Diagnosis Of Peripheral Pulmonary Lesions Research Articles

Rapid on-site cytologic evaluation by pulmonologist improved diagnostic accuracy of endobronchial ultrasound-guided transbronchial biopsy

Rapid on-site cytologic evaluation (ROSE) has been shown to improve the diagnostic accuracy of endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB). However, ROSE by a cytopathologist or cytotechnologist is not always available during the procedure. The purposes of this study were to verify that a pulmonologist, after receiving training in cytology, could accurately assess an EBUS-TBB specimen on-site, and to evaluate the contribution of ROSE to EBUS-TBB. A retrospective chart review of patients who underwent EBUS-TBB for diagnosis of peripheral pulmonary lesions (PPLs) from January 2014 to June 2017 was performed. PPLs without a malignant diagnosis were excluded. The ROSE result determined by a pulmonologist was compared to the formal imprint cytologic report and pathologic report. The diagnostic accuracy of EBUS-TBB was also compared between those with and without ROSE. Two hundred ninety-three patients who underwent 336 EBUS-TBB procedures for PPL diagnosis and were found to have proven malignancy were enrolled. Eighty-six procedures were performed with ROSE. With the formal imprint cytologic diagnosis as the standard, ROSE had 96.9% sensitivity, 68.2% specificity, 89.9% positive predictive value (PPV), 88.2% negative predictive value (NPV), and 89.5% diagnostic accuracy. With the formal pathologic result as the standard, ROSE had 88.2% sensitivity, 80% specificity, 97.1% PPV, 47.1% NPV, and 87.2% diagnostic accuracy, respectively. The diagnostic accuracy was significantly higher when ROSE was performed during EBUS-TBB (88.4% vs 68.0%, P<0.001). A trained pulmonologist can interpret adequately cytologic smears on-site and effectively improve the accuracy of EBUS-TBB in the diagnosis of PPLs.

Study of ultrasound-guided transthoracic fine-needle aspiration and core-needle biopsy in the diagnosis of peripheral pulmonary lesions

Background Transthoracic ultrasound (TUS) is a useful diagnostic tool in peripheral pulmonary lesions. US-guided transthoracic needle biopsy has become an easy and safe procedure that provides adequate tissue samples of lesions for cytological or histopathological examination. Aim The purpose of the study was to evaluate the role of transthoracic fine-needle aspiration and core-needle biopsy under US guidance in the diagnosis of peripheral pulmonary lesions. Patients and methods The study included 30 patients with undiagnosed peripheral parenchymal lesions. Fine-needle aspiration with or without core-needle biopsy under US guidance was performed using needles of different pores and lengths, and spring-loaded biopsy needles having needle size (16–18–20 gauge) and core length (1–2 cm) for core biopsy. Results The total diagnostic yield of transthoracic lung sampling was 80%. The diagnostic yields of fine-needle aspiration, core-needle biopsy, and their combined techniques were 70%, 72.73%, and 81.82%, respectively. The sensitivity of the combined technique (94.12%) was higher than fine-needle aspiration alone (76%) and that of core-needle biopsy alone (88.24%). Conclusion TUS-guided biopsy is an easy and reliable cheap sampling method with less complication. US-guided fine-needle aspiration and core-needle biopsy can be used as complementary procedures for sampling tissue in the diagnosis of peripheral pulmonary lesions abutting the pleura.

Comparative study between medical thoracoscopic, bronchoscopic transbronchial, and ultrasound-guided transthoracic lung biopsies in diagnosis of peripheral pulmonary lesions

Background Peripheral pulmonary lesions are common clinical problems which need to be diagnosed through techniques less invasive than surgical biopsies. Objectives To compare safety and diagnostic yield of fiberoptic transbronchial, medical thoracoscopic, and ultrasound (US)-guided transthoracic lung biopsies in assessment of peripheral lung disorders. Patients and methods We recruited 45 patients with peripheral lung lesions. In 19 patients pathology was solitary and it was diffuse in 26 patients. Patients were randomly divided into three groups 15 patients each: Group A: patients underwent flexible bronchoscopy. The biopsy instrument was advanced under fluoroscopic guidance to reach the target lesion. Group B: patients underwent medical thoracoscopy and lung biopsies were taken using coagulating forceps. Group C: patients underwent US-guided transthoracic needle. Results Symptoms, investigations, findings, and hazards related to each technique were recorded. A conclusive diagnosis was achieved in 34 patients: 15 patients were diagnosed as bronchogenic carcinoma and 12 patients had metastatic lesions. Seven patients had benign pathology. Transbronchial, medical thoracoscopic, and US-guided biopsies had a sensitivity of 67.7, 87.7, and 73.7%, respectively for the diagnosis of peripheral lung disorders. Transbronchial biopsies showed less diagnostic accuracy than thoracoscopy in solitary lesions. 73.3%, of both bronchoscopy and medical thoracoscopy patients and 40% of US-guided patients had minor complications. The diagnostic performance of transbronchial lung biopsy under fluoroscopic guidance, thoracoscopic lung biopsies, and US-guided transthoracic biopsies are comparable. However, risk of potential complications makes US-guided method preferred in cases of respiratory insufficiency.

