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

EBUS guided trans-esophgeal cryobiopsy-two case reports

ABSTRACT

Endobronchial ultrasound (EBUS) guided mediastinal cryobiopsy is a novel technique which can be combined with EBUS -TBNA to improve the diagnostic yield. Recent studies report, this technique is safe and superior to EBUS TBNA alone in terms of acquisition of larger tissue samples and thereby a better diagnostic yield and adequacy of tissue for molecular studies. However, safety of this technique in patients do not tolerate a bronchoscopic procedure due to hypoxia or respiratory distress is not clarified yet. Alternatively, EBUS guided FNA via trans-esophageal route(EUS-B-FNA) is a proven technique with a similar diagnostic yield as EBUS TBNA with a better tolerance and a more patient comfort. We report two patients here, in whom EUS- B guided cryobiopsy was successfully done via trans-esophageal route, due to intolerance for bronchoscopic procedure and inconclusive ROSE reports.

An update on the role of endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer management

INTRODUCTION

Accurate diagnosis and staging are essential for optimizing lung cancer management. The 9th edition of the TNM classification emphasizes distinguishing between single-station and multi-station N2 disease, highlighting the necessity of comprehensive mediastinal node assessment for clinical staging. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive modality used for nodal staging and diagnosis of lung cancer, offering a diagnostic yield comparable to that of mediastinoscopy when performed by experts. Additionally, EBUS-TBNA facilitates essential ancillary testing, including next-generation sequencing (NGS)-based biomarker panels and PD-L1 immunohistochemistry, which are critical for evaluating the suitability of targeted therapies and immune checkpoint inhibitors. Notably, advancements in perioperative management, such as neoadjuvant and adjuvant therapies with immunotherapy and targeted agents, have improved the outcomes of locally advanced diseases. EBUS-TBNA helps identify patients with early-stage lung cancer who are candidates for perioperative therapy.

AREAS COVERED

This review discusses lung cancer diagnosis, nodal staging, the 9th TNM classification, biomarker testing, PD-L1 immunohistochemistry, and precision medicine.

EXPERT OPINION

Lung cancer management requires pathological diagnosis, including histological subtyping, accurate nodal staging of the hilum and mediastinum, and NGS-based biomarker and PD-L1 testing. EBUS-TBNA achieves all three in a single session, making it indispensable in modern lung cancer care.

Silicosarcoidosis: Histologic and Clinical Features of an Occupational Granulomatous Disease

Sarcoidosis is a multisystem inflammatory disease of unknown etiology. Growing evidence indicates that occupational exposure to respirable crystalline silica (RCS) is associated with an increased incidence of sarcoidosis. Yet a diagnosis of sarcoidosis rarely prompts investigation to identify preventable exposures. We sought to elucidate features that identify this important clinical syndrome of silicosarcoidosis. We assembled a multinational case series of workers with sarcoidosis who also reported occupational RCS exposure. We characterized clinical and histopathologic findings using a standardized instrument. We also assessed lung specimens using a novel quantitative microscopy technique to measure birefringent dust density in silicosarcoidosis cases and compared them to control groups. We identified 35 silicosarcoidosis cases (97% male, mean age 48 years) from the United States, Israel, and Taiwan who reported 21 ± 9 years of RCS exposure. On histology scoring, 25/29 (86%) had granulomas and 17/18 (94%) with evaluable lung tissue had lymphocytic inflammation and/or lymphoid aggregates. Common lung interstitial findings included silicotic nodules (39%), mixed-dust macules/nodules (44%), and birefringent dust (50%). Quantitative birefringent dust density was significantly greater (p < 0.001) in silicosarcoidosis cases compared with healthy controls (147 ± 179 vs. 12 ± 9 particles/mm2) but lower than in coal miners with silica-related progressive massive fibrosis (623 ± 777). We found significant differences in the frequency of histologic abnormalities in large versus small biopsy specimens, with fewer findings of RCS exposure in smaller tissue samples. The use of the term silicosarcoidosis should enhance recognition of this significant exposure-related granulomatous lung disease and will help guide clinical management that addresses exposure prevention in combination with appropriate pharmacologic treatment.

Efficacy and safety of topical lignocaine anesthesia in improving patient satisfaction after endobronchial ultrasound-guided transbronchial needle aspiration under general anesthesia: A randomized controlled trial

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an effective technique used by thoracic surgeons and pulmonologists. This study evaluated the safety and efficacy of topical lignocaine anesthesia during bronchoscopy to improve the satisfaction of patients undergoing elective EBUS-TBNA under general anesthesia.

METHODS

This was a single-center prospective randomized, double-blind clinical trial in University-affiliated teaching hospitals. A total of 196 patients underwent elective EBUS-TBNA under general anesthesia. Patients were randomly assigned to receive topical anesthesia with 1% lignocaine (T) or saline (C). The primary outcome was coughing frequency immediately after laryngeal mask removal. Secondary outcomes included coughing frequency and intensity (visual analog scale [VAS]), vital sign changes, adverse events, postoperative pulmonary complications, and the Quality of Recovery-15 (QoR-15) questionnaire.

RESULTS

A total of 196 patients underwent randomization (91 in. T and 94 in C). Topical anesthesia with lignocaine significantly reduced the cough rate and VAS score immediately (P < 0.001 and < 0.001, respectively), 10 min (P < 0.001 and < 0.001), and 30 min (P = 0.005 and 0.001) after mask removal, and 2 h post-procedure (P = 0.003 and 0.006). No significant effect on vital signs was observed. The QoR-15 values 24 h after the procedure in group T were higher than those in group C (P < 0.001).

CONCLUSIONS

During EBUS-TBNA under general anesthesia, 1% lignocaine for topical anesthesia significantly decreased the incidence of postoperative coughing and increased patient satisfaction. Topical anesthesia should be routinely administered to patients undergoing EBUS-TBNA under general anesthesia.

REGISTRATION

Chinese Clinical Trial Registry; Registration number: ChiCTR2300072386; URL: https://www.chictr.org.cn/showproj.html?proj=197032.

Impact of Pulmonary and Critical Care Fellow Participation during Advanced Diagnostic Bronchoscopy

Background: Pulmonary and critical care medicine (PCCM) fellows frequently participate in advanced diagnostic bronchoscopy (ADB) procedures. Objective: To investigate the impact of PCCM fellow involvement during ADB on various procedural outcomes in a real-world setting. Methods: This was a retrospective observational cohort study analyzing prospectively collected registry data of consecutive ADB procedures performed between February 2018 and December 2021. Procedure duration, safety, breadth, and diagnostic performance of ADBs performed by PCCM fellows supervised by interventional pulmonologists (IPs) were compared with those completed solely by IP faculty. Results: Among 628 ADBs, fellows participated in 379 (60.3%). With unadjusted analysis, fellow-involved cases were a median 11.5 minutes longer for convex-probe endobronchial ultrasound bronchoscopy (95% confidence interval [CI], 6.0-14.0; P < 0.001) and 10.5 minutes longer for peripheral bronchoscopy (95% CI, 2.0-18.0; P = 0.016). Compared with ADBs performed by IP faculty alone, procedures with second-year (post-graduate year 5) fellows had the largest duration differences. These included convex-probe endobronchial ultrasound bronchoscopy (+14.5 min; 95% CI, 7.0-18.0 min; P < 0.001), cases not using rapid on-site evaluation (+14.0 min; 95% CI, 8.0-21.0 min; P < 0.001) and those performed with moderate sedation (+12.0 min; 95% CI, 7.0-18.0 min; P < 0.001). After multivariate adjustment, fellow-involved procedures overall were 7.2 minutes longer in duration (95% CI, 3.8-10.5; P < 0.001), and 8.8 minutes longer when performed by post-graduate year 5 fellows-an approximate 16% decrease in efficiency. Bronchoscopies performed with fellows were also more likely to experience complications (38.7% compared with 25.8% with faculty procedures; adjusted odds ratio [OR], 2.0; 95% CI, 1.3-3.0; P < 0.001) and be prematurely terminated (adjusted OR, 4.95; 95% CI, 1.44-17.02; P = 0.011). Diagnostic performance and occurrence of major complications were similar between fellow and no-fellow bronchoscopies. Conclusion: Participation of PCCM fellows during ADB increases procedure duration and the risk for minor complications compared with cases completed solely by IPs. Procedures performed with fellows on the steepest portion of the ADB learning curve are the least efficient. Fellowship directors and faculty bronchoscopists should acknowledge these potential impacts on ABD practice while optimizing the approach to bronchoscopy training.

