Conventional Bronchoscopy Research Articles

Design of a prospective, multicenter, global, cohort study of electromagnetic navigation bronchoscopy.

BackgroundElectromagnetic navigation bronchoscopy (ENB) procedures allow physicians to access peripheral lung lesions beyond the reach of conventional bronchoscopy. However, published research is primarily limited to small, single-center studies using previous-generation ENB software. The impact of user experience, patient factors, and lesion/procedural characteristics remains largely unexplored in a large, multicenter study.Methods/DesignNAVIGATE (Clinical Evaluation of superDimension™ Navigation System for Electromagnetic Navigation Bronchoscopy) is a prospective, multicenter, global, cohort study. The study aims to enroll up to 2,500 consecutive subjects presenting for evaluation of lung lesions utilizing the ENB procedure at up to 75 clinical sites in the United States, Europe, and Asia. Subjects will be assessed at baseline, at the time of procedure, and at 1, 12, and 24 months post-procedure. The pre-test probability of malignancy will be determined for peripheral lung nodules. Endpoints include procedure-related adverse events, including pneumothorax, bronchopulmonary hemorrhage, and respiratory failure, as well as quality of life, and subject satisfaction. Diagnostic yield and accuracy, repeat biopsy rate, tissue adequacy for genetic testing, and stage at diagnosis will be reported for biopsy procedures. Complementary technologies, such as fluoroscopy and endobronchial ultrasound, will be explored. Success rates of fiducial marker placement, dye marking, and lymph node biopsies will be captured when applicable. Subgroup analyses based on geography, demographics, investigator experience, and lesion and procedure characteristics are planned.DiscussionStudy enrollment began in April 2015. As of February 19, 2016, 500 subjects had been enrolled at 23 clinical sites with enrollment ongoing. NAVIGATE will be the largest prospective, multicenter clinical study on ENB procedures to date and will provide real-world experience data on the utility of the ENB procedure in a broad range of clinical scenarios.Trial registrationClinicalTrials.gov NCT02410837. Registered 31 March 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12890-016-0228-y) contains supplementary material, which is available to authorized users.

Navigational Bronchoscopy for Early Lung Cancer: A Road to Therapy.

Peripheral lung nodules remain challenging for accurate localization and diagnosis. Once identified, there are many strategies for diagnosis with heterogeneous risk benefit analysis. Traditional strategies such as conventional bronchoscopy have poor performance in locating and acquiring the required tissue. Similarly, while computerized-assisted transthoracic needle biopsy is currently the favored diagnostic procedure, it is associated with complications such as pneumothorax and hemorrhage. Video-assisted thoracoscopic and open surgical biopsies are invasive, require general anesthesia and are therefore not a first-line approach. New techniques such as ultrathin bronchoscopy and image-based guidance technologies are evolving to improve the diagnosis of peripheral lung lesions. Virtual bronchoscopy and electromagnetic navigation systems are novel technologies based on assisted-computerized tomography images that guide the bronchoscopist toward the target peripheral lesion. This article provides a comprehensive review of these emerging technologies.

Is the Ambu aScope 3 Slim single-use fiberscope equally efficient compared with a conventional bronchoscope for management of the difficult airway?

Study ObjectiveThe study objective was to evaluate whether the single-use fiberoptic bronchoscope (FOB), Ambu aScope 3 Slim, was equally efficient compared with the conventional reusable FOB, Olympus LF-GP, for nasal fiberoptic intubation in a manikin. DesignA randomized crossed-over study. SettingThe postanesthesia care unit of Tokyo Women's Medical University Hospital. SubjectsTwenty anesthesiologists who have experienced >50 one-lung ventilation thoracic surgery procedures were invited to participate in this study. InterventionsA 6.5-mm internal diameter cuffed endotracheal tube (ET) was inserted into the manikin under Ambu aScope 3 Slim (group A) or Olympus LF-GP (group C) guidance. MeasurementsThe following time parameters from the beginning of FOB insertion through a nostril were compared between groups: until vocal cord visualization (T1); visualization of the carina (T2); and proper ET placement, as confirmed by the distance of the ET tip to carina (T3). Main ResultsMean (SD) T1 in group A and group C were 20 seconds (17 seconds) and 14 seconds (12 seconds), respectively (P= .1050). Mean (SD) T2 in group A and group C were 40 seconds (29 seconds) and 25 seconds (15 seconds), respectively (P= .0287). Mean (SD) T3 in group A and group C were 70 seconds (33 seconds) and 50 seconds (22 seconds), respectively (P= .0098). One case in group A had failed intubation ConclusionsThe Ambu aScope 3 Slim required more time to intubate than the conventional reusable FOB. It requires more rigidity, similar to the conventional FOB for management of the difficult airway.

