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Mohan A, Madan K, Hadda V, Mittal S, Suri T, Shekh I, Guleria R, Khader A, Chhajed P, Christopher DJ, Swarnakar R, Agarwal R, Aggarwal AN, Aggarwal S, Agrawal G, Ayub II, Bai M, Baldwa B, Chauhan A, Chawla R, Chopra M, Choudhry D, Dhar R, Dhooria S, Garg R, Goel A, Goel M, Goyal R, Gupta N, Manjunath BG, Iyer H, Jain D, Khan A, Kumar R, Koul PA, Lall A, Arunachalam M, Madan NK, Mehta R, Loganathan N, Nath A, Nangia V, Nene A, Patel D, Pattabhiraman VR, Raja A, Rajesh B, Rangarajan A, Rathi V, Sehgal IS, Shankar SH, Sindhwani G, Singh PK, Srinivasan A, Talwar D, Thangakunam B, Tiwari P, Tyagi R, Chandra NV, Sharada V, Vadala R, Venkatnarayan K. Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations. Lung India 2023; 40:368-400. [PMID: 37417095 PMCID: PMC10401980 DOI: 10.4103/lungindia.lungindia_510_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/30/2022] [Accepted: 01/31/2023] [Indexed: 07/08/2023] Open
Abstract
Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.
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Affiliation(s)
- Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tejas Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Irfan Shekh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abdul Khader
- Institute of Pulmonology, Allergy and Asthma Research, Calicut, India
| | | | | | | | | | - Ritesh Agarwal
- Department of Pulmonary Medicine, PGIMER, Chandigarh, India
| | | | - Shubham Aggarwal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gyanendra Agrawal
- Department of Internal Medicine, Respiratory and Critical Care Medicine, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Irfan Ismail Ayub
- Department of Pulmonology, Sri Ramachandra, Medical Centre, Chennai, India
| | - Muniza Bai
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bhvya Baldwa
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Chauhan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Chawla
- Department of Pulmonary Medicine, Jaipur Golden Hospital, Delhi, India
| | - Manu Chopra
- Department of Medicine, Command Hospital Eastern Command Kolkata, India
| | - Dhruva Choudhry
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | - Raja Dhar
- Department of Pulmonology, Calcutta Medical Research Institute, Kolkata, India
| | | | - Rakesh Garg
- Department of Onco-Anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Goel
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Goel
- Department of Pulmonology, Fortis, Gurugram, India
| | - Rajiv Goyal
- Department of Respiratory Medicine, Rajiv Gandhi Cancer Institute, Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - BG Manjunath
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | - Hariharan Iyer
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajmal Khan
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, India
| | - Raj Kumar
- Director, Vallabhbhai Patel Chest Institute, Delhi, India
| | - Parvaiz A. Koul
- Director, Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ajay Lall
- Department of Pulmonary Medicine, Max Hospital, Saket, Delhi, India
| | - M. Arunachalam
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neha K. Madan
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ravindra Mehta
- Department of Pulmonary and Critical Care Medicine, Apollo Hospitals, Bengaluru, India
| | - N Loganathan
- Department of Pulmonary Medicine, Sri Ramakrishna Hospital, Coimbatore, India
| | - Alok Nath
- Department of Pulmonary Medicine, SGPGIMS, Lucknow, India
| | - Vivek Nangia
- Department of Pulmonology and Respiratory Medicine, Max Super Speciality Hospital Saket, New Delhi, India
| | - Amita Nene
- Bombay Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Arun Raja
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Benin Rajesh
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Amith Rangarajan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vidushi Rathi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sujay H. Shankar
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Girish Sindhwani
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Pawan K. Singh
- Department of Pulmonary and Critical Care Medicine, PGIMS, Rohtak, India
| | | | | | | | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Tyagi
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naren V. Chandra
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - V. Sharada
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Vadala
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kavitha Venkatnarayan
- Department of Pulmonary Medicine, St. John’s National Academy of Health Sciences, Bengaluru, India
