Predicting malignancy in mediastinal lymph nodes by endobronchial ultrasound: A new ultrasound scoring system

Background and objective: Endobronchial ultrasound (EBUS) is now widely used in patients with resectable non‐small‐cell lung cancer to sample mediastinal lymph nodes (LN) for preoperative staging. The aim of this study was to investigate prospectively the utility of six ultrasound criteria to predict malignancy in mediastinal LN. Methods: EBUS was performed in patients with mediastinal lymphadenopathy irrespective of the underlying disease. The following criteria were expected to predict malignancy: short axis >1 cm, heterogeneous pattern, round shape, distinct margin, absence of a central hilar structure and high blood flow in a LN. A sum score prediction model for malignancy was built. If more than two criteria were present, LN was classified as high risk for malignancy. Moreover, interrater variability of two blinded investigators was evaluated. Results: Two hundred eighty‐one LN in 145 patients were analysed. Forty‐four percent of LN were found malignant, 10% revealed sarcoidosis, and 10% revealed tuberculosis. Interobserver agreement was very good. Positive predictive value was best for heterogeneity (73%), with a negative predictive value of more than 80%. The sum score resulted in an odds ratio of 15.5 if more than two criteria were positive (P < 0.00001). Conclusions: The assessment of ultrasound criteria during routine EBUS examinations is feasible and reproducible with very good interrater agreement. If less than three of the described criteria are present, a LN has a very low chance of being malignant. The best single criterion to predict malignancy is heterogeneity. The introduction of the sum score of ultrasound criteria could potentially increase diagnostic accuracy.     

The value of endobronchial ultrasound-guided transbronchial needle aspiration, 18-fluorodeoxyglucose positron emission tomography/computed tomography,and ultrasonography imaging techniques in the diagnosis of mediastinal and/or hilar malignant,anthracotic, and other benign lymph nodes

Introduction:Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a simple, reliable, minimally invasive and effective procedure. However, a surgical technique may be required, if the results are negative. Therefore, there is a need for new studies to increase the diagnostic value of EBUS-TBNA and provide additional information to guide the biopsy in performing the procedure. Here, we aimed to investigate the diagnostic value of EBUS-TBNA and 18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in diagnosis of hilar and/or mediastinal lymph nodes (LNs). It was also aimed to determine the contributions of real-time ultrasonography (USG) images of LNs to distinguishing between the malignant and benign LNs during EBUS-TBNA, and in the diagnosis of anthracotic LNs.Material and Method:In the retrospective study including 545 patients, 1068 LNs were sampled by EBUS-TBNA between January 2015 and February 2020. EBUS-TBNA, 18-FDG PET/CT and images of USG were investigated in the diagnosis of mediastinal and/or hilar malignant, anthracotic and other benign LNs.Results:The sensitivity, specificity, positive predictive value and negative predictive value of EBUS-TBNA were found as 79.5, 98.1, 89.5, and 91.7%, respectively. Mean maximum standardized uptake value (SUVmax) values of 18F-FDG PET/CT were 6.31±4.3 in anthracotic LNs and 5.07 ± 2.53 in reactive LNs. Also, mean SUVmax of malignant LNs was 11.02 ± 7.30 and significantly higher than that of benign LNs. In differentiation of malignant-benign tumors, considering the cut off value of 18F-FDG PET/CT SUVmax as 2.72, the sensitivity and specificity was 99.3 and 11.7%, but given the cut off value as 6.48, the sensitivity, specificity, positive predictive value and negative predictive value was found as 76.5, 64, 20.49, and 78.38% for benign LNs, respectively. Compared LNs as to internal structure and contour features, malignant LNs had most often irregular contours and heterogeneous density. Anthracotic, reactive and other benign LNs were most frequently observed as regular contours and homogeneous density. The difference between malignant and benign LNs was significant.Conclusion:EBUS can contribute to the differential diagnosis of malignant, anthracotic and other benign LNs. Such contributions can guide clinician bronchoscopists during EBUS-TBNA. The triple modality of EBUS-TBNA, 18FDG PET/CT, and USG may increase the diagnostic value in hilar and mediastinal lymphadenopathies.     