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

BACKGROUND

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

STUDY DESIGN AND METHODS

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

RESULTS

Our systematic review and critical analysis of the literature of the nine Population, Intervention, Comparator, and Outcome questions related to handling and processing EBUS-TBNA specimens resulted in nine evidence-based statements.

INTERPRETATION

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

Real-Life Comparison of Diagnostic Yield and Sample Adequacy of 22 G and 25 G EBUS-TBNB Needles: A Retrospective Study

Background/Objectives: EBUS-TBNA is a safe and minimally invasive procedure to evaluate hilar and mediastinal lymph nodes (LNs). The Franseen needle provides a transbronchial needle biopsy (TBNB). Various needle sizes are available. In the literature, diagnostic yield (DY) and sample adequacy (SA) between needle sizes are still being debated. Methods: In total, 88 patients with lymphadenopathy were consecutively enrolled from June to December 2021. Chest CT and PET/CT scans were performed. Dimension at imaging and EBUS and the standardized uptake value (SUV) were recorded. EBUS-TBNB was performed with 22 G or 25 G needle sizes. DY for cancer and SA for predictive markers were evaluated. Overall DY (ODY) was also evaluated. Results: A 22 G needle was used in 51 patients and a 25 G needle was used in 37 patients with no differences in sex and age. The 22 G population presented a larger median dimension of LN both at imaging and EBUS compared to the 25 G population. Median LN SUV was higher in the 22 G population. Notably, 70 out of 88 patients had LNs suspicious for malignancy, which was higher in the 22 G group compared to the 25 G group (n = 46, 90% vs. n = 24, 65%; p = 0.004). DY for cancer was similar in both groups (84% for 22 G; 91% for 25 G). Also, SA for predictive markers was similar. ODY values were 78% and 92%, respectively, for the 22 G and 25 G needles. Conclusions: The 25 G needle has a higher DY (even if not statistically significant) and SA for predictive markers similar to the 22 G needle; further studies are necessary to evaluate if 25 G is comparable to the 22 G needle.

Effect of high flow nasal cannula versus conventional nasal cannula oxygen therapy in patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration

Patients undergoing endobronchial ultrasound-guided fine needle aspiration may have multiple comorbidities, contributing to higher risks of hypoxia and adverse events, such as arrhythmias. The current study compared the efficacy of two oxygenation modalities: the high-flow nasal cannula (HFNC) vs. conventional oxygen therapy (CNC). Patients were randomized to either the HFNC or the CNC arm. HFNC and CNC were initiated and escalated as per predefined protocols. The number of desaturation events [fall in saturation of peripheral oxygen (SpO2) by 3% from the baseline] and change in levels of transcutaneous CO2 (tcCO2) from baseline were noted. Subgroup analysis was done in patients with cardiopulmonary comorbidities and in patients with SpO2<97%. A total of 122 patients were randomized. Overall, there was no significant difference in the number of desaturation events and change in tcCO2 levels; however, in patients with cardiopulmonary comorbidities (obstructive sleep apnea, heart diseases, and stable chronic obstructive airway disease), 50% in the HFNC arm had no desaturation compared to 11.7% in the CNC arm (p=0.007). 41.17% of patients in the HFNC arm had a rise in tcCO2 levels, compared to 36.11% of patients in the CNC arm (p>0.5). In patients with SpO2<97%, 48.88% in the HFNC arm had no desaturations compared to 14.70% in the CNC arm (p=0.001); there was no statistical difference in rise in tcCO2. Hence, HFNC would be a better modality for oxygenation in patients with a high risk of hypoxia without increasing the risk of hypercapnia.

Diagnostic value and safety of contact laser-assisted endobronchial ultrasound-guided tunnel drilling biopsy in mediastinal and hilar lymphadenopathy: a retrospective study

Introduction

Mediastinal and hilar lymphadenopathies are primarily diagnosed pathologically. Contact laser-assisted endobronchial ultrasound-guided tunnel drilling biopsy (EBUS-TDB), which uses a laser as a tunneling and incision tool, may yield more satisfactory specimens than conventional endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), thereby improving the diagnostic yield. This study aims to evaluate the diagnostic value and safety of contact laser-assisted EBUS-TDB compared to EBUS-TBNA in the assessment of mediastinal and hilar lymph nodes.

Methods

This retrospective study included patients who presented to our hospital between October 2022 and April 2024 with mediastinal or hilar lymph nodes of short diameter ≥ 1 cm on computed tomography (CT) or abnormally increased lymph node metabolism on positron emission tomography (PET)-CT. All patients underwent both EBUS-TBNA and EBUS-TDB procedures successively.

Results

Overall, 278 patients were included in the study, and 244 cases were confirmed. The diagnostic rates (p-values) for EBUS-TDB and EBUS-TBNA in pulmonary and extrapulmonary malignancies, lymphoma, sarcoidosis, and lymph node tuberculosis were 96.6% vs. 76.3% (0.043), 100% vs. 67.7% (-), 88.9% vs. 31.1% (0.555), and 69.2% vs. 30.8% (0.049), respectively. No serious adverse events occurred during or after either procedure.

Conclusion

Contact laser-assisted EBUS-TBNB demonstrates superior diagnostic performance compared to EBUS-TBNA for the evaluation of mediastinal or hilar lymph nodes, making it an alternative to EBUS-TBNA for enhanced diagnostic precision.

Cryoprobe biopsy versus mechanical biopsies in pulmonary diagnostics

PURPOSE OF REVIEW

Biopsy tools have been essential in improving the diagnostic accuracy of bronchoscopic procedures. Of these tools, cryobiopsy has emerged as a promising technique for diagnosing thoracic diseases. This review summarizes the existing data comparing cryobiopsies to other mechanical biopsy methods for sampling endobronchial, parenchymal, and mediastinal targets.

RECENT FINDINGS

Initially adopted for managing airway stenoses, the use of cryoprobes has expanded to diagnosing endobronchial lesions, parenchymal opacities, and mediastinal lymph node pathologies. Studies have demonstrated that cryobiopsy offers a higher diagnostic yield than forceps biopsy alone. By leveraging the Joule-Thomson effect to freeze and collect larger tissue samples compared to traditional methods, cryobiopsy improves diagnostic accuracy and helps in better characterizing the nature of the lesions. While the risk of complications, such as pneumothorax and hemorrhage are comparable to, or higher than traditional biopsy methods, cryobiopsy's enhanced diagnostic capabilities make it a valuable tool in the assessment of pulmonary disease.

SUMMARY

Compared with other mechanical biopsy techniques, cryoprobe biopsies significantly enhance the diagnostic yield for endobronchial lesions, interstitial lung disease, pulmonary nodules, and mediastinal lymph nodes.

Ultrasound-guided transbronchial cryobiopsy of mediastinal and hilar lesions: a multicenter pragmatic cohort study with real-world evidence

BACKGROUND

Limited data exist on the reliability, efficacy and safety of ultrasound-guided transbronchial cryobiopsy for suspicious mediastinal and hilar lesions. This study shares findings from implementing this method and compares the results with those of the standard endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

METHODS

Patients undergoing diagnostic bronchoscopy for mediastinal or hilar lesions in four Swiss centres were included. The study aims to assess the diagnostic yield and safety of EBUS-guided cryobiopsy compared with EBUS-TBNA. Tunnelling to the target lesion was performed using an electric needle knife (70.8%), a 19 G- (12.4%) or a 22 G needle (16.8%). Cryobiopsies were obtained with a freezing time of 4-7 s (18.2% with a 1.7 mm probe) or 6-10 s (81.8% with a 1.1 mm probe).