Bronchoscopic Indocyanine Green Fluorescence Imaging of the Anastomotic Perfusion After Tracheal Surgery

Anastomotic failure is a rare but severe complication after airway surgery. A sufficient blood supply is crucial for the healing of the anastomosis. Currently, judging the appearance of the mucosa by conventional bronchoscopy is the only available technique to monitor the anastomosis. Near-infrared imaging using indocyanine green (ICG) as an intravasal fluorescent can be used to directly assess tissue perfusion. For technical reasons, bronchoscopic ICG angiography to evaluate blood supply of airway anastomosis was unavailable in the past. We sought to investigate the technical feasibility of ICG perfusion using a newly developed bronchoscopy unit with an integrated near-infrared filter to monitor perfusion during the healing of tracheal anastomosis. Twelve patients who underwent elective airway surgery were included in this prospective, single-center feasibility study. The ICG was administered intravenously at 0.2 mg/kg body weight at three timepoints: at the end of surgery; 3 to 5 days postoperatively; and 2 months postoperatively. A custom-made bronchoscopy unit (Karl Storz, Tuttlingen, Germany) was used to assess the anastomosis with white light and additionally with near-infrared light to monitor the distribution and intensity of the fluorescence signal. A total of 32 ICG fluorescence bronchoscopies were performed in our study cohort. In all measurements, a sufficient fluorescence signal was detected. A lack of perfusion was detected in all patients confined to the anastomotic suture line immediately after the operation. This malperfusion resolved gradually after 3 to 5 days and disappeared completely after 2 months. No anastomotic complication developed in our series of patients during follow-up (median 7 months). To the best of our knowledge, this is the first report on ICG fluorescence bronchoscopy in the literature. It is an easy and effective method to evaluate the perfusion at the tracheal anastomosis. In the future, it might contribute to an early detection of anastomotic failure and reduce morbidity and mortality after airway surgery.

Diagnosis of Peripheral Lung Lesions via Conventional Flexible Bronchoscopy with Multiplanar CT Planning.

Background. Conventional flexible bronchoscopy has limited sensitivity in the diagnosis of peripheral lung lesions and is dependent on lesion size. However, advancement of CT imaging offers multiplanar reconstruction facilitating enhanced preprocedure planning. This study aims to report efficacy and safety while considering the impact of patient selection and multiplanar CT planning. Method. Prospective case series of patients with peripheral lung lesions suspected of having lung cancer who underwent flexible bronchoscopy (forceps biopsy and lavage). Endobronchial lesions were excluded. Patients with negative results underwent CT-guided transthoracic needle aspiration, surgical biopsy, or clinical-radiological surveillance to establish the final diagnosis. Results. 226 patients were analysed. The diagnostic yield of bronchoscopy was 80.1% (181/226) with a sensitivity of 84.2% and specificity of 100%. In patients with a positive CT-Bronchus sign, the diagnostic yield was 82.4% compared to 72.8% with negative CT-Bronchus sign (p = 0.116). Diagnostic yield was 84.9% in lesions > 20 mm and 63.0% in lesions ≤ 20 mm (p = 0.001). Six (2.7%) patients had transient hypoxia and 2 (0.9%) had pneumothorax. There were no serious adverse events. Conclusion. Flexible bronchoscopy with appropriate patient selection and preprocedure planning is more efficacious in obtaining a diagnosis in peripheral lung lesions compared to historical data. This trial is registered with ClinicalTrials.gov Identifier: NCT01374542.

Efficacy and safety of electromagnetic navigation bronchoscopy with or without radial endobronchial ultrasound for peripheral lung lesions.

