Endobronchial ultrasound with a guide sheath for small malignant pulmonary nodules: a retrospective comparison between central and peripheral locations

Endobronchial Ultrasonography With Guide Sheath for the Diagnosis of Peripheral Pulmonary Lesions in Japan: A Literature Review

We evaluated the usefulness of endobronchial ultrasonography with guide sheath (EBUS-GS) for the diagnosis of peripheral pulmonary lesions (PPLs) in Japan. We searched the PubMed/Medline database using the keywords "EBUS guide sheath" for Japanese studies on EBUS-GS published between January 2004 and August 2023. We included 32 original articles that evaluated the diagnostic yield of EBUS-GS for PPLs. Case reports and conference abstracts were excluded due to limited information available for quality assessment. The diagnostic yield of EBUS-GS was 73.6% for 2996 malignant lesions, 65.4% for 752 ground-glass nodules, 59.4% for 414 benign lesions, 61.3% for 1114 lesions of size ≤2 cm, and 75.6% for 1246 lesions of size >2 cm; it was 69.4% for lesions located in the upper lobe (n=793), 71.9% for the middle lobe/lingula (n=121), and 62.5% for the lower lobe (n=334). None of the patients experienced severe complications. In this review, EBUS-GS is effective for the diagnosis of malignant and benign PPLs. A multimodality approach is needed to further enhance its diagnostic performance.

Predictors of improvement of radial-endobronchial ultrasonography findings from "adjacent to" to "within" in endobronchial ultrasonography using a guide sheath: a retrospective cohort study

Background

In flexible bronchoscopy, endobronchial ultrasonography using a guide sheath (EBUS-GS) has varying diagnostic yield depending on the findings of radial-endobronchial ultrasonography (R-EBUS). The diagnosis rate is lower when the ultrasound probe is "adjacent to", than when it is "within" the lesion. However, these findings are inconsistent, and the imaging status may change from "adjacent to" to "within" as examination progresses. In this study, we analyzed the predictive factors for this change, which remain unexplored till date.

Methods

Patients who underwent flexible bronchoscopic biopsy with EBUS-GS at Kameda Medical Centre between 1 April 2014 and 31 March 2019 were included in this retrospective cohort study. Patients without "adjacent to" lesions were excluded. The appearance of "A to W" (the change from "adjacent to" to "within" imaging status) was the primary outcome. Based on multivariate regression and receiver operating characteristic curve analysis, we evaluated the discriminative properties of the factors strongly correlated with "A to W".

Results

In total, 260 patients were included in this study. In 84 cases, the R-EBUS findings were "A to W". No such findings were observed in 176 cases. The mean lesion diameter was significantly larger (P=0.021) in the group with "A to W" than in the group without. The odds ratio [1.023 (1.003-1.046)] for lesion diameter showed statistical significance in the multivariable regression model. The sensitivity and specificity were 0.346 and 0.852, respectively, at the optimal threshold (29.25 mm) set using the Youden index.

Conclusions

We found that lesion diameter was a significant factor in predicting "A to W", with a cut-off value of 29.25 mm and high specificity (0.852).

Predictive value of the resistance of the probe to pass through the lesion in the diagnosis of peripheral pulmonary lesions using radial probe endobronchial ultrasound with a guide sheath

Background

Transbronchial lung biopsy guided by radial probe endobronchial ultrasonography with a guide sheath (EBUS-GS-TBLB) is becoming a significant approach for diagnosing peripheral pulmonary lesions (PPLs). We aimed to explore the clinical value of the resistance of the probe to pass through the lesion in the diagnosis of PPLs when performing EBUS-GS-TBLB, and to determine the optimum number of EBUS-GS-TBLB.

Methods

We performed a prospective, single-center study of 126 consecutive patients who underwent EBUS-GS-TBLB for solid and positive-bronchus-sign PPLs where the probe was located within the lesion from September 2019 to May 2022. The classification of probe resistance for each lesion was carried out by two bronchoscopists independently, and the final result depended on the bronchoscopist responsible for the procedures. The primary endpoint was the diagnostic yield according with the resistance pattern. The secondary endpoints were the optimum number of EBUS-GS-TBLB and factors affecting diagnostic yield. Procedural complications were also recorded.

Results

The total diagnostic yield of EBUS-GS-TBLB was 77.8%, including 83.8% malignant and 67.4% benign diseases (P=0.033). Probe resistance type II displayed the highest diagnostic yield (87.5%), followed by type III (81.0%) and type I (61.1%). A significant difference between the diagnostic yield of malignant and benign diseases was detected in type II (P = 0.008), whereas others did not. Although most of the malignant PPLs with a definitive diagnosis using EBUS-GS-TBLB in type II or type III could be diagnosed in the first biopsy, the fourth biopsy contributed the most sufficient biopsy samples. In contrast, considerably limited tissue specimens could be obtained for each biopsy in type I. The inter-observer agreement of the two blinded bronchoscopists for the classification of probe resistance was excellent (κ = 0.84).

