Diagnostic Yield For Malignancy Research Articles

A survey of flexible bronchoscopy practice at Kenyatta National Hospital, Kenya

Objectives: Flexible bronchoscopy (FB) is an essential diagnostic and therapeutic tool for managing respiratory diseases, and an audit of its practice is important; it enhances standardization of practice and improves outcomes and patient safety. This study aimed to describe the FB practice at Kenyatta National Hospital (KNH) regarding indications, peri-procedure practice, gross and histologic findings, and safety. Materials and Methods: This study was a quantitative and retrospective chart review of files of 282 patients who underwent flexible bronchoscopies over 5 years in KNH. Results: We reviewed 282 flexible bronchoscopies done between January 2016 and December 2020. There was a significant documentation gap (22%); 54 out of the 282 cases audited had incomplete documentation. The male-to-female ratio was 1:1, with a median age of 51 years. Most (58.2%) of the patients were residents of counties outside Nairobi. Despite a lack of evidence for routine evaluation, we noted significant rates (75.9%) of routine laboratory evaluations (International normalized ratio (INR), platelet count). The most common indication of bronchoscopy was the evaluation of a lung mass (100) 35.7%, pulmonary infiltrate 53 (18.9%), and assessment for interstitial lung disease 39 (13.9%). The most common gross bronchoscopic findings were visible tumors at 38.5% (107) and normal endoscopic findings at 29.5% (82). The practice was safe, with a complication rate of 3.2%. The most common diagnostic outcome was lung cancer (40.1%), with adenocarcinoma being the most common (45.1%) histologic subtype. The diagnostic yield for malignancy where there was a visible tumor was 87.2%. Conclusion: Our study showed that FB practice at KNH is safe and provides a good diagnostic yield, but a significant documentation gap and record keeping exist. Adenocarcinoma was the most predominant lung cancer histologic subtype among the mostly non-smoker population.

Anesthesia care provider sedation versus conscious sedation for endoscopic ultrasound-guided tissue acquisition: a retrospective cohort study.

We aimed to study the effects of sedation on endoscopic ultrasound-guided tissue acquisition. We conducted a retrospective study evaluating the role of sedation in endoscopic ultrasound-guided tissue acquisition by comparing two groups: anesthesia care provider (ACP) sedation and endoscopist-directed conscious sedation (CS). Technical success was achieved in 219/233 (94.0%) in the ACP group and 114/136 (83.8%) in the CS group (p=0.0086). In multivariate analysis, the difference in technical success between the two groups was not significant (adjusted odds ratio [aOR], 0.5; 95% confidence interval [CI], 0.234-1.069; p=0.0738). A successful diagnostic yield was present in 146/196 (74.5%) in the ACP group and 66/106 (62.3%) in the CS group, respectively (p=0.0274). In multivariate analysis, the difference in diagnostic yield between the two groups was not significant (aOR, 0.643; 95% CI, 0.356-1.159; p=0.142). A total of 33 adverse events (AEs) were observed. The incidence of AEs was significantly lower in the CS group (5/33 CS vs. 28/33 ACP; OR, 0.281; 95% CI, 0.095-0.833; p=0.022). CS provided equivalent technical success and diagnostic yield for malignancy in endoscopic ultrasound-guided tissue acquisition. Increased AEs were associated with anesthesia for the endoscopic ultrasound-guided tissue acquisition.

Improving CT-guided transthoracic biopsy diagnostic yield of lung masses using intraprocedural CT and prior PET/CT fusion imaging

ObjectiveThe purpose of this study was to evaluate the usefulness of intraprocedural CT and prior PET/CT fusion imaging in improving the diagnostic yield of CT-guided transthoracic core-needle biopsy (CNB) in lung masses.MethodsIn total, 145 subjects with lung masses suspicious for malignancy underwent image-guided transthoracic CNB. According to imaging modality the subjects were divided into two groups. PET/CT images obtained no more than 14 days before the biopsy were integrated with intraprocedural CT images. The integrated or fused images were then used to plan the puncture sites. The clinical characteristics, diagnostic yield of CNB, diagnostic accuracy rate, procedure-related complications and procedure duration were recorded and compared between the two groups. Final clinical diagnosis was determined by surgical pathology or at least 6-months follow-up. The diagnostic accuracy of CNB was obtained by comparing with final clinical diagnosis.Results145 subjects underwent CNB with adequate samples, including 76 in fusion imaging group and 69 in routine group. The overall diagnostic yield and diagnostic accuracy rate were 80.3% (53/66), 82.9% (63/76) for fusion imaging group, 70.7% (41/58), 75.4% (52/69) for routine group, respectively. In addition, the diagnostic yield for malignancy in fusion imaging group (98.1%, 52/53) was higher than that in routine group (81.3%, 39/48). No serious procedure-related complications occurred in both two groups.ConclusionCNB with prior PET/CT fusion imaging is particularly helpful in improving diagnostic yield and accurate rate of biopsy in lung masses, especially in heterogeneous ones, thus providing greater potential benefit for patients.