Rapid On-Site Evaluation During Radial Endobronchial Ultrasound-Guided Transbronchial Lung Biopsy for the Diagnosis of Peripheral Pulmonary Lesions.

Objective:To evaluate the diagnostic value of radial endobronchial ultrasound (R-EBUS) combination with rapid on-site evaluation (ROSE) guided transbronchial lung biopsy (TBLB) for peripheral pulmonary lesions.Methods:Peripheral pulmonary lesions identified by computed tomography underwent R-EBUS with or without ROSE randomly from February 2016 to August 2017. The diagnostic yield and the operation time were compared.Results:In total, 158 patients were involved in and completed this research, including 84 cases in the group of R-EBUS with ROSE, and 74 in the group without ROSE. The diagnostic yield of ROSE group was 85.7%. Among these positive cases, 69.4% cases were malignant tumors, and 30.6% cases were benign lesions. The operation time was (24.6 ± 6.3) min. In the group without ROSE, the diagnostic yield was 70.3%, including 35 malignant tumors (67.3%), and 17 benign lesions (32.7%). The operation time was (31.5 ± 6.8) min. There were significant differences between both groups in the diagnostic yield (χ2 = 5.556, P = 0.018) and in the operation time (t = 3.187, P < 0.01). No serious procedure related complications were observed, such as pneumothorax and hemorrhage.Conclusion:ROSE can improve the diagnostic yield, and shorten the operation time. R-EBUS combined with ROSE is a safe and effective technique for peripheral pulmonary lesions.

Virtual bronchoscopic navigation without fluoroscopy guidance for peripheral pulmonary lesions in inexperienced pulmonologist.

ObjectiveFluoroscopy guidance is generally required for endobronchial ultrasonography with guide sheath (EBUS-GS) in peripheral pulmonary lesions (PPLs). Virtual bronchoscopic navigation (VBN) can guide the bronchoscope by creating virtual images of the bronchial route to the lesion. The diagnostic yield and safety profiles of VBN without fluoroscopy for PPLs have not been evaluated in inexperienced pulmonologist performing EBUS-GS.MethodsBetween January 2016 and June 2017, consecutive patients with PPLs referred for EBUS-GS at a single cancer center were enrolled. The diagnostic yield as well as safety profiles was retrospectively analyzed, and our preliminary experience was shared.ResultsA total of 109 patients with 109 lesions were included, 99 (90.8%) lesions were visible on EBUS imaging. According to the procedure time needed to locate the lesion on EBUS, 24.8% (27/109) were deemed technically difficult procedures; however, no significant relationships were identified between candidate parameters and technically difficult procedures. The overall diagnosis yield was 74.3% (81/109), and the diagnostic yield of malignancy was 83.7% (77/92). Lesions larger than 20 mm [odds ratio (OR), 2.758; 95% confidence interval (95% CI), 1.077−7.062; P=0.034] and probe of within type (OR, 3.174; 95% CI, 1.151−8.757, P=0.026) were independent factors leading to a better diagnostic yield in multivariate analysis. About 30 practice procedures were needed to achieve a stable diagnostic yield, and the proportion of technically difficult procedures decreased and stabilized after 70 practice procedures. Regarding complications, one patient (0.9%) had intraoperative hemorrhage (100 mL) which was managed under endoscopy.ConclusionsVBN without fluoroscopy guidance is still useful and safe for PPLs diagnosis, especially for malignant diseases when performed by pulmonologist without previous experience of EBUS-GS. VBN may simplify the process of lesion positioning and further multi-center randomized studies are warranted.

Accuracy of a Robotic Endoscopic System in Cadaver Models with Simulated Tumor Targets: ACCESS Study