RESULTS

Altogether, 137 patients were enrolled with a median follow-up of 89 days. The overall diagnostic yield was 56.2% for EBUS-TBNA and 91.2% for cryobiopsies (p<0.001). Cryobiopsies increased the diagnostic yield for benign disorders (+28.5%), uncommon tumours (+5.9%) and other metastatic cancer (+0.6%), but not for lung cancer (+0%). For lung cancer (n=27), immunohistochemistry was obtainable in 40.7% of EBUS-TBNA (median of 3 probes [IQR 3 to 3]), significantly lower than cryobiopsy's 88.9% yield (median of 4 probes [IQR 3 to 5]) (p<0.001). Adverse events were found in 23.4% of participants; 10.2% had mild to moderate bleeding, 0.7% had pneumonia, and 0.7% (one) of patients had pneumothorax following pneumomediastinum. No deaths or mediastinum infections were observed.

CONCLUSION

Cryobiopsy of mediastinal and hilar lesions improves the diagnostic yield compared with EBUS-TBNA while maintaining a favourable safety profile.

Successful Diagnosis of a SMARCA4-Deficient Undifferentiated Tumor via Endobronchial Ultrasound-Guided Fine Needle Aspiration and Endobronchial Biopsies

Lung cancer is the third most prevalent cancer, following breast cancer in women and prostate cancer in men. However, it remains the leading cause of cancer-related mortality. As treatment options have advanced, the significance of accurate diagnosis has increased, enabling targeted and more personalized therapeutic treatments. SMARCA4-deficient thoracic tumors are a relatively new classification of mediastinal lung cancers that are known to be difficult to diagnose with conventional endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). Newer modalities such as endobronchial ultrasound with cryobiopsy have emerged, and studies have indicated that they offer increased diagnostic yield when coupled with conventional EBUS-TBNA. Here, we present a case in which EBUS-TBNA alone produced sufficient tissue volume for immunohistochemistry at NeoGenomics (Fort Myers, FL), leading to a successful diagnosis.

The Impact of Balloon Use during Endobronchial Ultrasound: A Randomized Pilot Study

INTRODUCTION

During endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA), a saline-filled balloon placed over the tip of the bronchoscope is used to improve coupling of the ultrasound transducer to the airway wall. However, it is unknown whether it objectively improves image quality or affects procedural outcomes. Our aim was to establish whether the use of a balloon during EBUS impacts image quality, diagnostic yield, procedure duration or complications.

METHODS

A pilot randomized control trial of patients undergoing EBUS-TBNA of mediastinal lymph nodes was performed at a single academic center. Patients were randomized to use a saline-filled balloon (versus no balloon use) during EBUS-TBNA of the right lower paratracheal lymph node (station 4R). The EBUS videos were recorded and scored on a 4-point Likert scale by three blinded external reviewers. The primary outcome of this study was ultrasound image quality. Secondary outcomes included diagnostic yield, procedure duration, and complications.

RESULTS

Forty-six patients were randomized. In the balloon group, 61% of patients had an image quality score of "excellent" or "good," compared to 47% in the no balloon group (p = 0.009). There was no significant difference in diagnostic yield, procedure duration, or complications between the groups.

CONCLUSION

Inflation of the balloon during EBUS-TBNA at the right lower paratracheal lymph node improves ultrasound image quality but does not impact diagnostic yield, procedure duration, or safety. This study provides a framework for additional studies with complete nodal assessment to determine if balloon use has a clinically meaningful benefit to procedural outcomes.

Different pathways to lung cancer diagnosis in a real-life setting

BACKGROUND

Most lung cancers are diagnosed at an advanced stage and therefore have a poor prognosis. One major challenge is to choose the most adapted sampling technique to obtain a rapid pathological diagnosis so as to start treatment as early as possible. A growing number of techniques have been developed in recent years. This study sought to assess the diagnostic efficiency of each, along with the respective duration of the diagnostic pathways.

METHODS

This retrospective, bicentric, observational study enrolled patients with inoperable lung cancer (stage III or IV) diagnosed in 2018-2019. Diagnostic efficiency was assessed based on the different examinations performed to achieve a precise diagnosis (pathology, immunohistochemistry, and/or molecular biology). The time between the first medical contact and treatment initiation was also assessed.

RESULTS

Overall, 625 patients were included (median age 67 years; men 67 %; adenocarcinoma 55 %). The most frequent examinations were bronchial endoscopy (n = 469, 75 %), followed by metastasis biopsy (n = 137, 21.9 %) and guided transthoracic core-needle biopsy (TCNB) (n = 116, 18.6 %). 372 patients had only one procedure (59.5 %), mainly bronchial endoscopy (n = 217, 34.7 %) and metastasis biopsy (n = 71, 11 %). The most efficient examination was thoracic surgery (surgical pleural biopsy, (n = 32, 100 %); mediastinoscopy (n = 26, 96.3 %); surgical pulmonary biopsy (n = 14, 93.3 %). The second most efficient examination was metastasis biopsy (n = 126, 94 %) followed by guided TCNB (n = 108, 93.1 %). The median time from first medical contact to first examination was 4 days (interquartile range 25 %-75 % 1-8). The median time from first medical contact to pathological result was 17 days (10-34). The median time from first medical contact to treatment start was 48 days (30-69).

CONCLUSIONS

In order to make an accurate and rapid diagnosis of lung cancer, it is crucial to choose the most appropriate technique. Bronchial endoscopy remains the first-line examination for central lesions, as it is efficient and easily accessible. Guided TCNB and metastasis biopsy are the preferred techniques for peripheral lesions. The choice of the diagnostic technique should be part of a multidisciplinary approach and a dedicated pathway to optimize initial management.

Biomarker Testing for Guiding Precision Medicine for Patients With Non-Small Cell Lung Cancer

The initial management of patients with lung cancer is growing more complex in the context of an expanding number of precision medicine treatments. These challenges are accompanied by opportunities to deliver more efficacious and less toxic treatments to patients. Indications for these treatments are also expanding, and patients with lung cancer across multiple stages now require biomarker testing. Given their role in the initial management of patients being diagnosed with lung cancer, pulmonologists must have fundamental knowledge regarding the importance, indications, and implications of biomarker testing across the spectrum of histology and stage. The purpose of this review is to provide fundamental knowledge regarding biomarker testing, its incorporation into the initial diagnostic and staging evaluation, and guidance for working within a multidisciplinary team to achieve timely and comprehensive biomarker testing to direct the use of precision medicine treatments.

Pulmonologists' Attitudes and Role in Precision Medicine Biomarker Testing for Non-Small Cell Lung Cancer

BACKGROUND

Despite advances in precision medicine for non-small cell lung cancer (NSCLC), biomarker testing for these therapies remains frequently underused, delayed, and inequitable. Pulmonologists often play a critical role in the initial diagnostic steps for patients with lung cancer, and previous data show variability in their knowledge and practices regarding biomarker testing. The purpose of this study is to better understand how pulmonologists view their role in lung cancer care.

RESEARCH QUESTION

With the increasing importance of biomarker testing and precision medicine, how do pulmonologists view their role in lung cancer care?

STUDY DESIGN

An electronic survey consisting of 31 items focused on attitudes and practices regarding diagnostic steps for NSCLC was randomly distributed to a sample of practicing pulmonologists in the American College of Chest Physicians (CHEST) analytics database. Inferential statistics were performed using χ2 tests and multivariable logistic regression models.

RESULTS

A total of 401 pulmonologists responded to the survey. Most (92%) were general pulmonologists, and more than one-half (62%) indicated they order biomarker testing. Longer practice tenure, higher case volumes, and participation in a multidisciplinary tumor board were associated with ordering biomarkers (P < .05). Pulmonology was identified to have the leading responsibility for the initial diagnostic biopsy by most respondents (83%) and less often for staging (45%), leading discussions about biomarker testing with patients (28%), and for ordering biomarkers (22%). The most common reasons for not ordering biomarkers included the following: oncology was responsible (84%), it was not within their scope of practice (46%), or lack of the necessary knowledge (51%).

