The influences of various factors on the likelihood of a successful outcome were analysed.

RESULTS

Fifty percent (71/142) of patients undergoing TBNA received an exact histological diagnosis whilst in 72% (97/134) of patients in whom a final diagnosis was made, TBNA results correctly predicted malignant versus benign conditions. We defined the former, more stringent, outcome measure as "success--exact". This outcome was not significantly affected by patient age or gender, lesion size or position, experience of the bronchoscopist or number of aspiration attempts. Final diagnosis strongly influenced "success--exact" with NSCLC 6.5 times and small cell lung cancer 28.5 times more likely to yield a diagnostic sample than benign conditions.

CONCLUSIONS

TBNA should be used as a standard first line invasive investigation for diagnosis of mediastinal lymphadenopathy or submucosal endobronchial disease. The stringent outcome defined in this study as "success--exact" is simple for clinicians and patients to understand and would be a useful definition to standardise audit and future research.

Flexible Bronchoscopy in the Evaluation of Mediastinal and Hilar Lymphadenopathy

BACKGROUND

The diagnosis in cases of mediastinal and/or hilar lymphadenopathy with no lung parenchymal involvement is often difficult. We undertook this study to assess the diagnostic value of flexible bronchoscopy (FOB) especially transbronchial needle aspiration (TBNA) and transbronchial lung biopsy (TBLB) in these patients.

METHODS

Forty eight patients with hilar and/or mediastinal lymphadenopathy without any parenchymal lung lesions, managed between 2000 to 2004 at a tertiary care centre who underwent FOB were evaluated retrospectively.

RESULTS

Out of 48 patients, FOB showed widening of carina in six, widening of secondary carina in four, bulge in airways because of extrinsic compression in seven and endobronchial nodule in two patients. It was normal in rest 29 patients. TBNA was done in all patients and TBLB in 13 patients where clinico-radiologic findings were consistent with stage 1 sarcoidosis. FOB established diagnosis in 18 patients (caseating granuloma in eight, noncaseating granuloma in nine, and AFB culture positive in one). It was inconclusive in other patients. One patient developed pneumothorax requiring intercostal tube drainage.

CONCLUSION

FOB especially TBNA has an important role in the diagnosis of hilar and mediastinal lymphadenopathy and should be considered before other invasive procedures.

Transbronchial biopsy guided by low-dose MDCT: a new approach for assessment of solitary pulmonary nodules

OBJECTIVE

The objective of our study was to determine whether transbronchial bronchoscopic biopsy of solitary pulmonary nodules under CT guidance using a low-dose protocol can increase diagnostic yield in patients who had undergone unsuccessful conventional bronchoscopic biopsy.

SUBJECTS AND METHODS

We included 33 consecutive patients (25 men; mean age +/- SD, 64 +/- 9.6 years) with solitary pulmonary nodules at different sites and with a lesion-to-pleura distance of at least 2 cm who previously underwent conventional bronchoscopy that did not result in histologic diagnosis. All patients were prospectively investigated with transbronchial bronchoscopic biopsy under MDCT guidance. Examinations were performed with the patient in conscious sedation using a low-dose protocol (80 kV, 20 mAs, 5-mm collimation, 10-mm slices). The position of the tip of the biopsy device was confirmed and documented before biopsies were performed. All specimens were examined by standard histopathologic techniques. The effective radiation dose was calculated for every patient.

RESULTS

The diagnostic yield was 24 in 33 selected patients (overall accuracy, 72.7%): 13 (54%) had primary lung cancer and 11 (46%) had benign diagnoses. The formal operative characteristics were sensitivity, 59%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 55%. The final diagnoses of the remaining nine patients in whom transbronchial bronchoscopic biopsy was not diagnostic were non-small cell lung cancer (n = 3); small cell lung cancer (n = 3); and alveolar carcinoma, carcinoid tumor, and hemorrhaged bulla (n = 1 each). All nonmalignant diagnoses were confirmed by 6 months radiographic and clinical follow-up. The mean duration of the procedure was 39 +/- 15 minutes, and the average effective dose was 0.7 mSv (range, 0.5-1.1 mSv). One case of pulmonary hemorrhage (3%) occurred after the procedure.