Background: Bronchoscopy for the diagnosis of peripheral pulmonary lesions continues to present clinical challenges, despite increasing experience using newer guided techniques. Robotic bronchoscopic platforms have been developed to potentially improve diagnostic yields. Previous studies in cadaver models have demonstrated increased reach into the lung periphery using robotic systems compared to similarly sized conventional bronchoscopes, although the clinical impact of additional reach is unclear. Objectives: This study was performed to evaluate the performance of a robotic bronchoscopic system’s ability to reach and access artificial tumor targets simulating peripheral nodules in human cadaveric lungs. Methods: Artificial tumor targets sized 10–30 mm in axial diameter were implanted into 8 human cadavers. CT scans were performed prior to procedures and all cadavers were intubated and mechanically ventilated. Electromagnetic navigation, radial probe endobronchial ultrasound, and fluoroscopy were used for all procedures. Robotic-assisted bronchoscopy was performed on each cadaver by an individual bronchoscopist to localize and biopsy peripheral lesions. Results: Sixty-seven nodules were evaluated in 8 cadavers. The mean nodule size was 20.4 mm. The overall diagnostic yield was 65/67 (97%) and there was no statistical difference in diagnostic yield for lesions <20 mm compared with lesions measuring 21–30 mm, the presence of a concentric or eccentric radial ultrasound image, or relative distance from the pleura. Conclusions: The robotic bronchoscopic system was successful at biopsying 97% of peripheral pulmonary lesions 10–30 mm in size in human cadavers. These findings support further exploration of this technology in prospective clinical trials in live human subjects.

Diagnostic contribution of cytological examination to endobronchial ultrasound-guided transbronchial biopsy for lung malignancies.

ABSTRACTAlthough endobronchial ultrasound guided transbronchial biopsy (TBB) with a guide sheath (EBUS-GS) is widely used for diagnosis of peripheral pulmonary lesions, the diagnostic contribution of cytology (bronchial brushing, bronchial washing and biopsy forceps rinse) has not been established. To determine the diagnostic contribution of cytological examination to EBUS-GS-TBB, we reviewed medical records of patients with lung malignancies who had undergone TBB with EBUS-GS (EBUS-GS group, n=187) or TBB without EBUS-GS (conventional TBB [CTBB] group, n=197) at Nagoya University Hospital. Although the mean size of target lesions was significantly larger in the CTBB group than the EBUS-GS group, the total diagnostic rate was equivalent between two groups (EBUS-GS: 73.3%, CTBB: 66.0%). In the EBUS-GS group, cytological procedures increased the diagnostic rate by 9.1% (17/137), compared with only 4.1% (8/130) in the CTBB group. Sensitivity of cytology among biopsy-negative patients was significantly higher in EBUS-GS group than CTBB group (P=0.022). Furthermore, in the EBUS-GS group, among 17 patients whose malignant diagnoses could only be established cytologically, bronchial brushing contributed to the malignant diagnosis in 64.7% (11/17). These data may suggest that cytological examination, especially bronchial brushing, may be an important diagnostic contributor in EBUS-GS-TBB.

ES07.03 Radial Endosonography

Flexible bronchoscopy, with its attendant procedures, is a valuable tool for diagnosis and staging of patients with suspected lung cancer. The development of endobronchial ultrasound (EBUS) has extended the view of the bronchoscopist beyond the bronchial wall. Two types of EBUS exist. The curved linear (convex) probe EBUS and the radial probe EBUS. The convex ultrasound transducer is located at the tip of a flexible bronchoscope (linear scanning EBUS) and allows real-time sampling. This technique is mainly used for mediastinal nodal staging and assessment of centrally located lung tumours when lung cancer is known or suspected. The radial EBUS probe houses a rotating ultrasound transducer at the distal end which produces a high-resolution radial (360˚) ultrasound image of the airway wall and surrounding structures. This probe is inserted through the biopsy channel of a standard bronchoscope. In a lung cancer setting, this technique is used for evaluation of the depth of tumour invasion in the central airways enabling differentiation between early and invasive lung cancer and detection of peripheral pulmonary lesions (PPLs). Radial EBUS does not permit sampling in real-time such that sequential sampling with separate equipment is necessary. The current focus of this abstract is the role of radial EBUS for PPLs. With the increased use of chest CT-scans, the frequency of incidentally found PPLs has increased as well. Guidelines advise to evaluate and manage individuals with pulmonary nodules by estimating the probability of malignancy. The goal is to diagnose a malignancy promptly for timely treatment and to avoid invasive procedures and surgery in patients with benign lesions. Approaches to establish a tissue diagnosis include imaging-guided transthoracic and bronchoscopic sampling techniques. The sensitivity of traditional flexible bronchoscopy – with or without fluoroscopic guidance – for peripheral lesions in patients suspected of having lung cancer is suboptimal and is affected most by the size of the lesion (<2cm 34%; >2cm 63%).(1) For PPLs, the sensitivity of transthoracic needle aspiration (TTNA) is greater than that of bronchoscopy. In this setting, TTNA has an approximately 90% chance of providing confirmation of a diagnosis. However, CT-guided percutaneous TTNA has a considerable risk of pneumothorax.(1) This has led to the development of new modalities as radial EBUS, virtual bronchoscopy, electromagnetic navigation bronchoscopy and ultrathin bronchoscopes. In 2002, radial EBUS was first used to guide transbronchial lung biopsy (TBLB).(2) Numerous papers has been published since, reporting varying diagnostic performances of radial EBUS. Three systematic reviews and meta-analyses report a sensitivity of radial EBUS for diagnosis of peripheral lesions of 70% to 73%. Although there is considerable heterogeneity in lesion size, prevalence of malignancy, variable use of additional image guiding technology and reference standard in included studies.(3-5) The diagnostic yield of radial EBUS is significantly higher for lesion > 2 cm in size, malignant in nature and those associated with a bronchus sign on CT scan.(3-5) The diagnostic yield is also higher when the radial EBUS probe is in the center of the lesion opposed to being adjacent to it.(3) The diagnostic yield of radial EBUS does not exceed CT-guided percutaneous needle biopsy / aspiration. The major advantage of radial EBUS over a transthoracic approach is its safety profile (overall pneumothorax rate of just 1.0%)(4) and the ability to combine with staging procedures. In conclusion, to diagnose PPLs (not visible by bronchoscopy) radial EBUS is a safe and has a reasonably high diagnostic yield. Main limitations of the technique include operator dependence and the need for sequential sampling as radial EBUS does not allow real-time sampling. 1. Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e142S-e65S. 2. Herth FJ, Ernst A, Becker HD. Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions. The European respiratory journal. 2002;20(4):972- 3. Ali MS, Trick W, Mba BI, Mohananey D, Sethi J, Musani AI. Radial endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis. Respirology (Carlton, Vic). 2017;22(3):443-53. 4. Steinfort DP, Khor YH, Manser RL, Irving LB. Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. The European respiratory journal. 2011;37(4):902-10. 5. Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385-93. Radial endosonography, diagnosis, lung cancer

