The Endobronchial Ultrasound-Guided Transbronchial Needle Biopsy Learning Curve for Mediastinal and Hilar Lymph Node Diagnosis

Abstract

To the EditorThe learning curve required for the endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) of mediastinal or hilar lymph nodes is unclear, and the evidence is scarce and contradictory.1Unroe MA Shofer SL Wahidi MM Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques.Curr Opin Pulm Med. 2010; 16: 295-300Crossref PubMed Scopus (22) Google Scholar, 2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar, 4Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J, In press. doi:10.1111/j.1445-5994.2009.02142.xGoogle Scholar Two of the evidentiary studies2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar only analyzed the learning curve of EBUS-TBNA for lung cancer diagnosis and staging and did not include the use of this technique in the study of lymph nodes affected by other pathologies. Other factors that might be influenced by learning have also not been examined.2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar, 4Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J, In press. doi:10.1111/j.1445-5994.2009.02142.xGoogle ScholarTo address these issues, we conducted a prospective study to describe the learning curve of an experienced bronchoscopy team in a unselected sample of patients with mediastinal or hilar lymph nodes. Team performance was analyzed not only in terms of the diagnostic yield of the procedure, but also to evaluate procedure length, number of lymph node passes performed to obtain adequate samples, and number of lymph nodes studied per patient. We included unselected consecutive patients with mediastinal or hilar lymph node >10 mm in the short axis on CT scan or >5 mm in the presence of PET scan-positive uptake. The study involved a team of two bronchoscopists with >10 years experience in diagnostic bronchoscopy, including conventional transbronchial needle biopsy. The bronchoscopists had previously conducted extensive theoretical training and several practical workshops and performed between five and 10 supervised procedures. The learning curve was evaluated by analyzing consecutive groups of 20 patients, the number of adequate samples obtained, and the diagnostic accuracy of the procedure. We also recorded the other variables shown in Table 1. Over a period of 13 months, EBUS-TBNA was performed for 215 lymph nodes in 120 patients (71 with lung cancer, 16 with extrapulmonary carcinomas, seven with lymphomas, and 26 with several nonmalignant pathologies). Table 1 shows these values in groups of 20 consecutive patients. No serious complications were reported.Table 1Lymph Node Characteristics, Procedure Variables, Adequate Samples, and Diagnostic Accuracy of 20 Consecutive PatientsConsecutive PatientsShort Axis Diameter by EBUS, mmLymph Nodes Punctured by PatientaP < .05Passes by Lymph NodeaP < .05Procedure Length, minAdequate Samples, %aP < .05Accuracy, %aP < .05From 1 to 2012.3 (4.3)1.4 (0.7)2.3 (0.5)30.3 (7.9)80.870.0From 21 to 4012.7 (6.1)1.6 (0.7)2.3 (0.5)28.1 (6.8)81.881.8From 41 to 6013.2 (8.2)1.5 (0.7)2.4 (0.8)33.4 (7.7)86.783.3From 61 to 8012.0 (5.8)2.1 (0.6)2.2 (0.8)31.5 (7.7)95.189.8From 81 to 10011.5 (4.3)2.1 (1.0)2.0 (0.7)29.7 (9.9)90.590.5From 101 to 12011.5 (5.6)2.0 (1.0)1.8 (0.5)26.8 (9.2)95.094.5Date are presented as mean (SD) unless otherwise indicated. EBUS = endobronchial ultrasound.a P < .05 Open table in a new tab The present study demonstrated that the diagnostic effectiveness of EBUS-TBNA clearly improved with an increasing number of procedures performed, allowing for access to a greater number of lymph nodes without increasing the length of the procedure by reducing the number of punctures in each nodal station. Analyzing the studies included in systematic reviews and published meta-analyses,5Varela-Lema L Fernández-Villar A Ruano-Ravina A Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review.Eur Respir J. 2009; 33: 1156-1164Crossref PubMed Scopus (336) Google Scholar, 6Gu P Zhao YZ Jiang LY Zhang W Xin Y Han BH Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis.Eur J Cancer. 2009; 45: 1389-1396Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar the diagnostic accuracy of EBUS-TBNA is between 85% and 98%. Accordingly, and based on our findings, we could argue that the minimal diagnostic yield is achieved with procedure 60 but can be improved and even reach optimal results after 100 patients. We hope that this study and others in the same line help scientific societies to establish specific recommendations for learning linear EBUS-TBNA.1Unroe MA Shofer SL Wahidi MM Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques.Curr Opin Pulm Med. 2010; 16: 295-300Crossref PubMed Scopus (22) Google Scholar, 7Sheski FD Mathur PN Endobronchial ultrasound.Chest. 