Cumulative sum learning curves guiding multicenter multidisciplinary quality improvement of EUS-guided tissue acquisition of solid pancreatic lesions.

Background and study aims In this study, we evaluated the performance of community hospitals involved in the Dutch quality in endosonography team regarding yield of endoscopic ultrasound (EUS)-guided tissue acquisition (TA) of solid pancreatic lesions using cumulative sum (CUSUM) learning curves. The aims were to assess trends in quality over time and explore potential benefits of CUSUM as a feedback-tool. Patients and methods All consecutive EUS-guided TA procedures for solid pancreatic lesions were registered in five community hospitals between 2015 and 2018. CUSUM learning curves were plotted for overall performance and for performance per center. The American Society of Gastrointestinal Endoscopy-defined key performance indicators, rate of adequate sample (RAS), and diagnostic yield of malignancy (DYM) were used for this purpose. Feedback regarding performance was provided on multiple occasions at regional interest group meetings during the study period. Results A total of 431 EUS-guided TA procedures in 403 patients were included in this study. The overall and per center CUSUM curves for RAS improved over time. CUSUM curves for DYM revealed gradual improvement, reaching the predefined performance target (70 %) overall, and in three of five contributing centers in 2018. Analysis of a sudden downslope development in the CUSUM curve of DYM in one center revealed temporary absence of a senior cytopathologist to have had a temporary negative impact on performance. Conclusions CUSUM-derived learning curves allow for assessment of best practices by comparison among peers in a multidisciplinary multicenter quality improvement initiative and proved to be a valuable and easy-to-interpret means to evaluate EUS performance over time.

Optimal Techniques for EUS-Guided Fine-Needle Aspiration of Pancreatic Solid Masses at Facilities without On-Site Cytopathology: Results from Two Prospective Randomised Trials.

Background: EUS-guided fine-needle aspiration (EUS-FNA) has emerged as the primary modality for the cytologic diagnosis of pancreatic solid masses. The aim of this study is to determine whether technical factors including suction (S), non-suction (NS), capillary sampling with stylet slow-pull (CSSS), and the number of needle actuations (to-and-fro needle movements) may affect the accuracy of EUS-FNA for pancreatic solid masses at facilities without on-site cytopathology. Methods: The diagnostic yield of malignancy, blood contamination and cellularity at each sample acquired from EUS-FNA with or without S and different numbers of actuation (10, 15 and 20) were measured (study I). The optimal actuation number was determined and a head-to-head comparison trial between S and CSSS was performed (study II). Results: In study I, significant blood contamination was seen using S with 20 compared with 15 actuations (p = 0.002). Diagnostic yield of malignancy was not significantly different between 10, 15, and 20 actuations with S, whereas it was statistically higher for 15 actuations compared with 10 actuations with NS (p = 0.001). In study II, no difference was noted in diagnostic yield with 15 actuations between S and CSSS (88% vs. 90%, p = 0.74). Conclusions: Increasing actuation in NS resulted in a better diagnostic yield for EUS-FNA without significant blood contamination, whereas increasing actuation in S did not change the diagnostic yield of EUS-FNA while causing significant blood contamination. With 15 actuations, the diagnostic yield was comparable between S and CSSS.

Comparison of the efficiency of endobronchial ultrasound-guided transbronchial needle aspiration using a 22G needle versus 25G needle for the diagnosis of lymph node metastasis in patients with lung cancer: a prospective randomized, crossover study.

BackgroundEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is generally performed for the diagnosis of hilar/mediastinal lymph node metastasis in patients with lung cancer. Recently, a 25-gauge (G) needle became available, but robust evidence of its usefulness in routine clinical practice is still lacking.MethodsA prospective randomized crossover trial was performed, in which patients with suspected hilar/mediastinal lymph node metastasis of lung cancer underwent EBUS-TBNA. The primary endpoint was the rate of yield histology specimens containing malignant cells.ResultsFrom December 2018 to February 2020, 102 patients were randomly assigned to EBUS-TBNA using a 22G needle first, followed by a 25G needle (n=50) or EBUS-TBNA using a 25G needle first, followed by a 22G needle (n=52). There was no difference in the diagnostic yield of malignancy between the histology specimens obtained by using the 22G and 25G needles (75% vs. 75%, respectively, P=0.37). The sizes of the tissue samples (16.4 vs. 4.9 mm2, respectively) and number of malignant cells in the tissue samples (626 vs. 400, respectively) were both significantly higher when using the 22G needle than when using the 25G needle.ConclusionsNo significant difference in the diagnostic yield between the 22G and 25G needles was observed for the diagnosis of lymph node metastasis of lung cancer, suggesting that needles of either gauge could be used for the biopsy. However, we would recommend use of the 22G needle, because it provided larger specimens and specimens containing larger numbers of malignant cells.Trial RegistrationUniversity hospital Medical Information Network Clinical Trial Registry (ID: UMIN000036680).

Outcomes of patients with a non-diagnostic initial bronchoscopy for suspected thoracic malignancy

Lung cancer is 1 of the leading causes of cancer-related deaths and bronchoscopy is an essential tool for the diagnosis. The diagnostic yield varies based on the characteristics of the lesion and bronchoscopic techniques employed. There is limited data regarding outcomes of patients suspected of thoracic malignancies with a non-diagnostic initial bronchoscopy. The goal of the study was to evaluate the outcomes of patients with a non-diagnostic bronchoscopy for suspected thoracic malignancies and to evaluate variables predictive of a diagnostic bronchoscopy.Retrospective analysis of adult patients at BronxCare Hospital Center who underwent bronchoscopy for suspected thoracic malignancy. The study period was January 2012 to February 2019. Exclusion criteria included patients who underwent only inspection bronchoscopy or bronchoalveolar lavage as the diagnostic yield for malignancy with these techniques is low. All other bronchoscopic procedures were included that is, endobronchial biopsies, transbronchial biopsies, and endobronchial ultrasound guided-transbronchial needle aspiration. Bronchoscopy was considered diagnostic when a specific histopathological diagnosis was established.311 patients underwent bronchoscopy to rule out malignancy. A diagnosis was obtained in 153 (49.2%) patients, 81 (52.9%) had primary lung cancer and 14 (9.15%) other malignancies. 158 (50.8%) patients had initial non-diagnostic bronchoscopy; 86 (54.43%) were lost to follow up. Of the remaining 72 (45.57%) patients, radiological resolution or stability was observed in 51 (70.8%) patients. Primary lung cancer was found in 13 (18.05%) patients and other malignancies in 5 (6.94%). Predictive of a diagnostic bronchoscopy was the performance of endobronchial biopsies and endobronchial ultrasound guided-transbronchial needle aspiration.This study highlights some of the barriers to the timely diagnosis of thoracic malignancies. Following patients with a non-diagnostic procedure as well as all those patients with diagnosed malignancies it of the utmost importance. In patients available for follow up, close to 25% of additional cases with treatable malignancy could be identified and patients diagnosed with cancer could receive timely treatment.

The diagnostic utility of cell block in fine needle aspiration cytology of palpable breast lesions in a Nigerian tertiary health institution.

Although fine needle aspiration cytology (FNAC) is highly accurate for detecting breast malignancies, concerns remain among cytopathologists about false-positive and false-negative diagnoses. Cell block (CB) preparations have been advocated by some cytopathologists as one of the methods to improve and consolidate the diagnostic accuracy of FNAC. The aim of this study was to determine the diagnostic utility of CB in FNAC of palpable breast lesions among female patients. Following FNA, CBs were prepared using 10% neutral-buffered formalin from the residual breast aspirates of 100 consecutive female patients attending the FNAC clinic. The slides of the conventional smears, CB and excisional biopsies were examined, and results were analysed using the SPSS. Of the 100 patients that had FNAC, 44 (44%) had excisional biopsy performed. An additional 13% diagnostic yield for malignancy was obtained with the use of CB preparations. CB reduced equivocal diagnoses by 25%, corresponding with 90.9% improvement on definitive diagnoses. In our setting, the addition of CB to smear remarkably improved the diagnostic utility of breast FNAC by minimising atypical and suspicious for malignancy diagnostic categories.

