Endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an advance in bronchoscopy. It is a staging tool for nonsmall cell lung cancer (NSCLC) but also allows diagnosis of unexplained mediastinal lymphadenopathy due to malignant and benign disease. It is a minimally invasive procedure that is used to stage suspected NSCLC with hilar nodes, discrete N2 or N3 disease, or bulky mediastinal disease. After a negative EBUS-TBNA result, if the pretest probability of lung cancer is high, a mediastinoscopy is still recommended, although in the light of recent trial data this is likely to change. EBUS-TBNA is expensive, which may limit its development in resource-rationed health care systems. Conventional (without ultrasound) transbronchial needle aspiration (TBNA) still has a useful role in lung cancer staging, especially where EBUS-TBNA is not available; it can help avoid unnecessary mediastinoscopies.     

Endobronchial ultrasound-guided transbronchial needle aspiration of lesions in mediastinum

Background

Lesions in mediastinum can represent malignancy and warrants further workup. Commonly a diagnosis is achieved by conventional bronchoscopy, transbronchial needle aspiration or CT guided fine needle aspiration, however a number of patients remain undiagnosed despite these common investigations

Methods

During a period of 36 months 601 patients underwent EBUS at our institution. Two hundred ninety three patients had an established diagnosis of lung cancer and were referred to us for mediastinal staging. The remaining patients had a radiologically suspicious intrathoracic lesion of which 107 had an undiagnosed lesion in mediastinum. All patients had been investigated by previous chest CT and bronchoscopy including brush cytology but remained undiagnosed.

Results

Of the 107 patients with undiagnosed lesions in the mediastinum 89 enlarged lymph nodes and 18 mediastinal tumours. Forty-eight of the 89 patients (54%) with enlarged mediastinal lymph nodes were diagnosed by EBUS of the remaining 41 patients 11 went on to more invasive methods. In patients with undiagnosed tumours in mediastinum we achieved a final diagnosis by EBUS in 14 of the 18 patients (78%) and 3 went on to more invasive methods.

Conclusion

EBUS provides a final diagnosis in 78% of patients with tumour in mediastinum and in more than half of patients with enlarged lymph nodes despite previous workup.     

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): Applications in chest disease

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) offers a minimally invasive option for staging the mediastinum in suspect lung cancer but also in the diagnosis of mediastinal lesions accessible from the airway. This review is aimed at centres considering establishing an EBUS service that may not be so familiar with the technique. It focuses primarily on technical aspects of EBUS-TBNA, training issues, cost considerations, indications, advantages and disadvantages compared with other mediastinal sampling techniques as well as some reference to its performance in clinical studies.
In summary, EBUS-TBNA is primarily used for staging non-small cell lung cancer, especially for bulky mediastinal disease and discrete N2 or N3 disease on CT, but also used for the diagnosis of unexplained mediastinal lymphadenopathy. For radical treatment staging, mediastinoscopy is still used at many centres and negative EBUS-TBNA results should be corroborated by mediastinoscopy. In the future, EBUS-TBNA may be used for staging the radiologically normal mediastinum and in re-staging. It is a procedure that can be taught with ease by an experienced operator, has numerous advantages over mediastinoscopy and is potentially cost saving by reducing the number of mediastinoscopies and associated peri-operative support required.     

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of small cell lung cancer

BackgroundMassive lymphadenopathy and direct mediastinal invasion are well-recognized phenomena in patients with small cell lung cancer (SCLC). The aim of this study was to assess the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of SCLC.MethodsWe retrospectively reviewed the records of 780 patients who underwent EBUS-TBNA at our institution from March 2004 to June 2012. Of these, 101 had a final diagnosis of SCLC. Excluding 3 patients with known SCLC who underwent EBUS-TBNA for staging purposes and including 2 patients who underwent EBUS-TBNA twice for the diagnosis of recurrence after achieving complete response by chemoradiation therapy during the study period, a total of 100 EBUS-TBNA procedures in 98 patients were analyzed.ResultsOther diagnostic tests prior to the initial EBUS-TBNA had failed to yield a diagnosis in 41 patients. The overall diagnostic yield of EBUS-TBNA for SCLC was 97% (97 of 100). Rapid on-site cytologic evaluation (ROSE) was performed at the operator's discretion in 77 procedures. ROSE did not have any impact on diagnostic yield (99% with ROSE vs. 90% without ROSE, p=0.1), but the use of ROSE was associated with fewer lesions (mean 1.1 with ROSE vs. 1.6 without ROSE, p<0.01) or aspirates (mean 2.3 with ROSE vs. 4.0 without ROSE, p<0.01).ConclusionsEBUS-TBNA provided a high diagnostic yield in SCLC with or without ROSE. EBUS-TBNA can be recommended for patients suspected to have SCLC, even if other diagnostic tests have failed.     

Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can sample enlarged mediastinal lymph nodes in patients with nonsmall cell lung cancer (NSCLC). To date, EBUS-TBNA has only been used to sample nodes visible on computed tomography (CT). The aim of the present study was to determine the accuracy of EBUS-TBNA in sampling nodes 1 cm) in the mediastinum underwent EBUS-TBNA. Identifiable lymph nodes at locations 2r, 2l, 4r, 4l, 7, 10r, 10l, 11r and 11l were aspirated. All patients underwent subsequent surgical staging. Diagnoses based on aspiration results were compared with those based on surgical results. In 100 patients (mean age 58.9 yrs; 68 males), 119 lymph nodes ranging 5-10 mm in size were detected and sampled. Malignancy was detected in 19 patients but missed in two; all diagnoses were confirmed by surgical findings. The mean diameter of the punctured lymph nodes was 8.1 mm. The sensitivity of EBUS-TBNA for detecting malignancy was 92.3%, specificity was 100%, and the negative predictive value was 96.3%. No complications occurred. In conclusion, endobronchial ultrasound-guided transbronchial needle aspiration can accurately sample even small mediastinal nodes, therefore avoiding unnecessary surgical exploration in one out of six patients who have no computed tomography evidence of mediastinal disease. Potentially operable patients with no signs of mediastinal involvement on computed tomography may benefit from pre-surgical endobronchial ultrasound-guided transbronchial needle aspiration and staging.     

经支气管镜超声内镜针吸活检应用进展

气管镜超声引导针吸活检术是近年来出现的一项新的微创诊断技术,目前有关其在肺癌诊断和分期中的应用价值、诊断纵隔淋巴结等病变正日益引起人们的关注。本文就这一技术的临床应用现状作一综述。     

Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging: early experience in Brazil

Objective:

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe and accurate method for collecting samples from mediastinal and hilar lymph nodes. This study focused on the initial results obtained with EBUS-TBNA for lung cancer and lymph node staging at three teaching hospitals in Brazil.

Methods:

This was a retrospective analysis of patients diagnosed with lung cancer and submitted to EBUS-TBNA for mediastinal lymph node staging. The EBUS-TBNA procedures, which involved the use of an EBUS scope, an ultrasound processor, and a compatible, disposable 22 G needle, were performed while the patients were under general anesthesia.

Results:

Between January of 2011 and January of 2014, 149 patients underwent EBUS-TBNA for lymph node staging. The mean age was 66 ± 12 years, and 58% were male. A total of 407 lymph nodes were sampled by EBUS-TBNA. The most common types of lung neoplasm were adenocarcinoma (in 67%) and squamous cell carcinoma (in 24%). For lung cancer staging, EBUS-TBNA was found to have a sensitivity of 96%, a specificity of 100%, and a negative predictive value of 85%.

Conclusions:

We found EBUS-TBNA to be a safe and accurate method for lymph node staging in lung cancer patients.     

Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial

STUDY OBJECTIVE: Our group performed a randomized trial to assess whether the addition of endobronchial ultrasound (EBUS) guidance will lead to better results than standard transbronchial needle aspiration (TBNS). EBUS guidance seems to be beneficial in increasing the yield of TBNA but has not been proven to be superior to conventional procedures in a randomized trial. METHODS: Consecutive patients who were referred for TBNA were randomized to an EBUS-guided and a conventional TBNA arm. Patients with subcarinal lymph nodes were randomized and analyzed separately (group A) from all other stations (group B). A positive result was defined as either lymphocytes or a specific abnormality on cytology. RESULTS: Two hundred patients were examined (100 patients each in groups A and B). Half of the patients underwent EBUS-guided TBNA rather than conventional TBNA. In group A, the yield of conventional TBNA was 74% compared to 86% in the EBUS group (difference not significant). In group B, the overall yields were 58% and 84%, respectively. This difference was statistically highly significant (p < 0.001). The average number of passes was four. CONCLUSION: EBUS guidance significantly increases the yield of TBNA in all stations except in the subcarinal region. It should be considered to be a routine adjunct to TBNA. On-site cytology may be unnecessary, and the number of necessary needle passes required is low.     

支气管内超声引导针吸活检术（EBUS-TBNA）的护理配合

支气管内超声引导针吸活检术（endobronchial ultrasound-guided transbronchial needle aspiration,EBUS-TBNA）是利用具有超声波功能的支气管镜,通过超声波图像来确认淋巴结,用专门的抽吸式活检针进行穿刺来提取检查标本.EBUS-TBNA主要用于明确支气管黏膜下或管外病变性质,并对肺癌的TNM分期有重要作用.我科是国内较早开展EBUS-TBNA的单位,并在护理配合方面积累了丰富的临床经验,现报道如下.     