Background and Objectives:Electromagnetic navigation bronchoscopy (ENB) is a promising new technology to increase the diagnostic yield of peripheral lung and mediastinal lesions. Conventional flexible bronchoscopy has a limited yield in peripheral pulmonary lesions, even in experienced hands. Radial endobronchial ultrasound (r-EBUS) with its real-time imaging capability can help to diagnose peripheral pulmonary lesions. In the present study, we aimed to investigate the diagnostic yield and safety of ENB with or without r-EBUS for peripheral lung lesions.Materials and Methods:This study was conducted in a tertiary medical center, and 56 consecutive patients who were thought to be the best candidates for bronchoscopic biopsies at a multidisciplinary meeting were enrolled. ENB was performed under conscious sedation by using an electromagnetic tracking system with multiplanar reconstruction of previously acquired computed tomography (CT) data. Sampling was performed by biopsy forceps, endobronchial brush, and bronchoalveolar lavage.Results:Fifty-six patients (50 men and 6 women; mean age, 60 ± 9 years) were studied. While an electromagnetic navigation system was used in all patients, r-EBUS was used in 26 of 56 patients. The median diameter of the lesions was 30 mm (interquartile range: 23-44 mm). Mean distance of the lesions from the pleura was 14.9 ± 14.6 mm. Mean procedure time was 20 ± 11.5 min. Mean registration error was 5.8 ± 1.5 mm. Mean navigation error was 1.2 ± 0.5 mm. The diagnostic yield of the procedure was 71.4% for peripheral lesions (non-small cell lung cancer = 23, small cell lung cancer = 3, benign diseases = 14). Pneumothorax occurred in only 1 patient (1.7%).Conclusion:ENB with or without r-EBUS is a safe, efficient, and easily applied method for sampling of peripheral lung lesions, with high diagnostic yield independent of lesion size and location.

Navigational transbronchial needle aspiration, percutaneous needle aspiration and its future.

Peripheral lung nodule evaluation represents a clinical challenge. Given that many nodules will be incidentally found with lung cancer screening following the publication of the National Lung Screening Trial (NLST), the goal is to find an accurate, safe and minimally-invasive diagnostic modality to biopsy the concerning lesions. Unfortunately, conventional bronchoscopic techniques provide a poor diagnostic yield of 18-62%. In recent years advances in technology have led to the introduction of electromagnetic navigational bronchoscopy (ENB) as a tool to guide sampling of peripheral lung nodules. The same principle has also recently been expanded and applied to the transthoracic needle biopsy, referred to as electromagnetic transthoracic needle aspiration (E-TTNA). An improved diagnostic yield has afforded this technology a recommendation by the 2013 3(rd) Edition ACCP Guidelines for the Diagnosis and Management of Lung Cancer which state that "in patients with peripheral lung lesions difficult to reach with conventional bronchoscopy, ENB is recommended if the equipment and the expertise are available (Grade 1C)". In this review we will discuss the technology, devices that are available, techniques and protocols, diagnostic yield, safety, cost effectiveness and more.

Endobronchial Ultrasound Changed the World of Lung Cancer Patients: A 11-Year Institutional Experience.

ObjectivesThe role of advanced bronchoscopic diagnostic techniques in the detection and staging of lung cancer has increased sharply in recent years. The development of endobronchial ultrasound (EBUS) improved minimally invasive mediastinal staging and diagnosis of peripheral lung lesions (PLLs). We investigated the impact of using EBUS as a diagnostic method for tissue acquisition in lung cancer patients.MethodsIn a single center observational retrospective study, 3712 subjects were diagnosed with lung cancer from 2003 to 2013 (EBUS was introduced in 2008). Thus, we divided the data into two periods: the conventional bronchoscopy period (2003 to 2007) and the EBUS period (2008 to 2013).ResultsA total of 3712 patients were included in the analysis. Comparing the conventional bronchoscopy period with the EBUS period data, there has been a significant reduction in the use of diagnostic modalities: CT-guided biopsy (P < 0.0001) and pleural effusion cytology (P < 0.0001). The proportion of subjects diagnosed using bronchoscopy significantly increased from 39.4% in the conventional period to 47.4% in the EBUS period (P < 0.0001). In the EBUS period, there has also been a significant increase in the proportion of patients proceeding directly to diagnostic surgery (P < 0.0001). Compared to bronchoscopy, the incidence of complications was higher in those who underwent CT guide biopsy. The incidence of iatrogenic pneumothorax significantly decreased in the EBUS period.ConclusionsAdvanced bronchoscopic techniques are widely used in the diagnosis of lung cancer. At our institution, the increasing use of EBUS for providing lung cancer diagnosis has led to a significant reduction in other diagnostic modalities, namely CT-guided biopsy and pleural effusion cytology. These changes in practice also led to a reduction in the incidence of complications.