Conclusion

The probe resistance is a useful predictive factor for successful EBUS-GS-TBLB diagnosis of solid and positive-bronchus-sign PPLs where the probe was located within the lesion. Four serial biopsies are appropriate for both probe resistance type II and type III, and additional diagnostic procedures are needed for type I.

Impact of rapid on-site evaluation combined with endobronchial ultrasound and virtual bronchoscopic navigation in diagnosing peripheral lung lesions

BACKGROUND

To investigate the value of endobronchial ultrasound (EBUS) and virtual bronchoscopic navigation (VBN) combined with rapid on-site evaluation (ROSE) in diagnosing peripheral pulmonary lesions (PPLs).

METHODS

Between January 1st 2019 to September 1st 2021, EBUS and VBN examination were performed in expected consecutive patients with PPLs who were admitted to Zhangzhou Affiliated Hospital of Fujian Medical University (Fujian, China). Finally, based on the calculation of expected diagnostic yield of R-EBUS biopsy and drop out, 198 eligible patients were randomly divided into ROSE group (100 cases) and non-ROSE group (98 cases). The diagnostic yield of brushing and biopsy, the complications, the procedure time, the diagnosis time and expense during diagnosis were analyzed.

RESULTS

In the ROSE group, the positive rate of EBUS brushing and biopsy were 68%, 84%, respectively. The average procedure time and diagnosis time were 18.6 ± 6.8 min, 3.84 ± 4.28 days, respectively, and the average expense was 643.44 ± 706.56 US.$ (4093.15 ± 4494.67 yuan ¥). In the controls, the positive rate of brushing and biopsy were 44%, 74%, respectively. The average procedure time and diagnosis time were 15.4 ± 5.7 min, 6.46 ± 3.66 days, respectively. And the average expense during diagnosis was 1009.27 ± 713.89 US.$ (6420.28 ± 4541.33 yuan ¥). There was significant difference in the positive rate of EBUS brushing and biopsy, diagnosis time and expense during diagnosis between both groups. And no significant difference was observed in the complications and the procedure time. Additionally, the impact of ROSE on diagnostic yield in right upper lobe and the size of lesion ≤ 2 cm in diameter was significant.

CONCLUSION

In combination with ROSE, EBUS could significantly improve the positive rate of diagnosing PPLs, shorten diagnosis time and reduce expense during diagnosis. ROSE will be of great importance in the diagnosis of PPLs and medical resource.

Yield of tumor samples with a large guide-sheath in endobronchial ultrasound transbronchial biopsy for non-small cell lung cancer: A prospective study

Background

Adequate tumor tissue is required to make the best treatment choice for non-small cell lung cancer (NSCLC). Transbronchial biopsy (TBB) by endobronchial ultrasonography with a guide sheath (EBUS-GS) is useful to diagnose peripheral lung lesions. The data of tumor cell numbers obtained by two different sizes of GSs is limited. We conducted this study to investigate the utility of a large GS kit to obtain many tumor cells in patients with NSCLC.

Methods

Patients with a peripheral lung lesion and suspected of NSCLC were prospectively enrolled. They underwent TBB with a 5.9-mm diameter bronchoscope with a large GS. When the lesion was invisible in EBUS, we changed to a thinner bronchoscope and TBB was performed with a small GS. We compared the tumor cell number prospectively obtained with a large GS (prospective large GS group) and those previously obtained with a small GS (small GS cohort). The primary endpoint was the tumor cell number per sample, and we assessed characteristics of lesions that could be obtained by TBB with large GS.

Results

Biopsy with large GS was performed in 55 of 87 patients (63.2%), and 37 were diagnosed with NSCLC based on histological samples. The number of tumor cells per sample was not different between two groups (658±553 vs. 532±526, estimated difference between two groups with 95% confidence interval (CI); 125 (-125–376), p = 0.32). The sample size of the large GS group was significantly larger than that of the small GS cohort (1.75 mm² vs. 0.83 mm², estimated difference with 95% CI; 0.92 (0.60–1.23) mm², p = 0.00000019). The lesion involving a third or less bronchus generation was predictive factors using large GS.

Conclusions

The sample size obtained with large GS was significantly larger compared to that obtained with small GS, but there was no significant difference in tumor cell number. The 5.9-mm diameter bronchoscope with large GS can be used for lesions involving a third or less bronchus generation.

Advances in Diagnostic Bronchoscopy

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

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.