Application of endobronchial ultrasonography using a guide sheath and electromagnetic navigation bronchoscopy in the diagnosis of atypical bacteriologically-negative pulmonary tuberculosis.

In the absence of a positive sputum bacteriological result, pathological and bacteriological examinations of lung lesion biopsies are important methods to confirm bacteriological-negative tuberculosis. Endobronchial ultrasonography with guide sheath (EBUS-GS) and electromagnetic navigation bronchoscopy (ENB) are two new endobronchial diagnostic techniques, the combination of which has greatly facilitated the diagnosis of peripheral pulmonary lesions and is an especially useful, minimally invasive, effective diagnostic method for bacteriologically-negative tuberculosis cases. A total of 78 patients were included in this study with suspected pulmonary tuberculosis based on clinical manifestations, laboratory tests, and imaging studies. The patients underwent a high-resolution chest CT scan before bronchoscopy, A method was selected (EBUS-GS alone, or EBUS-GS + ENB) based on the lesion site and the level and angle of the bronchus involved. After the lesion was found, a puncture needle, biopsy forceps, and brushing forceps were used to collect a tissue sample. Forty-four patients were diagnosed with tuberculosis; 1, nontuberculous Mycobacteria (NTM) lung disease; 15, lung cancer; 15, pulmonary infection; 1, allergic bronchopulmonary aspergillosis (ABPA); and 2, pneumoconiosis. A total of 25 patients of TB (56.8%) were successfully diagnosed with EBUS-GS plus ENB. Among the patients with confirmed diagnosis, 9 were diagnosed with pathological examination; 4, genetic analysis; 11, positive smear; and 14, positive culture. The introduction of EBUS and ENB in China has provided a new direction for the diagnosis of atypical bacteriological-negative tuberculosis, as the techniques are less invasive and less expensive than thoracoscopy.

Performance of transbronchial cryobiopsy in eccentrically and adjacently orientated radial endobronchial ultrasound lesions.

BackgroundRadial endobronchial ultrasound (R-EBUS) is an effective technique in the diagnosis of peripheral pulmonary lesions (PPL). However, lesion orientation with regards to the radial probe remains an important factor for effective biopsy. “Within” orientation was associated with significantly higher diagnostic yield. Cryobiopsy is a novel technique in obtaining larger tissue samples with the frozen tip allowing biopsy in a 360° direction, thus potentially achieving more effective biopsy in eccentrically and adjacently orientated lesions. We aimed to evaluate the performance and safety of transbronchial cryobiopsy versus forceps biopsy in eccentrically and adjacently orientated R-EBUS lesions.MethodsRetrospective review of R-EBUS transbronchial biopsy for PPL over 17 months.Results114 R-EBUS scans were included for analysis during the study period. Forceps biopsy was performed in 76 (66.7%) cases and cryobiopsy in 38 (33.3%) cases. Baseline demographics and lesion characteristics did not differ between the two groups. Median (interquartile range) lesion size was 3.48 (2.63–4.51) cm. Overall, 41.2% of lesions were of eccentric orientation and 15.8% adjacent orientation; only 43% were concentric in orientation. Overall diagnostic yield was 67.5% (77 out of 114). Orientation remained an important factor affecting diagnostic yield. Transbronchial cryobiopsy significantly increased the diagnostic yield in eccentrically and adjacently orientated lesions to 75.0% (18 out of 24), compared to 48.8% (20 out of 41) obtained via forceps biopsy (p<0.05); but not in concentric lesions. Cryobiopsy was associated with more mild and moderate bleeding complications compared to the forceps biopsy group.ConclusionsTransbronchial cryobiopsy under R-EBUS guidance is a safe procedure which potentially increases diagnostic yield in eccentrically and adjacently orientated PPLs.

