Comparison of radial endobronchial ultrasound with a guide sheath and with distance by thin bronchoscopy for the diagnosis of peripheral pulmonary lesions: a prospective randomized crossover trial

Radial endobronchial ultrasound - guided bronchoscopy for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis of prospective trials

Background

The diagnostic yield of radial endobronchial ultrasound (r-EBUS) for the diagnosis of peripheral pulmonary lesions (PPLs) varies between studies and is affected by multiple factors. We aimed to evaluate the efficacy and safety of r-EBUS, and to explore the factors influencing the diagnostic yield of r-EBUS in patients with PPLs.

Methods

The PubMed, Web of Science, and EMBASE databases were searched to identify relevant studies that used r-EBUS for diagnosing PPLs from the date of inception to Dec 2022. Meta-analysis was conducted using Review Manager 5.4 and Stata 15.1.

Results

An analysis of 46 studies with a total of 7252 PPLs was performed. The pooled diagnostic yield of r-EBUS was 73.4 % (95 % CI: 69.9%-76.7 %), with significant heterogeneity detected among studies (I2 = 90 %, P < 0.001). Further analysis demonstrated PPLs located in the middle or lower lobe, >2 cm in size, malignant in type, solid in appearance on computerized tomography (CT), present in bronchus sign, the within probe location, and the addition of rapid on-site evaluation (ROSE) were associated with increased diagnostic yield, whereas use of a guide sheath (GS), bronchoscopy type, and a multimodality approach failed to influence the outcome. The pooled incidence rates of overall complications, pneumothorax and moderate and severe bleeding were 3.1 % (95 % CI: 2.1%-4.3 %), 0.4 % (95 % CI: 0.1%-0.7 %) and 1.1 % (95 % CI: 0.5%-2.0 %), respectively.

Conclusions

r-EBUS has an appreciable diagnostic yield and an excellent safety manifestation when used to deal with PPLs.

[Advanced bronchoscopic techniques for the diagnosis of peripheral lung nodule]

The endoscopic diagnosis of peripheral lung nodules is a challenging aspect of oncological practice. More often than not inaccessible by traditional endoscopy, these nodules necessitate multiple imagery tests, as well as diagnostic surgery for benign lesions. Even though transthoracic ultrasonography has a high diagnostic yield, a sizeable complication rate renders it suboptimal. Over recent years, a number of safe and accurate navigational bronchoscopic procedures have been developed. In this first part, we provide an overview of the bronchoscopic techniques currently applied for the excision and diagnostic analysis of peripheral lung nodules; emphasis is laid on electromagnetic navigation bronchoscopy and the association of virtual bronchoscopy planner with radial endobronchial ultrasound. We conclude by considering recent innovations, notably robotic bronchoscopy.

Cryobiopsy: A Breakthrough Strategy for Clinical Utilization of Lung Cancer Organoids

One major challenge associated with lung cancer organoids (LCOs) is their predominant derivation from surgical specimens of patients with early-stage lung cancer. However, patients with advanced lung cancer, who are in need of chemotherapy, often cannot undergo surgery. Therefore, there is an urgent need to successfully generate LCOs from biopsy specimens. Conventional lung biopsy techniques, such as transthoracic needle biopsy and forceps biopsy, only yield small amounts of lung tissue, resulting in a low success rate for culturing LCOs from biopsy samples. Furthermore, potential complications, like bleeding and pneumothorax, make it difficult to obtain sufficient tissue. Another critical issue is the overgrowth of normal lung cells in later passages of LCO culture, and the optimal culture conditions for LCOs are yet to be determined. To address these limitations, we attempted to create LCOs from cryobiopsy specimens obtained from patients with lung cancer (n = 113). Overall, the initial success rate of establishing LCOs from cryobiopsy samples was 40.7% (n = 46). Transbronchial cryobiopsy enables the retrieval of significantly larger amounts of lung tissue than bronchoscopic forceps biopsy. Additionally, cryobiopsy can be employed for peripheral lesions, and it is aided via radial endobronchial ultrasonography. This study significantly improved the success rate of LCO culture and demonstrated that the LCOs retained characteristics that resembled the primary tumors. Single-cell RNA sequencing confirmed high cancer cell purity in early passages of LCOs derived from patients with advanced lung cancer. Furthermore, the three-dimensional structure and intracellular components of LCOs were characterized using three-dimensional holotomography. Finally, drug screening was performed using a specialized micropillar culture system with cryobiopsy-derived LCOs. LCOs derived from cryobiopsy specimens offer a promising solution to the critical limitations of conventional LCOs. Cryobiopsy can be applied to patients with lung cancer at all stages, including those with peripheral lesions, and can provide sufficient cells for LCO generation. Therefore, we anticipate that cryobiopsy will serve as a breakthrough strategy for the clinical application of LCOs in all stages of lung cancer.