Comparison of narrow band imaging to white light bronchoscopy for evaluation of histopathological biopsy

BackgroundIt is difficult to detect precancerous lesions such as dysplasia and carcinoma in situ (CIS) by conventional white light bronchoscopy (WLB). Narrow Band Imaging Bronchoscopy (NBI) has been reported to detect such lesions more readily. ObjectiveThe objective of the present study is to characterize the appearance of different airway mucosal lesions under NBI mode and to evaluate the role of NBI compared to WLB in diagnosis of premalignant and malignant lesions. Methods30 patients presented with radiological changes to chest department in Fayoum University Hospital. They were subjected to full airway examination by fiberoptic bronchoscopy first under WLB then under NBI. Biopsies were taken from susceptible lesions; pathological interpretation was performed. Results18 patients (60%) were proved by NBI to have invasive carcinoma compared to 11 patients (36.7%) by WLB. 3 patients (10%) were proved by NBI to have severe dysplasia/CIS compared to 6 patients (20%) by WLB. 3 patients (10%) were proved by NBI to have mild/moderate dysplasia compared to 4 patients (13.3%) by WLB (p value=0.03). The sensitivity of both WLB and NBI (76.9%) is better than WLB alone or NBI alone (9.1% and 57.1% respectively) in detecting premalignant lesions while the sensitivity of both WLB and NBI (52.6%) is less than WLB alone (55.6%) and better than NBI alone (26.7%) in detecting malignant lesions. ConclusionNBI can be used in combination with WLB to improve detection of premalignant lesions. It influences biopsy selection and therapeutic planning.

A randomized controlled trial evaluating airway inspection effectiveness during endobronchial ultrasound bronchoscopy.

Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) has revolutionized the evaluation of patients with mediastinal and hilar adenopathy. Limitations of conventional endobronchial ultrasound (C-EBUS) bronchoscopes include the inability to perform a complete airway inspection, low definition optics, and limited maneuverability. These limitations require the use of a standard bronchoscope to perform an airway examination prior to the EBUS procedure. Recently, a hybrid endobronchial ultrasound (H-EBUS) bronchoscope with high definition optics and increased maneuverability has been introduced. Our objective was to assess the ability of H-EBUS to perform a full airway inspection and TBNA. Patients referred for EBUS-TBNA were prospectively randomized to either form of EBUS from November 2013 to January 2014. The primary outcome was the airway segment visualization in each lobe using an EBUS bronchoscope. Secondary outcomes included the number of bronchoscopes used per procedure, procedure length, diagnostic yield and specimen adequacy. Sixty-two consecutive patients undergoing EBUS-TBNA were randomized to H-EBUS (n=30) or C-EBUS (n=32). In cases in which EBUS-TBNA was the only procedure performed (n=32), use of a second bronchoscope to perform an adequate airway inspection was significantly higher in C-EBUS compared to H-EBUS (5 vs. 0, P=0.046). There was better segmental visualization achieved in multiple lobes when using H-EBUS (P<0.01). No differences in TBNA sample diagnostic yield, specimen adequacy or procedure time were noted when comparing bronchoscopes (P= NS). Use of an H-EBUS may improve the ability to perform an adequate airway inspection potentially obviating the need for a conventional bronchoscope.

Transbronchial Catheter Aspiration and Transbronchial Needle Aspiration in the Diagnostic Workup of Peripheral Lung Lesions.

Increasingly frequent, it is clinically indicated to obtain tissue from a peripheral lung lesion (PLL) to yield a pathological diagnosis. The aim of the present study was to evaluate the diagnostic sensitivity of transbronchial needle aspiration (TBNA) and transbronchial catheter aspiration (TBCA) in addition to transbronchial forceps biopsy (TBB) at conventional bronchoscopy. Eligible patients showing a PLL on computed tomography scans were included in the study. In all patients, following TBB, TBNA and TBCA were employed in randomised order under fluoroscopy. Fourty-eight patients were enrolled, of whom 46 patients with 46 PLLs were included in the analysis. The mean ± SD diameter of the PLL was 27.0 ± 13.3 mm. The overall sensitivity for all modalities was 69.6%; PLL ≤20 or >20 and ≤30 mm in diameter showed a sensitivity of 60.0 and 72.2%, respectively. For malignant PLL (n = 33), the combined sensitivity of TBNA + TBCA versus TBB was significantly higher (63.6 vs. 33.3%, p ≤ 0.05), and could not further be improved by TBB. For benign PLL, TBB was superior to TBNA + TBCA (76.9 vs. 38.5%). TBB, TBNA and TBCA are complementary to one another. Combining the three techniques, even allows transbronchial specimen collection of PLL <3 cm in diameter at conventional bronchoscopy.

Improvements to bronchoscopic brushing with a manual mapping method: A three-year experience of 1143 cases.