CT Guided Needle Biopsy of Peripheral Lesions-Lesion Characteristics That May Increase the Diagnostic Yield and Reduce the Complication Rate

Computed tomography-guided needle biopsy (CT-GNB) has a high diagnostic yield for lung cancer but higher complication rates compared to those of other biopsy modalities. We sought to clarify in which thoracic lesions we could achieve a quick pathological diagnosis using CT-GNB, considering the risks and benefits. We retrospectively enrolled 110 patients who underwent CT-GNB and 547 patients who underwent transbronchial biopsy (TBB) for parenchymal lung lesions in clinical practice. The diagnostic rates of CT-GNB and TBB were 87.3% and 75.3%. After failed diagnosis with other biopsy modalities, 92.3% of patients were finally diagnosed using CT-GNB and 65.8% using TBB. In cases with a negative bronchial sign, there was a statistically higher diagnostic rate with CT-GNB than with TBB (p < 0.001: 89.4% vs. 0%). Complication rates were higher with CT-GNB (50.9%) than with TBB (16.3%). However, there were lower rates of complications in cases with inhomogeneous tumors, subpleural lesions, and when more than 15 mm of the punctured needle length was within the target. We conclude that CT-GNB is an effective biopsy modality with a high diagnostic rate that is especially recommended when the bronchus sign is negative. It can be safely performed if risk factors for complications are taken into account.

Propensity-score-matching analysis to compare efficacy and safety between 16-gauge and 18-gauge needle in ultrasound-guided biopsy for peripheral pulmonary lesions

Background

Definitive diagnosis of peripheral pulmonary lesions (PPLs) depends on the histological analysis of the pleural biopsy sample. Ultrasound (US)-guided sampling is now standard practice in the clinical setting. However, determining a suitable needle size and sampling times to improve the efficacy and safety of the biopsy remains challenging. Here, we compared the efficacy between 16- and 18-gauge core biopsy needles in US-guided percutaneous transthoracic biopsy for PPLs on histological diagnosis and procedure-related complications.

Materials and methods

In total, 1169 patients (767 men, 402 women; mean age, 59.4 ± 13.2 years) who received biopsy for PPLs between September 2011 and February 2019 were included. The propensity score matching (PSM) analysis was performed to adjust the baseline differences, and the rate of successful specimen assessment and complications were compared between the 16-gauge (249 patients) and 18-gauge (920 patients) groups. The number of pleural surfaces crossed (NOPSC) was defined as the number of times the visceral pleural surface was transgressed. Stratified analysis was performed based on NOPSC.

Results

The overall success rate was 92.0% (1076/1169). The overall complication rate was 9.6%, including pneumothorax, hemorrhage, and vasovagal reaction, which occurred in 2.5% (29/1169), 6.6% (77/1169), and 0.5% (6/1169) of the patients, respectively. When NOPSC was 1 or > 2, the success and complication rates in the 16-gauge group were comparable to those of the 18-gauge group (all P > 0.05). When the NOPSC was 2, the success rate in the 16-gauge group was significantly higher than that in the 18-gauge group (P = 0.017), whereas the complication rate was comparable (P > 0.05).

Conclusion

Higher success rate could be achieved using a 16-gauge than an 18-gauge core biopsy needle in the US-guided percutaneous transthoracic biopsy for PPLs when the NOPSC was 2. We recommend using 16-gauge needles with 2 times of needle passes in biopsy for PPLs in clinical practice.

An update on the role of bronchoscopy in the diagnosis of pulmonary disease

Bronchoscopy has evolved over the past few decades and has been used by respiratory physicians to diagnose various airway and lung diseases. With the popularization of medical check-ups and growing interest in health, early diagnosis of lung diseases is essential. With the development of endobronchial ultrasound, ultrathin bronchoscopy, and electromagnetic navigational bronchoscopy, bronchoscopy has been able to widen its scope in diagnosing pulmonary diseases. In this review, we have described the brief history, role, and complications of bronchoscopy used in diagnosing pulmonary lesions, from simple flexible bronchoscopy to bronchoscopy combined with several up-to-date technologies.

Rapid On-Site Evaluation During Radial Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy for the Diagnosis of Peripheral Pulmonary Lesions

Objective:

To evaluate the diagnostic value of radial endobronchial ultrasound (R-EBUS) combination with rapid on-site evaluation (ROSE) guided transbronchial lung biopsy (TBLB) for peripheral pulmonary lesions.

Methods:

Peripheral pulmonary lesions identified by computed tomography underwent R-EBUS with or without ROSE randomly from February 2016 to August 2017. The diagnostic yield and the operation time were compared.

Results:

In total, 158 patients were involved in and completed this research, including 84 cases in the group of R-EBUS with ROSE, and 74 in the group without ROSE. The diagnostic yield of ROSE group was 85.7%. Among these positive cases, 69.4% cases were malignant tumors, and 30.6% cases were benign lesions. The operation time was (24.6 ± 6.3) min. In the group without ROSE, the diagnostic yield was 70.3%, including 35 malignant tumors (67.3%), and 17 benign lesions (32.7%). The operation time was (31.5 ± 6.8) min. There were significant differences between both groups in the diagnostic yield (χ2 = 5.556, P = 0.018) and in the operation time (t = 3.187, P < 0.01). No serious procedure related complications were observed, such as pneumothorax and hemorrhage.

Conclusion:

ROSE can improve the diagnostic yield, and shorten the operation time. R-EBUS combined with ROSE is a safe and effective technique for peripheral pulmonary lesions.