Diagnosis of peripheral pulmonary lesions using endobronchial ultrasonography with a guide sheath and computed tomography guided transthoracic needle aspiration.

Peripheral pulmonary lesions (PPL) are difficult to diagnose. We analysed the diagnostic values and risks of endobronchial ultrasonography with a guide sheath (EBUS-GS) and computed tomography-guided transthoracic needle aspiration (CT-TTNA) in diagnosing PPL. We collected 250 cases received EBUS-GS examination, and 279 cases received CT-TTNA examination. We analysed the diagnosis results and the complications of each operation and determined the relevant indications. Biopsy was successful in 239 cases (95.6%) using EBUS-GS and in 279 cases (100%) using CT-TTNA. Lesions were smaller than or equal to 30mm for biopsy using EBUS-GS in 60.7% of the cases. The distances of lesions from the chest wall were greater than 80 mm for EBUS-GS examination in 89.1% of the cases. The diagnostic rate of EBUS-GS was 78.2%, including 41.8% (100 cases) malignant diseases. EBUS-GS is a highly safe method. The distances of lesions from the chest wall were no greater than 80mm for CT-TTNA examination in 90.0% of the cases. The diagnosis rate using CT-TTNA was 94.6%, including 90.0% (251 cases) malignant diseases. For CT-TTNA, there is a high chance of complications such as pneumothorax and intrapulmonary hemorrhage. EBUS-GS and CT-TTNA each have their own limitations. EBUS-GS has a slightly lower diagnostic rate but higher safety, while CT-TTNA has a higher diagnostic rate but requires attention to complications. For lesions 80mm more from the chest wall, we recommend EBUS-GS. For lesions 80mm from or closer to the chest wall, we recommend CT-TTNA.

Combination of electromagnetic navigation bronchoscopy-guided biopsy with a novel staining for peripheral pulmonary lesions

BackgroundThe diagnosis of peripheral pulmonary lesions (PPLs) is a challenging task for pulmonologists, especially for small PPLs. Conventional localization of these small PPLs, which are > 1 cm away from the visceral pleura in operation, is quite difficult. Currently used methods inevitably damage the visceral pleura and may cause a series of complications, such as pneumothorax and hemothorax. Hence, the present study aimed to find out an intraoperative localization method with no damage to the visceral pleura.MethodsWe retrospectively reviewed 21 patients with PLLs who underwent electromagnetic navigation bronchoscopy (ENB)-guided biopsy plus a new methylene blue staining with the help of massage (Massage Staining) in our department between August 2017 and December 2018.ResultsThe median age of these 21 patients was 51.3 ± 2.1 years. The diameter of the PPLs was 8.2 ± 2.3 mm. The rate of successful biopsy was 76.2%, and the rate of excellent or satisfactory of Massage Staining was 81.0%, while all lesions of these 21 cases were included in the range of staining, and the median distance from the edge of the stained site to the edge of the lesion was 29 ± 18 mm. The duration of ENB-guided biopsy plus Massage Staining was 26.7 ± 5.3 min, and the intraoperative blood loss was 3.3 ± 1.5 ml. No pneumothorax, hemorrhage, and tracheal injury occurred intraoperatively.ConclusionsThe ENB-guided biopsy combined with Massage Staining is an innovative one-stop strategy designed to enhance the precision of thoracic surgery. The Massage Staining avoids damage to the visceral pleura, causes the low incidence of complications, but yields precise localization of PPLs.

