EBUS-TNBA 22G samples: Comparison of PD-L1 expression between DAKO and BIOCARE®

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): revolutionizing the landscape of lung disease diagnostics

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a revolutionary diagnostic tool for lung diseases, including lung cancer, sarcoidosis, and lymphoproliferative diseases. This minimally invasive procedure offers a superior diagnostic yield while ensuring maximum patient safety when compared to traditional invasive techniques such as mediastinoscopy and thoracoscopy. By enabling real-time imaging and sampling of mediastinal and hilar lymph nodes and masses directly from the bronchoscope, EBUS-TBNA has redefined the precision of diagnostic bronchoscopy. This comprehensive review explores the origins, development, and current status of EBUS-TBNA, highlighting its successes and identifying potential areas for improvement. Technological advancements have continuously enhanced the reliability and efficacy of EBUS-TBNA over time. The mechanisms underlying the superior diagnostic yield of EBUS-TBNA are thoroughly discussed, further solidifying its position as the gold standard for lung cancer staging and diagnosis. Furthermore, this review delves into the crucial role of EBUS-TBNA in lung cancer diagnosis, supported by studies comparing its accuracy, safety, and cost-effectiveness to other diagnostic tools. Looking ahead, ongoing research aims to expand the applications of EBUS-TBNA and improve its diagnostic performance. Notable advancements in needle design and sampling techniques hold promise for further enhancing its efficacy. Maximizing its potential through comprehensive training and continuous technological developments will enable broader clinical applications, ultimately leading to improved patient outcomes. As EBUS-TBNA continues to evolve, its diagnostic impact is expected to increase, solidifying its position as an indispensable tool in the diagnosis and management of lung diseases.

Immunotherapy and Chemotherapy Versus Sleep Disturbances for NSCLC Patients

INTRODUCTION

Cancer patients are known to experience sleep disturbances that differ between disease stages and treatments. Regarding lung cancer patients and immunotherapy, information on their sleep disturbances has been recently acquired, but no comparison has been made between different treatment modalities.

PATIENTS AND METHODS

We recruited 98 non-small cell lung cancer patients; 49 had programmed death-ligand 1 expression of ≥50% and received immunotherapy as first-line treatment and 49 had programmed death-ligand 1 expression in the range from 0-49 and received chemotherapy as first-line treatment. All patients were stage IV, but with no bone metastasis. Sleep disturbances were recorded through polysomnography and sleep questionnaires.

RESULTS

For immunotherapy patients with PD-L1 expression ≥ 50%, the disease response was rapid and the sleep disturbances decreased rapidly. On the other hand, for chemotherapy patients, the sleep disturbances remained for all those patients that had partial response and stable disease. It was noticed that chemotherapy drugs induce severe adverse effects.

DISCUSSION

In our study, it was observed that patients with complete response had reduced sleep disturbances in the case of immunotherapy patients. However, sleep disturbances continued for several patients in the chemotherapy group due to the adverse effects of chemotherapy drugs.

IN CONCLUSION

Immunotherapy drugs on their own do not induce sleep disturbances and, through treatment response, alleviate sleep disturbances in lung cancer patients.

Radial-EBUS: CryoBiopsy Versus Conventional Biopsy: Time-Sample and C-Arm

Introduction: Diagnosis of lung nodules is still under investigation. We use computed tomography scans and positron emission tomography in order to identify their origin. Patients and Methods: In our retrospective study, we included 248 patients with a single lung nodule or multiple lung nodules of size ≥1 cm. We used a radial-endobronchial ultrasound and a C-Arm. We used a 1.1 mm cryoprobe versus a 22G needle vs. forceps/brush. We compared the sample size of each biopsy method with the number of cell-block slices. Results: Central lesions indifferent to the method provided the same mean number of cell-block slices (0.04933–0.02410). Cryobiopsies provide less sample size for peripheral lesions due to the higher incidence of pneumothorax (0.04700–0.02296). Conclusion: The larger the lesion ≥2 cm, and central, more cell-blocks are produced indifferent to the biopsy method (0.13386–0.02939). The time of the procedure was observed to be less when the C-Arm was used as an additional navigation tool (0.14854–0.00089).