Diagnostic value of the combined use of radial probe endobronchial ultrasound and transbronchial biopsy in lung cancer

BACKGROUND

Although the use of radial endobronchial ultrasound (R-EBUS) with a guide sheath has shown improved diagnostic capability in peripheral pulmonary lesions, its utility is still low due to variable performance. To overcome its limitation, we evaluated the feasibility and efficacy of R-EBUS combined with transbronchial biopsy (TBB) under fluoroscopic guidance.

METHODS

We retrospectively reviewed medical records of 74 patients with non-small cell lung cancer (NSCLC) who underwent R-EBUS combined with TBB or TBB alone as a diagnostic technique. Subjects were grouped according to the diagnostic modality used (R-EBUS combined with TBB vs. TBB alone). Each group was matched for age, sex, and location of the biopsy. The chi-square test and paired t-test were used to compare characteristics and identify factors that affected the diagnostic yield.

RESULTS

The mean age of the study cohort was 67.4 ± 12.8 years, with 21 (56.8%) men and 16 (43.2%) women in each group. The lesion size was significantly smaller in the R-EBUS group (23.6 vs. 33.9, P < 0.001). The diagnostic yield with the combined use of R-EBUS and TBB (27/37, 72.9%) was significantly higher than that with standard TBB alone (22/37, 59.4%). Lung lesions with a positive bronchus sign were associated with a higher diagnostic yield (odds ratio = 3.52 [1.17-10.62]; P = 0.025).

CONCLUSIONS

The combination of R-EBUS with TBB resulted in a higher diagnostic yield than either technique alone. Thus, the addition of R-EBUS biopsy would be helpful to improve the diagnostic yield of TBB.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: The combination of R-EBUS with TBB under fluoroscopic guidance improved the diagnostic yield of PPLs compared to TBB alone. A tissue diagnosis was more likely in pulmonary lesions with the air-bronchus sign.

WHAT THIS STUDY ADDS

The use of R-EBUS could help improve the low diagnostic yield of TBB under fluoroscopic guidance without increasing the incidence of complications.

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.

Virtual bronchoscopic navigation without fluoroscopy guidance for peripheral pulmonary lesions in inexperienced pulmonologist

Objective

Fluoroscopy guidance is generally required for endobronchial ultrasonography with guide sheath (EBUS-GS) in peripheral pulmonary lesions (PPLs). Virtual bronchoscopic navigation (VBN) can guide the bronchoscope by creating virtual images of the bronchial route to the lesion. The diagnostic yield and safety profiles of VBN without fluoroscopy for PPLs have not been evaluated in inexperienced pulmonologist performing EBUS-GS.

Methods

Between January 2016 and June 2017, consecutive patients with PPLs referred for EBUS-GS at a single cancer center were enrolled. The diagnostic yield as well as safety profiles was retrospectively analyzed, and our preliminary experience was shared.

Results

A total of 109 patients with 109 lesions were included, 99 (90.8%) lesions were visible on EBUS imaging. According to the procedure time needed to locate the lesion on EBUS, 24.8% (27/109) were deemed technically difficult procedures; however, no significant relationships were identified between candidate parameters and technically difficult procedures. The overall diagnosis yield was 74.3% (81/109), and the diagnostic yield of malignancy was 83.7% (77/92). Lesions larger than 20 mm [odds ratio (OR), 2.758; 95% confidence interval (95% CI), 1.077-7.062; P=0.034] and probe of within type (OR, 3.174; 95% CI, 1.151-8.757, P=0.026) were independent factors leading to a better diagnostic yield in multivariate analysis. About 30 practice procedures were needed to achieve a stable diagnostic yield, and the proportion of technically difficult procedures decreased and stabilized after 70 practice procedures. Regarding complications, one patient (0.9%) had intraoperative hemorrhage (100 mL) which was managed under endoscopy.

Conclusions

VBN without fluoroscopy guidance is still useful and safe for PPLs diagnosis, especially for malignant diseases when performed by pulmonologist without previous experience of EBUS-GS. VBN may simplify the process of lesion positioning and further multi-center randomized studies are warranted.

Diagnostic Value of Non-Real-Time Radial Probe Endobronchial Ultrasound (RP-EBUS) Guided Positioning Method for Peripheral Pulmonary Lesions

Background

The aim of this study was to analyze the diagnostic value of thin bronchoscopy lung biopsy for peripheral pulmonary lesions under non-real-time guidance of radial ultrasound (RP-EBUS).

Material/Methods

We used a retrospective analysis of ultrasound images of 165 patients with peripheral pulmonary disease admitted to Suzhou Municipal Hospital Affiliated to Nanjing Medical University from February 2016 to December 2018 who were given RP-EBUS examination. Ultrasound images were obtained for all patients. There were 76 patients treated using traditional positioning method as the control group; 89 patients were treated by probe combined with bronchoscopy positioning method as the research group where the biopsy of the lesion along the path of the ultrasound probe was taken. The positive rate of the 2 methods was observed, and the factors affecting the quality of ultra-thin bronchoscopy under RP-EBUS non-real-time guidance were analyzed.