INTERPRETATION

This study shows that pulmonologists vary in their practices for ordering biomarkers, and many defer this responsibility to oncology. Despite the role of bronchoscopy and pulmonology societal guidelines for staging, many defer leadership of this process. Many pulmonologists lack the necessary resources and multidisciplinary infrastructure likely required to efficiently accomplish biomarker testing.

Minimally Invasive Sampling of Mediastinal Lesions

This narrative review examines the existing literature on minimally invasive image-guided sampling techniques of mediastinal lesions gathered from international databases (Medline, PubMed, Scopus, and Google Scholar). Original studies, systematic reviews with meta-analyses, randomized controlled trials, and case reports published between January 2009 and November 2023 were included. Four authors independently conducted the search to minimize bias, removed duplicates, and selected and evaluated the studies. The review focuses on the recent advancements in mediastinal sampling techniques, including EBUS-TBNA, EUS-FNA and FNB, IFB, and nodal cryobiopsy. The review highlights the advantages of an integrated approach using these techniques for diagnosing and staging mediastinal diseases, which, when used competently, significantly increase diagnostic yield and accuracy.

Diagnostic yield and safety of repeat bronchoscopy in pulmonary disease: A five-year retrospective analysis

AIM

In this study, we aim to analyze the frequency and indications of repeat bronchoscopic procedures performed at our hospital over a five-year period.

METHODS

This retrospective study was conducted at the Department of Pulmonary Diseases, Akdeniz University, and included patients who underwent bronchoscopy between January 1, 2018, and May 31, 2024. Patients who required a repeat bronchoscopy were identified. Inclusion criteria for the repeat bronchoscopy group were non-diagnostic initial bronchoscopy or the need for additional samples for molecular testing in lung cancer patients. Exclusion criteria included patients with incomplete medical records or those who did not provide informed consent for the repeat procedure.

FINDINGS

A total of 3877 patients underwent bronchoscopy in this time periods. Among these, 69 patients (1.8 %) required a repeat bronchoscopy. The mean age of these patients was 61.3 ± 11.7 years, with 54 (78 %) being male. The most common reason for the repeat procedure was the non-diagnostic outcome of the initial bronchoscopy (n = 53, 77 %), followed by cases where the initial bronchoscopy was diagnostic for lung cancer but insufficient for molecular testing (n = 16, 23 %). Among the 16 patients who underwent molecular testing, sufficient samples for molecular tests were obtained in 12 patients (75 %) following the second bronchoscopy. Molecular tests were negative for driver mutations in 6 patients, while 6 patients tested positive (PD-L1, n = 5; EGFR, n = 1). In 4 patients (25 %), the sample was reported as insufficient for molecular testing. Patients who underwent repeat bronchoscopy had the second procedure an average of 38.5 ± 59.7 days after the initial procedure. No complications developed in patients undergoing repeat bronchoscopy, except for bleeding not requiring intervention related to the bronchoscopy procedure.

CONCLUSION

In conclusion, regardless of the reason, repeated bronchoscopy in suitable patients is safe and has a high diagnostic yield.

Differential Diagnosis of Pathological Type of Peripheral Lung Cancer with Multimodal Contrast-Enhanced Ultrasound

OBJECTIVE

The goal of the work described here was to investigate the role of multimodal contrast-enhanced ultrasound in the differential diagnosis of peripheral lung cancer.

METHODS

From April 2017 to July 2021, 109 patients with confirmed pulmonary malignant lesions who underwent CEUS examination were involved in our study. Seven patients were excluded because of the short duration of CEUS video or unsatisfactory imaging. Finally,102 patients with peripheral lung cancer were enrolled in this study. The maximum diameter of the lesions ranged from 1.6 to 13.0 cm (mean 6.2 ± 2.3 cm). On the basis of the pathological results, the patients were divided into the small cell lung cancer (SCLC) group and non-small cell lung cancer (NSCLC) group (including adenocarcinoma, lung squamous cell carcinoma and large cell neuroendocrine carcinoma). A Logiq E9 ultrasonic machine equipped with a 3.5 to 5.0 MHz C5-1 probe was used. Patient clinical information, CEUS features, CPI patterns and TIC parameters were analyzed and compared between different groups. Statistical analyses were performed with SPSS software and MedCalc software. The receiver operating characteristic curve was plotted.

RESULTS

In the differential diagnosis of SCLC and NSCLC, color parametric imaging indicated great performance. NSCLC exhibited a centripetal enhancement pattern more frequently (72.7%), while SCLC exhibited an eccentric enhancement pattern more frequently (92.9%) (p < 0.001). In the differential diagnosis of adenocarcinoma and squamous cell carcinoma, logistic regression analysis revealed that patient age of onset ≤60 y, difference in arrival time between lung and tumor ≤3.8 s, drop time of the time-intensity curve >23.2 s and absence of internal necrosis on CEUS were independent predictors for adenocarcinoma (area under the curve = 0.861).

CONCLUSION

In our study, multimodal contrast-enhanced ultrasound provided useful information in the differential diagnosis between small cell lung cancer and non-small cell lung cancer, especially between adenocarcinoma and squamous cell carcinoma.

Evaluating Fellowship Training for Endobronchial Ultrasound-Transbronchial Needle Aspiration (EBUS-TBNA) Using the EBUS-Skills and Task Assessment Tool (STAT) and High-Fidelity Bronchoscopy Simulator

BACKGROUND

There are two approaches for endobronchial ultrasound (EBUS) training: the traditional apprenticeship approach involving 'see one, do one, teach one', and the computer-based simulation approach. In the traditional approach, the trainee learns under direct supervision from an expert preceptor while performing on patients. In the latter approach, trainees use a high-fidelity bronchoscopy simulator, undertake a skills assessment exam (Endobronchial Ultrasound Skills and Task Assessment Tool (EBUS-STAT)), and receive supervised patient-based training from experienced clinicians. The primary objective of this study was to determine whether a single-day EBUS-transbronchial needle aspiration (TBNA) training course, using high-fidelity simulation and the EBUS-STAT tool, increased the confidence of pulmonary fellows for performing EBUS-TBNA procedures.

METHODS

Fellowship confidence was measured using a 10-item questionnaire, the EBUS self-assessment tool (EBUS-SAT). This questionnaire was completed before and after EBUS training. The secondary objectives were to determine whether EBUS-STAT varied by year of training and to evaluate the utility of incorporating the EBUS-TBNA training session into fellowship education.

RESULTS

We found that a single day of EBUS-TBNA training using high-fidelity simulation and the EBUS-STAT tool increased the confidence of the first- and third-year pulmonary fellows. The mean improvements in EBUS-SAT questionnaire scores pre- and post-EBUS training session were 13.3 points (p = 0.002) for the first-year fellows and 8.5 points (p = 0.0001) for the third-year fellows. Regarding the secondary objectives, we found no significant difference between EBUS-STAT scores of the first- and third-year pulmonary fellows (p = 0.71).

CONCLUSIONS

Combining high-fidelity bronchoscopy simulator training with the EBUS-STAT assessment tool was found to benefit and improve training in EBUS-TBNA and should be incorporated into fellowship training programs.

Comparison of cryobiopsy and forceps biopsy for the diagnosis of mediastinal lesions: A randomised clinical trial

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard approach for lung cancer staging. However, its diagnostic utility for other mediastinal diseases might be hampered by the limited tissue retrieved. Recent evidence suggests the novel sampling strategies of forceps biopsy and cryobiopsy as auxiliary techniques to EBUS-TBNA, considering their capacity for larger diagnostic samples.

METHODS

This study determined the added value of forceps biopsy and cryobiopsy for the diagnosis of mediastinal diseases. Consecutive patients with mediastinal lesions of 1 cm or more in the short axis were enrolled. Following completion of needle aspiration, three forceps biopsies and one cryobiopsy were performed in a randomised pattern. Primary endpoints included diagnostic yield defined as the percentage of patients for whom mediastinal biopsy led to a definite diagnosis, and procedure-related complications.