Use of an Ultrathin vs Thin Bronchoscope for Peripheral Pulmonary Lesions: A Randomized Trial

When evaluating peripheral pulmonary lesions, a 3.0-mm ultrathin bronchoscope (UTB) with a 1.7-mm working channel is advantageous regarding good access to the peripheral airway, whereas a 4.0-mm thin bronchoscope provides a larger 2.0-mm working channel, which allows the use of various instruments including a guide sheath (GS), larger forceps, and an aspiration needle. This study compared multimodal bronchoscopy using a UTB and a thin bronchoscope with multiple sampling methods for the diagnosis of peripheral pulmonary lesions. Patients with peripheral pulmonary lesions≤ 30mm in diameter were recruited and randomized to undergo endobronchial ultrasonography, virtual bronchoscopy, and fluoroscopy-guided bronchoscopy using a 3.0-mm UTB (UTB group) or a 4.0-mm thin bronchoscope (thin bronchoscope group). In the thin bronchoscope group, the use of small forceps with a GS or standard forceps without the GS was permitted. In addition, needle aspiration was performed for lesions into which an ultrasound probe could not be inserted. A total of 360 patients were enrolled, and 356 were included in the analyses (median largest lesional diameter, 19mm). The overall diagnostic yield was significantly higher in the UTB group than in the thin bronchoscope group (70.1%vs58.7%, respectively; P= .027). The procedure duration was significantly shorter in the UTB group (median, 24.8 vs26.8 min, respectively; P= .008). The complication rates were 2.8%and 4.5%, respectively (P= .574). Multimodal bronchoscopy using a UTB afforded a higher diagnostic yield than that using a thin bronchoscope in the diagnosis of small peripheral pulmonary lesions. UMIN Clinical Trials Registry; No.: UMIN000010133; URL: https://www.umin.ac.jp/ctr/.

Safety and Usefulness of Cryobiopsy and Stamp Cytology for the Diagnosis of Peripheral Pulmonary Lesions.

Reports on the use of cryobiopsy (CB) for lung cancer diagnosis are limited. The aims of the present study were to evaluate the safety and usefulness of CB using radial endobronchial ultrasonography, without a guide sheath, for the diagnosis of peripheral pulmonary lesions and determine the utility of stamp cytology, an on-site diagnostic technique for determining tumor inclusion in CB samples. We retrospectively analyzed data for 35 patients (36 lesions) with suspected peripheral lung cancer who underwent CB between August 2017 and February 2019 at our medical facility. The diagnostic yield, incidence of complications, and the utility of stamp cytology for diagnosis were investigated. The diagnostic yield of CB was 86.1% (31/36) with histological diagnosis, and 80.5% (29/36) with diagnosis using stamp cytology; the overall yield was 91.6% (33/36). Pneumothorax requiring thoracic drainage occurred in two patients, both of whom had lesions contacting the pleura. Grade 2 and grade 1 bleeding occurred in one and 25 patients, respectively. CB enables the collection of very large, nearly intact tissue samples, thus resulting in an improvement in the true diagnosis rate and facilitating the measurement of multiple biomarkers as well as rapid histological diagnosis.

Factors affecting bacterial culture positivity in specimens from bronchoscopy in patients with suspected lung cancer.

Bronchoscopy is important to diagnose lung cancer. However, some patients who undergo bronchoscopic procedures develop respiratory tract infections. Little is known about the proportion of pathogen-positive results in bacterial cultures from diagnostic bronchoscopy samples in patients with suspected lung cancer. This study aimed to determine the rate of positive bacterial cultures after diagnostic bronchoscopy in patients with suspected lung cancer and the relationship among culture results, clinical characteristics, and respiratory tract infections. We retrospectively reviewed the medical records of all immunocompetent patients who underwent bronchoscopy and had culture and histological samples for the diagnosis of peripheral pulmonary lesions from September 2012 to August 2014 at the National Cancer Center in Tokyo. We analyzed data and classified radiological lesions into the following categories: calcifications, cavitations, low-density areas, margin irregularities, and satellite nodules. The study population consisted of 328 patients (median age, 69 years). We found that 65.9% of patients had malignant lesions and 4.2% of patients had positive cultures for pathogenic bacteria. The number of calcifications (p = 0.002, 95% CI: 2.17-41.10) was significantly higher in patients with positive bacterial isolates, according to the multivariate analysis, and bacterial culture positivity was not associated with the development of respiratory complications after bronchoscopy. Of the three patients with respiratory complications, all presented with cavitations. Because of the low prevalence of positive bacterial cultures in patients with suspected lung cancer, bacterial culture may be limited to specific patients, such as those with calcifications. Lesions with cavitation warrant close monitoring.