Results

The detection rate of the study group was 77.64%, which was significantly higher than that in control group, which was 63.16% (χ²=5.238, P<0.05). The number of biopsies in the study group was 6±1.25, which was significantly lower than that of the control group which was 9±1.87 (t=4.116, P<0.05). The diagnostic positive rate of the RP-EBUS probe was significantly higher than that of the RP-EBUS probe (χ²=5.081, P<0.05).

Conclusions

The diagnostic positive rate of RP-EBUS non-real-time guided subtotal bronchoscopy lung biopsy for peripheral lung disease using probe combined with bronchoscopy positioning method was higher than the traditional positioning method, and the number of biopsies in the study group was significantly lower than that in the control group, which was related to the size, location, whether the probe was wrapped, or the characteristics of the ultrasound image.

[Diagnostic Utility of Virtual Bronchoscopic Navigation Assisted Endobronchial Ultrasonography with Guide Sheath for Peripheral Pulmonary Lesions]

背景与目的

虚拟支气管镜导航（virtual bronchoscopic navigation, VBN）联合支气管超声导向鞘技术（endobronchial ultrasonography with guide sheath, EBUS-GS）用于经支气管肺活检术（transbronchus lung biopsy, TBLB），能够减少甚至避免射线暴露。本研究拟评价VBN联合EBUS-GS对肺周围性病变（pulmonary peripheral lesions, PPLs）的诊断价值及安全性。

方法

回顾性分析2016年1月-2017年12月在北京大学肿瘤医院内镜中心接受EBUS-GS-TBLB患者的临床病理资料，评价诊断率及安全性，并对影响诊断率的因素进行分析。

结果

121例患者纳入本研究，男性65例，女性56例；平均年龄（58.8±10.3）岁。108例（89.3%）可在EBUS图像中显示，共有89例（73.5%）经EBUS-GS-TBLB获得明确诊断。EBUS-GS-TBLB对恶性病变的诊断率为82.5%。联合刷检、活检及肺泡灌洗中两种或三种方式取检的诊断率（87.2%）高于仅采用单一方式取检（58.8%）（χ²=6.084, P=0.014）。影响EBUS-GS-TBLB诊断率的因素包括超声探头位于病灶内部（χ²=20.372, P=0.000）、病灶位于肺野内带及中带（χ²=10.810, P=0.001）。1例（0.8%）患者术中出血量较多。

结论

VBN联合EBUS-GS-TBLB是一种诊断PPLs安全且有效的方法。

Efficacy and safety of ultrasound (US) guided percutaneous needle biopsy for peripheral lung or pleural lesion: comparison with computed tomography (CT) guided needle biopsy

Background

Ultrasound (US)-guided percutaneous needle biopsy is a useful diagnostic technique with short examination time and real-time monitoring at the bedside. However, there are only a few studies that report on thoracic lesions, whereas the computed tomography (CT)-guided biopsy is well established. There is also limited data comparing US- and CT-guided biopsy. We aimed to clarify the efficacy and safety of US-guided biopsy for thoracic lesions adjacent to the chest wall.

Methods

We retrospectively enrolled consecutive patients who underwent US- or CT-guided percutaneous biopsies for thoracic lesions adjacent to the chest wall between April 2012 and December 2017. Clinical characteristics, lesion size, lesion-pleura contact arc length (LPCAL), diagnostic rate, and complications were compared between the 2 groups.

Results

This study enrolled 61 US-guided and 70 CT-guided biopsies. No significant difference was found in age or sex. The lesion size and LPCAL in the US-guided group were significantly larger than those in the CT-guided group (P<0.0001). The diagnostic rate was marginally higher in the US-guided group (93.4%) than in the CT-guided group (84.3%) (P=0.101). When the median cut-off of the LPCAL was defined as 40 mm in all cases, the diagnostic rate for lesion size >40 mm was significantly higher in the US-guided group than in the CT-guided group (P=0.009). Complication rates were significantly lower in the US-guided group (3.3%) than in the CT-guided group (24.3%) (P<0.001).

Conclusions

US-guided percutaneous needle biopsy for thoracic lesions adjacent to the chest wall is a feasible technique compared with CT-guided biopsy because of its higher diagnostic rate with a longer LPCAL and reduced complications.

Radial EBUS versus CT-guided needle biopsy for evaluation of solitary pulmonary nodules

Objective

This study is aimed to compare the diagnostic yield, complications and influencing factors between Radial endobroncheal ultrasonography guided bronchoscopy(R-EBUS) and CT-guided needle biopsy (CT-PNB), for evaluation of solitary pulmonary nodules(SPNs).

Matrials and Methods

160 cases of consecutive patients with SPNs were enrolled and divided into R-EBUS and CT-PNB groups randomly. The diagnostic yield, complications and influencing factors between the two groups were evaluated.