RESULTS

In total, 155 patients were recruited and randomly assigned. Supplementing EBUS-TBNA with either forceps biopsy or cryobiopsy increased diagnostic yield, with no significant difference between EBUS-TBNA plus forceps biopsy and EBUS-TBNA plus cryobiopsy (85.7 % versus 91.6 %, P = 0.106). Yet, samples obtained by additional cryobiopsies were more qualified for lung cancer molecular testing than those from forceps biopsies (100.0 % versus 89.5 %, P = 0.036). When compared directly, the overall diagnostic yield of cryobiopsy was superior to forceps biopsy (85.7 % versus 70.8 %, P = 0.001). Cryobiopsies produced greater samples in shorter procedural time than forceps biopsies. Two (1.3 %) cases of postprocedural pneumothorax were detected.

CONCLUSIONS

Transbronchial mediastinal cryobiopsy might be a promising complementary tool to supplement traditional needle biopsy for increased diagnostic yield and tissue harvesting.

TRIAL REGISTRATION

ChiCTR2000030373.

Navigated ultrasound bronchoscopy with integrated positron emission tomography-A human feasibility study

BACKGROUND AND OBJECTIVE

Patients suspected to have lung cancer, undergo endobronchial ultrasound bronchoscopy (EBUS) for the purpose of diagnosis and staging. For presumptive curable patients, the EBUS bronchoscopy is planned based on images and data from computed tomography (CT) images and positron emission tomography (PET). Our study aimed to evaluate the feasibility of a multimodal electromagnetic navigation platform for EBUS bronchoscopy, integrating ultrasound and segmented CT, and PET scan imaging data.

METHODS

The proof-of-concept study included patients with suspected lung cancer and pathological mediastinal/hilar lymph nodes identified on both CT and PET scans. Images obtained from these two modalities were segmented to delineate target lymph nodes and then incorporated into the CustusX navigation platform. The EBUS bronchoscope was equipped with a sensor, calibrated, and affixed to a 3D printed click-on device positioned at the bronchoscope's tip. Navigation accuracy was measured postoperatively using ultrasound recordings.

RESULTS

The study enrolled three patients, all presenting with suspected mediastinal lymph node metastasis (N1-3). All PET-positive lymph nodes were displayed in the navigation platform during the EBUS procedures. In total, five distinct lymph nodes were sampled, yielding malignant cells from three nodes and lymphocytes from the remaining two. The median accuracy of the navigation system was 7.7 mm.

CONCLUSION

Our study introduces a feasible multimodal electromagnetic navigation platform that combines intraoperative ultrasound with preoperative segmented CT and PET imaging data for EBUS lymph node staging examinations. This innovative approach holds promise for enhancing the accuracy and effectiveness of EBUS procedures.

Near-Infrared On-Site Evaluation (NOSE) Examination of EBUS/EUSb Samples-A New Method for Sample Adequacy Evaluation

Fine-needle aspiration biopsy is crucial for modern diagnostics of endoscopic procedures and thus an efficient and reliable method for increasing biopsy yields is urgently needed. In our study, we address the limited availability and high price of the rapid onsite evaluation (ROSE) technique by introducing the technique of near-infrared on-site evaluation (NOSE) consisting of spectral measurement of near-infrared radiation (NIR) transmitted through the evaluated material. For this purpose, we designed a special optical probe consisting of two fibres, of which one is a source fibre and the second is a detector fibre. The distal ends of both fibres are brought together into one bundle which is, with the help of a special extension, applied to a cuvette with an analysed sample at a defined distance from the cuvette bottom and fixed in place. A portion of the NIR radiation received by the detector fibre after it propagates through the sample then depends on the optical and therefore morphological characteristics of the sample. Based on the measured spectral curve, we can calculate the attenuation coefficient curve and subsequently the parameter of the sample richness and the parameter characterising the autofluorescence peak as well. We found that the value of our introduced parameters is in significant relation to sample richness as well as to sample malignity. NOSE evaluation of EBUS/EUSb (endobronchial/oesophageal ultrasound bronchoscopy) specimens can be considered an easy new technique aiming to improve sampling diagnostic accuracy and to diminish costs related to the presence of a cytopathologist and related instrumentation in the endoscopy suite.

Comparison between Endobronchial Ultrasound-Guided Transbronchial Node Biopsy and Transbronchial Needle Aspiration: A Meta-Analysis

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be limited by the inadequacy of intact tissues, especially in patients with lymphoma, sarcoidosis, and lymph node tuberculosis. A novel technique called transbronchial node biopsy (TBNB) by forceps or cryoprobe has been proposed and studied to improve specimen quality and diagnostic yield. We performed a systematic review of studies describing the safety and sensitivity of EBUS-TBNB versus EBUS-TBNA in diagnosing intrathoracic lymphadenopathy/masses.

METHODS

We systematically searched MEDLINE, Embase, Cochrane, and China National Knowledge Infrastructure to identify studies focusing on the application of EBUS-TBNB for diagnosis of intrathoracic lymphadenopathy. The quality of each study was evaluated using the QUADAS-2 tool. Using inverse-variance (I-V) weighting, we performed a meta-analysis of diagnostic yield estimations. We also reviewed the complications related to the procedure.

RESULTS

Thirteen studies were included in the final analysis. The meta-analysis yielded a pooled overall diagnostic yield of 77.80% (939/1,207) for EBUS-TBNA and 86.01% (834/958) for EBUS-TBNB, with an inverse-variance-weighted odds ratio of 3.13 (95% confidence interval [CI], 1.61-6.01; p = 0.0008) and I2 of 82%. The pooled diagnostic yield of EBUS-TBNB versus EBUS-TBNA for the diagnosis of malignancy (including primary lung cancer and extrapulmonary malignancy) was 84.53% (590/698) for EBUS-TBNA and 90.84% (476/524) for EBUS-TBNB, with an I-V-weighted OR of 2.33 (95% CI, 1.15-4.74; p = 0.02) and I2 of 64%. The pooled diagnostic yield of EBUS-TBNB versus EBUS-TBNA for the diagnosis of benignancy was 71.19% (252/354) for EBUS-TBNA and 86.62% (233/269) for EBUS-TBNB, with an I-V-weighted OR of 4.39 (95% CI, 2.00-9.65; p = 0.002) and I2 of 59%. The overall complications included bleeding (n = 11, 0.90%), pneumomediastinum (n = 6, 0.49%), pneumothorax (n = 6, 0.49%), pneumonia (n = 4, 0.33%), respiratory failure (n = 1, 0.08%), and haemoptysis (n = 1, 0.08%). The funnel plot analysis illustrated no major publication bias.

CONCLUSIONS

EBUS-TBNB improves the overall diagnostic yield of sampling intrathoracic lymphadenopathy and mass lesions relative to EBUS-TBNA. The complication rate of EBUS-TBNB is higher than that of EBUS-TBNA but reportedly lower than that of surgical biopsies.

An explorative analysis on the optimal cryo-passes and freezing time of the ultrathin cryoprobe in endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy

EBUS-guided transbronchial mediastinal cryobiopsy (TBMC) has emerged as a promising biopsy tool for diagnosing hilar and mediastinal pathologies. However, several fundamental technical aspects of TBMC remain unexplored. This study aims to determine the optimal number of cryo-passes and freezing time of the ultrathin cryoprobe in EBUS-TBMC concerning specimen size and procedural diagnostic yield. We conducted a retrospective chart review of patients with mediastinal and hilar lesions who underwent EBUS-TBMC between January 2021 and April 2023 across three hospitals in Malaysia. A total of 129 EBUS-TBMC procedures were successfully completed, achieving an overall diagnostic yield of 88.4%. Conclusive TBMC procedures were associated with larger specimen sizes (7.0 vs. 5.0 mm, p < 0.01). Specimen size demonstrated a positive correlation with diagnostic yield (p < 0.01), plateauing at specimen size of 4.1-6.0 mm. A significant positive correlation was also observed between the number of cryo-passes and both specimen size (p < 0.01) and diagnostic yield (p < 0.05). Diagnostic yield plateaued after 2-3 cryo-passes. In contrast, longer freezing times trended towards smaller specimens and lower diagnostic yield, though not reaching statistical significance. The highest diagnostic yield was recorded at the 3.1-4.0 s freezing time. The safety profile of TBMC remains favourable, with one case (0.8%) of pneumothorax and nine cases (7%) of self-limiting bleeding. In our cohort, TBMC performance with 2-3 cryo-passes and a 3.1-4.0 s freezing time to achieve a total aggregate specimen size of 4.1-6.0 mm appeared optimal. Further prospective studies are needed to validate these findings.

