Biopsy needles for mediastinal lymph node sampling by endosonography: current knowledge and future perspectives

Transesophageal Endoscopic Ultrasound Fine Needle Biopsy for the Diagnosis of Mediastinal Masses: A Retrospective Real-World Analysis

Background: Endoscopic ultrasound (EUS) plays an important role in the diagnosis and staging of thoracic disease. Our report studies the diagnostic performance and clinical impact of EUS fine needle aspiration (FNA) in a homogenous cohort of patients according to the distribution of the enlarged MLNs or pulmonary masses. Methods: We retrospectively reviewed the diagnostic performance of 211 EUS-FNA in 200 consecutive patients with enlarged or PET-positive MLNs and para-mediastinal masses who were referred to our oncological center between January 2019 and May 2020. Results: The overall sensitivity of EUS-FNA was 85% with a corresponding negative predictive value (NPV) of 56% and an accuracy of 87.5%. The sensitivity and accuracy in patients with abnormal MLNs were 81.1% and 84.4%, respectively. In those with para-mediastinal masses, sensitivity and accuracy were 96.4% and 96.8%. The accuracy for both masses and lymph nodes was 100%, and in the LAG (left adrenal gland), it was 66.6%. Conclusions: Our results show that, in patients with suspected mediastinal masses, EUS-FNA is an accurate technique to evaluate all reachable mediastinal nodal stations, including station 5.

Utilization of High-pressure Suction for EBUS-TBNA Sampling in Suspected Lung Cancer

BACKGROUND

Sample adequacy for immediate molecular testing is paramount in lung cancer. To date, several endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) sampling setups have been evaluated, however, the utilization of high-pressure suction (HPS) has not yet been reported.The aim of this study was to evaluate the utilization of HPS onto the needle and its effect on sample volume and adequacy for molecular testing in patients with suspected lung cancer.

METHODS

We retrospectively analyzed 128 consecutive EBUS-TBNA performed for suspected lung cancer. This was confirmed in 109 patients. Other diagnoses confirmed in 12, and 7 referred for surgery. Sixty-three patients (89 targets) had HPS (May to September 2020), and compared with 46 (72 targets) who had standard vacuum syringe suction (October 2019 to March 2020). Several parameters and outcomes evaluated, such as number of needle passes, needle strokes, needle size, target size, positron emission tomography avidity, procedure time, blood content score, sample volume, adequacy for molecular testing, as well as baseline patient characteristics and complication rate.

RESULTS

There was no difference between the 2 groups in all baseline parameters and characteristics. In multivariable analysis, HPS was associated with significantly higher sample volume (11.2 vs. 9.1 mm3, P=0.036) and less additional procedures to achieve full molecular profiling (2/52 vs. 7/40, P=0.042), in necrotic targets of non-small cell lung cancer. Diagnostic yields were comparable.

CONCLUSION

HPS appears to be simple, no-cost, and safe, promising higher sample volume compared with vacuum syringe suction, and also appears to be associated with higher success of full molecular testing with less additional procedures, in non-small cell lung cancer necrotic targets.

Is endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) reliable and safe procedure in geriatric patients?

BACKGROUND

Even though studies have indicated the usefulness and safety of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), elderly patient data are limited due to the small sample sizes.

AIM

We aimed to evaluate usage and safety of EBUS-TBNA in elderly population.

METHODS

This single-center retrospective study was conducted with patients who underwent an EBUS-TBNA procedure between September 2011 and December 2019. The patients were categorized into two groups: those aged 65 years or older (elderly group) and those younger than 65 years (younger group).

RESULTS

2444 patient data, 1069 of which were in the elderly group, were analyzed. The cytological examination of EBUS-TBNA identified specimen adequacy in 96.8% of patients. One hundred and thirty patients (5.3%) experienced complications, with similar complication rates recorded in both the elderly and younger groups (5.4% vs 5.2%, p: 0.836). Logistic regression analyses revealed that age, and presence of hypertension, diabetes mellitus, coronary artery disease and malignancy are associated significantly with complication-related EBUS-TBNA. For the lymph nodes with a final diagnosis of malignancy, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EBUS-TBNA revealed a diagnostic performance in excess of 90% except for metastasis and lymphoma.

CONCLUSION

EBUS-TBNA can be considered a safe and effective technique in patients aged 65 years and over.

