Abstract

Background : There is conflicting data on the utility of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) for the detection and subtyping of lymphomas. Herein, we present our experience with EBUS-TBNA in suspected lymphoma.

Methods :This was a multicenter retrospective study of subjects with suspected lymphoma who underwent EBUS-TBNA (July 2011 to June 2017). The performance characteristics of EBUS-TBNA were calculated separately for suspected new-onset and recurrent lymphoma as well as for subtyping. We also analyzed the factors predicting the yield of EBUS-TBNA in suspected lymphoma.

Results : Among the 4803 EBUS procedures performed, 92 (1.9%) subjects had either suspected or proven lymphoma; 48 were finally diagnosed to have lymphoma. The diagnostic sensitivities of EBUS-TBNA in new-onset and recurrent lymphomas were 72.7% and 73.3%, respectively. Only 24.2% (8/33) subjects with new-onset lymphoma could be appropriately subtyped. This low yield was possibly due to inadequate material for cell block in 10 subjects, and performance of immunophenotyping and flow cytometry in only 5 and 1 subjects, respectively. Among the suspected cases of recurrence, EBUS-TBNA was sufficient for management in 81.8% (18/22). On a multivariate analysis, no factor (rapid onsite evaluation, needle size, number of lymph nodes sampled, passes per node, and size of the largest lymph node sampled) predicted the diagnostic yield.

Conclusion :EBUS-TBNA is a useful investigation in the diagnostic algorithm of suspected lymphoma as it helps avoid other invasive diagnostic procedures. The sensitivity of EBUS-TBNA in subtyping new-onset mediastinal lymphoma depends on the adequacy of cell aspirate and the judicious utilization of pathologic techniques.

Abstract

This study aimed to examine the use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the rapid diagnosis of mediastinal tuberculous lymphadenitis and drug-resistant mediastinal tuberculous lymphadenitis. A diagnosis of TB was confirmed by a positive Xpert MTB/RIF test or Mycobacterium tuberculosis culture. Rifampicin-resistant TB (RR-TB) or multidrug-resistant TB (MDR-TB) was diagnosed upon the detection of rifampicin resistance by Xpert MTB/RIF or resistance to rifampicin and isoniazid by phenotypic drug susceptibility testing (DST). Xpert MTB/RIF was positive in 43 of 56 patients (77%) and TB culture was positive in 31 of 56 patients (55%). Of these 56 patients, 25 (45%) were Xpert MTB/RIF positive and TB culture negative, 13 (23%) were Xpert MTB/RIF negative and TB culture positive, and 18 (32%) were Xpert MTB/RIF positive and TB culture positive. 11 patients (20%) had drug-resistant TB: seven with RR/MDR-TB, one with pre-extensively drug-resistant (XDR) TB, two with XDR-TB and one with isoniazid mono-resistance. An Xpert MTB/RIF assay carried out on EBUS-TBNA specimens provides rapid diagnosis of TB. Xpert MTB/RIF testing appears to have additional and more rapid sensitivity compared with culture alone. Culture-based DST provides an additional exclusive yield and the full resistance profile in addition to or instead of rifampicin resistance.

Abstract

Real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has earned its place as a standard of care in the evaluation of mediastinal and hilar lymphadenopathy. It is a minimally invasive and a safe procedure with high diagnostic accuracy and efficacy. The increased usage of EBUS-TBNA worldwide has thrown light on its possible complications including death. The complications range from minor to life threatening in few and may occur either early or later in the course after the procedure. The present review summarizes the reported complications from EBUS-TBNA, their outcome and the modalities used for their management.

Keywords : bronchoscopy; death, endobronchial ultrasound-guided transbronchial needle aspiration; haemorrhage; infection; risk.

Abstract

Introduction : Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the initial modality of choice in sampling mediastinal lymphadenopathy. It is possible to obtain both cytological and histological samples using both 21-gauge and 22-gauge EBUS-TBNA needles. The current study was undertaken to compare the diagnostic yield of cytology and histology samples obtained by the same EBUS-TBNA 21-gauge needle.