Results

Sensitivity of R-EBUS for malignancy was 73.7% (42/57) and for benign, was 43.5% (10/23), overall diagnostic accuracy was 65% (52/80). In CT-PNB group, overall diagnostic accuracy was 85% (68/80), sensitivity for malignancy was 87.9% (51/58), and for benign was 81.0% (17/21), respectively. Both overall diagnostic yield and incidence of complications in CT-PNB group were higher than those in R-EBUS group (P = 0.006, P = 0.002). In R-EBUS group, the factors affecting diagnostic yield were size (P = 0.027), the distance between SPNs and pleura (P = 0.031) and the location of the probe to lesions (P = 0.009). In CT-PNB group, the distance from the lesions to pleura was correlated with the incidence of pneumothorax (P = 0.001) and pulmonary haemorrhage (P = 0.042). The location of SPNs were adjacent to great vessels was another influencing factor for pulmonary haemorrhage (P = 0.042).

Conclusions

Both R-EBUS and CT-PNB are valuable tools for diagnosis. SPNs located in medial 1/2 of lung field, or were adjacent to great vessels may be fit for R-EBUS. Those SPNs located in lateral 1/2 of lung field, near to pleura or with less vessels around may be more suitable for CT-PNB.

The imaging of small pulmonary nodules

Lung cancer is the leading cause of cancer death worldwide. The major goal in lung cancer research is the improvement of long-term survival. Pulmonary nodules have high clinical importance, they may not only prove to be an early manifestation of lung cancer, but decide to choose the right therapy. This review will introduce the development and current situation of several imaging examination methods: computed tomography (CT), positron emission tomography/computed tomography (PET/CT), endobronchial ultrasound (EBUS).

Comparison between endobronchial ultrasound-guided transbronchial biopsy and CT-guided transthoracic lung biopsy for the diagnosis of peripheral lung cancer: a systematic review and meta-analysis

BACKGROUND

With the release of the National Lung Screening Trial results, the detection of peripheral pulmonary lesions (PPLs) is likely to increase. Computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and radial probe endobronchial ultrasound (r-EBUS)-guided transbronchial lung biopsy (TBLB) are recommended for tissue diagnosis of PPLs.

METHODS

A systematic review of published literature evaluating the accuracy of r-EBUS-TBLB and CT-PTNB for the diagnosis of PPLs was performed to determine point sensitivity and specificity, and to construct a summary receiver-operating characteristic curve.

RESULTS

This review included 31 publications dealing with EBUS-TBLB and 14 publications dealing with CT-PTNB for the diagnosis of PPLs. EBUS-TBLB had point sensitivity of 0.69 (95% CI: 0.67-0.71) for the diagnosis of peripheral lung cancer (PLC), which was lower than the sensitivity of CT-PTNB (0.94, 95% CI: 0.94-0.95). However, the complication rates observed with EBUS-TBLB were lower than those reported for CT-PTNB.

CONCLUSIONS

This meta-analysis showed that EBUS-TBLB is a safe and relatively accurate tool in the investigation of PLC. Although the yield remains lower than that of CT-PTNB, the procedural risks are lower.

Endobronchial ultrasound plus fluoroscopy-guided biopsy compared to fluoroscopy-guided transbronchial biopsy for obtaining samples of peripheral pulmonary lesions: A systematic review and meta-analysis

BACKGROUND:

We report a meta-analysis of recent studies comparing the diagnostic yields of endobronchial ultrasonography plus fluoroscopically-guided transbronchial biopsy (EBUS + TBB) with that of conventional fluoroscopically-guided TBB for peripheral pulmonary lesions (PPLs).

METHODS:

We searched Medline, the Cochrane Library, PubMed, and Google Scholar through 31 March 2013 using the keywords: lung neoplasm, pulmonary lesions, diagnosis, endobronchial ultrasound, fluoroscopy, and fluoroscopic.

RESULTS:

Four studies were included in the study with a total of 461 patients, 222 in the EBUS + TBB group and 239 in the TBB only group. The meta-analysis revealed that the group with EBUS + TBB was more favored in terms of positive diagnostic yield than the group diagnosed with only conventional TBB (odds ratio [OR] = 2.211, 95% confidence interval [CI] = 1.422–3.438, P < 0.001). Subgroup analysis based on lesion size found that smaller PPLs had higher accuracy (OR = 4.502, 95% CI = 2.002–10.126, P < 0.001) than PPLs of large size (OR = 1.849, 95% CI = 1.033–3.311, P = 0.039).

CONCLUSION:

Obtaining TBB samples for histopathological diagnosis is enhanced by the addition of EBUS to conventional fluoroscopic guidance; this is, especially important for patients with small peripheral lung lesions who benefit greatly from early diagnosis.

Endobronchial ultrasonography using a guide sheath technique for diagnosis of peripheral pulmonary lesions

Endobronchial ultrasonography using a guide sheath (EBUS-GS) is a novel method used for collecting peripheral pulmonary lesion (PPL) samples. EBUS-GS is performed by introducing a guide sheath-covered miniprobe into the target bronchus and then withdrawing the miniprobe after lesion detection, leaving the guide sheath in situ as a working channel for obtaining lesion samples. EBUS-GS can improve PPL diagnosis rates and be used for obtaining specimens for molecular analysis. In this review, we discuss the clinical applications of EBUS-GS, the factors that affect its diagnostic sensitivity, and potential complications. We also compare EBUS-GS with other available diagnostic techniques and discuss the strengths and limitations of this method.