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.

Clinicopathological Study of 117 Body Fluids: Comparison of Conventional Smear and Cell Block Technique.

Background. Cell block method (CB) has emerged as an invaluable tool for diagnosis of effusions. It can help overcome the problems faced by conventional smear (CS) by differentiating between reactive, inflammatory and malignant cells. The aim of the study is to compare and correlate the CB diagnosis with the CS findings of various pathological conditions including malignancy. Materials and Methods. Two years prospective cross-sectional study of 117 fluids received for routine examination and/or for cytology was conducted. CS as well as CB was simultaneously prepared from the fluid and the results were correlated and tabulated for statistical analysis. Results. Mean age of presentation was 43±21.1 years and male: female ratio was 1.3:1. Ascitic fluid (46.2%) was the most common followed by pleural (40.2%). Among malignancies, primary ovarian and lung carcinoma were the most common to present with malignant ascites (33.3%) and pleural effusion (66.7%) respectively. Six suspicious for malignancy on CS were provided a definitive diagnosis of malignancy on CB. Overall, CB increased the yield of malignancy by 8.3%. The agreement between CB and CS for malignant effusions and suspicious for malignancy were 41.7% and 14.3% respectively. Sensitivity of CS method when compared to CB, for malignant peritoneal and pleural effusions was 90% and 75% respectively while the specificity was 68% and 79% respectively. Conclusion. CB has a better diagnostic yield of malignancy and helps in providing a definitive diagnosis for cases that are suspicious for malignancy on CS. Hence, CB should be routinely employed along with CS for all effusions.

Diagnostic Yield of Malignancy and Coeliac Disease in Biopsies at Upper Gastrointestinal Endoscopy in Patients with Iron Deficiency Anaemia (IDA)

Diagnostic Yield of Malignancy and Coeliac Disease in Biopsies at Upper Gastrointestinal Endoscopy in Patients with Iron Deficiency Anaemia (IDA)

2801 Does Rapid On-Site Evaluation by a Cytopathologist During Endoscopic Ultrasound-Guided Fine-Needle Aspiration (EUS FNA) of Pancreatic Masses Improve Diagnostic Yield and Accuracy? A Systematic Review and Meta-Analysis

INTRODUCTION: EUS FNA plays an important role in the diagnostic evaluation of pancreatic masses. Studies comparing the diagnostic yield of EUS FNA of pancreatic masses when performed with rapid onsite evaluation (ROSE) by a cytopathologist vs. without ROSE have reported conflicting results. By systematic review and meta-analysis, we aim to compare the diagnostic yield and diagnostic accuracy of EUS FNA when performed with and without ROSE in the evaluation of pancreatic masses. METHODS: We reviewed Pubmed, Scopus and Web of Science from inception to November 15, 2018 to identify studies comparing EUS FNA with and without ROSE for evaluation of pancreatic masses. The primary outcome of interest was diagnostic yield for malignancy. Secondary outcomes were diagnostic accuracy and sample inadequacy. A random effects model was used to analyze the data. Pooled odds ratios (ORs) with 95% confidence interval (CI) were used to summarize the data. Heterogeneity was assessed by I2statistic. RESULTS: We included 7 studies (6 publications and 1 abstract) comprising 1327 patients. EUS FNA was performed with and without ROSE in 641 and 686 patients, respectively. 5 studies were retrospective and 2 were randomized controlled trials. Diagnostic yield and accuracy were similar between the two groups. Seven studies reported data on diagnostic yield for malignancy; pooled OR was 0.96 (0.71, 1.31) with low heterogeneity (I2 = 26%; Figure 1). 4 studies reported data on diagnostic accuracy; pooled OR was 0.73 (0.39, 1.36) with low heterogeneity (I2 = 42%; Figure 2). 4 studies reported data on inadequate samples; no difference was observed between groups (OR 1.99; 95% CI 0.82, 4.85; I2 = 36%). CONCLUSION: This meta-analysis found that ROSE by a cytopathologist during EUS FNA of pancreatic masses does not improve diagnostic yield or diagnostic accuracy.