Endobronchial ultrasound with a guide sheath during bronchoscopy for peripheral pulmonary lesions

INTRODUCTION

Radial probe endobronchial ultrasound (rEBUS) improves the diagnostic yield of peripheral pulmonary lesions (PPLs). A notable methodological limitation of rEBUS is that it does not provide real-time images during transbronchial biopsy (TBB) procedures. To overcome this limitation, a guide sheath (GS) method was developed.

AREAS COVERED

This review covers the procedures and complications of rEBUS-guided TBB with a GS (EGS method). We also present the data from key randomized controlled trials (RCTs) of the EGS method and summarize the usefulness of combining the EGS method with various techniques. Finally, we discuss in which situations EGS should be used.

EXPERT OPINION

A large RCT showed that the diagnostic yield of the EGS method for PPLs was significantly higher than that of rEBUS-guided TBB without a GS (non-GS method). However, since the EGS and non-GS methods each have their own advantages and disadvantages, they should be considered complementary and used flexibly in different cases. In some cases, a combination of the two may be an option. The appropriate combination of EGS with various techniques may enhance the diagnostic yield of PPLs and help prevent complications. The choice should be based on the location and texture of the target lesion, as well as operator skill, resource availability, safety, and accuracy.

Diagnostic yield of radial probe endobronchial ultrasonography-guided transbronchial biopsy without fluoroscopy in peripheral pulmonary lesions: A systematic review and meta-analysis

PURPOSE

Although radial probe endobronchial ultrasound (R-EBUS) has been used to investigate peripheral pulmonary lesions (PPLs), its diagnostic performance without fluoroscopy remains unclear. We sought to determine the diagnostic yield of R-EBUS-guided transbronchial biopsy (TBB) without fluoroscopy.

METHODS

We performed a systematic literature review using Pubmed, Embase, and the Cochrane Central Register. Then, we performed a proportional meta-analysis to determine the diagnostic yield of this modality. Subgroup and meta-regression analyses were used to identify factors affecting the performance of R-EBUS-guided TBB without fluoroscopy.

RESULTS

We identified 31 studies consisting of a total of 6491 patients. Pooled overall diagnostic yield of R-EBUS-guided TBB without fluoroscopy was 0.70 (95% confidence interval [CI], 0.67-0.74). There was significant heterogeneity across studies (I²  = 89.45%, p < 0.001). In subgroup and meta-regression analyses, air bronchus sign on chest computed tomography scans, larger size PPLs, probe location within lesions, and heterogeneous echogenicity were associated with significantly higher diagnostic yield. Diagnostic yield from the upper lobe was statistically lower than that from the middle and lower lobes. Pooled pneumothorax rate was 0.01 (95% CI, 0.01-0.01, I²  = 63.51%, p < 0.001).

CONCLUSIONS

R-EBUS-guided TBB without fluoroscopy appears to be a relatively useful tool with a low pneumothorax rate for the diagnosis of PPLs. Factors mentioned above may affect the diagnostic yield of this tool. Because of substantial between-study heterogeneity, our results should be interpreted with caution.