Patients and methods :One hundred sixty-six consecutive patients who underwent EBUS-TBNA with a 21-gauge EBUS-TBNA needle over a period of 3 years were included in this retrospective analysis. The diagnostic yields of EBUS-TBNA histology (EBUS-TBNA-H) and EBUS-TBNA cytology (EBUS-TBNA-C) specimens were compared using the McNemar test.

Results : The overall sensitivity and specificity of EBUS-TBNA were 89% and 100%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) of EBUS-TBNA were 100% and 53%, respectively. The overall sensitivity and specificity of EBUS-TBNA-H were 85% and 100%, respectively. The PPV and NPV of EBUS-TBNA-H were 100% and 43%, respectively. The overall sensitivity and specificity of EBUS-TBNA-C were 65% and 100%, respectively. The PPV and NPV of EBUS-TBNA-C were 100% and 14%, respectively. The diagnostic yield of EBUS-TBNA-H over EBUS-TBNA-C was statistically significant (P < 0.0001).

Conclusion : EBUS-TBNA-H with 21-gauge needle significantly improves the diagnostic yield of EBUS-TBNA. EBUS-TBNA-H improves the NPV of EBUS-TBNA. The combination of EBUS-TBNA-H and EBUS-TBNA-C improves the overall diagnostic yield of EBUS-TBNA.

Abstract

Lung cancer is one of the most prevalent types of cancer in the world. A complete diagnosis of lung cancer involves tissue acquisition for pathological subtype, molecular diagnosis and accurate staging of the disease to guide appropriate therapy. Real-time endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is minimally invasive and relatively safe procedure, which can be done on an outpatient basis under moderate sedation. EBUS-TBNA has been shown to be a safe modality to obtain tissue for diagnosis, staging and molecular profiling in lung cancer. EBUS-TBNA stands out in comparison with other modalities for tissue acquisition in lung cancer. EBUS-TBNA performed with the patient under moderate sedation yields sufficient tissue for sequential molecular analysis in most patients. In this review, we describe the role of EBUS-TBNA in various aspects of diagnosis and staging of lung cancer in the present era along with its future aspects.

Keywords :CP-EBUS; EBUS-TBNA; diagnosis; endobronchial ultrasound; lung cancer; molecular analysis; re-staging; staging; technical aspects.

Abstract

Mediastinal lymphadenopathy in patients with malignancy may not be always metastatic disease. We present three patients with proven thoracic or extra thoracic malignancies with mediastinal lymphadenopathy which were subsequently proven as granulomatous lymphadenitis by endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). The objective of the current report is to emphasise that granulomatous lymphadenitis should be considered as an important differential diagnosis in such patients especially in tuberculosis endemic countries like India.

Abstract

Objective :Assess the diagnostic yield of real-time bronchoscopic ultrasound transbronchial needle aspiration (EBUS TBNA) in conventional TBNA-negative mediastinal lymphadenopathy and hilar lymphadenopathy.

Materials and methods :Sixty-two patients having either conventional TBNA-negative mediastinal lymphadenopathy or hilar lymphadenopathy underwent real-time EBUS TBNA.

Results : EBUS TBNA was performed on 72 lymph nodes (mediastinal = 48; and hilar = 24). 31 of the 72 (43%) lymph node samples were positive for malignancy (29) or benign diagnosis (2), and 17 of the 72 (24%) lymph nodes were true negative at EBUS TBNA confirmed at surgery. Out of 48 mediastinal lymph nodes EBUS TBNA was diagnostic for malignancy in 19 (40%) and negative in 14 of which 12 (86%) were surgically confirmed true negative and 2 (14%) false negative. In 10 of the 24 (42%) hilar lymph nodes, EBUS TBNA was diagnostic for malignancy while 5 were true negative and 1 false negative. All false-negative lymph nodes were PET positive. Adequacy of EBUS TBNA based on positive aspiration and surgically confirmed true negative was 67% and in patients suspected for malignancy was 77%.