Endobronchial ultrasound‐guided transbronchial needle biopsy for the diagnosis of intrathoracic lymph node metastases from extrathoracic malignancies: A meta‐analysis and systematic review

Intrathoracic lymph node metastases in patients with extrathoracic malignancies are a common clinical manifestation. Several studies evaluating intrathoracic lymph node metastases in patients with extrathoracic malignancy by using the endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) have been reported. The objective of this meta‐analysis is to investigate the diagnostic value of EBUS‐TBNA for diagnosing intrathoracic lymph node metastases in patients with extrathoracic malignancies. We systematically searched Cochrane Library, Medline and Embase for relevant studies published prior to May 2013. Studies specifically designed to evaluate the diagnostic accuracy of EBUS‐TBNA for intrathoracic lymph node metastases in patients with an extrathoracic malignancy were selected. Diagnostic accuracy meta‐analysis was conducted by pooling estimates of sensitivity, specificity, negative likelihood ratio (NLR), positive likelihood ratio (PLR) and diagnostic odds ratios (DOR) derived from a summary receiver operating characteristic (SROC) analysis of the original studies. Six studies were included, which provided a dataset of 533 patients. EBUS‐TBNA pooled estimates had 0.85 sensitivity (95% confidence interval (CI): 0.80–0.89), 0.99 specificity (95% CI: 0.95–1.00), PLR 28.63 (95% CI: 11.51–71.22) and NLR 0.16 (95% CI: 0.12–0.21). The overall DOR was 179.77 (95% CI: 66.29–487.50). The area under the SROC curve and the diagnostic accuracy were 0.9247 and 0.8588, respectively. Evidence gathered from studies of moderate quality reveals a high degree of diagnostic accuracy of EBUS‐TBNA for diagnosing intrathoracic lymph node metastases in patients with extrathoracic malignancies.     

Endoscopic ultrasound‐guided fine needle aspiration biopsy in esophageal and mediastinal diseases: Clinical indications and results

Background: Endoscopic ultrasound‐guided fine needle aspiration biopsy (EUS‐FNAB) was developed to attain endosonographical images in real time in endoscopic biopsy, just like in percutaneous biopsy with ultrasonic or computer‐tomographical images. The results of EUS‐FNAB in esophageal and mediastinal diseases were evaluated and clinical indications of this technique were investigated. Methods: The study was performed in 58 patients, consisting of 30 with esophageal or mediastinal tumors and 28 requiring mediastinal lymph node examination. The instruments were linear array EUS transducer PEF‐703FA (Toshiba‐Fujinon, Tokyo, Japan) and 21G Endosonopsy (Hakko Shoji, Tokyo, Japan). The aspirated material was recovered on a filter paper and was formalin‐fixed to be examined histopathologically. Results: The tumors measured 6–60 mm (mean 29 mm). Collection of tissue was successful in 95% of the patients, and diagnostic accuracy was 95%. The biopsy specimen was satisfactory to establish histological diagnosis in every case of 27 patients with malignant diseases. No complication was experienced. Conclusion: The EUS‐FNAB is indicated in cases where the technique of EUS‐guided puncture is required, or is considered optimum in view of the safety and in cases where histological diagnosis is critical for the decision of treatment program. In many cases of mediastinal diseases, not even a detection of lesion is feasible without this technique, let alone a collection of tissue. The EUS‐FNAB is thus performed as a first choice of examination to obtain biopsy specimen in such cases. Endoscsopic ultrasound‐guided lymph node puncture is applied in order to assess the appropriateness of endoscopic mucosal resection (EMR) in patients with esophageal cancer, to follow up the patients after EMR and chemoradiotherapy (CRT), and to evaluate the efficacy of neoadjuvant CRT.