CONCLUSION

MDCT-guided transbronchial bronchoscopic biopsy is a promising and safe tool for the diagnostic pathway of solitary pulmonary nodules in previously undiagnosed patients. Image quality was sufficient with low-dose protocols, which resulted in low radiation exposure for patients and personnel.

Effectiveness of transbronchial needle aspiration in the diagnosis of exophytic endobronchial lesions and submucosal/peribronchial diseases of the lung

The role of transbronchial needle aspiration (TBNA) in diagnosing endobronchial lung cancers has not been elucidated. The definitive combination of procedures that offers the best diagnostic yield following fiberoptic bronchoscopy remains controversial. This study was designed to investigate the diagnostic yield of transbronchial needle aspiration and other cytologic and histologic diagnostic procedures (i.e., forceps biopsy, brushing, and washing) and to assess the optimal combination for diagnosing endobronchial lung cancers. This prospective study included 95 patients presenting with visible tumors detected during bronchoscopic procedure as either an exophytic endobronchial lesion (EEL) or submucosal-peribronchial disease (SPD). Transbronchial needle aspiration, forceps biopsy, brushing, and washing were performed in all patients, and 91 patients were diagnosed. Rates of positive results were 75.8% for needle aspiration, 71.6% for forceps biopsy, 61.1% for brushing, and 32.6% for washing. Needle aspiration was used as the sole diagnostic method in 11, forceps biopsy was the sole diagnostic method in 5, and brushing was the sole diagnostic method in 4 patients. Washing was not used as the sole diagnostic method in any case. Forceps biopsy yielded the highest diagnostic rate for an EEL (86.4%); however, when compared with needle aspiration (77.9%), no significant difference was observed between these two procedures (P = 0.302). In patients with a diagnosis of SPD, needle aspiration was determined to be the sole diagnostic method in eight patients. In this group of patients, the highest rate of diagnosis was achieved with needle aspiration (72.2%), and when compared with forceps biopsy (47.2%), a significant difference between the two procedures (forceps biopsy versus needle aspiration) was observed (P = 0.049). By adding transbronchial needle aspiration to the conventional diagnostic methods (forceps biopsy, brushing, and washing), the rate of diagnosis increased from 82.1% to 95.8% (P = 0.001), and in patients with a diagnosis of SPD, this rate increased from 69.4% to 94.4% (P = 0.008). In patients with a diagnosis of an EEL, addition of needle aspiration led to an increase in diagnostic yield but this difference was not statistically significant (89.8% versus 96.6%, P = 0.250). In endobronchial lung cancers, transbronchial needle aspiration is a safe method that can be used together with conventional diagnostic procedures to increase the diagnostic yield and should be considered a valuable diagnostic tool, particularly in cases of SPD. The highest rate of diagnostic yield in this study was obtained using a combination of forceps biopsy, transbronchial needle aspiration, and brushing; washing did not contribute to this high rate.

Transbronchial needle aspiration in the diagnosis of endobronchial malignant lesions: a 3-year experience

STUDY OBJECTIVES

To establish the diagnostic yield of transbronchial needle aspiration (TBNA) and its contribution to conventional diagnostic techniques (CDT) such as forceps biopsy, bronchial washing, and bronchial brushing in the diagnosis of malignant endobronchial lesions.

DESIGN

Retrospective clinical study.

PATIENTS

One hundred fifteen lung cancer patients

MEASUREMENT AND RESULTS

We reviewed files of 115 lung carcinoma cases diagnosed in our clinic from 2001 to 2003 with endobronchial lesions sampled by CDT and TBNA. The lesions were classified into three groups: exophitic mass lesion (EML), submucosal disease, and peribronchial disease. The diagnostic yield of TBNA and CDT was compared to that of the combination of CDT and TBNA with respect to the type and location of the lesion and the histopathologic subgroups. Of the 115 cases, histology findings were confirmed by TBNA in 91 cases (79%), CDT in 75 cases (65%), and TBNA plus CDT in 105 cases (91%). The difference of the diagnostic yield of CDT vs TBNA plus CDT was statistically significant (p < 0.001). In peribronchial disease, the sensitivity of TBNA plus CDT was significantly better than CDT (87% vs 52%, p < 0.001). In EML and submucosal disease, addition of TBNA to CDT improved sensitivity from 85 to 100% and from 84 to 97%, respectively (p > 0.05). Regarding localization, the addition of TBNA to CDT increased sensitivity in the trachea and main bronchi, and in right upper and middle lobe lesions (p < 0.05). By the addition of TBNA to CDT, small cell lung cancer and non-small cell lung cancer cases demonstrated improvements in sensitivity from 74 to 100% and 61 to 87%, respectively. This significant difference (p < 0.05) was attributed to the peribronchial disease group.