Diagnostic Utility of Virtual Bronchoscopic Navigation Assisted Endobronchial Ultrasonography with Guide Sheath for Peripheral Pulmonary Lesions

背景与目的虚拟支气管镜导航（virtual bronchoscopic navigation, VBN）联合支气管超声导向鞘技术（endobronchial ultrasonography with guide sheath, EBUS-GS）用于经支气管肺活检术（transbronchus lung biopsy, TBLB），能够减少甚至避免射线暴露。本研究拟评价VBN联合EBUS-GS对肺周围性病变（pulmonary peripheral lesions, PPLs）的诊断价值及安全性。方法回顾性分析2016年1月-2017年12月在北京大学肿瘤医院内镜中心接受EBUS-GS-TBLB患者的临床病理资料，评价诊断率及安全性，并对影响诊断率的因素进行分析。结果121例患者纳入本研究，男性65例，女性56例；平均年龄（58.8±10.3）岁。108例（89.3%）可在EBUS图像中显示，共有89例（73.5%）经EBUS-GS-TBLB获得明确诊断。EBUS-GS-TBLB对恶性病变的诊断率为82.5%。联合刷检、活检及肺泡灌洗中两种或三种方式取检的诊断率（87.2%）高于仅采用单一方式取检（58.8%）（χ2=6.084, P=0.014）。影响EBUS-GS-TBLB诊断率的因素包括超声探头位于病灶内部（χ2=20.372, P=0.000）、病灶位于肺野内带及中带（χ2=10.810, P=0.001）。1例（0.8%）患者术中出血量较多。结论VBN联合EBUS-GS-TBLB是一种诊断PPLs安全且有效的方法。

Diagnostic utility of cell blocks and an immunomarker panel in the cytological evaluation of serous effusions

Introduction: Cell blocking (CB) has gained wide acceptance as an integral diagnostic tool in cyto-diagnosis. It allows retrieval and concentration of exfoliated cells in fluid specimens to form paraffin blocks that are interpreted in a biopsy like fashion. The aim of this study was to compare the diagnostic utility of CB to conventional smears (CSs) in the evaluation of serous effusions and to evaluate whether the tested immunomarker panel increases the diagnostic yield of malignancy. Materials and Methods: Serous effusion specimens were processed using both techniques; CSs and CB. An immunomarker panel (Ber-EP4, EMA E29, D2-40 and desmin) was then applied on CB sections. Results: CB enhanced the cellularity; it increased the diagnostic yield by 27.4% over CSs. Both nuclear and cytoplasmic details were better demonstrated in CBs. CBs were superior in the preservation of architectural patterns as acini, papillae and sheets. The diagnosis of CBs concurred with that of CSs in 79% of cases, however the diagnostic yield of malignancy increased by 9.6% using CBs. Adding the immunomarker panel totally eliminated the suspicious category and further increased the diagnostic yield for malignancy by 9.7% over CBs and by 19.3% over CSs. Furthermore, categorization of malignant cases into primary malignant mesothelioma and metastatic carcinoma was feasible after thorough interpretation of the combined immunoprofile. Conclusion: CB represents a cost-effective adjunct to CSs in the evaluation of serous effusions. It increases the cellular yield, provides superior cytomorphology, architectural preservation, and supplies material for ancillary studies. Keywords: Serous effusions, Cell blocks, Immunohistochemistry, Marker panel.

Randomized controlled trial to evaluate the utility of suction and inner-stylet of EBUS-TBNA for mediastinal and hilar lymphadenopathy