Endobronchial ultrasonography guidance for transbronchial needle aspiration using a double-channel bronchoscope

STUDY OBJECTIVES: Endobronchial ultrasonography (EBUS) is used as guidance for transbronchial needle aspiration (TBNA), and real-time imaging of the needle position cannot be confirmed with a single-channel bronchoscope. We assessed the usefulness of EBUS-guided TBNA using a double-channel bronchoscope (EBUS-D), which provides real-time needle position, and compared it with EBUS-guided TBNA using a single-channel bronchoscope (EBUS-S). DESIGN: Randomized, comparative prospective study. SETTING: Hiroshima City Hospital, a tertiary-referral teaching hospital. PATIENTS: Between January 2000 and August 2003, 55 patients with intrathoracic lymphadenopathy were included. Patients were randomized to undergo EBUS-D (n = 30) or EBUS-S (n = 25). METHODS: EBUS-D: The EBUS probe and TBNA catheter were inserted simultaneously through a double-channel bronchoscope. Once the needle placement in the lesion was confirmed by EBUS, TBNA was performed. EBUS-S: The EBUS probe was removed after the determination of the penetration site. Then, the TBNA catheter was inserted and TBNA was performed. RESULTS: All the lymph nodes could be visualized with EBUS in each group of patients. In the EBUS-D group, the TBNA needle was visualized as a hyperechoic point on the real-time EBUS image. The diagnostic accuracy rate of EBUS-D and EBUS-S were statistically significantly different (97% vs 76%, respectively; p = 0.025). On second attempt of TBNA, the diagnostic rate of the EBUS-D group was superior to that of the EBUS-S group (85.7% vs 33.3%, respectively; p = 0.036). The mean number of penetrations was 1.24 in the EBUS-D group and 1.36 in the EBUS-S group. No complications were observed in the EBUS-D group, but a self-limiting hemorrhage occurred in a patient in the EBUS-S group. CONCLUSION: EBUS-D is useful for diagnosing intrathoracic lymphadenopathy, and the obtained specimen with real-time confirmation of the needle is directly proportional to an accurate diagnosis.     

Metastatic chordoma detected by endobronchial ultrasound-guided transbronchial needle aspiration

Chordomas are rare, slow-growing malignant bone tumours arising from cellular remnants of the notochord. These tumours are locally invasive but have also a metastastic potential.Chordomas are characterized by the presence of physaliferous cells in a myxofibrillary stromal background. In cytological aspirates, these characteristic cells are usually absent, revealing only clusters of cells with varying degrees of vacuolation. This makes definitive diagnosis of chordoma difficult as the tumor can mimic other myxoid neoplasms including renal cell carcinomas and well-differentiated chondrosarcomas. In such situations, a confident diagnosis of chordoma requires comparison with histology of the primary tumor.We describe the first case of metastatic chordoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).KEY WORDS : Chordoma, metastasis, endobronchial ultrasound-guided transbronchial needle aspiration     

Evaluation of a learning system for endobronchial ultrasound-guided transbronchial needle aspiration

BackgroundEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established modality for nodal staging in lung cancer; nevertheless, acquisition on effective fiberscope handling and puncture techniques remains challenging. Here, we present a novel EBUS-TBNA learning system protocol and evaluate the ability of physicians trained using this protocol to perform cytological diagnosis and histological sampling.Material and methodsWe designed a 5-step learning system as follows: (1) preparation, (2) probe insertion, (3) sonographic observation, (4) TBNA assistant, and (5) TBNA operator. Each trainee must accomplish the first 4 steps before beginning step 5. In step 5, EBUS-TBNA was performed in tandem by the trainee and supervisor. Diagnostic accuracy and success of histological sampling were recorded for each trial; results of the corresponding supervisor served as a control.ResultsAll 11 trainees entered step 5 after completing steps 1–4 over 5–10 trials. A total of 308 nodes were punctured in step 5. The overall accuracy of cytological diagnosis was 91.2% among trainees, and the histological sampling success rate was 85.4%. The diagnostic accuracy increased from 85.4% to 93.9% (p=0.027) after 12 needle aspiration experiences. The sizes of nodes associated with success and failure were 13.6 and 11.1 mm (p=0.001), respectively.ConclusionsOur EBUS-TBNA learning system provided a satisfactory educational pathway for trainees and can be used to improve accessibility of EBUS-TBNA.     

Comparison of 21-gauge and 22-gauge aspiration needle during endobronchial ultrasound-guided transbronchial needle aspiration

Background and objective: Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has typically been performed using the 22gauge (G) dedicated TBNA needle. Recently a new 21G TBNA needle has been introduced. The efficacy of using a larger gauge biopsy needle during EBUS‐TBNA has not been reported. The purpose of this study was to compare the diagnostic yield and utility of 21G and 22G needles during EBUS‐TBNA. Methods: EBUS‐TBNA was performed using both 21G and 22G needles. Cytological and histological findings were recorded for each samples obtained by an independent cytologist and pathologist. The cellularity and blood contamination were evaluated in the cytological samples. The quality of the histological core was evaluated by the amount of blood clots versus the actual tissue. Each factor was compared within two slides from the two different size needles. The diagnostic yield and the differences of the cytology and histology were analysed. Results: The evaluation of 45 lesions by EBUS‐TBNA revealed that tumour cells were equally detected by both 21G and 22G needles. Two patients of adenocarcinoma were histologically diagnosed only by the 21G needle. Although histological structure was better preserved in five lesions collected by the 21G needle, there was more blood contamination with the 21G needle (P < 0.0001). Conclusions: There were no differences in the diagnostic yield between the 21G and 22G needles during EBUS‐TBNA. The preserved histological structure of the samples obtained by the 21G needle may be useful for the diagnosis of mediastinal and hilar adenopathy of unknown aetiology which may be a challenge with the 22G needle.