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

BACKGROUND

Transbronchial biopsy (TBB) using radial endobronchial ultrasound with a guide sheath (REBUS-GS) has improved the diagnosis of peripheral pulmonary lesions (PPLs). Because of the high cost of the GS, REBUS with distance (REBUS-D) has certain advantages. The aim of this study was to compare the diagnostic yield of the REBUS-GS and REBUS-D by thin bronchoscopy for PPLs.

METHODS

Patients with PPLs were enrolled in a prospective randomized crossover study from August 2014 and July 2015. Once the lesion was localized, TBB using REBUS-GS and TBB using REBUS-D were performed sequentially in a randomized order in each patient. Each patient received four to five transbronchial biopsies with REBUS-GS as well as four to five transbronchial biopsies with REBUS-D. All brushing was performed through GS.

RESULTS

A total of 54 patients were enrolled in this study. After excluding seven participants with PPLs that were not detected by REBUS, a total of 47 subjects underwent REBUS-TBB. The diagnostic yield of REBUS-GS-TBB and REBUS-D-TBB was 72.2% (39/54) and 75.9% (41/54) respectively (P=0.625). Moreover, there was no statistically significant difference in diagnostic yield between REBUS-GS and REBUS-D in different lobe lesions and lesion sizes. Two cases of adenocarcinoma were only diagnosed with REBUS-GS-TBB. Two cases of tuberculosis, one case of mucosa-associated lymphoid tissue lymphoma (MALT) and one case of adenocarcinoma were only diagnosed by REBUS-D-TBB. The mean biopsy time after visualization of PPLs for REBUS-GS-TBB and REBUS-D-TBB were 5.17±2.34 and 7.36±3.18 min (P=0.00053).

CONCLUSIONS

Using thin bronchoscopy, the diagnostic yield for PPLs with REBUS-D-TBB is not inferior to the yield with REBUS-GS-TBB. The diagnosis rate of small subpleural lesions with REBUS-D is lower than the rate with REBUS-GS. Although it is associated with shorter operation time and less bleeding, REBUS-GS has a higher cost and sometimes leads to check failure due to small specimens and the impact of the bronchoscope curvature.

Endobronchial ultrasonography with guide sheath versus computed tomography guided transthoracic needle biopsy for peripheral pulmonary lesions: a propensity score matched analysis

BACKGROUND

Computed tomography guided transthoracic needle aspiration (CT-TTNA) and endobronchial ultrasonography with guide sheath (EBUS-GS) transbronchial lung biopsy are important methods for the diagnosis of peripheral pulmonary lesions (PPLs). Without enough evidence, it is controversial which is a better choice for diagnosing PPLs. In this study, we hypothesized that the complication rate of EBUS-GS would be lower than CT-TTNA and the diagnostic accuracy of EBUS-GS were not inferior to CT-TTNA.

METHODS

This study was a retrospective analysis of a prospective registry with propensity matching. Patients with PPLs were divided into EBUS-GS group and CT-TTNA group according to patients' intent to treatment. Pathological results and procedure related complications of EBUS-GS and CT-TTNA were recorded. Propensity score matching(PSM) was used to eliminate the intergroup bias. Diagnostic yields and complications of two groups were compared. Subgroup analysis was performed to conclude the indications of different procedures.

RESULTS

A total of 187 patients (CT-TTNA: 130; EBUS-GS: 57) were enrolled. After propensity score matching, 54 paired patients were included. Diagnostic yield was 81% (44/54) for EBUS-GS and 87% (47/54) for CT-TTNA (P=0.43), respectively. Diagnostic sensitivity in malignancy was 93% (42/45) for CT-TTNA and 79% (37/47) for EUBS-GS (P=0.04). Subgroup analysis revealed that the sensitivity of CT-TTNA was significantly higher in diagnosing of lesions close to the chest wall (100% vs. 80%, P=0.04), and bronchus sign on CT was a predictive factor for accurate diagnosis by EBUS-GS. The overall complication rate was 13% (7/54) for CT-TTNA group, which was not significantly higher than that of EBUS-GS group (2%, P=0.06). Subgroup analysis showed that patients combined with pulmonary comorbidities and lesions apart from chest wall were risk factors for complications of CT-TTNA.

CONCLUSIONS

Both of the two procedures are effective for the diagnosis of PPLs, but CT-TTNA has a higher diagnostic sensitivity for malignancy. EBUS-GS has fewer complications, and it is more suitable for patients combined with pulmonary comorbidities and lesions with bronchus signs.

Radial endobronchial ultrasound with a guide sheath for diagnosis of peripheral cavitary lung lesions: a retrospective study

Background

Radial endobronchial ultrasound with a guide sheath (EBUS-GS) has improved the diagnostic outcomes of peripheral lung lesions. However, to our knowledge, reports on the use of EBUS-GS for diagnosis of cavitary lesions are unavailable. Therefore, this study aimed to assess the effectiveness and safety of EBUS-GS for diagnosis of peripheral cavitary lung lesions (PCLLs).