CONCLUSION

In the case of peribronchial disease, the addition of TBNA to CDT improves the diagnostic yield of the bronchoscopic examination.

Endobronchial ultrasonography guidance for transbronchial needle aspiration using a double-channel bronchoscope

STUDY OBJECTIVES

Endobronchial ultrasonography (EBUS) is used as guidance for transbronchial needle aspiration (TBNA), and real-time imaging of the needle position cannot be confirmed with a single-channel bronchoscope. We assessed the usefulness of EBUS-guided TBNA using a double-channel bronchoscope (EBUS-D), which provides real-time needle position, and compared it with EBUS-guided TBNA using a single-channel bronchoscope (EBUS-S).

DESIGN

Randomized, comparative prospective study.

SETTING

Hiroshima City Hospital, a tertiary-referral teaching hospital.

PATIENTS

Between January 2000 and August 2003, 55 patients with intrathoracic lymphadenopathy were included. Patients were randomized to undergo EBUS-D (n = 30) or EBUS-S (n = 25).

METHODS

EBUS-D: The EBUS probe and TBNA catheter were inserted simultaneously through a double-channel bronchoscope. Once the needle placement in the lesion was confirmed by EBUS, TBNA was performed. EBUS-S: The EBUS probe was removed after the determination of the penetration site. Then, the TBNA catheter was inserted and TBNA was performed.

RESULTS

All the lymph nodes could be visualized with EBUS in each group of patients. In the EBUS-D group, the TBNA needle was visualized as a hyperechoic point on the real-time EBUS image. The diagnostic accuracy rate of EBUS-D and EBUS-S were statistically significantly different (97% vs 76%, respectively; p = 0.025). On second attempt of TBNA, the diagnostic rate of the EBUS-D group was superior to that of the EBUS-S group (85.7% vs 33.3%, respectively; p = 0.036). The mean number of penetrations was 1.24 in the EBUS-D group and 1.36 in the EBUS-S group. No complications were observed in the EBUS-D group, but a self-limiting hemorrhage occurred in a patient in the EBUS-S group.

CONCLUSION

EBUS-D is useful for diagnosing intrathoracic lymphadenopathy, and the obtained specimen with real-time confirmation of the needle is directly proportional to an accurate diagnosis.

Transbronchial Needle Aspirates

STUDY OBJECTIVES

Transbronchial needle aspiration has evolved as a key bronchoscopic sampling method. Specimen handling and preparation are underrated yet crucial aspects of the technique. This study was designed to identify which of two widely practiced sample preparation methods has a higher yield.

DESIGN

Prospective comparison of two diagnostic methods.

SETTING

Tertiary academic hospital.

PATIENTS

Consecutive patients undergoing transbronchial needle aspiration.

INTERVENTIONS

Transbronchial aspirates were obtained pairwise. One specimen was placed directly onto a slide and smears were prepared on site (ie, the direct technique), and the other specimen was deposited into a vial containing 95% alcohol and further prepared in the laboratory (ie, the fluid technique). In total, 282 pairs of samples were aspirated from 145 target sites (paratracheal, 10 sites; tracheobronchial, 101 sites; hilar, 17 sites; endobronchial or peripheral, 17 sites).

MEASUREMENTS AND RESULTS

The measured outcome was the presence of diagnostic material at the final laboratory assessment. At least one diagnostic aspirate was obtained in 66% of 86 investigated patients (small cell lung cancer, 18 patients; non-small cell lung cancer, 47 patients; other diagnoses, 21 patients). The direct technique had a better yield overall than the fluid technique (positive aspirates, 36.2% vs 12.4%, respectively; p < 0.01), as well as after stratification for tumor type and for anatomic site.