Conventional bronchoscopy with brushing alone for diagnosing peripheral pulmonary lesions (PPLs) is of low sensitivity. A manual mapping method was introduced and evaluated in this study, which could be routinely applied with bronchoscopic brushing to improve the sensitivity for malignant PPLs. This mapping method involves the bronchoscopist drawing the route with a series of bronchial opening sketches and marking the leading bronchus at every bifurcation point based on thin-section computed tomography. This map is then used to guide bronchoscope insertion for brushing. A cross-sectional study on the evaluation of this method for the diagnosis of malignant PPLs was conducted on patients from July 2010 to June 2013. The sensitivity for malignant PPLs of conventional brushing, conventional brushing with mapping on a portion of patients, and conventional brushing with mapping method increased from 17.0% to 25.8% to 31.5% (P < 0.001), respectively. For lesion sizes over 3 cm, the rate of these three groups increased from 25.1% to 38.6% to 50.9% (P < 0.001), respectively. The sensitivity of this mapping method for malignant PPLs was statistically associated with lesion size, lesion character, relationship between the lesion and the leading bronchus, linear distance between the targeted bronchus and the opening of the lobe bronchus, and accessibility (P < 0.001, P = 0.039, P < 0.001, P = 0.031, and P = 0.020, respectively). The manual mapping method greatly increased the bronchoscopic brushing sensitivity for malignant PPLs compared to the conventional brushing method. During routine clinical work, it is economical and convenient for guiding bronchoscope insertion.

Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS).

This is an official guideline of the European Society of Gastrointestinal Endoscopy (ESGE), produced in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). It addresses the benefit and burden associated with combined endobronchial and esophageal mediastinal nodal staging of lung cancer. The Scottish Intercollegiate Guidelines Network (SIGN) approach was adopted to define the strength of recommendations and the quality of evidence.The article has been co-published with permission in the European Journal of Cardio-Thoracic Surgery and the European Respiratory Journal. Recommendations 1 For mediastinal nodal staging in patients with suspected or proven non-small-cell lung cancer (NSCLC) with abnormal mediastinal and/or hilar nodes at computed tomography (CT) and/or positron emission tomography (PET), endosonography is recommended over surgical staging as the initial procedure (Recommendation grade A). The combination of endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic (esophageal) ultrasound with fine needle aspiration, with use of a gastrointestinal (EUS-FNA) or EBUS (EUS-B-FNA) scope, is preferred over either test alone (Recommendation grade C). If the combination of EBUS and EUS-(B) is not available, we suggest that EBUS alone is acceptable (Recommendation grade C).Subsequent surgical staging is recommended, when endosonography does not show malignant nodal involvement (Recommendation grade B). 2 For mediastinal nodal staging in patients with suspected or proven non-small-cell peripheral lung cancer without mediastinal involvement at CT or CT-PET, we suggest that EBUS-TBNA and/or EUS-(B)-FNA should be performed before therapy, provided that one or more of the following conditions is present: (i) enlarged or fluorodeoxyglucose (FDG)-PET-avid ipsilateral hilar nodes; (ii) primary tumor without FDG uptake; (iii) tumor size ≥ 3 cm (Fig. 3a - c) (Recommendation grade C). If endosonography does not show malignant nodal involvement, we suggest that mediastinoscopy is considered, especially in suspected N1 disease (Recommendation grade C).If PET is not available and CT does not reveal enlarged hilar or mediastinal lymph nodes, we suggest performance of EBUS-TBNA and/or EUS-(B)-FNA and/or surgical staging (Recommendation grade C). 3 In patients with suspected or proven < 3 cm peripheral NSCLC with normal mediastinal and hilar nodes at CT and/or PET, we suggest initiation of therapy without further mediastinal staging (Recommendation grade C). 4 For mediastinal staging in patients with centrally located suspected or proven NSCLC without mediastinal or hilar involvement at CT and/or CT-PET, we suggest performance of EBUS-TBNA, with or without EUS-(B)-FNA, in preference to surgical staging (Fig. 4) (Recommendation grade D). If endosonography does not show malignant nodal involvement, mediastinoscopy may be considered (Recommendation grade D). 5 For mediastinal nodal restaging following neoadjuvant therapy, EBUS-TBNA and/or EUS-(B)-FNA is suggested for detection of persistent nodal disease, but, if this is negative, subsequent surgical staging is indicated (Recommendation grade C). 6 A complete assessment of mediastinal and hilar nodal stations, and sampling of at least three different mediastinal nodal stations (4 R, 4 L, 7) (Fig. 1, Fig. 5) is suggested in patients with NSCLC and an abnormal mediastinum by CT or CT-PET (Recommendation grade D). 7 For diagnostic purposes, in patients with a centrally located lung tumor that is not visible at conventional bronchoscopy, endosonography is suggested, provided the tumor is located immediately adjacent to the larger airways (EBUS) or esophagus (EUS-(B)) (Recommendation grade D). 8 In patients with a left adrenal gland suspected for distant metastasis we suggest performance of endoscopic ultrasound fine needle aspiration (EUS-FNA) (Recommendation grade C), while the use of EUS-B with a transgastric approach is at present experimental (Recommendation grade D). 9 For optimal endosonographic staging of lung cancer, we suggest that individual endoscopists should be trained in both EBUS and EUS-B in order to perform complete endoscopic staging in one session (Recommendation grade D). 10 We suggest that new trainees in endosonography should follow a structured training curriculum consisting of simulation-based training followed by supervised practice on patients (Recommendation grade D). 11 We suggest that competency in EBUS-TBNA and EUS-(B)-FNA for staging lung cancer be assessed using available validated assessment tools (Recommendation Grade D).