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Demirkol B, Tanrıverdi E, Gül Ş, Koç AS, Akgün E, Yardımcı AH, Baydili KN, Çetinkaya E. The role of endobronchial ultrasonography elastography in the diagnosis of hilar and mediastinal lymph nodes. Turk J Med Sci 2023; 53:712-720. [PMID: 37476908 PMCID: PMC10388034 DOI: 10.55730/1300-0144.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 06/19/2023] [Accepted: 02/07/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Endobronchial ultrasonography (EBUS) is a minimally invasive diagnostic tool in the diagnosis of mediastinal lymph nodes (LNs) and has sonographic features. We aimed to investigate the diagnostic accuracy of EBUS elastography, which evaluates tissue compressibility integrated into EBUS, on malignant vs. benign mediastinal-hilar LNs. METHODS A single-center, prospective study was conducted at the University of Health Sciences Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital between 01/10/2019 and 15/11/2019. The features of 219 LNs evaluated by thoracic computed tomography (CT), positron emission tomography (PET)/CT, EBUS sonography and EBUS elastography were recorded. The LNs sampled by EBUS-guided fine needle aspiration were classified according to EBUS elastography color distribution findings as follows: type 1, predominantly nonblue (green, yellow, and red); type 2, part blue, part nonblue; type 3, predominantly blue. The strain ratio (SR) was calculated based on normal tissue with the relevant region. RESULTS The average age of 131 patients included in the study was 55.86 ± 13 years, 76 (58%) were male. Two hundred and nineteen lymph nodes were sampled from different stations. Pathological diagnosis of 75 (34.2%) LNs was malignant, the rest was benign. When EBUS B-mode findings and pathological results were compared, sensitivity was 65.33%, specificity 63.19%, positive predictive value (PPV) 48%, negative predictive value (NPV) 77.8%, and diagnostic yield (DY) 64%. When the pathological diagnoses and EBUS elastography findings were compared, while type 1 LNs were considered to be benign and type 3 LNs malignant, sensitivity 94.12%, specificity 86.54%, PPV 82.1%, NPV 95.7%, and DY 89.5%. SR of malignant LNs was significantly higher than benign LNs (p < 0.001). When the classification according to color scale and SR were compared, no difference was found in DY (p = 0.155). DISCUSSION The diagnostic accuracy of EBUS elastography is high enough to distinguish malignant LN from benign ones with the SR option. When compared with EBUS-B mode sonographic findings, it was found to have a higher diagnostic yield.
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Affiliation(s)
- Barış Demirkol
- Department of Pulmonology, Başaksehir Çam and Sakura City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Elif Tanrıverdi
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Şule Gül
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Aysu Sinem Koç
- Department of Pulmonology, Bahçeşehir Liv Hospital, İstinye University, İstanbul, Turkey
| | - Elife Akgün
- Department of Nuclear Medicine, Kırıkkale Yüksek İhtisas Hospital, Kırıkkale, Turkey
| | - Aytül Hande Yardımcı
- Department of Radiology, Başakşehir Çam and Sakura City Hospital, University of Health Sciences, İstanbul, Turkey
| | - Kürşad Nuri Baydili
- Department of Biostatistics and Medical Informatics, Faculty of Hamidiye Medical, University of Health Sciences, İstanbul, Turkey
| | - Erdoğan Çetinkaya
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, İstanbul, Turkey
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Madan K, Madan M, Iyer H, Mittal S, Madan NK, Rathi V, Tiwari P, Hadda V, Mohan A, Pandey RM, Guleria R. Utility of Elastography for Differentiating Malignant and Benign Lymph Nodes During EBUS-TBNA: A Systematic Review and Meta-analysis. J Bronchology Interv Pulmonol 2022; 29:18-33. [PMID: 34132684 DOI: 10.1097/lbr.0000000000000781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ultrasound elastography noninvasively estimates tissue hardness. Studies have evaluated elastography for differentiating malignant from benign lymph nodes during endobronchial ultrasound-guided transbronchial needle aspiration. Several methods of performing elastography are described with variable diagnostic accuracy. METHODS The aim of this study was to evaluate endobronchial ultrasound-guided elastography in differentiating malignant from benign mediastinal lymphadenopathy. We performed a systematic search of the PubMed and Embase databases to extract the relevant studies. A diagnostic accuracy meta-analysis was carried out to calculate the pooled sensitivity and specificity [with 95% confidence intervals (CIs)], and positive and negative likelihood ratios of elastography. RESULTS After a systematic search, 20 studies (1600 patients, 2712 nodes) were selected. The pooled sensitivity and specificity of elastography were 0.90 (95% CI, 0.84-0.94) and 0.79 (95% CI, 0.73-0.84), respectively. The summary receiver operating curve demonstrated an area under the curve for elastography of 0.90 (0.88-0.93). The positive and negative likelihood ratios and the diagnostic odds ratio were 4.3 (95% CI, 3.3-5.5), 0.12 (95% CI, 0.07-0.20), and 35 (95% CI, 19-63), respectively. Of the most commonly described methods, the color classification method (type 3 malignant vs. type 1 benign) demonstrated the highest area under the curve of 0.91 (0.88-0.93). There was significant heterogeneity and publication bias. Subgroup analyses indicated no significant difference between the sensitivity and specificity of quantitative and qualitative elastography methods. CONCLUSIONS Ultrasound elastography is useful in differentiating malignant and benign lymph nodes during endobronchial ultrasound-guided transbronchial needle aspiration. However, elastography does not replace the requirement of lymph node aspiration.