Utility of cell-free DNA from bronchial washing fluid in diagnosis and genomic determination for radiology-suspected pulmonary nodules

BACKGROUND

Bronchial washing fluid (BWF) is a less-invasive specimen. Due to the limited sensitivity of BWF cellular component diagnosis, the aim of this study was to explore the potential role of BWF supernatant as a source of liquid biopsy of lung cancer.

METHODS

This prospective study enrolled 76 suspected and 5 progressed lung cancer patients. Transbronchial biopsy tissues, BWF supernatant (BWF_Sup) and BWF precipitant (BWF_Pre) were tested by a targeted panel of 1021 genes.

RESULTS

BWF_Sup cell-free DNA (cfDNA) was superior to tissue biopsy and BWF_Pre in determining mutational allele frequency, tumour mutational burden, and chromosomal instability. Moreover, BWF_Sup and BWF_Pre achieved comparable efficacy to tissue samples in differentiating malignant and benign patients, but only BWF_Sup persisted differentiated performance after excluding 55 malignancies pathologically diagnosed by bronchoscopic biopsy. Among 67 malignant patients, 82.1% and 71.6% of tumour-derived mutations (TDMs) were detected in BWF_Sup and BWF_Pre, respectively, and the detectability of TDMs in BWF_Sup was independent of the cytological examination of BWF. BWF_Sup outperformed BWF_Pre in providing more subclonal information and thus might yield advantage in tracking drug-resistant markers.

CONCLUSIONS

BWF_Sup cfDNA is a reliable medium for lung cancer diagnosis and genomic profiles and may provide important information for subsequent therapeutic regimens.

Comparison of radial endobronchial ultrasound-guided transbronchial lung biopsy with distance measurement versus with guide sheath in diagnosing peripheral pulmonary lesions with a diameter ≥3 cm by thin bronchoscope

OBJECTIVE:

This study aims to explore the diagnostic values of radial endobronchial ultrasound-guided transbronchial lung biopsy with distance (rEBUS-D-TBLB) measurement and with guide sheath (rEBUS-GS-TBLB) for peripheral pulmonary lesions (PPLs) with a diameter ≥3 cm by thin bronchoscope.

PATIENTS AND METHODS:

Six hundred and three patients with PPL (diameter ≥3 cm) were enrolled in this study. The subjects were divided into the rEBUS-D-TBLB and rEBUS-GS-TBLB groups by the random number table method. Patients were assigned to undergo rEBUS-D-TBLB or rEBUS-GS-TBLB, respectively. The histopathology, positive diagnosis rates, duration of the procedure, and postoperative adverse effects between the two groups were examined.

RESULTS:

A total of 569 patients were included in this study according to the inclusion and exclusion criteria, with 282 cases in the rEBUS-D-TBLB group and 287 cases in the rEBUS-GS-TBLB group. For malignant diseases, the positive diagnosis rates of PPL in the outer/inner-middle lung bands and the right-upper/-lower lung lobes by rEBUS-D-TBLB were noninferior to those of rEBUS-GS-TBLB. The duration of the procedure of rEBUS-D-TBLB was longer than that of rEBUS-GS-TBLB. There were 14 cases of hemorrhage >50 mL, 1 case of postoperative chest pain in the rEBUS-D-TBLB group, and 3 cases of hemorrhage >50 mL in the rEBUS-GS-TBLB group.

CONCLUSION:

REBUS-D-TBLB by thin bronchoscope has a high diagnostic value for PPL with a diameter ≥3 cm, which may be considered a useful alternative for rEBUS-GS-TBLB in the clinic.

Guide sheath versus non-guide sheath method for endobronchial ultrasound-guided biopsy of peripheral pulmonary lesions: A multicenter randomized trial

INTRODUCTION

Guide sheaths (GSs) have been widely used during radial probe endobronchial ultrasound-guided transbronchial biopsy (rEBUS-TBB) of peripheral pulmonary lesions. However, it remains unknown whether a GS enhances the diagnostic yield. We compared the diagnostic yields of small peripheral pulmonary lesions between rEBUS-TBB with and without a GS.