BackgroundThe optimal procedure for maximizing the diagnostic yield and minimizing the procedural complexity of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is controversial. We conducted a prospective randomized controlled trial to determine the optimal procedure of EBUS-TBNA for mediastinal and hilar lymphadenopathy, with a particular focus on the roles of the inner-stylet and suction.MethodsConsecutive patients with enlarged mediastinal and hilar lymph nodes (LNs), detected by computed tomography (CT) or positron emission tomography-CT (PET-CT), who underwent EBUS-TBNA were included. Each LN was sampled with three needle passes using suction–stylet, suction–no stylet, and stylet–no suction procedures. The samples were smeared onto glass slides for cytological evaluation. A single, blinded cytopathologist evaluated each set of slides. The primary outcomes were cytological specimen adequacy rate and diagnostic yield of malignant LNs. The secondary outcomes were tissue-core acquisition rate, procedural time, and the amount of bleeding.ResultsThis study evaluated 97 patients with a total of 255 LNs. The final LN diagnosis was benign in 144, malignant in 104, and inadequate in 7 cases. There were no significant differences among the suction–stylet, suction–no stylet, and stylet–no suction groups in specimen adequacy rate (87.1, 88.2, 85.9%, respectively) or diagnostic yield of malignancy (32.2, 31.8, 31.0%, respectively). However, the use of suction was associated with an increase in tissue-core acquisition rate (P < 0.001). The no-stylet procedure decreased the average procedural time by 14 s (P < 0.001). There was no significant difference in the amount of bleeding among the procedures.ConclusionsThe use of suction or non-use of an inner-stylet does not make a significant difference in cytological specimen adequacy or diagnostic yield when performing EBUS-TBNA. While omitting the stylet can simplify the procedure, applying suction can increase the tissue-core acquisition rate. These findings may assist endoscopic physicians in determining the optimal EBUS-TBNA procedure and warrant clinical verification in a future multicentre study.Trial registrationTrial registration: (ChiCTR-IOR-17010616). Retrospective registered date: 12th February, 2017.

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice

It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). In this prospective multicenter study, we found that although competence cannotbe confirmed for all AETs at the end of training, mostmeet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms theeffectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Diagnostic Yield and Safety of Bronchoscopist-directed Moderate Sedation With a Bolus Dose Administration of Propofol During Endobronchial Ultrasound Bronchoscopy.

The propofol use for moderate sedation (MS) during endobronchial ultrasound (EBUS) bronchoscopy is primarily restricted for use by an anesthesiologist because of safety concerns. The goals of this study were to demonstrate the safety and the diagnostic yield of the use of propofol by bronchoscopists and trained endoscopy nurses during EBUS bronchoscopy without intubation. We tested a bolus propofol administration protocol targeting MS for EBUS bronchoscopy. A fixed initial dose of 40 mg of propofol along with a fixed 50 mcg fentanyl dose were administered. Sedation assessment was performed every 2 minutes, and repeated bolus doses of propofol were given to maintain MS under the direction of the bronchoscopist. A total of 122 subjects underwent EBUS bronchoscopy with a goal of MS from August 2015 to April 2017. In total, 110 subjects who underwent convex EBUS bronchoscopy under MS with propofol were included in the analysis. Median procedure duration was 57 minutes (range, 15 to 97 min). Deep sedation and agitation-related delay were occurred in 14 and 21 subjects, respectively. Hemodynamic instability and hypoxemia occurred in 23 subjects. However, there was no need for vasopressors or artificial airway placement. Median of total propofol dose per case was 560 mg. Diagnostic yield for malignancy and granuloma was 68%, and a median of 4 lymph node stations were sampled per subject. All specimens with adenocarcinoma were sufficient for genetic marker analysis. There were no major sedation-related complications. A bolus administration of propofol during EBUS bronchoscopy provided excellent adequacy of sedation and well tolerance safety profile.

CT-guided percutaneous transthoracic needle biopsy for paramediastinal and nonparamediastinal lung lesions: Diagnostic yield and complications in 1484 patients.

Computed tomography-guided percutaneous transthoracic needle biopsy (PTNB) is used for identifying paramediastinal lung lesions that cannot be diagnosed by bronchoscopy, but the diagnostic performance and complication rate are unreported.This retrospective study was approved by the institutional review board committee. A total of 1484 patients who underwent PTNB between April 2012 and April 2015 were enrolled. The cohort was divided into a paramediastinal (n = 195) and a nonparamediastinal group (n = 1289) based on lesion location. Diagnostic yield for malignancy and complication rates were analyzed in both groups. Univariate and multivariate logistic regression analysis was used to determine independent risk factors for hemoptysis complication in the paramediastinal group.Percutaneous transthoracic needle biopsy showed 95.6% (109/114) sensitivity and 100% (77/77) specificity for the diagnosis of lesions in the paramediastinal group, with similar accuracy (95.4%, 186/195) to that in the nonparamediastinal group (94.7%, 1221/1289; P = 0.699). Compared with PTNB for nonparamediastinal lesions, PTNB for paramediastinal lesions demonstrated a comparable pneumothorax rate (8.21% vs 8.69%; P = 0.823) and hemothorax rate (2.56% vs 1.47%; P = 0.261), and a higher hemoptysis rate (28.2% vs 19.4%; P = 0.005). Among 6 defined paramediastinal regions, the overall complication rate was the highest in the posterior region (42.4%) and the lowest in the paraventricular region (13.6%). Multivariate analysis revealed that lesion size of 2 to 3 cm (odds ratio [OR] 3.22), intrapulmonary length of needle path >2 cm (OR 8.85), and proximal to pulmonary artery (OR 10.33) were independent risk factors for hemoptysis in the paramediastinal group.Computed tomography-guided PTNB can diagnose paramediastinal lesions with high yield and acceptable complication rates. Given higher rate of hemoptysis in PTNB for paramediastinal lesions, more attention should be paid in cases with high risks.

