Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer

Interventional pulmonology in elderly in tuberculosis and respiratory diseases-challenges

With the increasing number of the elderly population, the number of people with respiratory diseases along with other comorbidities is also increasing. With the good number of available evidence, the use of interventional pulmonary procedures is also increasing. However, the studies on the safety and therapeutic benefit of these procedures in the elderly population are limited. Because of the paucity of data, we decided to do a systematic review of the scientific literature that is currently available, to boost confidence to do these procedures by clinicians. This review deals with the procedures that are commonly performed in elderly respiratory patients, their indications, safety and the diagnostic and therapeutic yield, and compares them with the results in the younger population. It also focuses on the safety of anaesthetic techniques used for these procedures in the elderly. The bottom line of this review is that there is no significant difference between the older and younger age groups with regard to the above parameters and that age alone is not a criterion to decide whether the patients may undergo interventional pulmonary procedures.

Diagnostic Utility and Safety of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration in the Elderly

BACKGROUND

There is limited evidence regarding the effect of age on the specimen adequacy, positivity rate of specimen on cytology (PR), and safety of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA). The aim of this study was to investigate the utility of EBUS-TBNA in the elderly.

METHODS

This was a retrospective study of subjects who underwent EBUS-TBNA. We compare the specimen adequacy, PR, and the incidence of complications in the elderly (age 65 y and above) versus the younger subjects (age younger than 65 y). A multivariate logistic regression analysis was performed to identify the factors affecting the diagnostic yield.

RESULTS

Of the 1816 subjects, 258 (14.2%) were elderly. The specimen adequacy was similar between the old and the young (93.5% vs. 96.3%, P=0.053). The PR in the elderly (48.8%) was lower (P<0.001) than the younger subjects (66.7%). Among those with a definite diagnosis made on EBUS-TBNA, 55.4% of the older subjects had malignancy, while 82.4% of the young had granulomatous disorders. The incidence of complications was similar in the 2 groups (3.9% vs. 4.4%, P=0.87). The specimen adequacy, PR and complications were also similar among the different age groups within the older population (65 to 69, 70 to 74, 75 to 79, and 80 y and above). On multivariate logistic regression analysis, older age, the number of lymph nodes sampled, the lymph node size, and needle reuse influenced the PR.

CONCLUSION

EBUS-TBNA appears to have a similar specimen adequacy and safety but a lower PR in the elderly as compared with the younger individuals.

Interventional pulmonology techniques in elderly patients with comorbidities

Respiratory diseases are common cause of disability in the elderly and are often concomitant with other non-respiratory medical conditions. Interventional pulmonology includes advanced diagnostic and therapeutic techniques, successfully employed for benign and malignant pulmonary diseases with a good safety profile. A few studies are available on the efficacy and the safety of these procedures (both bronchoscopic and pleural techniques) in the elderly. Paucity of data in these patients may support reluctant clinicians. We carried out a non-systematic review aimed at describing the scientific literature on interventional pulmonology techniques in elderly patients with comorbidities. We summarized indications, performance characteristics, and safety profile of bronchoscopic techniques in the elderly, comparing outcomes between older and younger patients. We explored the role of age on anesthesia and sedation protocols during endoscopic procedures and assessed the influence of comorbidities on bronchoscopic outcomes. This review underlines that older age is not a barrier for implementing interventional pulmonology for diagnostic and therapeutic purposes.

Diagnostic utility of conventional transbronchial needle aspiration in older patients

BACKGROUND

In older patients, diagnosis and initial treatment should be considered as soon as possible because of high disease burden and complications. Conventional transbronchial needle aspiration (C-TBNA) is an important and safe method for the diagnosis of mediastinal lesions and staging lung cancer in the general population. We aimed to evaluate the diagnostic utility and complications of C-TBNA procedure in older patients aged ≥ 65 years.

METHOD

We retrospectively evaluated C-TBNA results consecutively. Demographic data, clinical, radiological and flexible bronchoscopy (FB) findings, complications during C-TBNA and incidence of diagnostic C-TBNA with the presence of abundant lymphoid cells of polymorphous appearance both in patients aged ≥ 65 years and in younger patients were determined.

RESULTS

C-TBNA was performed to a total of 317 patients, including 109 older and 208 younger patients attended to our clinic between 2012 and 2016. The mean ages of older and younger patients were 70.3 ± 4.6 and 52.5 ± 10 years, respectively (p < 0.001). Overall, 75.2% of older and 80.3% of younger patients had diagnostic C-TBNA. The diagnostic utility of C-TBNA did not differ significantly between older and younger patients (p = 0.297). During C-TBNA, one older patient had a complication of bronchospasm, and four younger patients had complications such as bleeding (n = 1) and bronchospasm (n = 3). There was no statistically significant difference between older and younger patients in terms of complications during C-TBNA procedure (p = 0.49).

CONCLUSION

C-TBNA is a safe procedure with similar diagnostic yield in older patients.

Intrabronchial display of hilar-mediastinal lymph nodes by virtual bronchoscopic navigation system

The description of precise intrabronchial positions for the sampling of mediastinal‐hilar lymph nodes is critical to successfully perform conventional transbronchial needle aspiration. Previously published maps of mediastinal‐hilar lymph nodes were primarily drawn based on experts’ experience. We generated a virtual map of the most frequently sampled intrathoracic lymph nodes from an intrabronchial perspective using a virtual bronchoscopic navigation system, to assist with training in conventional transbronchial needle aspiration.

An Algorithmic Approach for Assessment of Mediastinal Lesions Using Conventional Transbronchial Needle Aspiration and Endoscopic Ultrasonography in a Single Procedure

BACKGROUND

In the era of endobronchial/esophageal ultrasound (EBUS-TBNA/EUS-FNA), many centers forgo conventional transbronchial needle aspiration (C-TBNA) in favour of EBUS-TBNA/EUS-FNA despite no conclusive evidence showing better yields with EBUS-TBNA/EUS-FNA.

OBJECTIVES

Assess the feasibility of an algorithmic approach for mediastinal sampling beginning with C-TBNA utilizing rapid onsite cytologic evaluation.

METHODS

Descriptive analysis of 92 consecutive patients referred for adenopathy that underwent C-TBNA and subsequent EBUS-TBNA/EUS-FNA if C-TBNA was negative or nondiagnostic.

RESULTS

92 procedures were analyzed. In 50 (54.3%) of cases, C-TBNA alone was sufficient. EBUS-TBNA was performed after C-TBNA in 27 (29.3%) of cases and EUS-FNA in 33 (35.9%) of cases. The yield was 92.9% for C-TBNA, 92.5% for EBUS-TBNA, and 89.7% for EUS-FNA. There were no statistically significant differences in yields by LN station (P = 0.51), the relationship between yield and LN size (P = 0.37), or time difference in procedures following the algorithm compared to EBUS/EUS only procedures (33.7 minutes versus 32.4 minutes on average [95% CI for difference: -9.1 to 11.7], P = 0.80).

CONCLUSIONS

An algorithmic approach to assess the mediastinum using C-TBNA initially is feasible without sacrificing yield or procedure times. C-TBNA was sufficient for diagnosis in 54.3% of cases and can be efficiently taught in an IP training program.