METHODS

In eight institutions, patients with peripheral pulmonary lesions≤30 mm in diameter were enrolled and randomized to undergo rEBUS-TBB with a GS (GS group) or without a GS (non-GS group) using a 4.0-mm thin bronchoscope, virtual bronchoscopic navigation, and fluoroscopy. The primary endpoint was the diagnostic yield of the histology specimens.

RESULTS

A total of 605 patients were enrolled; ultimately, data on 596 (300 in the GS group and 296 in the non-GS group) with peripheral pulmonary lesions having a longest median diameter of 19.6 mm were analyzed. The diagnostic yield of histological specimens from the GS group was significantly higher than that from the non-GS group (55.3% versus 46.6%, respectively; p=0.033). Interactions were evident between the diagnostic yields, procedures, lobar locations (upper lobe versus other regions, p=0.003), and lesion texture (solid versus part-solid nodules, p=0.072).

CONCLUSIONS

The diagnostic yield for small peripheral pulmonary lesions afforded by rEBUS-TBB using a GS was higher than that without a GS.

Advanced bronchoscopic techniques for the diagnosis and treatment of peripheral lung cancer

Lung cancer is the leading cause of cancer related deaths worldwide. As a result of the increasing use of chest CT scans and lung cancer screening initiatives, there is a rapidly increasing need for lung lesion analysis and - in case of confirmed cancer - treatment. A desirable future concept is the one-stop outpatient bronchoscopic approach including navigation to the tumor, malignancy confirmation and immediate treatment. Several novel bronchoscopic diagnostic and treatment concepts are currently under evaluation contributing to this concept. As the majority of suspected malignant lung lesions develop in the periphery of the lungs, improved bronchoscopic navigation to the target lesion is of key importance. Fortunately, the field of interventional pulmonology is evolving rapidly and several advanced bronchoscopic navigation techniques are clinically available, allowing an increasingly accurate tissue diagnosis of peripheral lung lesions. Additionally, multiple bronchoscopic treatment modalities are currently under investigation. This review will provide a concise overview of advanced bronchoscopic techniques to diagnose and treat peripheral lung cancer by describing their working mechanisms, strengths and weaknesses, identifying knowledge gaps and indicating future developments. The desired one-step concept of bronchoscopic 'diagnose and treat' peripheral lung cancer is on the horizon.

Endobronchial ultrasound-guided transbronchial biopsy with or without a guide sheath for peripheral pulmonary malignancy

Endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) is a common procedure used to diagnose peripheral pulmonary lesions (PPLs). However, existing literature did not conclusively show a difference in the ability of EBUS-TBB with and without a guide sheath (GS) to diagnose PPLs. This multicenter cohort study enrolled patients presenting for EBUS-TBB of PPLs that finally proved to be malignant. The diagnostic yield and complication rate were compared between patients undergoing EBUS-TBB with and without a GS (EBUS-TBB+GS versus EBUS-TBB-GS). A propensity score matching method was used to balance differences of pertinent clinical features between the two groups. The original cohort consisted of 975 patients (556 in EBUS-TBB-GS; 419 in EBUS-TBB+GS). GS guidance was more likely to be used with smaller (40 mm versus 44 mm) and middle or lower lobe (60% versus 35%) lesions. After propensity score matching, 720 (360 in each group) patients were included; the diagnostic yields for PPLs were 79% and 78% for EBUS-TBB-GS and EBUS-TBB+GS groups, respectively (p=0.649). The complication rates (5.8% versus 7.2% for bleeding; 0.6% versus 1.9% for pneumothorax) appeared to be lower in the EBUS-TBB+GS group, but the differences did not reach statistical significance. The procedure time was significantly longer in the EBUS-TBB+GS group than in the EBUS-TBB-GS group (29 min versus 24 min; p<0.001). In conclusion, adding a GS to EBUS-TBB did not improve the diagnostic yield for malignant PPLs. GS guidance was seemingly associated with a lower number of complications after TBB but contributed significantly to a longer procedure time.