Is bronchoscopy necessary in the preoperative workup of a solitary pulmonary nodule?

ObjectiveThis study evaluated the role of conventional bronchoscopy in the preoperative workup of patients with solitary pulmonary nodules (SPNs). MethodsPatients with SPNs of unknown origin were enrolled for preoperative bronchoscopy at our institution. Bronchoscopic findings were prospectively collected, and their impact on planned therapy was analyzed. ResultsA total of 1026 patients were included. Bronchoscopy identified unsuspected findings in 80 (7.8%) of them, with a total of 826 (80.5%) malignant nodules. Referent values for bronchoscopic detection of malignant SPNs were: accuracy, 24.3% (95% confidence interval [CI]: 21.7%-27.0%); sensitivity, 5.9% (95% CI: 4.5%-7.4%); specificity, 100%; and negative predictive value, 20.5% (95% CI: 18.0%-22.9%). Malignant bronchoscopic findings were more common in male patients (odds ratio [OR] = 2.1, 95% CI: 1.1-3.9, P = .021) and large nodules (OR = 2.3, 95% CI: 1.6-3.3, P < .001). Surgery was cancelled in 2 (0.2%) patients and modified in 36 (3.5%) patients because of bronchoscopic findings. In all, for 268 (26.1%) SPNs that presented with ground-glass opacity, the bronchoscopy was unrevealing. ConclusionsIn the preoperative evaluation of SPN, bronchoscopy is most likely to reveal malignancy in larger SPNs and in male patients. Bronchoscopy is not indicated in SPNs that present with ground-glass opacity on computed tomography scan.

Diagnostic yield of non‐guided flexible bronchoscopy for peripheral pulmonary neoplasia

BackgroundThe role of conventional bronchoscopy for peripheral pulmonary neoplasia remains controversial. We aimed to assess the diagnostic yield and the added value of non-guided bronchial aspiration, bronchoalveolar lavage (BAL), and brushing for the diagnosis of pulmonary neoplasia not visible endoscopically.MethodsWe retrospectively assessed 207 consecutive patients with a final diagnosis of peripheral lung malignancy who underwent bronchoscopy with non-guided aspiration, brushing, and BAL as their initial evaluation. The influence of clinical and radiological factors on diagnostic yield was assessed using univariate logistic regression analyses.ResultsThe overall sensitivity of non-guided bronchoscopy was 25.6%, whereas sensitivities for bronchial aspiration, BAL, and brushing were 14.2%, 11.6%, and 16.5%, respectively. Younger age, larger lesion, central/intermediate distance from the hilum, presence of a bronchus sign, and higher standardized uptake value (SUV) on positron emission tomography scan were predictors of a higher diagnostic yield. Conversely, forced expiratory volume in one second, fellow implication in the procedure, and tumor histology did not influence sensitivity. The overall sensitivity of bronshoscopy was >40% for tumors >4 cm, located in the central/intermediate thirds of the lung, showing a bronchus sign, with an SUV >12 or occurring in patients <50 years of age. Conversely, the sensitivity was <10% for tumors <2 cm, located peripherally or with an SUV <4.ConclusionNeoplasia characteristics may help targeting situations in which conventional bronchoscopy could be used as the initial diagnostic procedure when advanced techniques are unavailable. However, advanced diagnostic tools should probably be proposed as the initial modality for the diagnosis of peripheral malignant lesions when available.

Endobronchial ultrasound-guided transbronchial needle aspiration: unraveling myths of mass in the chest.