Conclusion :EBUS TBNA has a good diagnostic yield in hilar lymphadenopathy and in conventional TBNA-negative mediastinal lymphadenopathy.

Abstract

Transbronchial needle aspiration (TBNA) has the potential to allow adequate mediastinal staging of non-small cell lung cancer with enlarged lymph nodes in most patients without the need for mediastinoscopy. Metastasis to the mediastinal lymph nodes is one of the most important factors in determining resectability and prognosis in non-small cell lung cancer. The importance of TBNA as a tool for diagnosing intrathoracic lymphadenopathy as well as in the staging of lung cancer has been reported in various studies. We performed a literature search in PubMed and Journal of Bronchology using the keyword transbronchial needle aspiration. TBNA is a safe and effective procedure to diagnose mediastinal lymphadenopathy. Real-time bronchoscopic ultrasound-guided TBNA is the new kid on the block, which can further enhance the sensitivity of bronchoscopy in the diagnosis of mediastinal lesions.

Abstract

There are no data available combining transbronchial needle aspiration (TBNA) of mediastinal lymph nodes and positron emission tomography (PET) in the staging of nonsmall cell lung cancer (NSCLC). The aim of the current study was to determine if these two methods can enhance the negative predictive value of the individual modality alone, for a specific lymph node station, and if this integrated approach can reduce the number of mediastinoscopies. A total of 113 patients with enlarged mediastinal lymph nodes (> or = 1 cm), who underwent both TBNA and PET scanning, were included. In 51 patients, histopathology, confirmed by surgical lymph node dissection, was compared with PET results and TBNA. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy to detect malignant lymphadenopathy was 68 (13/19), 89 (119/134), 46 (13/28), 95 (119/125) and 86% (132/152) for PET, respectively; 54% (6/11), 100 (53/53), 100 (6/6), 91 (53/58) and 92% (59/64), respectively for TBNA; and 100 (11/11), 94 (50/53), 79 (11/14), 100 (50/50) and 95 (61/64) for combined TBNA and PET, respectively. Combination of transbronchial needle aspiration and positron emission tomography has the potential to allow adequate mediastinal staging of nonsmall cell lung cancer with enlarged lymph nodes in most patients without the need for mediastinoscopy.

Abstract

The fifty six-year-old Transbronchial Needle Aspiration (TBNA) has proved its efficacy, safety and cost-effectiveness particularly in diagnosing and staging lung cancer as well as in diagnosing benign granulomatous disease: sarcoidosis and tuberculous lymphadenitis. Although highly specific, the sensitivity and accuracy of TBNA may vary depending on the study methods, patient population (severity of disease) and prevalence of mediastinal metastasis. Conventional "blind" TBNA should be a "sine quo non" of routine bronchoscopy. However, it has not been used as extensively as it deserves to be owing to a multitude of factors ranging from concerns about its efficacy and safety to cost. Cost of the transbronchial aspiration needle might have an important impact on underuse of TBNA particularly in developing countries and therefore cost of the needles should be either adapted to the income of the countries or should be manufactured locally. Experience and training will, no doubt, improve TBNA performance and yield considerably.

Abstract

Study objectives :Although various techniques are available for obtaining pathology specimens from the mediastinal lymph nodes, including conventional bronchoscopic transbronchial needle aspiration (TBNA), transesophageal ultrasonography-guided needle aspiration, and mediastinoscopy, there are limitations to these techniques, which include low yield, poor access, need for general anesthesia, or complications. To overcome these problems, we undertook the current study to evaluate the clinical utility of the newly developed ultrasound puncture bronchoscope to visualize and perform real-time TBNA of the mediastinal and hilar lymph nodes under direct endobronchial ultrasonography (EBUS) guidance.

Design :Prospective patient enrollment.

Setting: :University teaching hospital.