The Utility of Virtual Bronchoscopy Using a Computed Tomography Workstation for Conducting Conventional Bronchoscopy: A Retrospective Analysis of Clinical Practice

Background: Recent clinical trials demonstrated the benefits of several guided-bronchoscopy technologies for the diagnosis of peripheral pulmonary lesions (PPLs). However, introduction of these technologies is expensive. Therefore, in clinical practice, these are unavailable in many hospitals. In contrast, virtual bronchoscopy (VB) using the computed tomography (CT) workstation can be made available immediately without additional cost as many hospitals already have the CT scan facility. However, the effectiveness of VB alone remains to be shown. Objectives: The aim of this study was to investigate the effect of VB using the CT workstation in hospitals performing conventional bronchoscopy. Methods: Results from consecutive patients who underwent bronchoscopy for small PPLs (major diameter ≤30 mm) were retrospectively reviewed. Sixty-nine patients who underwent bronchoscopy without VB from April 2014 to March 2015 and 56 patients who underwent bronchoscopy with VB from April 2015 to December 2015 were assigned to non-VB and VB groups, respectively. We compared the two groups and analyzed the factors affecting the diagnostic yield. Results: The VB group had a significantly higher diagnostic yield than the non-VB group (57.1 vs. 33.3%; p = 0.008). In the multivariate analysis, VB was identified as a significant factor affecting the diagnostic yield (odds ratio: 3.30, p = 0.011). Conclusions: In the conventional bronchoscopy settings, VB using the CT workstation is efficient for the diagnosis of PPLs when other guided-bronchoscopy techniques are unavailable.

Transthoracic fine-needle aspiration versus tru-cut biopsy under computed tomography-scan guide in diagnosis of peripheral lung lesions

Background: Lung cancer is the number one cause of cancer-related death in the Western world. Intrapulmonary nodules are presenting either solitary or multiples. Primary bronchogenic carcinoma is the most common malignant tumor that presents as a solitary pulmonary nodule. Fine-needle aspiration (FNA) and Tru-cut biopsy are parts from several interventional procedures that need to reach to the final diagnosis. Aim: This study aims to assess the comparison between transthoracic FNA results and Tru-cut biopsy results in the diagnosis of peripheral pulmonary lesions and the possibility of depending on one of them in the diagnosis of these lesions. Materials and Methods: FNA and true cut biopsy under computed tomography scan guided were performed to patients had peripheral pulmonary lesion and sent to the cytological and histopathological laboratory for analysis. Results: All patients (20) that had pulmonary lesion were evaluated. Results of FNA were; 15/20 of them were adequate samples for diagnosis while 5/20 were inadequate. Results of Tru-cut biopsies were – 17/20 were adequate for histopathological assessment while 3/20 were inadequate. Thirteen out of 20 patients had malignancy, five patients diagnosed by both Tru-cut biopsy and FNA, other five diagnosed by Tru-cut biopsy only and three patients diagnosed by FNA only. One patient had benign lesion and diagnosed by both procedures. Six out of 20 patients had other results that diagnosed by both procedures. Squamous cells carcinoma was 5/13 patients (38.46%) and adenocarcinoma was the same percentage. The concordance of FNA results with Tru-cut biopsy results was 60%. Conclusion: The study demonstrated that Tru-cut biopsy is moderately superior to FNA in the evaluation of peripheral malignant lung lesions. Therefore, we advise not using the FNA alone in the evaluation of peripheral chest lesions that suspected of malignancy (except if large bullae or severe emphysema present) and Tru-cut biopsy is often required together to reach the diagnosis.

Diagnostic Utility of Electromagnetic Navigation Bronchoscopy Combined with Radial Probe Endobronchial Ultrasound in Peripheral Pulmonary Lesions

背景与目的随着高分辨计算机断层扫描（computed tomography, CT）的广泛应用和健康体检的普遍开展，大量周围型肺部病灶被发现，对临床诊断治疗提出了新的挑战。电磁导航支气管镜（electromagnetic navigation bronchoscope, ENB）和径向探头支气管内超声（radial probe bronchoscopy ultrasound, R-EBUS）是用于周围型肺部病灶诊断的新兴技术，本研究旨在探讨ENB联合R-EBUS对肺周围型病灶诊断中的应用价值。方法2016年9月-2017年11月苏州大学附属第一医院胸外科应用ENB技术对18例患者的30处肺部周围型病灶进行了检查，术前制定导航计划，术中导航成功到达预定位置后使用R-EBUS确认病灶，依次使用穿刺针、细胞刷、活检钳进行病灶组织活检。结果30处肺部周围型病灶，导航成功率为100%（30/30），阳性诊断率为90%（27/30）。手术时间为（95.61±28.74）min，每处病灶导航时间为（25.90±11.29）min，发生气胸1例，未见其他严重并发症。结论利用ENB联合R-EBUS技术诊断肺周围型病灶具有较高的导航成功率和诊断阳性率，安全有效，值得进行临床推广。

P2.12-001 Early Experience with Radial Endobronchial Ultrasound with Guide Sheath For Diagnosis of Peripheral Pulmonary Lesion

Diagnostic yield for routine unguided bronchoscopy for peripheral pulmonary lesion (PPL) is less than 20%. Hence, CT guided transthoracic needle aspiration (TTNA) is currently the preferred method with a high diagnostic yield of 90%, however running risk of pneumothorax of around 25%. Radial endobronchial ultrasound with guide sheath (R-EBUS-GS) for diagnosis of PPL is a novel technique with diagnostic yield of 70.6% with good safety profile. However, this advanced technique is not readily available in developing nations and were further limited by the availability of other supporting modalities such as thin section computed tomography (CT) scan, fluoroscopy, thin bronchoscope, availability of rapid onsite evaluation (ROSE) and an established cytology services.