2008; 133: 264-270Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar To the EditorThe learning curve required for the endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) of mediastinal or hilar lymph nodes is unclear, and the evidence is scarce and contradictory.1Unroe MA Shofer SL Wahidi MM Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques.Curr Opin Pulm Med. 2010; 16: 295-300Crossref PubMed Scopus (22) Google Scholar, 2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar, 4Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J, In press. doi:10.1111/j.1445-5994.2009.02142.xGoogle Scholar Two of the evidentiary studies2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar only analyzed the learning curve of EBUS-TBNA for lung cancer diagnosis and staging and did not include the use of this technique in the study of lymph nodes affected by other pathologies. Other factors that might be influenced by learning have also not been examined.2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar, 4Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J, In press. doi:10.1111/j.1445-5994.2009.02142.xGoogle ScholarTo address these issues, we conducted a prospective study to describe the learning curve of an experienced bronchoscopy team in a unselected sample of patients with mediastinal or hilar lymph nodes. Team performance was analyzed not only in terms of the diagnostic yield of the procedure, but also to evaluate procedure length, number of lymph node passes performed to obtain adequate samples, and number of lymph nodes studied per patient. We included unselected consecutive patients with mediastinal or hilar lymph node >10 mm in the short axis on CT scan or >5 mm in the presence of PET scan-positive uptake. The study involved a team of two bronchoscopists with >10 years experience in diagnostic bronchoscopy, including conventional transbronchial needle biopsy. The bronchoscopists had previously conducted extensive theoretical training and several practical workshops and performed between five and 10 supervised procedures. The learning curve was evaluated by analyzing consecutive groups of 20 patients, the number of adequate samples obtained, and the diagnostic accuracy of the procedure. We also recorded the other variables shown in Table 1. Over a period of 13 months, EBUS-TBNA was performed for 215 lymph nodes in 120 patients (71 with lung cancer, 16 with extrapulmonary carcinomas, seven with lymphomas, and 26 with several nonmalignant pathologies). Table 1 shows these values in groups of 20 consecutive patients. No serious complications were reported.Table 1Lymph Node Characteristics, Procedure Variables, Adequate Samples, and Diagnostic Accuracy of 20 Consecutive PatientsConsecutive PatientsShort Axis Diameter by EBUS, mmLymph Nodes Punctured by PatientaP < .05Passes by Lymph NodeaP < .05Procedure Length, minAdequate Samples, %aP < .05Accuracy, %aP < .05From 1 to 2012.3 (4.3)1.4 (0.7)2.3 (0.5)30.3 (7.9)80.870.0From 21 to 4012.7 (6.1)1.6 (0.7)2.3 (0.5)28.1 (6.8)81.881.8From 41 to 6013.2 (8.2)1.5 (0.7)2.4 (0.8)33.4 (7.7)86.783.3From 61 to 8012.0 (5.8)2.1 (0.6)2.2 (0.8)31.5 (7.7)95.189.8From 81 to 10011.5 (4.3)2.1 (1.0)2.0 (0.7)29.7 (9.9)90.590.5From 101 to 12011.5 (5.6)2.0 (1.0)1.8 (0.5)26.8 (9.2)95.094.5Date are presented as mean (SD) unless otherwise indicated. EBUS = endobronchial ultrasound.a P < .05 Open table in a new tab The present study demonstrated that the diagnostic effectiveness of EBUS-TBNA clearly improved with an increasing number of procedures performed, allowing for access to a greater number of lymph nodes without increasing the length of the procedure by reducing the number of punctures in each nodal station. Analyzing the studies included in systematic reviews and published meta-analyses,5Varela-Lema L Fernández-Villar A Ruano-Ravina A Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review.Eur Respir J. 2009; 33: 1156-1164Crossref PubMed Scopus (336) Google Scholar, 6Gu P Zhao YZ Jiang LY Zhang W Xin Y Han BH Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis.Eur J Cancer. 2009; 45: 1389-1396Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar the diagnostic accuracy of EBUS-TBNA is between 85% and 98%. Accordingly, and based on our findings, we could argue that the minimal diagnostic yield is achieved with procedure 60 but can be improved and even reach optimal results after 100 patients. We hope that this study and others in the same line help scientific societies to establish specific recommendations for learning linear EBUS-TBNA.1Unroe MA Shofer SL Wahidi MM Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques.Curr Opin Pulm Med. 2010; 16: 295-300Crossref PubMed Scopus (22) Google Scholar, 7Sheski FD Mathur PN Endobronchial ultrasound.Chest. 