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Affiliation(s)
- Karan Madan
- Departments of Pulmonary, Critical Care, and Sleep Medicine
| | - Manu Madan
- Departments of Pulmonary, Critical Care, and Sleep Medicine
| | - Hariharan Iyer
- Departments of Pulmonary, Critical Care, and Sleep Medicine
| | - Saurabh Mittal
- Departments of Pulmonary, Critical Care, and Sleep Medicine
| | | | - Vidushi Rathi
- Departments of Pulmonary, Critical Care, and Sleep Medicine
| | - Pavan Tiwari
- Departments of Pulmonary, Critical Care, and Sleep Medicine
| | - Vijay Hadda
- Departments of Pulmonary, Critical Care, and Sleep Medicine
| | - Anant Mohan
- Departments of Pulmonary, Critical Care, and Sleep Medicine
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Huang J, Lu Y, Wang X, Zhu X, Li P, Chen J, Chen P, Ding M. Diagnostic value of endobronchial ultrasound elastography combined with rapid onsite cytological evaluation in endobronchial ultrasound-guided transbronchial needle aspiration. BMC Pulm Med 2021; 21:423. [PMID: 34930196 PMCID: PMC8690901 DOI: 10.1186/s12890-021-01748-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022] Open
Abstract
Background Endobronchial ultrasound (EBUS) elastography has been used in EBUS-guided transbronchial needle aspiration (EBUS-TBNA) to identify malignant lymph nodes based on tissue stiffness. Rapid onsite cytological evaluation (ROSE) has been widely utilized for onsite evaluation of sample adequacy and for guiding sampling during EBUS-TBNA. The aim of this study was to investigate the diagnostic value of combined EBUS elastography and ROSE in evaluating mediastinal and hilar lymph node status. Methods Retrospective chart review was performed from December 2018 to September 2020. Patient demographics, EBUS elastography scores, and ROSE, pathologic, and clinical outcome data were collected. The EBUS elastography scores were classified as follows: Type 1, predominantly nonblue; Type 2, partially blue and partially nonblue; and Type 3, predominantly blue. A receiver operating characteristic curve was used to compare the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for evaluation of malignant lymph nodes among the EBUS elastography, ROSE, and EBUS combined with ROSE groups. Results A total of 245 patients (345 lymph nodes) were included. The sensitivity and specificity of the EBUS elastography group for the diagnosis of malignant lymph nodes were 90.51% and 57.26%, respectively. The sensitivity and specificity in the ROSE group were 96.32% and 79.05%, respectively. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of EBUS elastography combined with ROSE were 86.61%, 92.65%, 11.78, and 0.14, respectively, and the area under the curve was 0.942. Conclusions Combining EBUS elastography and ROSE significantly increased the diagnostic value of EBUS-TBNA in evaluating mediastinal and hilar lymph node status compared to each method alone. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01748-4.
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Affiliation(s)
- Jing Huang
- Department of Respiratory and Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China
| | - Yuan Lu
- Department of Respiratory and Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China
| | - Xihua Wang
- Department of Respiratory and Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China
| | - Xiaoli Zhu
- Department of Respiratory and Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China
| | - Ping Li
- Department of Respiratory and Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China
| | - Jing Chen
- Department of Respiratory and Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China
| | - Pingsheng Chen
- Department of pathology and pathophysiology, School of Medicine, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China.
| | - Ming Ding
- Department of Respiratory and Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Dingjiaqiao 87#, Nanjing, Jiangsu, China.
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