Comparison of different transbronchial biopsy sampling techniques for the diagnosis of peripheral pulmonary lesions with radial endobronchial ultrasound-guided bronchoscopy: A prospective study

BACKGROUND

Data regarding the transbronchial biopsy (TBB) techniques in radial endobronchial ultrasound (R-EBUS)-guided bronchoscopy are limited. The purpose of this study was to compare three R-EBUS-guided TBB techniques for the diagnosis of peripheral pulmonary lesions (PPLs).

METHODS

A prospective pilot study was conducted including 90 patients with positive bronchus sign PPLs, who underwent R-EBUS-guided TBB. TBB techniques were performed in all patients using small biopsy forceps with a guide sheath (GS). These samples were submitted for both cell block histology (CB) and conventional histology (SB). Standard biopsy forceps were used to collect further samples that were submitted for conventional histology (LB). The diagnostic yields of the three techniques were compared.

RESULTS

The mean diameter of the PPLs was 25.5 ± 8.2 mm and the final diagnoses included 70 malignant and 20 benign lesions. The overall diagnostic yield of R-EBUS-guided bronchoscopy was 82.2%. Although the difference was not statistically significant, CB provided the highest yield of the three TBB techniques: 68.9%, 65.6%, and 62.2% for CB, SB, and LB, respectively (P = 0.20). When the GS was removed and standard biopsy forceps were introduced, misplacement (detected by fluoroscopy) was observed in 24 cases, and LB provided a diagnosis in 11 cases. PPLs ≤20 mm were associated with misplacement (P = 0.003). After the exclusion of misplaced cases, the diagnostic yields were 69.7%, 71.2%, and 68.2% for CB, SB, and LB, respectively (P = 0.65).

CONCLUSIONS

Neither the size of biopsy forceps nor the histology process affected the diagnostic yield of R-EBUS-guided bronchoscopy.

The Value of Combined Radial Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy and Metagenomic Next-Generation Sequencing for Peripheral Pulmonary Infectious Lesions

Background

Metagenomic next-generation sequencing (mNGS) is a new technology that allows for unbiased detection of pathogens. However, there are few reports on mNGS of lung biopsy tissues for pulmonary infection diagnosis. In addition, radial endobronchial ultrasound (R-EBUS) is widely used to detect peripheral pulmonary lesions (PPLs), but it is rarely used in the diagnosis of peripheral lung infection.

Objective

The present study aims to evaluate the combined application of R-EBUS-guided transbronchial lung biopsy (TBLB) and mNGS for the diagnosis of peripheral pulmonary infectious lesions.

Methods

From July 2018 to April 2019, 121 patients from Tianjin Medical University General Hospital diagnosed with PPLs and lung infection were enrolled in this prospective randomized study . Once the lesion was located, either TBLB or R-EBUS-guided-TBLB was performed in randomly selected patients, and mNGS was applied for pathogen detection in lung biopsy tissues. The results of mNGS were compared between the TBLB group and R-EBUS-guided TBLB group. In addition, the clinical characteristics and EBUS images from 61 patients receiving bronchoscopy for peripheral lung infectious detection were analyzed and compared with the results of mNGS.

Results

The positivity rate of mNGS in R-EBUS-guided TBLB was (78.7%, 48/61) that was significantly higher than (60.0%, 36/60) in the TBLB group. Difference in the position of R-EBUS probe and image characteristics of peripheral lung infectious lesions affected the positivity rate of mNGS. Tissue collected by R-EBUS within the lesion produced higher positivity rate than samples collected adjacent to the lesion (P=0.030, odds ratio 17.742; 95% confidence interval, from 1.325 to 237.645). Anechoic areas and luminant areas of ultrasonic image characteristics were correlated with lower positivity rate of mNGS (respectively, P=0.019, odds ratio 17.878; 95% confidence interval, from 1.595 to 200.399; P=0.042, odds ratio 16.745; 95% confidence interval, from 1.106 to 253.479).