Endoscopic Ultrasonography is a Promising Tool for Preoperative Prediction of the Operability of Pancreatic Carcinoma

This work discussed the efficiency of endoscopic ultrasonography (EUS) as a diagnostic modality for early detection of pancreatic cancer. The present study was constructed by doing imaging modalities EUS on 24 patients admitted to surgery department in the faculty of medicine with suspected pancreatic malignancy. Pancreatic cancer was found more in older ages above 55 years predominately in males coming from rural areas presenting with abdominal pain with or without jaundice. Histopathological examination revealed that ductal adenocarcinoma represented by 70.83% of cases. This study also shows significant elevation in serum CA19-9 in the presenting cases to confirm a close relation between cancer pancreas and CA19-9 as a good biochemical marker for PC. EUS was found to be able to detect masses less than 20 mm in diameter. Moreover, EUS can accurately detect the mass nature. EUS showed correct information as regards lymph node involvement and vascular invasion which affected the results of respectability of pancreatic masses. Finally, this study clearly showed that EUS is an accurate pre-operative tool in the assessment of nodal staging, vascular invasion, and respectability in patients with pancreatic adenocarcinoma.

Image-guided lymph node fine-needle aspiration: the Johns Hopkins Hospital experience

INTRODUCTION

Although the diagnostic utility of lymph node fine-needle aspiration (FNA) is well established in the evaluation of metastatic malignancy, its value in the diagnosis of lymphoma is more controversial; yet, there is a growing trend among practitioners towards less-invasive procedures such as FNA and core needle biopsy (CNB). The guidelines recently published by the American Society for Clinical Pathology/College of American Pathology (CAP) regarding the workup of lymphoma include recommendations on the value and limitations of FNA.

MATERIALS AND METHODS

We reviewed 1237 image-guided lymph node aspirates from 695 procedures (410 nodes from 360 ultrasound [US]-guided cases, 799 from 309 endobronchial ultrasound [EBUS], 25 from 23 endoscopic ultrasound [EUS], and 3 from 3 computed tomography [CT]).

RESULTS

The majority (40 of 46, 87%) of lymph nodes suspected of lymphomatous involvement were aspirated under ultrasound. Core needle biopsy [CNB] was obtained for 41 (89%) lymph nodes, including all 40 US specimens. Flow cytometry (FC) was performed on 37 (80%) aspirates; aspirates without FC were from patients who had a history of Hodgkin lymphoma, or showed granulomata or non-hematologic malignancy onsite. Thirty-one (67%) lymph nodes were sent for review by hematopathology. Forty-two (91%) lymph node FNA/CNB yielded actionable diagnoses. Seventeen of 241(7%) cases aspirated for other indications (14 US, 3 EBUS) were involved by a lymphoproliferative process. All were reviewed by hematopathology. All 14 US cases had FC and CNB.

CONCLUSION

Our institutional approach towards lymph node cytopathology for lymphoma workup appears to be in accordance with the new CAP guidelines, and demonstrates a potential triage and workflow model for lymph node FNA specimens that allows for accurate diagnosis in cases where lymphoma is a consideration.

Evaluation of histological specimens obtained by two types of EBUS-TBNA needles: a comparative study

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration is a standard method for obtaining specimens of mediastinal and hilar lesions. Several types of needles of various sizes and materials are available. This study aimed to compare the quality of specimens collected using two needles, cobalt chromium and stainless steel for endobronchial ultrasound-guided transbronchial needle aspiration.

METHODS

This retrospective study included data of patients who underwent EBUS-TBNA with a 22-gauge needle made from either stainless steel (41 lesions, 121 punctures) or cobalt chromium (47 lesions, 145 punctures). Histological data per puncture, diagnostic yield per lesion, procedure time and complication rates were compared.

RESULTS

There were no significant differences between the groups in the baseline characteristics of the patients or lesions or in the complication rates. The rate of diagnostic histological specimens in each sample (71.0% vs. 58.7%, P = 0.039), fewer samples with cartilage alone (1.4% vs. 6.6%, P = 0.047) and fewer samples containing cartilage (7.6% vs. 16.5%, P = 0.034) were seen in the cobalt chromium needle group than in the stainless steel needle group. In both groups, the rate of specimens that only contained blood clots in each sample and diagnostic yield per lesion were similar, but the procedure time was significantly shorter (22 min vs. 26 min, P = 0.007) in the cobalt chromium needle group.

CONCLUSION

Compared with stainless steel needles, cobalt chromium needle for EBUS-TBNA showed lower cartilage contamination and a higher ratio of obtaining diagnostic specimens in each sample. Bronchoscopists should consider using the optimal needle gauges and materials for collecting adequate specimens.

New developments in respiratory medicine: a primary immunodeficiency perspective

PURPOSE OF REVIEW

To consider recent developments in respiratory medicine that are of relevance to clinicians caring for adults affected by primary immunodeficiency disorders.

RECENT FINDINGS

We consider impulse oscillometry, new bronchoscopic techniques for sampling, MRI and PET, the concept of the human airway microbiome, and new treatment approaches for bronchiectasis and interstitial lung disease to better understand the future of respiratory care for people with PID.