Preoperative mediastinal staging in early-stage lung cancer: Targeted nodal sampling is not inferior to systematic nodal sampling

OBJECTIVE

To determine whether targeted sampling (TS), which omits biopsy of triple- normal lymph nodes (LNs) on positron emission tomography, computed tomography, and endobronchial ultrasound (EBUS), is noninferior to systematic sampling (SS) of mediastinal LNs during EBUS for staging of patients with early-stage non-small cell lung cancer (NSCLC).

METHODS

Patients who are clinical nodal (cN)0-N1 with suspected NSCLC eligible for EBUS based on positron emission tomography/computed tomography were enrolled in this prospective, multicenter trial. During EBUS, all patients underwent TS and then crossed over to SS, whereby at least 3 mediastinal LN stations (4R, 4L, 7) were routinely sampled. Gold standard of comparison was pathologic results. Based on the previous feasibility trial, a noninferiority margin of 6% was established for difference in missed nodal metastasis (MNM) incidence between TS and SS. The McNemar test on paired proportions was used to determine MNM incidence for each sampling method. Analysis was per-protocol using a level of significance of P < .05.

RESULTS

Between November 2020 and April 2022, 91 patients were enrolled at 6 high-volume Canadian tertiary care centers. A total of 256 LNs underwent TS and SS. Incidence of MNM was 0.78% in SS and 2.34% in TS, with an absolute difference of 1.56% (95% confidence interval, -0.003% to 4.1%; P = .13). This falls within the noninferiority margin. A total of 6/256 LNs from 4 patients who were not sampled by TS were found to be malignant when sampled by SS.

CONCLUSIONS

In high-volume thoracic endosonography centers, TS is not inferior to SS in nodal staging of early-stage NSCLC. This results in change of clinical management for a minority of patients.

Improving diagnostic strategies in bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

In the past two decades, bronchoscopy of peripheral pulmonary lesions (PPLs) has improved its diagnostic yield due to the combination of various instruments and devices. Meanwhile, the application is complex and intertwined.

AREAS COVERED

This review article outlines strategies in diagnostic bronchoscopy for PPLs. We summarize the utility and evidence of key instruments and devices based on the results of clinical trials. Future perspectives of bronchoscopy for PPLs are also discussed.

EXPERT OPINION

The accuracy of reaching PPLs by bronchoscopy has improved significantly with the introduction of combined instruments such as navigation, radial endobronchial ultrasound, digital tomosynthesis, and cone-beam computed tomography. It has been accelerated with the advent of approach tools such as newer ultrathin bronchoscopes and robotic-assisted bronchoscopy. In addition, needle aspiration and cryobiopsy provide further diagnostic opportunities beyond forceps biopsy. Rapid on-site evaluation may also play an important role in decision making during the procedures. As a result, the diagnostic yield of bronchoscopy for PPLs has improved to a level comparable to that of transthoracic needle biopsy. The techniques and technologies developed in the diagnosis will be carried over to the next step in the transbronchial treatment of PPLs in the future.

Imbalance of B-Cell Subpopulations in the Microenvironment of Sarcoidosis or Lung Cancer

Although the role of T lymphocytes in sarcoidosis (SA) and lung cancer (LC) is quite well reported, the occurrence of B cells in disease microenvironments may suggest their potential role as natural modifiers of the immune response. The aim of this study was to investigate the B-cell profile and lymphocyte-related hematological parameters between patients with SA, LC and healthy controls (HCs). The cells were assessed by flow cytometry and a hematological analyzer in peripheral blood (PB) and material from lymph nodes (LNs) obtained by the EBUS/TBNA method. We showed that in SA patients, there were higher percentages of naïve B and CD21low B cells and a lower percentage of class-switched memory B cells than LC patients in LNs. We observed a higher median proportion of non-switched memory and transitional B cells in the PB of SA patients than in LC patients. We noticed the lowest median proportion of class-switched memory B cells in the PB from SA patients. LC patients had a higher percentage of RE-LYMP and AS-LYMP than SA patients. Our study presented a different profile of B-cell subpopulations in SA and LC patients, distinguishing dominant subpopulations, and showed the relocation from distant compartments of the circulation to the disease microenvironment, thus emphasizing their role.

Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States

INTRODUCTION

Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9].

METHODS

We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States.

RESULTS

We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows.

DISCUSSION

This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

Comparing Patient Comfort During Bronchoscopy Under Conscious Sedation and Monitored Anesthesia Care: A Prospective, Observational, Controlled Study

BACKGROUND

Flexible bronchoscopy (FB) often involves sedation, with the choice left to the bronchoscopist's discretion. Prior research on sedation in gastroscopic endoscopies yields conflicting information regarding the preferred method for FB. This study compares patient comfort levels during bronchoscopy with mindful sedation using fentanyl, nalbuphine, and midazolam versus monitored anesthesia care (MAC) using propofol, midazolam, and ketamine.

METHODS

This prospective observational study assessed 83 patients undergoing bronchoscopy under either conscious sedation (CS) (n=40) or MAC (n=43). Patient comfort, sedation levels, emotional state, recovery time, safety, and the impact of smoking history and comorbidities were evaluated. Data collection included direct patient questioning and observation using the Modified Observed Assessment of Alertness and Sedation (MOAA/S) form.

RESULTS

Comfort levels were similar between groups, with mean scores of 3.6±0.89 for CS and 3.3±0.54 for MAC. MAC induced deeper sedation (mean scores: 4.37±0.66 vs. 3.8±0.98). Recovery time and complications were comparable. Emotional states and medical history did not significantly differ between groups.

CONCLUSION

CS is not inferior to MAC for bronchoscopy, providing comparable comfort and safety with less intense sedation and lower cost. These findings support the use of CS for bronchoscopy procedures, offering a cost-effective alternative without compromising patient comfort or safety.

Dexmedetomidine Moderate Sedation Versus General Anesthesia on the Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Randomized Controlled Study

Background

One of the factors that affect the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the level of sedation.

Objectives

Therefore, we aimed to compare dexmedetomidine (DEX) as moderate sedation (MS) versus general anesthesia (GA) on the diagnostic yield of EBUS-TBNA.

Methods

This randomized open-label controlled trial was carried out on 70 patients older than 18 years of age, classified as American Society of Anesthesiologists (ASA) II or III, and scheduled for EBUS-TBNA. Patients were randomly allocated into two equal groups. Group D received 1 μg/kg fentanyl 2 minutes before induction with a 1 μg/kg infusion of DEX for 10 minutes, then maintenance with 0.5 - 1 μg/kg/h aiming for a Ramsey Sedation Scale of 4 - 5 while preserving hemodynamics. Group GA received 1 μg/kg fentanyl, 2 mg/kg propofol, and 0.5 mg/kg atracurium (then 0.1 mg/kg every 20 minutes).

Results

Group D had a significantly higher rate of recalling the procedure (P = 0.005) and a lower rate of shortness of breath compared to group GA (P = 0.038). Intraoperative heart rate measurements at baseline were not significantly different between groups but were significantly lower at 5 min, 10 min, 15 min, 20 min, and at the end of surgery in group D compared to group GA (P < 0.05). Intraoperative mean arterial blood pressure measurements at baseline, 5 min, 10 min, 15 min, 20 min, and at the end of surgery were not significantly different between groups. Recovery time was significantly shorter in group D compared to group GA (P < 0.001).