Patients :From March 2002 to September 2003, 70 patients were included in the study.

Interventions : The new convex probe (CP) EBUS is integrated with a convex scanning probe on its tip with a separate working channel, thus permitting real-time EBUS-guided TBNA. The indications for CP-EBUS were the diagnosis of mediastinal and/or hilar lymphadenopathy for known or suspected malignancy. Lymph nodes and the surrounding vessels were first visualized with CP-EBUS using the Doppler mode. The dimensions of the lymph nodes were recorded, followed by real-time TBNA under direct EBUS guidance. Final diagnosis was based on cytology, surgical results, and/or clinical follow-up.

Results :All lymph nodes that were detected on the chest CT scan could be visualized using CP-EBUS. In 70 patients, CP-EBUS-guided TBNA was performed to obtain samples from mediastinal lymph nodes (58 nodes) and hilar lymph nodes (12 nodes). The sensitivity, specificity, and accuracy of CP-EBUS-guided TBNA in distinguishing benign from malignant lymph nodes were 95.7%, 100%, and 97.1%, respectively. The procedure was uneventful, and there were no complications.

Conclusions : Real-time CP-EBUS-guided TBNA of mediastinal and hilar lymph nodes is a novel approach that is safe and has a good diagnostic yield. This new ultrasound puncture bronchoscope has an excellent potential for assisting in safe and accurate diagnostic interventional bronchoscopy.

Abstract

The radial endobronchial ultrasound (EBUS) probe is conventionally inserted through the working channel of the flexible bronchoscope and limits interventional diagnostics and therapeutics under direct ultrasound control. The aim of this study was to assess the new convex probe EBUS (CP-EBUS) in the visualization of the hilar lymph nodes in surgically resected specimens and explore its feasibility to perform transbronchial needle aspiration (TBNA) under direct EBUS guidance prior to its clinical use. Fourteen surgically resected specimens from lung cancer (n=12) and metastatic lung cancer (n=2) patients were included in the study. The resected specimens included eight right upper lobes, one right middle lobe, and five left lower lobes. The EBUS examination was performed with a flexible bronchoscope equipped with a 7.5 MHz convex probe (CP) that scans parallel to the insertion direction of the bronchoscope. The appearance of the hilar lymph nodes using this CP-EBUS was noted. The size of hilar lymph nodes was measured at CP-EBUS and compared with the actual size of the lymph nodes, which was measured with a Vernier's caliper. Hilar lymph nodes could be clearly visualized with CP-EBUS. There was a good correlation between the actual size of the lymph node and that measured using CP-EBUS (R(2)=0.950). A dedicated transbronchial aspiration needle could be inserted into the hilar lymph node under direct ultrasonic control. There is a possibility in the underestimation of the size of large lymph nodes due to the scanning nature of the convex probe. The CP-EBUS was successfully used to visualize the hilar lymph node and perform TBNA in surgical resected lung specimens. This technique has an excellent potential to perform direct ultrasound guided TBNA of mediastinal and hilar lymph nodes.

Abstract

The last decade has seen the increasing application of bronchoscopic methods such as transbronchial needle aspiration in the staging of lung cancer as well as in the diagnosis of peripheral lung cancer, balloon dilatation using flexible bronchoscopy, development of new tracheobronchial stents to manage central airway obstruction, autofluorescence bronchoscopy for the early diagnosis of lung cancer and pediatric flexible bronchoscopy. There is also a better understanding in the mechanisms and management of hypoxemia during bronchoscopy such as upper airway obstruction. Recent developments include direct endobronchial ultrasound to increase the yield of transbronchial needle aspiration, high magnification bronchoscopy to assist in the diagnosis of early lung cancer and bronchoscopic lung volume reduction to gain the effects lung volume reduction surgery without the need for surgery in patients with severe emphysema. In this article the new and upcoming bronchoscopic techniques are discussed, which we believe will find a broader clinical application in the near future to manage patients in a better way.