Lung cancer is one of the most common neoplasms worldwide and a major cause of cancer death. Rapid diagnosis and accurate staging for patients with suspected lung cancer are essential to appropriate treatment. However, many of submucosal or parabronchial intrapulmonary lesions are invisible by bronchoscopy despite their adjacency to the central airway. Classical approaches in these cases, such as conventional bronchoscopy, transbronchial needle aspiration (TBNA) and computed tomography-guided transthoracic needle aspiration (TTNA), are of limited use in a sense of definitive diagnosis (1-3).

Radial Probe Endobronchial Ultrasound and Novel Navigation Biopsy Techniques

Peripheral pulmonary lesions are an increasingly common finding in clinical practice. While many nodules are followed with radiographic surveillance, some may require biopsy. Conventional bronchoscopy with transbronchial lung biopsy has traditionally performed poorly for small, peripheral lesions, and transthoracic needle aspiration with computed tomographic (CT) guidance has been favored as the diagnostic test of choice. Despite the high diagnostic yield of transthoracic needle aspiration, procedural complications such as pneumothorax continue to be problematic. New technology has been developed to improve the diagnostic yield of bronchoscopy for peripheral lesions over conventional methods, while maintaining the favorable safety profile of a bronchoscopic approach. Virtual bronchoscopy and electromagnetic navigation are CT-based image guidance systems that create virtual bronchoscopic representations of the tracheobronchial tree to assist the bronchoscopist in locating peripheral lesions. Radial probe endobronchial ultrasound utilizes real-time ultrasound to confirm the location of peripheral lesions before biopsy. This article summarizes the technical platforms, procedures, and clinical evidence for these emerging technologies.

P275 Ebus Or Eus In The Diagnosis Of Sarcoidosis?

Introduction The utility of endoscopic ultrasonography in the diagnosis of sarcoidosis was shown in the GRANULOMA trial. 1 However, in the study, two thirds of samples were obtained using Endoscopic Ultrasound (EUS) via the gastrointestinal tract, and one third by Endobronchial Ultrasound (EBUS). Since this does not reflect typical practice in many areas, we assessed the diagnostic sensitivity of EBUS in suspected sarcoidosis and whether sampling nodes not accessible by EUS confers benefit. Methods We retrospectively collected data relating to 128 consecutive patients in two separate experienced centres, who underwent EBUS over a 3 year period (2011–2013) with a pretest differential diagnosis of sarcoidosis. Final diagnosis was based on decision at subsequent clinic review. Results 129 EBUS procedures were performed in 128 patients (57% male, mean (range) age 49 (22–79) years. 221 nodal stations were sampled (median of 2 stations each patient) with no significant complications. Concurrent trans-bronchial biopsy (TBB) was carried out in 30 patients and endobronchial biopsy (EBB) in 10. Overall diagnostic sensitivity (for each biopsy procedure alone) was as follows: EBB 44%, TBB 50%, EBUS 71%, while combining EBUS with EBB/TBB conferred a sensitivity of 79%. Diagnostic sensitivity of EBUS was 77% for stage 1 and 62% for stage 2 sarcoidosis, and increased according to number of stations sampled (1 station 66%, 2 stations 70%, ≥3 stations 92%). Sensitivity from EUS-accessible nodes (Stations 7 and 4) was 72%, while this was 56% in EUS- inaccessible nodes (Stations 2, 10 and 11). If EUS-accessible nodes were present and sampled, additional sampling of EUS-inaccessible nodes did not further the diagnosis. Conclusions In suspected sarcoidosis, the diagnostic yield of EBUS was 71%. Using additional bronchial biopsy techniques increased this by 8%. Mediastinal nodes, accessible by both EUS and EBUS, would appear to be the preferred site of sampling. However, EBUS allows sampling of nodes not accessible to EUS, which may be diagnostic if there is isolated hilar lymphadenopathy. Reference von Bartheld MB, Dekkers OM, Szlubowski A, et al . Endosonography vs Conventional Bronchoscopy for the Diagnosis of Sarcoidosis. JAMA ; 2013;309(23): 2547-2464

Endocytoscopy and Narrow Band Imaging for Superficial Extension of Squamous Cell Carcinoma