ES 07.04 Endoscopic Options for Solitary Pulmonary Nodules

World-wide, aside from men in France, Spain and the Netherlands, peripherally located adenocarcinomas have now overtaken squamous cell carcinoma as the predominant lung cancer cell type. With the implementation of lung cancer screening programs using low dose CT and increasing use of CT imaging for clinical investigations, a large number of people are found to have lung nodules. In contrast to symptomatic lung cancer, the size of screening CT detected or incidental lung nodules suspicious of malignancy is much smaller. Over 75% of screening CT detected lung cancers are ≤20 mm with 20% to 47% of the lung cancers found in the first screening CT and 33% to 62% of lung cancers found in annual repeat screening CT are ≤10 mm.1-4 Because of the small size of these lesions, currently only 20% to 34% of screening CT detected lung cancers are diagnosed by endoscopy. The diagnostic yield of bronchoscopic biopsies is modest.1,2 In the real world setting, even with advanced bronchoscopic methods such as navigation bronchoscopy and radial ultrasound, the diagnostic yield of peripheral lung lesions is less than 60%.5,6 Several factors account for the suboptimal diagnostic yield. The diameter of the airways leading to the lesion may be smaller than the 1.4 mm diameter radial EBUS probe. The lesion may be eccentric rather than perpendicular to the biopsy forceps. Removable of the imaging probe from a guide sheath and re-insertion of biopsy forceps or needle may cause displacement or migration of the guide sheath to a different airway. To improve the diagnostic accuracy, other methods are being developed for endoscopic detection and biopsy of peripheral lung lesions ≤20 mm. Bronchoscopic transparenchymal approach to access peripheral lung nodules from more central airways and real time fluoroscopic transbronchial guidance systems are under evaluation.7,8 Flexible 21G peripheral needles are becoming commercially available for transbronchial aspiration or core biopsy. Small optical imaging probes < 0.5 mm that can be inserted within a 21G needle to confirm abnormal pathology in real time using optical frequency domain imaging9,10 or diffuse reflectance spectroscopy before taking a biopsy. These newer endoscopic approaches hold promise to improve diagnostic accuracy while maintaining the advantage of lower complication rates such as pneumothorax and bleeding compares to CT guided transthoracic lung biopsy. 1. National Lung Screening Research Team, Church TR, Black WC, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013 May 23;368(21):1980-91. 2. Aberle DR, DeMello S, Berg CD, et al. Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med 2013; 369(10):920-31. 3. McWilliams A, Tammemagi MC, Mayo et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013;369:910-9.4. Horeweg N, van Rosmalen J, Heuvelmans MA, et al. Lung cancer probability in patients with CT- detected pulmonary nodules: a prespecified analysis of data from the NELSON trial of low-dose CT screening. Lancet Oncol. 2014 Nov;15(12):1332-41. 5. Ost DE, Ernst A, Lei X, et al. AQuIRE Bronchoscopy Registry. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Respir Crit Care Med. 2016 Jan 1;193(1):68-77. 6. Ali MS, Trick W, Mba BI, et al. Radial endobronchial ultrasound for the diagnosis of peripheral pulmonary lesions: A systematic review and meta-analysis. Respirology. 2017; 22(3):443-453. 7. Herth FJ, Li S, Jiayuan Sun J, Nader D. Bronchoscopic TransParenchymal Nodule Access: Evaluation of safety and feasibility of Archimedes System. Am J Respir Crit Care Med 2017;195:A7597. 8. Stoy SP, Whitten PE, Al-Zubaidi A, Hogarth K. Bronchoscopic peripheral lung nodule navigation by a novel Live fluoroscopic overlay guidance technology. Am J Respir Crit Care Med 2017;195:A2865. 9. Tan KM, Shishkov M, Chee A, et al. Flexible transbronchial optical frequency domain imaging smart needle for biopsy guidance. Biomed Opt Express 2012; 3::1947-1954. 10. Pahlevaninezhad H, Lee AM, A. R, et al. Endoscopic Doppler optical coherence tomography and autofluorescence imaging of peripheral pulmonary nodules and vasculature. Biomedical Optics xpress. 2015; 6(10):4191-9. Endoscopic biopsy