Program death ligand-1 immunocytochemistry in lung cancer cytological samples: A systematic review

In this era of personalized medicine, targeted immunotherapies like immune checkpoint inhibitors (ICI) blocking the programmed death‐1 (PD‐1)/program death ligand‐1 (PD‐L1) axis have become an integral part of treating advanced stage non‐small cell lung carcinoma (NSCLC) and many other cancer types. Multiple monoclonal antibodies are available commercially to detect PD‐L1 expression in tumor cells by immunohistochemistry (IHC). As most clinical trials initially required tumor biopsy for PD‐L1 detection by IHC, many of the currently available PD‐1/PD‐L1 assays have been developed and validated on formalin fixed tissue specimens. The majority (>50%) of lung cancer cases do not have a surgical biopsy or resection specimen available for ancillary testing and instead must rely primarily on fine needle aspiration biopsy specimens for diagnosis, staging and ancillary tests. Review of the literature shows multiple studies exploring the feasibility of PD‐L1 IHC on cytological samples. In addition, there are studies addressing various aspects of IHC validation on cytology preparations including pre‐analytical (e.g., different fixatives), analytical (e.g., antibody clone, staining platforms, inter and intra‐observer agreement, cytology‐histology concordance) and post‐analytical (e.g., clinical outcome) issues. Although promising results in this field have emerged utilizing cytology samples, many important questions still need to be addressed. This review summarizes the literature of PD‐L1 IHC in lung cytology specimens and provides practical tips for optimizing analysis.

Lung cancer, treatment and nutritional status

Lung cancer is often diagnosed at inoperable advanced stages, and most patients exhibit cancer cachexia. The nutritional status of patients has been previously observed to serve a key role in cancer survival and cancer surgery. The aim of the current study was to collect information regarding the treatment of patients and associate them with different nutritional measurements. A total of 82 patients with non-small cell lung cancer were included in the present study. Several parameters were assessed, such as body mass index (BMI), Mediterranian diet score, number of years spent smoking, basic metabolsim (RMR; kcal/day), VO₂ (ml/min), ventilation (lt/min) and physical activity. All the aforementioned parameters were associated with patient treatment, nutritional status and survival. Two-way ANOVA was conducted and pairwise group mean differences were tested using Fisher's LSD and Tukey tests. Normality and variance homogeneity was checked in all cases. The results revealed that RMR and oxygen consumption were negatively affected by the survival status of patients (P=0.012 and P=0.043, respectively). The mean fat difference was higher in patients treated with immunotherapy, and lower in those treated with chemotherapy in addition to immunotherapy, as demonstrated by Tukey comparisons. The survival of 25 patients were affected by the treatment they received (P=0.006). Chemotherapy administered in addition to immunotherapy prolonged patient life almost two-fold when compared with the individual effects of the two treatments, which became equal according to Fisher's LSD comparisons. In conclusion, the nutritional status of patients was associated with the administration of chemotherapy in addition to immunotherapy, and patient survival. Increased metabolism and fat mass were also associated with prolonged survival.

Biopsy and re-biopsy for PD-L1 expression in NSCLC. association between PD-L1 and checkpoint inhibitor efficacy through treatment in NSCLC. A pilot study

INTRODUCTION

Lung cancer is diagnosed at a late stage due to lack of early disease symptoms. Therefore an efficient treatment is necessary for prolonged disease free survival.

PATIENTS AND METHODS

In our study we recruited 124 patients NSCLC patients with adenocarcinoma and squamus cell carcinoma. All recuited patients had Programmed death-ligand 1 expression ≥50 (PD-L1)with DAKO technique. Immunotherapy was administered with as first line treatment. Re-biopsies were performed in the main lung lesion every 4 months with the restaging of the patient and also in the metastastic sites in other organs that occurred during treatment. PD-L1 expressed was evaluated in the biopsies of the metastatic sites.

RESULTS

It appears thereafter that the PD-L1 expression could easily be claimed as a promising bio-index with a cutoff value 65, below which a negative prognosis of the disease progress will be evident and above that value a positive continuation of the disease will be prominent.

CONCLUSION

The findings of this study suggest that the PD-L1-65 index works adequately either concerning the neo-metastatic sites or the patient disease responses. Re-biopsies in new metastastic sites are necessary since we probably have a new cancer and chemotherapy should be added. More studies should confirm are results and change the NSCLC treatment approach of these patients.

Priority of PET-CT vs CT Thorax for EBUS-TBNA 22G vs 19G: Mesothorax Lymphadenopathy

Introduction: Lung lesions and undiagnosed mesothorax lymphadenopathy is an issue that several doctors face in the everyday clinical practice. PET-CT and CT of the thorax are usually the first examinations to identify characteristics of the lesions before biopsy.

Patients and Methods: We performed a retrospective study with 450 patients that had EBUS-TBNA with 22G, Upgraded 22G and 19G needles with and without PET-CT in order to identify the cost effeteness of performing EBUS-TBNA before or after PET-CT. All centers used the same PET-CT equipment and EBUS-TBNA system. Three types of needle were used for the endoscopy in order to identify similarities and differences for the cost-effectiveness. The costs in every center for every examination and materials were the same.

Results: There were more block slices for 19G>22Gupgraded>21G>22G and there was cost-effectiveness when in general PET-CT was performed prior to biopsy of any lesion. 19G needle was more effective for lymphomas, while 22Gupgraded and 21G needles were more cost-effective when used for smaller lesions for primary lung cancer of metastatic disease.

Conclusions: We have been using PET-CT and EBUS-TBNA in the everyday clinical practice according to the current guidelines for initial disease staging and re-staging. However; we can also use both in a cost effective method based on the initial radiologic findings.

Effective early diagnosis for NSCLC: an algorithm

INTRODUCTION

Lung cancer still remains undiagnosed for most patients until the disease is inoperable.

AREAS COVERED

We performed search on PubMed with the keywords: EBUS, radial-EBUS, bronchoscopy, lung cancer, electromagnetic navigation, ct-biopsy, transthoracic biopsy. We present diagnostic equipment and imaging techniques such as positron emission tomography, endoscopical navigation systems, endobronchial ultrasound, radial-endobronchial ultrasound, transthoracic ultrasound biopsy, and computed tomography guided biopsies.

EXPERT OPINION

However, lack of early disease symptoms remains the most important issue and therefore we should direct our efforts to screening and early disease diagnosis. An algorithm is proposed for biopsy upon initial disease diagnosis.

Examination of endobronchial ultrasound-guided transbronchial needle aspiration using a puncture needle with a side trap

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is useful for diagnosing hilar and mediastinal lymph node enlargement; however, specimens obtained are often small and inadequate for pathologic diagnosis. In June 2017, EchoTip ProCore, a puncture needle with a side trap, was launched in Japan. In this single-center prospective interventional study, 57 patients with lymph nodes, intrapulmonary tumor or pleural mass were diagnosed using EBUS-TBNA with EchoTip ProCore between June 2017 and February 2020. EBUS-TBNA was performed for 57 patients and 53 patients had sufficient specimen for histologic diagnosis. The following pathologic subtypes were diagnosed: non-small cell lung cancer, 22; small cell lung cancer, 8; cancer of unknown primary, 2; neuroendocrine tumor (G2) recurrence, 1; lymphoma, 2; metastatic renal cell carcinoma, 3; thymoma recurrence, 1; sarcoidosis, 4; tuberculosis, 1; and non-malignancy, 9. In addition, the cytology showed Class V in 31 out of 57 cases (54.4%). In total, a definitive pathological diagnosis was obtained in 50 out of 57 cases (87.7%). The only complication was pneumonia caused by BAL simultaneously combined with EBUS-TBNA in one patient. Among 13 patients with inadequate specimens or without malignancy, only one patient was subsequently diagnosed with malignancy, and the median follow-up period was 300 days. EBUS-TBNA using EchoTip ProCore can obtain a sufficient specimen size for pathologic diagnosis.