A 60-year-old man presented with cough. Chest computed tomography revealed a nodule in right S2 (Fig 1A). By conventional bronchoscopy, the orifice of B2 was obstructed with tumor (squamous cell carcinoma; Fig 1B). Tumor extension was assessed in greater detail using autofluorescence imaging, narrow-band imaging and ultra-high-magnification bronchoscopy (endocytoscopy; ECS) [1Shibuya K. Fujiwara T. Yasufuku K. et al.In vivo microscopic imaging of the bronchial mucosa using an endo-cytoscopy system.Lung Cancer. 2011; 72: 184-190Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Autofluorescence imaging revealed magenta-colored epithelium at the orifice of the upper lobe bronchus (Fig 1C). Several dotted vessels were detected with narrow-band imaging at the same lesion (Fig 1D). Sleeve upper lobectomy was performed according to these bronchoscopic findings. ECS with methylene blue staining was performed in the resected bronchus intraoperatively. On these images of the bronchial epithelium, one could differentiate between normal epithelial cells (Fig 2A, left) and carcinoma cells (polymorphic, irregular cells; Fig 2A, right, methylene blue stain, 400× magnification achieved on a 14-inch television monitor). This clearly indicated, instead of intraoperative examination of the frozen section, that the resection site was appropriate. Intraepithelial papillary capillary loops corresponding to dotted vessels were also identified (Fig 2B, immunostain CD34, magnification ×200). There are no articles of direct comparisons between the diagnostic accuracies of ECS and frozen section for the tracheobronchial tumor. Using ECS in the bronchial tree after resection to assess for absence of R1 or R2 resection may be an attractive option, but limitations such as respiratory movements and coughing will degrade the ECS images.Fig 2View Large Image Figure ViewerDownload (PPT) A 60-year-old man presented with cough. Chest computed tomography revealed a nodule in right S2 (Fig 1A). By conventional bronchoscopy, the orifice of B2 was obstructed with tumor (squamous cell carcinoma; Fig 1B). Tumor extension was assessed in greater detail using autofluorescence imaging, narrow-band imaging and ultra-high-magnification bronchoscopy (endocytoscopy; ECS) [1Shibuya K. Fujiwara T. Yasufuku K. et al.In vivo microscopic imaging of the bronchial mucosa using an endo-cytoscopy system.Lung Cancer. 2011; 72: 184-190Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Autofluorescence imaging revealed magenta-colored epithelium at the orifice of the upper lobe bronchus (Fig 1C). Several dotted vessels were detected with narrow-band imaging at the same lesion (Fig 1D). Sleeve upper lobectomy was performed according to these bronchoscopic findings. ECS with methylene blue staining was performed in the resected bronchus intraoperatively. On these images of the bronchial epithelium, one could differentiate between normal epithelial cells (Fig 2A, left) and carcinoma cells (polymorphic, irregular cells; Fig 2A, right, methylene blue stain, 400× magnification achieved on a 14-inch television monitor). This clearly indicated, instead of intraoperative examination of the frozen section, that the resection site was appropriate. Intraepithelial papillary capillary loops corresponding to dotted vessels were also identified (Fig 2B, immunostain CD34, magnification ×200). There are no articles of direct comparisons between the diagnostic accuracies of ECS and frozen section for the tracheobronchial tumor. Using ECS in the bronchial tree after resection to assess for absence of R1 or R2 resection may be an attractive option, but limitations such as respiratory movements and coughing will degrade the ECS images.

Advanced Diagnostic Bronchoscopy Using Conscious Sedation and the Laryngeal Nerve Block: Tolerability, Thoroughness, and Diagnostic Yield

Although bronchoscopy has conventionally been performed using conscious sedation, advanced diagnostic techniques like endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), peripheral EBUS, and electromagnetic navigational bronchoscopy add to procedural complexity. The adaptation of these techniques by bronchoscopists of varied backgrounds is expanding. It is not clear how patients will tolerate these advanced procedures when they are performed using traditional conscious sedation. We prospectively studied patients that underwent diagnostic bronchoscopic procedures using conscious sedation over a 1-year period. The primary outcome was patient tolerability measured with four questions soliciting subjective responses. Secondary outcomes included required dosage of medications, thoroughness of the procedure, diagnostic yield, and occurrence of complications. A total of 181 patients were enrolled. Compared to patients in whom conventional bronchoscopy with transbronchial biopsies were performed, there was no difference in patient tolerability using the advanced techniques. Although some of the advanced procedures added to the procedure time, the required amount of medication was within commonly accepted dosages. When EBUS-TBNA was performed, a mean of 2.8 lymph node stations per patient were sampled. A specific diagnosis was obtained in 55.9 % of patients who solely underwent EBUS-TBNA. The diagnostic yield increased to 75.7 % when a parenchymal abnormality prompted additional biopsies. One patient required sedation reversal. Complications were minimal. This study suggests that advanced diagnostic bronchoscopic procedures are well tolerated using conscious sedation with no compromise of thoroughness, diagnostic yield, or safety. This may be useful for bronchoscopists using these techniques who do not have ready access to general anesthesia.