Methods

This study was a single-institution retrospective review of PCLLs examined by using EBUS-GS between July 2013 and October 2015. The diagnostic results of different EBUS-GS samples, including cytologic, histopathologic, and microbiologic samples, were analysed separately.

Results

Of 696 radial EBUS procedures performed during the study period, 50 were performed for examination of PCLLs. The overall diagnostic yield for EBUS-GS was 80 % (40/50). Regarding 27 malignant lesions, the diagnostic yields for cytologic and histopathologic samples were 63.0 % (17/27) and 74.1 % (20/27), respectively. Regarding 23 benign lesions, the diagnostic yields for histopathologic and microbiologic samples were 69.6 % (16/23) and 47.8 % (11/23), respectively. Uni- and multivariate analyses indicated that the EBUS probe being within the lesion was the only factor significantly associated with increased diagnostic yield (odds ratio, 7.04; P = 0.03). Although pulmonary infection occurred after the procedure in 1 patient (2.0 %), no other complications, including pneumothorax or significant haemorrhage, were reported.

Conclusion

EBUS-GS was found to be an effective and safe procedure for diagnosis of PCLLs.

Preoperative planning of thoracic surgery with use of three-dimensional reconstruction, rapid prototyping, simulation and virtual navigation

For the past decades, surgeries have become more complex, due to the increasing age of the patient population referred for thoracic surgery, more complex pathology and the emergence of minimally invasive thoracic surgery. Together with the early detection of thoracic disease as a result of innovations in diagnostic possibilities and the paradigm shift to personalized medicine, preoperative planning is becoming an indispensable and crucial aspect of surgery. Several new techniques facilitating this paradigm shift have emerged. Pre-operative marking and staining of lesions are already a widely accepted method of preoperative planning in thoracic surgery. However, three-dimensional (3D) image reconstructions, virtual simulation and rapid prototyping (RP) are still in development phase. These new techniques are expected to become an important part of the standard work-up of patients undergoing thoracic surgery in the future. This review aims at graphically presenting and summarizing these new diagnostic and therapeutic tools.

Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: combination of radial probe endobronchial ultrasound and rapid on-site evaluation

BACKGROUND

Rapid on-site evaluation (ROSE) of cytologic specimens is a useful ancillary technique in needle aspiration procedures of pulmonary/mediastinal lesions, but few reports had been carried out to confirm the utility in the diagnosis of peripheral pulmonary lesions (PPLs) by radial probe endobronchial ultrasound (R-EBUS).

METHODS

To evaluate the impact of ROSE on the diagnostic yield of R-EBUS for PPLs, we retrospectively analyzed the diagnostic yields of transbronchial biopsy (TBB) or brushing using R-EBUS for patients with PPLs in a tertiary university hospital from December 2012 to December 2014.

RESULTS

A total of 815 patients with PPLs were included. A definite diagnosis was made by R-EBUS-guided TBB or brushing for 627 patients (76.9%). A total of 279 patients (34.2%) were examined by a ROSE technique. The combination of R-EBUS guided TBB or brushing with ROSE raised the diagnostic yield in the diagnosis of PPLs, especially difficult cases: right apical and left apical-posterior segment locations, small PPLs <3 cm without bronchus signs on computed tomography (CT) scan, PPLs with pleural effusions, and the position of probe is not within.

CONCLUSIONS

ROSE can improve the PPLs diagnostic yield when using R-EBUS guided TBB or brushing.

Radial endobronchial ultrasound in diagnosing peripheral lung lesions in a high tuberculosis setting

Background

Current data for the utility of radial endobronchial ultrasound (EBUS) in investigating peripheral lung lesions (PLLs) has been restricted to populations with low pulmonary tuberculosis (TB) incidence. The aim of this study was to assess the diagnostic utility of radial EBUS with guide sheath in the diagnosis of peripheral lung lesions in Singapore, a high TB incidence setting.

Methods

A post-hoc database analysis was performed. 123 consecutive patients with computed tomographic evidence of PLLs who underwent radial EBUS guided bronchoscopy were included.

Results

The final diagnosis was malignancy in 76 cases and benign in 44 cases. Radial EBUS guided bronchoscopy had a sensitivity of 65.8 % for malignancy, positive predictive value of 100 %, negative predictive value of 62.9 %, and a diagnostic accuracy of 82.5 %. 22 patients had a final diagnosis of pulmonary TB. The diagnostic sensitivity for pulmonary TB was 77.3 %, with a positive predictive value of 100 %, negative predictive value of 95.2 % and a diagnostic accuracy of 95.8 %. Overall, 58.8 % of pulmonary TB cases relied on histology to make an early diagnosis.

Conclusion

Radial EBUS guided bronchosopy is useful in investigating PLLs in a high TB incidence setting. Our data also suggests that radial EBUS is a more rapid diagnosis technique for tuberculous lesions.