Conclusions

R-EBUS-guided TBLB is a safe and effective technique in the diagnosis of peripheral lung infectious lesions. R-EBUS significantly facilitates the accurate insertion of bronchoscope into the lesions, which improves positivity rate of mNGS analysis in pathogen detection. The R-EBUS probe position within lesion produced a higher positivity rate of mNGS analysis. Nevertheless, the presence of anechoic and luminant areas on ultrasonic image was correlated with poor mNGS positivity rate.

Diagnostic Performance of Radial Probe Endobronchial Ultrasound without a Guide-Sheath and the Feasibility of Molecular Analysis

BACKGROUND

Radial probe endobronchial ultrasound (R-EBUS), is effective for tissue diagnosis of lung lesions. We evaluated the diagnostic performance of R-EBUS both a guide-sheath and fluoroscopy and identified factors associated with accurate diagnosis. The feasibility of molecular and genetic testing, using specimens obtained by R-EBUS, was also investigated.

METHODS

The study retrospectively reviewed 211 patients undergoing R-EBUS without a guide-sheath and fluoroscopy, June 2016-May 2017. After excluding 27 patients of which the target lesion was not reached, 184 were finally included. Multivariate logistic regression was used, to identify factors associated with accurate diagnosis.

RESULTS

Among 184 patients, R-EBUS-guided biopsy diagnosed malignancy in 109 patients (59%). The remaining 75 patients (41%) with non-malignant results underwent additional work-ups, and 34 were diagnosed with malignancy. Based on final diagnosis, diagnostic accuracy was 80% (136/170), and sensitivity and specificity for malignancy were 76% (109/143) and 100% (27/27), respectively. In multivariate analysis, peripheral location (adjusted odds ratio [aOR], 3.925; 95% confidence interval [CI], 1.203-12.811; p=0.023), and central position of the probe (aOR, 2.435; 95% CI, 1.424-7.013; p=0.035), were associated with accurate diagnosis of malignancy. Molecular and genetic analyses were successful, in all but one case, with inadequate specimens.

CONCLUSION

R-EBUS-guided biopsy without equipment, is effective for tissue diagnosis. Peripheral location and central position of the radial probe, were crucial for accurate diagnosis. Performance of molecular and genetic testing, using samples obtained by R-EBUS, was satisfactory.

Radial endobronchial ultrasonography with distance measurement through a thin bronchoscope for the diagnosis of malignant peripheral pulmonary lesions

Background

Peripheral pulmonary lesions (PPLs) are being discovered more frequently. We investigated efficiency, safety, and influencing factors in radial probe endobronchial ultrasound with distance measurement (rEBUS-D) using a thin bronchoscope during transbronchial biopsy (TBB) for the diagnosis of malignant PPLs.

Methods

Patients with PPLs who underwent rEBUS were retrospectively analyzed. Cases with rEBUS-D and a gold-standard final diagnosis were considered.

Results

rEBUS was completed in 589 cases; 328 were analyzed. The lesion discovery rate was 85.06%; the overall rEBUS-D-TBB diagnostic rate was 54.88%. There were 193 cases of malignant tumors. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of rEBUS-D-TBB in the diagnosis of malignant PPLs were 63.73%, 100%, 100%, 65.85%, and 78.40%, respectively. Single- and multi-factor analyses showed that lesion size, ultrasound probe position, and a positive bronchus sign on thoracic computed tomography (CT) were significant factors influencing diagnosis (all P=0.000); probe position and the bronchus sign were independent influencing factors. The effect of lesion distribution on diagnosis was not significant. In seven cases, postoperative pathology showed mixed tumors. Two cases of malignant tumors were combined with benign pathology; rEBUS-D-TBB did not suggest two pathologies. Thirteen cases had 50-100 mL of blood loss (3.96%); no pneumothorax or infection was observed.

Conclusions

rEBUS-D-TBB had high sensitivity, 100% specificity, excellent safety, and a lower cost than rEBUS-GS-TBB in the diagnosis of malignant PPLs. Larger lesions, a positive bronchus sign on CT, and ultrasound probe position at the lesion's center yielded higher diagnostic rates.