Conclusions

Compared to GA, MS with DEX showed a comparable diagnostic yield with faster recovery time and better patient satisfaction, as evidenced by a willingness to repeat procedures when needed and less shortness of breath in EBUS-TBNA.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

SFB is useful for obtaining sufficient qualitative and quantitative specimens.

Pitfalls in Respiratory Tract Cytopathology

BACKGROUND

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

SUMMARY

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

KEY MESSAGES

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

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

BACKGROUND

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of Patient's Procedural Tolerance of EBUS-TBNA Performed Through Nasal Versus Oral Route: The NO-EBUS Randomized Clinical Trial

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a commonly performed procedure by the bronchoscopist for the evaluation of mediastinal lesions. However, evidence directly comparing the nasal and oral routes to guide the choice of an optimal insertion approach is scanty.

METHODS

In this prospective, parallel-group, open-label randomized clinical trial, adults posted for a linear EBUS-TBNA examination under conscious sedation were randomized to undergo the procedure via the nasal or oral route. The primary objective was to assess the equivalence of subject-rated tolerance of EBUS-TBNA procedure in the 2 groups. Key secondary objectives were to assess the equivalence of subject-rated overall experience, willingness for a repeat procedure, operator-rated subject's tolerance, and operator-rated ease of performing the procedure.

RESULTS

One hundred and eighty subjects were randomized in a 1:1 ratio to the nasal (n=98) or oral (n=82) group. Outcome measures were assessed by both per-protocol (PP) and intention-to-treat (ITT) analysis. Subject-rated procedural tolerance, overall satisfaction and operator's ease of performing the procedure were found to be equivalent in the 2 groups ( P <0.05 in all cases for PP and ITT analysis). The operator-rated subject's tolerance was, however, nonequivalent ( P =0.0596, 0.1286 for PP and ITT, respectively). Subject's willingness to undergo a repeat procedure was similar in both groups [90% CI of difference in proportions: (-0.023, 0.121) in PP and (-0.028, 0.115) in ITT analysis].

CONCLUSION

Nasal route for EBUS-TBNA could be considered where it is feasible and preferable for the patient as well as the operator.

Diagnostic Yield and Safety of the 19-Gauge versus 22-Gauge Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Needle in Subjects with Sarcoidosis (GUESS)

INTRODUCTION

Observational data suggest that the 19-gauge (G) needle for endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) offers a higher diagnostic yield than the 22-G needle in sarcoidosis. No randomized trial has compared the yield of the two needles.

METHODS

We randomized consecutive subjects with suspected sarcoidosis and enlarged thoracic lymph nodes to undergo EBUS-TBNA with either the 19-G or the 22-G needle. We compared the study groups for diagnostic sensitivity (primary outcome) assessed by the yield of granulomas in subjects finally diagnosed with sarcoidosis. We also compared the sample adequacy, difficulty performing the needle puncture assessed on a visual analog scale (VAS), the subject's cough intensity on an operator-rated VAS, and procedure-related complications (secondary outcomes).

RESULTS

We randomized 150 (mean age, 43.0 years; 55% women) subjects and diagnosed sarcoidosis in 116 subjects. The diagnostic sensitivity of the 19-G needle (45/60, 75.0%) was not higher (p = 0.52) than the 22-G needle (39/56, 69.6%). We obtained adequate aspirates in 90.0% and 85.7% of subjects in the respective groups (p = 0.48). The operators had greater difficulty puncturing lymph nodes with the 19-G needle (p = 0.03), while the operator-assessed cough intensity was similar in the groups (p = 0.41). Transient hypoxemia was the only complication encountered during EBUS-TBNA (two subjects in either group).

CONCLUSION

We did not find the 19-G needle superior to the 22-G in diagnostic sensitivity, specimen adequacy, or safety of EBUS-TBNA in sarcoidosis. Puncturing the lymph nodes was more difficult with the 19-G needle.

The application of artificial intelligence for Rapid On-Site Evaluation during flexible bronchoscopy

Background

Rapid On-Site Evaluation (ROSE) during flexible bronchoscopy (FB) can improve the adequacy of biopsy specimens and diagnostic yield of lung cancer. However, the lack of cytopathologists has restricted the wide use of ROSE.

Objective

To develop a ROSE artificial intelligence (AI) system using deep learning techniques to differentiate malignant from benign lesions based on ROSE cytological images, and evaluate the clinical performance of the ROSE AI system.

Method

6357 ROSE cytological images from 721 patients who underwent transbronchial biopsy were collected from January to July 2023 at the Tangdu Hospital, Air Force Medical University. A ROSE AI system, composed of a deep convolutional neural network (DCNN), was developed to identify whether there were malignant cells in the ROSE cytological images. Internal testing, external testing, and human-machine competition were used to evaluate the performance of the system.

Results

The ROSE AI system identified images containing lung malignant cells with the accuracy of 92.97% and 90.26% on the internal testing dataset and external testing dataset respectively, and its performance was comparable to that of the experienced cytopathologist. The ROSE AI system also showed promising performance in diagnosing lung cancer based on ROSE cytological images, with accuracy of 89.61% and 87.59%, and sensitivity of 90.57% and 94.90% on the internal testing dataset and external testing dataset respectively. More specifically, the agreement between the ROSE AI system and the experienced cytopathologist in diagnosing common types of lung cancer, including squamous cell carcinoma, adenocarcinoma, and small cell lung cancer, demonstrated almost perfect consistency in both the internal testing dataset (κ  =   0.930 ) and the external testing dataset (κ  =   0.932 ).

Conclusions

The ROSE AI system demonstrated feasibility and robustness in identifying specimen adequacy, showing potential enhancement in the diagnostic yield of FB. Nevertheless, additional enhancements, incorporating a more diverse range of training data and leveraging advanced AI models with increased capabilities, along with rigorous validation through extensive multi-center randomized control assays, are crucial to guarantee the seamless and effective integration of this technology into clinical practice.

Impact of rapid on-site evaluation in expediting the fast investigative lung cancer pathway

OBJECTIVE

EBUS-TBNA is a method of acquiring tissue samples from intrathoracic lymph nodes and central intrathoracic tumours in patients suspected of having lung cancer. Rapid on-site evaluation (ROSE) denotes assessing tissue samples during EBUS (or bronchoscopy), providing instant feedback on sample adequacy and provisional cytomorphological diagnosis. Sector multidisciplinary team (MDT) discussion can then make informed treatment decisions, with confirmatory immunohistochemistry being finalised before provision of final treatment. Currently, impact of ROSE on length of time patients spend on the lung cancer diagnostic pathway remains unclear.

METHODS

We retrospectively evaluated the impact of ROSE on the length of time between patients' EBUS/bronchoscopy procedures and discussion at sector MDT, referred to as time to treatment decision (TTD), at our institution. Additionally, we assessed impact of ROSE on number of passes (number of times nodes/masses were sampled) per procedure.

RESULTS

The mean TTD was 77.9% shorter (p = 0.001) with ROSE present than when absent. Patients who received ROSE spend 34.3% less time (p = 0.028) on lung cancer diagnostic pathway overall. There was a significant reduction in number of passes in non-malignant nodes with ROSE present (2.23) than when absent (3.14) (p < 0.001). With ROSE present there was a significantly greater number of passes at malignant sites (5.07) than non-malignant sites (2.23) (p < 0.001).

CONCLUSIONS

These findings support conclusions made in our institution's previous study, that utilisation of ROSE reduces TTD. ROSE also allows safe advancement through nodes with low suspicion of malignant involvement, focusing time on sampling nodes/masses of greater suspicion.

A Nomogram to Predict Benign/Malignant Mediastinal Lymph Nodes Based on EBUS Sonographic Features

Background

Endobronchial ultrasound (EBUS) sonographic features help identify benign/malignant lymph nodes while conducting transbronchial needle aspiration (TBNA). This study aims to identify risk factors for malignancy based on EBUS sonographic features and to estimate the risk of malignancy in lymph nodes by constructing a nomogram.