Intratumoral Treatment with Chemotherapy and Immunotherapy for NSCLC with EBUS-TBNA 19G

Introduction: Immunotherapy is being used for the past five years either as first line or second line treatment with great results. Chemotherapy and radiotherapy have been also used as combination to immunotherapy to further enhance this type of treatment. Intratumoral treatment has been previously proposed as a treatment option for certain non-small cell lung cancer patients.

Patients and Methods: We recruited in total seventy four patients with non-small cell lung cancer in their second line treatment who received only chemotherapy in their first line treatment with programmed death-ligand-1 ≤ 50. Only adenocarcinoma or squamous cell carcinoma, and all negative for epidermal growth factor receptor, anaplastic lymphoma kinase, proto-oncogene tyrosine-protein kinase-1 and proto-oncogene B-Raf. Data were first examined with descriptive statistics choosing frequencies for categorical variables and histograms for the continuous ones. Twenty five received only intravenous immunotherapy and forty-nine intravenous cisplatin with immunotherapy. Data were first examined with descriptive statistics choosing frequencies for categorical variables and histograms for the continuous ones.

Results: The relationships between changes of performance status and disease progression were examined via a single correspondence analysis. The two-dimensional scores (coordinates) derived from the correspondence analysis were then regressed against the predictors to form distinct splits and nodes obtaining quantitative results. The best fit is usually achieved by lowering exhaustively the AICc criterion and looking in parallel the change of R² expecting improvements more than 5%. both types of therapy are capable of producing best ameliorative effects, when either the programmed death-ligand-1 expression or parenchymal site in joint with low pack years are present in the sampling data.

Conclusions: Intratumoral treatment combination with cisplatin plus immunotherapy indifferent of nivolumab or pembrolizumab combination is an effective choice. In specific for those with endobronchial lesions. Moreover; patients with programmed death-ligand-1 ≥ 50 had their performance status and disease progression improved over the eight month observation.

Thyroid cancer diagnosis with transdermal probe 22G U/S versus EBUS-convex probe TBNA-B 22G and 19G: pros and cons

INTRODUCTION

Thyroid cancer is usually diagnosed both with imaging techniques and transdermal biopsy. Laboratory tests are also included in the initial work-up.

PATIENTS AND METHODS

One hundred and thirty patients were included in our study with pathological imaging findings in the thyroid region. Biopsies were performed with 22 G with transdermal convex probe, EBUS 22 G Mediglobe® needle and 19 G Olympus® needle. We investigated the efficiency and safety of both techniques and identified the best candidates for each method.

DISCUSSION

19 G needle identified cancer types such as; Lymphoma, Medullary thyroid cancer, and Hurthle cell cancer, which we know from previous pathology studies that a larger sample is necessary for diagnosis. No safety issues were observed for both techniques and the EBUS technique produced more cell block material when 22 G needle was compared to transdermal biopsy in peritracheal lesions.

CONCLUSION

The method of biopsy should be made based on the size and accessibility of the lesion.

Application of a Simulator-Based Teaching Method in the Training of the Flexible Bronchoscope-Guided Intubation

BACKGROUND

The study aimed to explore the effect of a bronchoscopic simulator-based comprehensive teaching method in the training of flexible bronchoscope-guided intubation for suspected lung cancer patients for doctors without bronchofibroscopic operation background.

METHODS

We designed a prospective self-control study involved in 35 trainees from the Navy Military Medical University's affiliated hospital to evaluate flexible bronchoscope-guided intubation's training outcome. Before and after the practice training, we recorded the flexible bronchoscope passing time from nasal to visible glottis and carina, tracheal placement tube, and ventilation.

RESULTS

All 35 trainees could complete flexible bronchoscope-guided intubation independently after training.