SUMMARY

New approaches to the diagnosis and management of respiratory manifestations of PID have been driven by better understanding of the lung in health and disease, progress in imaging and sampling modalities, and new therapeutics.

Improved diagnosis of pulmonary embolism causing cardiac arrest by combined endobronchial ultrasound and echocardiography

BACKGROUND

Pulmonary embolism (PE) is a life-threatening disease difficult to diagnose and manage in severe hemodynamic unstable patients. Transoesophageal echocardiography (TEE) is considered useful to improve diagnosis, but such approach has physical limitations for the interposition of the airways preventing the clear assessment of the left pulmonary artery. Endobronchial ultrasound (EBUS), a recently developed technique carried out using a modified bronchoscope having a small ultrasound convex probe at the tip allowing to perform ultrasonography examination of the mediastinum, can extensively visualize the pulmonary arteries on both sides.

CASE PRESENTATION

We present the first use of EBUS to rapidly diagnose and subsequently treat a 64 years old woman with history of lateral amyotrophic sclerosis admitted to the intensive care unit (ICU) for severe dyspnoea and rapidly experiencing a cardiac arrest.

CONCLUSIONS

Combined bedside EBUS and echocardiography allowed to rapidly diagnose the cause of cardiac arrest and avoid risks related to transferring the critical patient to the radiology department.

Small core needle biopsies in cytology practice: a survey of members of the American Society of Cytopathology

INTRODUCTION

The introduction of a new generation of core needle biopsies (CNBs) for endoscopic procedures has prompted reconsideration of the role of cytopathologists in the handling of small biopsies. The American Society of Cytopathology (ASC) has therefore conducted a survey with the intention of elucidating current practices regarding the handling of small CNBs.

MATERIALS AND METHODS

The membership of the ASC was invited by email to participate in an online survey over a 2-month period. The survey consisted of 20 multiple choice questions with 2-8 possible responses per question.

RESULTS

Of 2651 members contacted by e-mail, 282 (10.6%) responded to the survey questions, including 196 pathologists (69.5%) and 86 cytotechnologists (30.5%). Of these, 265 respondents were from the US/Canada (94.0%), with 156 from academic institutions (58.9%) and 109 from non-academic practices (41.1%); 17 were from other countries (6.0%). In 18.8% of all practices, cytopathologists sign out >90% of small CNBs from endoscopic and radiologically guided procedures; in 36.5% of practices >90% are signed out by surgical pathologists; the remainder have such cases divided more evenly between cytopathologists and surgical pathologists. Responses show that 78.0% of all respondents are interested in signing out more small biopsies in the future, and 80.5% desire increased small biopsy-related resources from the ASC.

CONCLUSIONS

The survey responses indicate that practices currently vary widely across institutions. Most indicated an interest in greater incorporation of small biopsies into the practice of cytopathology.

Clinical value of contrast-enhanced ultrasound in transthoracic biopsy of malignant anterior mediastinal masses

Background

Given low incidence and high heterogeneity, the treatment strategies of anterior mediastinal masses (AMMs) are diverse based on pathology. The purpose of the study is to evaluate the usefulness of contrast-enhanced ultrasound (CEUS) in transthoracic biopsy of malignant AMMs when compared with that of ultrasound (US) alone and to screen lesions that are more suitable for CEUS evaluation and guidance.

Methods

We reviewed all the US- and CEUS-guided transthoracic core needle biopsy (CNB) of AMMs performed in National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between July 2013 and April 2019. A total of 68 patients (mean age 36 years; male-female ration 1.6:1) who were suspected with malignant AMMs were enrolled in the study. Among them, 20 patients received pre-biopsy CEUS examination (CEUS group); 48 patients underwent conventional US examination and guidance (US group). Demographic, radiologic, pathologic, medical records, and biopsy procedure details were retrospectively reviewed and compared between the two groups.

Results

The display of internal necrosis areas was significantly improved when compared with that of the conventional US (70%, 30%; P=0.008). Specifically, CEUS improved the diagnostic accuracy of US-guided transthoracic biopsy (95.0%, 79.2%; P=0.210) and especially for AMMs exceeding 10 cm (100%, 68.2%; P=0.040) and carcinoma (100%, 0%; P=0.048). The number of punctures in US group and CEUS group was 2.6 and 4.4 times, respectively (P<0.001). In case of similar number of punctures (1 to 3 times), CEUS improved diagnostic accuracy when compared to that of the conventional US (100%, 75%; P=0.486). The technical success rate was 100% (68/68). In both groups, patients did not exhibit symptomatic complications such as bleeding, pneumothorax, or hemoptysis after the biopsy.

Conclusions

The application of CEUS in transthoracic biopsy of malignant AMMs improved diagnostic accuracy when compared with conventional US and especially played more important role in lesions exceeding 10 cm and presumptive clinical carcinoma.