Methods

1082 lymph nodes from 625 patients were randomly enrolled in training (n = 760) and validation (n = 322) sets. The subgroup of EBUS-TBNA postoperative negative lymph nodes (n = 317) was randomly enrolled in a training (n = 224) set and a validation (n = 93) set. Logistic regression analysis was used to identify the EBUS features of malignant lymph nodes. A nomogram was formulated using the EBUS features in the training set and later validated in the validation set.

Results

Multivariate analysis revealed that long-axis, short-axis, echogenicity, fusion, and central hilar structure (CHS) were the independent predictors of malignant lymph nodes. Based on these risk factors, a nomogram was constructed. Both the training and validation sets of 5 EBUS features nomogram showed good discrimination, with area under the curve values of 0.880 (sensitivity = 0.829 and specificity = 0.807) and 0.905 (sensitivity = 0.819 and specificity = 0.857). Subgroup multivariate analysis revealed that long-axis, echogenicity, and CHS were the independent predictors of malignancy outcomes of EBUS-TBNA postoperative negative lymph nodes. Based on these risk factors, a nomogram was constructed. Both the training and validation sets of 3 EBUS features nomogram showed good discrimination, with the area under the curve values of 0.890 (sensitivity = 0.882 and specificity = 0.786) and 0.834 (sensitivity = 0.930 and specificity = 0.636).

Conclusions

Our novel scoring system based on two nomograms can be utilized to predict malignant lymph nodes.

Liquid biopsy in lung cancer

Lung cancer is a highly prevalent malignancy worldwide and the primary cause of mortality. The absence of systematic and standardized diagnostic approaches for identifying potential pulmonary nodules, early-stage cancers, and indeterminate tumors has led clinicians to consider tissue biopsy and pathological sections as the preferred method for clinical diagnosis, often regarded as the gold standard. The conventional tissue biopsy is an invasive procedure that does not adequately capture the diverse characteristics and evolving nature of tumors. Recently, the concept of 'liquid biopsy' has gained considerable attention as a promising solution. Liquid biopsy is a non-invasive approach that facilitates repeated analysis, enabling real-time monitoring of tumor recurrence, metastasis, and response to treatment. Currently, liquid biopsy includes circulating tumor cells, circulating cell-free DNA, circulating tumor DNA, circulating cell-free RNA, extracellular vesicles, and other proteins and metabolites. With rapid progress in molecular technology, liquid biopsy has emerged as a highly promising and intriguing approach, yielding compelling results. This article critically examines the significant role and potential clinical implications of liquid biopsy in the diagnosis, treatment, and prognosis of lung cancer.

Accuracy of Cytologic vs Histologic Specimens for Assessment of Programmed Cell Death Ligand-1 Expression in Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Programmed cell death ligand-1 (PD-L1) expression on tumor cells, evaluated by immunohistochemistry, guides the use of immunotherapy in advanced non-small cell lung cancer (NSCLC).

RESEARCH QUESTION

What is the sensitivity and specificity of PD-L1 testing performed in cytologic vs paired histologic specimens in patients with NSCLC?

STUDY DESIGN AND METHODS

The MEDLINE, Embase, Web of Science, and Cochrane Library databases were searched through June 1, 2021. The primary outcome was pooled sensitivity and specificity of PD-L1 testing performed on cytologic specimens compared with the reference standard of histologic specimens, analyzed at the PD-L1 expression cutoffs (tumor proportion score) ≥ 1% and ≥ 50%. Pooled sensitivity and specificity, and associated 95% CIs, were estimated using bivariate generalized linear mixed models.

RESULTS

Twenty-six articles were included, encompassing a total of 1,064 pairs of histology specimens and cytology cell blocks, and 267 pairs of histology specimens and direct smears. Among these, 946 paired specimens were acquired without interval treatment between the collection of histology and cytology samples. The pooled sensitivity and specificity of cytology specimens compared with paired histology specimens at the PD-L1 expression cutoff ≥ 1% were 0.84 (95% CI, 0.77-0.89) and 0.88 (95% CI, 0.82-0.93), respectively, whereas the pooled sensitivity and specificity at cutoff ≥ 50% were 0.78 (95% CI, 0.69-0.86) and 0.94 (95% CI, 0.91-0.96), respectively. When only paired specimens acquired without interval treatment were considered, the pooled sensitivity and specificity of cytology specimens at PD-L1 expression cutoff ≥ 1% were 0.84 (95% CI, 0.76-0.90) and 0.89 (95% CI, 0.82-0.94), respectively, whereas the pooled sensitivity and specificity at cutoff ≥ 50% were 0.80 (95% CI, 0.71-0.89) and 0.94 (95% CI, 0.91-0.96), respectively.

INTERPRETATION

Cytologic specimens provide an accurate assessment of PD-L1 expression in most patients with NSCLC, at both ≥ 1% and ≥ 50% cutoffs, when compared with histologic specimens.

TRIAL REGISTRATION

PROSPERO; No.: CRD42020153279; URL: https://www.crd.york.ac.uk/prospero/.

Comparative yield of EBUS-TBNA with EBUS-IFBTLP for diagnosis of mediastinal lymphadenopathy

BACKGROUND

Patients with mediastinal lymph node enlargement (MLNE) are diagnosed depending on lymph node biopsy. Whereas, how to obtain larger tissue masses from mediastinal lymph nodes and improve the diagnostic yield of the disease remains to be investigated.

OBJECTIVES

Aiming to assess the diagnostic value of endobronchial ultrasound-guided intranodal forceps biopsy via transbronchial laser photoablation (EBUS-IFB-TLP) in patients with MLNE.

DESIGN

A prospective, self-controlled study.

METHODS

This study was conducted on 67 MLNE patients requiring a lymph node biopsy for diagnosis at the Henan Provincial People's Hospital and the Fuwai Central China Cardiovascular Hospital in China, from January 2020 to December 2022. Each patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA group) and EBUS-IFB-TLP (EBUS-IFB-TLP group) on the same mediastinal lymph node for biopsies. The operation time, diagnostic efficiency, and complication rates of the two biopsy methods were compared.

RESULTS

The number of diagnosed patients in the EBUS-IFB-TLP and the EBUS-TBNA groups was 65 (97.0%) and 57 (85.1%), respectively (p = 0.021). In the EBUS-IFB-TLP group, 28 cases (96.6%) were diagnosed with lung cancer and were classified into different epithelial types. In the EBUS-TBNA group, there were 27 cases (93.1%) diagnosed with lung cancer, of which 26 (89.7%) were classified into different epithelial types. There were 37 (97.4%) and 30 (78.9%) non-lung cancer patients diagnosed in the EBUS-IFB-TLP and EBUS-TBNA groups, respectively (p = 0.039), while 27 cases (96.4%) of sarcoidosis in the EBUS-IFB-TLP group and 20 cases (71.4%) of sarcoidosis in the EBUS-TBNA group were diagnosed (p = 0.016). The percentages of intraoperative mild to moderate bleeding complications were 23.9% (16/67) and 14.9% (10/67) in the EBUS-IFB-TLP and in the EBUS-TBNA groups, respectively (p = 0.109).

CONCLUSION

This study demonstrated that EBUS-IFB-TLP could be a feasible and effective method in the diagnosis of patients with MLNE, presenting an analogous safety profile compared with EBUS-TBNA. Further studies are needed to verify the diagnostic performance of EBUS-IFB-TLP for MLNE.

Controversies in endobronchial ultrasound

Endobronchial ultrasound (EBUS) is a minimally invasive highly accurate and safe endoscopic technique for the evaluation of mediastinal lymphadenopathy and mediastinal masses including centrally located lung tumors. The combination of transbronchial and transoesophageal tissue sampling has improved lung cancer staging, reducing the need for more invasive and surgical diagnostic procedures. Despite the high level of evidence regarding EBUS use in the aforementioned situations, there are still challenges and controversial issues such as follows: Should informed consent for EBUS and flexible bronchoscopy be different? Is EBUS able to replace standard bronchoscopy in patients with suspected lung cancer? Which is the best position, screen orientation, route of intubation, and sedation/anesthesia to perform EBUS? Is it advisable to use a balloon in all procedures? How should the operator acquire skills and how should competence be ensured? This Pro-Con article aims to address these open questions.