CONCLUSIONS

The bronchial diagnosis for suspected lung cancer patients and treatment-based model can be widely applied in tracheal intubation training.

Connection between PD-L1 expression and standardized uptake value in NSCLC: an early prognostic treatment combination

Objectives: Lung cancer is still diagnosed at advanced stage and early treatment initiation is needed. Therefore, we need biomarkers or clusters of information that can provide early treatment prognosis.Methods: Biopsies were acquired from 471 patients-lung masses with CT-guided biopsy, convex probe transthorasic biopsy, and EBUS-TBNA convex probe with 18 G needles and 19 G needles.Results: Standardized uptake value (SUV) measurement is associated with female, smoking status, hepatic metastasis, adenocarcinoma and programmed death-ligand 1 (PD-L1). In specific we expect that SUV ≥ 7 is associated with PD-L1 ≥ 50.Conclusions: Lung masses indifferent of size that have SUV ≥ 7 will also have PD-L1 expression ≥ 50. Also, it is likely that these patients will be female with intense smoking habit and hepar or multiple metastasis.

Lung cancer biopsies: Comparison between simple 22G, 22G upgraded and 21G needle for EBUS-TBNA

Introduction: Novel technologies are currently used for lung cancer diagnosis. EBUS-TBNA 22G is considered one of the most important tools. However; there are still issues with the sample size.Patients and Methods: 223 patients underwent EBUS-TBNA with a 21G Olympus needle, 22GUS Mediglobe and 22GUB Mediglobe. In order to evaluate the efficiency of 22GUB novel needle design. In order to evaluate the sample size of each needle, we constructed cell blocks and measured the different number of slices from each biopsy site. Results: The 22GUB novel needle had similar and larger number of slices from each biopsy site compared to 21G needle. Discussion: Firstly as a novel methodology we used the number of slices from the constructed cell blocks in order to evaluate the sample size. Secondly, we should seek novel needle designs and not only concentrate on the volume of the sample size.

The development of bronchoscopy in China: a national cross-sectional study

Objective: To investigate the development of bronchoscopy in China and compare it with its application in the early 21st century. Methods: The data collection was based on questionnaires. Three hundred and nineteen hospitals, which distributed across 30 provinces and 130 cities, were included in the study. Data about the application of bronchoscopy in Shanghai and Hunan province in the early 21st century are also involved for comparison. Results: The median period of performing diagnostic and therapeutic bronchoscopy was 19.7±11.0 and 7.4±7.0 years, respectively. On average, about 155.2 cases and 28.4 cases received diagnostic and therapeutic bronchoscopy in each hospital per month. The average area and number of the examination room was 122.7m² and 2.2m², respectively. More examination items were performed in specialty hospitals than those in general hospitals (P<0.05) and specialty hospitals owned more rooms exclusively for bronchoscopy (P<0.05), while no difference of the number of allocated doctors was found (P>0.05). On the other side, the whole amount of diagnosis and therapeutic items in teaching hospitals was slightly higher than that in non-teaching hospitals (P<0.01). Comparison of diagnosis and therapeutic endoscopy in Shanghai and Hunan province shows that the number of flexible bronchoscopy increased by 5.8 times in Shanghai from 2002 to 2017, while that increased by 3.4 times in Hunan province from 2005 to 2017. Furthermore, the average number of allocated doctors increased by 0.85 times in Shanghai, which was more rapidly compared with that of Hunan province (0.66 times) (P<0.05). Besides, the development rate of the diagnosis and therapeutic projects in Shanghai was significantly higher than that in Hunan province (P<0.05). Conclusion: All different classes of hospitals in China are capable of carrying out conventional bronchoscopy diagnosis and therapeutic projects, and newly developed bronchoscopy technology has gradually spread in high-level hospitals since 21st century. The higher class the hospital was, the earlier bronchoscopy was performed. Respiratory endoscopy in China has developed rapidly since the early 21st century and the construction of respiratory endoscopy center and the personnel training are on the right track, but it is also faced with inadequate equipment, unbalanced regional development and insufficient personnel allocation.