Investigation of unprovoked venous thromboembolism: a case for a tempered approach?

To investigate and review the diagnostic yield for occult malignancy in patients who underwent abdominopelvic computed tomography (CT) after the diagnosis of unprovoked venous thromboembolism (VTE) with reference to the guidelines set by The National Institute for Health and Clinical Excellence (NICE). We retrospectively reviewed all unprovoked VTE diagnosed within a large teaching hospital over a period of 21 months for subsequent imaging investigations and cancer diagnoses. The primary outcome was confirmed cancer diagnosis; patients were followed for a minimum of 12 months. Three hundred and five unprovoked VTEs were diagnosed in the study period, 31% of all VTEs. Of this cohort, 73.1% underwent further imaging for exclusion of occult malignancy. Fifteen (4.9%) cancers were diagnosed; with no subsequent malignancy reported in a 12-month follow-up period of the remaining 290 patients. Of the 15 cancers, seven were post-pulmonary emboli, all of which were identified on the initial CT pulmonary angiogram, thus abdominopelvic CT only was used to locate the primary and to undertake staging. Eight were post-deep-vein thrombosis (DVT). Thus the diagnostic yield for malignancy on abdominopelvic CT post-unprovoked VTE was 2.3%. The majority of diagnosed cancers were advanced with 80% dying in the follow-up period with a mean survival of 3.4 months. The pick-up rate of occult malignancy on abdominopelvic CT post-unprovoked VTE in the present study was 2.3%, far less than the generally quoted rate of 10%; however, similar to other rates in the literature. The benefit abdominopelvic CT brings to the diagnosis of occult malignancy post-unprovoked VTE is irresolute.

The clinical impact of immediate on-site cytopathology evaluation during endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: a prospective multicenter randomized controlled trial.

Observational data on the impact of on-site cytopathology evaluation (OCE) during endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic masses have reported conflicting results. We aimed to compare the diagnostic yield of malignancy and proportion of inadequate specimens between patients undergoing EUS-FNA of pancreatic masses with and without OCE. In this multicenter randomized controlled trial, consecutive patients with solid pancreatic mass underwent randomization for EUS-FNA with or without OCE. The number of FNA passes in the OCE+ arm was dictated by the on-site cytopathologist, whereas seven passes were performed in OCE- arm. EUS-FNA protocol was standardized, and slides were reviewed by cytopathologists using standardized criteria for cytologic characteristics and diagnosis. A total of 241 patients (121 OCE+, 120 OCE-) were included. There was no difference between the two groups in diagnostic yield of malignancy (OCE+ 75.2% vs. OCE- 71.6%, P=0.45) and proportion of inadequate specimens (9.8 vs. 13.3%, P=0.31). Procedures in OCE+ group required fewer EUS-FNA passes (median, OCE+ 4 vs. OCE- 7, P<0.0001). There was no significant difference between the two groups with regard to overall procedure time, adverse events, number of repeat procedures, costs (based on baseline cost-minimization analysis), and accuracy (using predefined criteria for final diagnosis of malignancy). There was no difference between the two groups with respect to cytologic characteristics of cellularity, bloodiness, number of cells/slide, and contamination. Results of this study demonstrated no significant difference in the diagnostic yield of malignancy, proportion of inadequate specimens, and accuracy in patients with pancreatic mass undergoing EUS-FNA with or without OCE.