CONCLUSION

The direct technique is superior to the fluid technique for the preparation of transbronchial needle aspirates.

Utility of Rapid On-Site Evaluation of Transbronchial Needle Aspirates

BACKGROUND

Rapid on-site evaluation has been proposed as a method to improve the yield of transbronchial needle aspiration.

OBJECTIVES

This study investigated whether on-site analysis facilitates routine diagnostic bronchoscopy in terms of sampling, yield and cost.

METHODS

Patients with lesions accessible for transbronchial needle aspiration on computed tomography were investigated. A cytopathologist screened the needle aspirates on site for the presence of diagnostic material. The bronchoscopic sampling process was adjusted according to the results. In 90 consecutive patients with neoplastic disease (n=70; 78%), non-neoplastic disease (n=16; 18%) or undiagnosed lesions (n=4; 4%) we aspirated 162 lung tumours or lymph node sites (mediastinal: 7%; tracheobronchial: 68%; other: 25%). In 90 consecutive patients with neoplastic disease (n=70; 78%), non-neoplastic disease (n=16; 18%) or undiagnosed lesions (n=4; 4%) we aspirated 162 lung lesions (paratracheal tumours or lymph nodes: 7%; tracheobronchial lymph nodes: 68%; other: 25%).

RESULTS

The diagnostic yield of needle aspiration was 77 and 25% in patients with neoplastic and non-neoplastic lesions, respectively. Sampling could be terminated in 64% of patients after needle aspiration had been performed as the only diagnostic modality, and on-site analysis identified diagnostic material from the first site aspirated in 50% of patients. Only in 2 patients (2%) diagnostic aspirates were not recognized on site. On-site analysis was cost effective due to savings for disposable diagnostic tools, which exceeded the extra expense for the on-site cytology service provided.

CONCLUSIONS

Rapid on-site analysis of transbronchial aspirates is a highly useful, accurate and cost-effective addition to routine diagnostic bronchoscopy.

Punção aspirativa transbrônquica por agulha no diagnóstico e estadiamento do câncer de pulmão

INTRODUÇÃO: Nos últimos anos, a punção aspirativa transbrônquica por agulha vem sendo utilizada cada vez com maior freqüência no diagnóstico e estadiamento do câncer de pulmão, principalmente nos EUA. Entretanto, muito pouco se tem publicado a respeito do método em nosso país. OBJETIVO: Avaliar a efetividade da punção aspirativa transbrônquica por agulha no diagnóstico e estadiamento do câncer de pulmão. MÉTODO: Setenta e quatro punções aspirativas transbrônquicas por agulha, realizadas no Hospital do Câncer-INCA/MS, foram revistas retrospectivamente. Todos os pacientes realizaram tomografia computadorizada do tórax previamente ao procedimento. RESULTADOS: Onze (15%) pacientes tinham massas mediastinais e 63 (85%) massas hilares. Foram encontradas 76 alterações endoscópicas: alargamento da carina principal em 44 (59%) pacientes, alargamento de carina secundária em 12 (16%), compressão paratraqueal em 5 (7%), compressão da parede posterior da traquéia em 3 (4%), e compressão de brônquio principal em 5 (7%) pacientes. O material foi satisfatório para o diagnóstico em 42 (57%) pacientes e em 34 (46%) o diagnóstico foi confirmado. O diagnóstico de doença maligna foi confirmado em 30/34 (88%) pacientes: carcinoma indiferenciado de pequenas células em 10/30 (33%), carcinoma escamoso em 7/30 (23%), adenocarcinoma em 7/30 (23%), e carcinoma não pequenas células em 6/30 (20%) pacientes. Em 4/30 (12%) pacientes foram diagnosticadas patologias benignas: tuberculose em 2/4 (50%) e sarcoidose em 2/4 (50%) pacientes. Não observamos nenhuma complicação com o método. CONCLUSÃO: Nossa experiência em 74 pacientes mostrou que o procedimento é seguro, rápido em sua realização, com mínimas complicações e de utilidade no diagnóstico e estadiamento de pacientes com neoplasia pulmonar.