2008; 133: 264-270Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar The learning curve required for the endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNA) of mediastinal or hilar lymph nodes is unclear, and the evidence is scarce and contradictory.1Unroe MA Shofer SL Wahidi MM Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques.Curr Opin Pulm Med. 2010; 16: 295-300Crossref PubMed Scopus (22) Google Scholar, 2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar, 4Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J, In press. doi:10.1111/j.1445-5994.2009.02142.xGoogle Scholar Two of the evidentiary studies2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar only analyzed the learning curve of EBUS-TBNA for lung cancer diagnosis and staging and did not include the use of this technique in the study of lymph nodes affected by other pathologies. Other factors that might be influenced by learning have also not been examined.2Groth SS Whitson BA D'Cunha J Maddaus MA Alsharif M Andrade RS Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve.Ann Thorac Surg. 2008; 86 (discussion 1109-1110): 1104-1109Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Kemp SV El Batrawy SH Harrison RN et al.Learning curves for endobronchial ultrasound using cusum analysis [published erratum in Thorax. 2010;65(9):844].Thorax. 2010; 65: 534-538Crossref PubMed Scopus (121) Google Scholar, 4Steinfort DP, Hew MJ, Irving LB. Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases performed at an Australian tertiary hospital. Intern Med J, In press. doi:10.1111/j.1445-5994.2009.02142.xGoogle Scholar To address these issues, we conducted a prospective study to describe the learning curve of an experienced bronchoscopy team in a unselected sample of patients with mediastinal or hilar lymph nodes. Team performance was analyzed not only in terms of the diagnostic yield of the procedure, but also to evaluate procedure length, number of lymph node passes performed to obtain adequate samples, and number of lymph nodes studied per patient. We included unselected consecutive patients with mediastinal or hilar lymph node >10 mm in the short axis on CT scan or >5 mm in the presence of PET scan-positive uptake. The study involved a team of two bronchoscopists with >10 years experience in diagnostic bronchoscopy, including conventional transbronchial needle biopsy. The bronchoscopists had previously conducted extensive theoretical training and several practical workshops and performed between five and 10 supervised procedures. The learning curve was evaluated by analyzing consecutive groups of 20 patients, the number of adequate samples obtained, and the diagnostic accuracy of the procedure. We also recorded the other variables shown in Table 1. Over a period of 13 months, EBUS-TBNA was performed for 215 lymph nodes in 120 patients (71 with lung cancer, 16 with extrapulmonary carcinomas, seven with lymphomas, and 26 with several nonmalignant pathologies). Table 1 shows these values in groups of 20 consecutive patients. No serious complications were reported. Date are presented as mean (SD) unless otherwise indicated. EBUS = endobronchial ultrasound. The present study demonstrated that the diagnostic effectiveness of EBUS-TBNA clearly improved with an increasing number of procedures performed, allowing for access to a greater number of lymph nodes without increasing the length of the procedure by reducing the number of punctures in each nodal station. Analyzing the studies included in systematic reviews and published meta-analyses,5Varela-Lema L Fernández-Villar A Ruano-Ravina A Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review.Eur Respir J. 2009; 33: 1156-1164Crossref PubMed Scopus (336) Google Scholar, 6Gu P Zhao YZ Jiang LY Zhang W Xin Y Han BH Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: a systematic review and meta-analysis.Eur J Cancer. 2009; 45: 1389-1396Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar the diagnostic accuracy of EBUS-TBNA is between 85% and 98%. Accordingly, and based on our findings, we could argue that the minimal diagnostic yield is achieved with procedure 60 but can be improved and even reach optimal results after 100 patients. We hope that this study and others in the same line help scientific societies to establish specific recommendations for learning linear EBUS-TBNA.1Unroe MA Shofer SL Wahidi MM Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques.Curr Opin Pulm Med. 2010; 16: 295-300Crossref PubMed Scopus (22) Google Scholar, 7Sheski FD Mathur PN Endobronchial ultrasound.Chest. 2008; 133: 264-270Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar