Diagnostic Yield Of Transbronchial Needle Aspiration Research Articles

An electromagnetic navigation system for transbronchial interventions with a novel approach to respiratory motion compensation

Bronchoscopic interventions, such as transbronchial needle aspiration (TBNA), are commonly performed procedures to diagnose and stage lung cancer. However, due to the complex structure of the lung, one of the main challenges is to find the exact position to perform a biopsy and to actually hit the biopsy target (e.g., a lesion). Today, most interventions are accompanied by fluoroscopy to verify the position of the biopsy instrument, which means additional radiation exposure for the patient and the medical staff. Furthermore, the diagnostic yield of TBNA is particularly low for peripheral lesions. To overcome these problems the authors developed an image-guided, electromagnetic navigation system for transbronchial interventions. The system provides real time positioning information for the bronchoscope and a transbronchial biopsy instrument with only one preoperatively acquired computed tomography image. A twofold respiratory motion compensation method based on a particle filtering approach allows for guidance through the entire respiratory cycle. In order to evaluate our system, 18 transbronchial interventions were performed in seven ventilated swine lungs using a thorax phantom. All tracked bronchoscope positions were corrected to the inside of the tracheobronchial tree and 80.2% matched the correct bronchus. During regular respiratory motion, the mean overall targeting error for bronchoscope tracking and TBNA needle tracking was with compensation on 10.4 ± 1.7 and 10.8 ± 3.0 mm, compared to 14.4 ± 1.9 and 13.3 ± 2.7 mm with compensation off. The mean fiducial registration error (FRE) was 4.2 ± 1.1 mm. The navigation system with the proposed respiratory motion compensation method allows for real time guidance during bronchoscopic interventions, and thus could increase the diagnostic yield of transbronchial biopsy.

Rapid On-site Evaluation of Transbronchial Aspirates in the Diagnosis of Hilar and Mediastinal Adenopathy: A Randomized Trial

Rapid on-site evaluation (ROSE) of transbronchial needle aspirates has long been used during flexible bronchoscopy, but its usefulness in the diagnosis of hilar and mediastinal adenopathy is controversial. The aim of the present study was to evaluate the extent to which ROSE can be valuable in patients undergoing transbronchial needle aspiration (TBNA) for the diagnosis of hilar and mediastinal adenopathy. A total of 168 consecutive patients with enlarged lymph nodes were randomized to undergo TBNA with or without ROSE. The primary outcome measure of the study was the diagnostic yield of TBNA on a per-patient basis. Secondary outcome measures included the percentage of adequate specimens on a per-lymph node basis, the number of biopsy sites on a per-patient basis, and the complication rate of bronchoscopy on a per-patient basis. We found no significant difference between the TBNA group and the ROSE group in terms of diagnostic yield (75.3% vs 78.3%, respectively; P = .64), and percentage of adequate specimens (86.5% vs 78.4%, respectively; P = .11). The median (interquartile range) number of biopsy sites was significantly lower in the ROSE group (1 [1-2] vs 2 [1-2], respectively; P = .0005). The complication rate of bronchoscopy was significantly lower in patients undergoing on-site review (6% vs 20%; P = .01), whereas the complication rate of TBNA was similar among the study groups. ROSE of transbronchial aspirates from hilar and mediastinal nodes enables avoidance of additional biopsy without loss in diagnostic yield and reduces the complication rate of bronchoscopy. ClinicalTrials.gov; No.: NCT00915330; URL: www.clinicaltrials.gov

First endoscopic procedure for diagnosis and staging ofmediastinal lymphadenopathy

To compare a first diagnostic procedure of transbronchial needle aspiration (TBNA) with selection of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or TBNA for mediastinal lymphadenopathy. Sixty-eight consecutive patients with mediastinal lymphadenopathy on computed tomography (CT), who required cytopathological diagnosis, were recruited. The first 34 underwent a sequential approach in which TBNA was performed first, followed by EUS-FNA if TBNA was unrevealing. The next 34 underwent a selective approach where either TBNA or EUS-FNA was selected as the first procedure based on the CT findings. The diagnostic yield of TBNA as the first diagnostic procedure in the sequential approach was 62%. In the selective approach, the diagnostic yield of the first procedure was 71%. There was no significant difference in the overall diagnostic yield, but there were significantly fewer combined procedures with the selective approach. Selecting either EUS-FNA or TBNA as the first diagnostic procedure achieved a comparable diagnostic yield with significantly fewer procedures than performing TBNA first in all patients.

Exclusive Diagnostic Contribution of the Histology Specimens Obtained by 19-Gauge Transbronchial Aspiration Needle in Suspected Malignant Intrathoracic Lymphadenopathy

Transbronchial needle aspiration (TBNA) performed with a 19-gauge needle provides both cytologic and histologic specimens. However, the diagnostic yield for malignancy gained by histologic examination is unclear. Moreover, this kind of needle is often reserved only for selected cases, in part due to fear for complications. The primary aim of this study was to investigate the diagnostic contribution for malignancy added by histologic to the cytologic specimen examination. The secondary aim was to evaluate the safety of using a 19-gauge needle routinely in all patients. Consecutive patients presenting with mediastinal and/or hilar lymph node enlargement of > or = 1 cm, in whom suspicion for malignancy was raised, underwent TBNA with a 19-gauge needle. Patients with negative aspirate test results underwent surgical investigation. Among 77 patients who were examined, 66 had malignant intrathoracic lymphadenopathy. TBNA proved malignancy in 58 patients, whereas it missed the diagnosis in 8 patients (sensitivity, 87.9%; negative predictive value, 57.9%). TBNA established the diagnosis in 94% of patients with small cell lung cancer (SCLC), and in 88% of patients with non-SCLC (p = 0.7). Exclusive diagnosis was obtained in 36.4% of patients by histology (compared with 18.2% of patients by cytology [p = 0.06]), representing an increase of 35.3% in the diagnostic yield of TBNA over sole cytology examination. No major complication occurred. Histology specimens obtained exclusively with a 19-gauge TBNA needle enabled diagnosis in about 36% of patients with malignant intrathoracic lymphadenopathy. The routine use of a 19-gauge needle is safe.

TBNA Versus TENA in the Diagnosis and Staging of Bronchogenic Carcinoma: “A Comparative Study”

Transbronchial needle aspiration (TBNA) through the flexible bronchoscope still remains underused and a poorly understood procedure. Recently, transesophageal needle aspiration (TENA) under ultrasound guidance has been used to help stage the posterior mediastinal lymph nodes. TBNA and TENA have both been used for the diagnosis and staging of bronchogenic carcinoma. This study is to compare the efficacy and complimentary potential of these techniques. Retrospective review and comparison of a series of consecutive patients. Tertiary referral hospital. Nineteen adult patients with mediastinal adenopathy. TBNA and TENA. Specific diagnostic yield of TBNA compared with TENA in adenopathy of the left paratracheal and subcarinal locations. Out of 19 patients, specific diagnosis was made in 15 patients (79%) by TBNA and in 13 patients (68%) by TENA. TBNA and TENA were both positive in 5 patients. TBNA alone was positive in 7 patients and TENA alone was positive in 1 patient. In the comparative study group lymph node stations 7, 8, and 5 (L4), there were no significant differences in the diagnostic yield of TBNA and TENA. Small sample size. TBNA remains highly effective for sampling mediastinal lymph node stations. TENA is limited for subcarinal, paraesophageal, and aorto-pulmonary window lymph nodes, which are adjacent to the esophagus. Adding TENA to TBNA did not increase the diagnostic yield even in these subgroups of lymph nodes in our study.

Transbronchial Needle Aspiration in the Diagnosis of Endobronchial Malignant Lesions: A 3-Year Experience

To establish the diagnostic yield of transbronchial needle aspiration (TBNA) and its contribution to conventional diagnostic techniques (CDT) such as forceps biopsy, bronchial washing, and bronchial brushing in the diagnosis of malignant endobronchial lesions. Retrospective clinical study. One hundred fifteen lung cancer patients We reviewed files of 115 lung carcinoma cases diagnosed in our clinic from 2001 to 2003 with endobronchial lesions sampled by CDT and TBNA. The lesions were classified into three groups: exophitic mass lesion (EML), submucosal disease, and peribronchial disease. The diagnostic yield of TBNA and CDT was compared to that of the combination of CDT and TBNA with respect to the type and location of the lesion and the histopathologic subgroups. Of the 115 cases, histology findings were confirmed by TBNA in 91 cases (79%), CDT in 75 cases (65%), and TBNA plus CDT in 105 cases (91%). The difference of the diagnostic yield of CDT vs TBNA plus CDT was statistically significant (p < 0.001). In peribronchial disease, the sensitivity of TBNA plus CDT was significantly better than CDT (87% vs 52%, p < 0.001). In EML and submucosal disease, addition of TBNA to CDT improved sensitivity from 85 to 100% and from 84 to 97%, respectively (p > 0.05). Regarding localization, the addition of TBNA to CDT increased sensitivity in the trachea and main bronchi, and in right upper and middle lobe lesions (p < 0.05). By the addition of TBNA to CDT, small cell lung cancer and non-small cell lung cancer cases demonstrated improvements in sensitivity from 74 to 100% and 61 to 87%, respectively. This significant difference (p < 0.05) was attributed to the peribronchial disease group. In the case of peribronchial disease, the addition of TBNA to CDT improves the diagnostic yield of the bronchoscopic examination.

Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy

Transbronchial Needle Aspiration Followed Immediately by Endoscopic Ultrasound Guided Needle Aspiration in the Evaluation of Mediastinal Lymphadenopathy Khay L. Khoo, Khek Y. Ho, Tow K. Lim Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a useful diagnostic tool in the evaluation of mediastinal lymphadenopathy, both as a primary modality and in cases of negative transbronchial needle aspiration (TBNA). Aim: To determine the utility of TBNA with rapid on-site cytopathologic evaluation (ROSE) combined with the option for immediate EUS-FNA in the diagnosis of mediastinal adenopathy of unknown etiology. Methods: We prospectively enrolled patients with mediastinal lymphadenopathy on CT scan who required cytologic evaluation. We first performed flexible videobronchoscopy with TBNA. If TBNA was inadequate on ROSE, EUS-FNA was performed immediately, all under topical anesthesia, conscious sedation, and in the same outpatient sitting. The same cytotechnologist was in attendance during both the consecutive procedures to make smears for instant examination. The procedures were terminated when adequate cellular specimens were achieved, or a maximum of six needle passages was done. Results: Twenty patients with mediastinal lymphadenopathy on chest CT underwent TBNA with ROSE. The TBNA specimens were adequate in 13 patients. In the remaining 7 patients, TBNA with ROSE was assessed to be inadequate; thus, EUS-FNA was also performed. Upon cytologic confirmation, TBNA with ROSE was falsely negative in one patient. The diagnostic yield of TBNA was thus 70%. EUS-FNA was positive in 6 of 7 patients, giving a diagnostic yield of 86%. Overall, this combined minimally invasive approach to mediastinal lymphadenopathy, which was well tolerated by all patients with no adverse effects, provided a diagnostic yield of 90%. The final diagnoses were non-small cell cancer (nZ 11), small cell cancer (nZ 2), metastatic adenocarcinoma (nZ 1), sarcoidosis (nZ 1), tuberculosis (nZ 1), and lymphoma (n Z 1). In the first case where this approach failed to give a diagnosis, TBNA showed lymphocytes but interval CT did not show progression of the lymphadenopathy. The second patient had non-small-cell lung cancer. Conclusions: TBNA with ROSE combined with the option for back-to-back EUS-FNA raised the diagnostic yield of TBNA alone from 70% to 90%. This combined approach is safe, convenient and potentially cost-effective for the patient, who needs not undergo another procedure on another day. Abstracts

Comparison of the Diagnostic Accuracy of Transbronchial Needle Aspiration for Bronchogenic Carcinoma and Other Malignancies

This study compares the accuracy of transbronchial needle aspiration (TBNA) for bronchogenic carcinoma with its accuracy in other cancers. A retrospective analysis of 120 consecutive TBNA procedures was performed. All patients who underwent TBNA at Stony Brook University Hospital from March 2000 to March 2002 were included in the analysis. The diagnostic yield of TBNA was 74 of 120 (62%). Of the 120 samples, 67 were true positives; 0, false positives; 31, true negatives; 11, false negatives; and 11 were not able to be determined. Using best-case and worst-case analysis, overall accuracy was 82 to 91%, sensitivity was 75 to 86%, and negative predictive value was 58 to 76%. In the subgroup of patients with bronchogenic carcinoma, accuracy was 86 to 91%, sensitivity was 85 to 90%, and negative predictive value was 42 to 53%. Of the 9 patients with cancer other than lung carcinoma, 5 TBNAs were positive, for an accuracy of 56%. TBNA is highly accurate for diagnosing and for staging the mediastinal lymph nodes in bronchogenic carcinoma, but it is less accurate for cancers other than bronchogenic carcinoma. Given the negative predictive value of TBNA, patients with a high pretest likelihood of malignancy require further workup of nondiagnostic biopsies.

The diagnostic yield of transbronchial needle aspiration in superior vena cava syndrome

Superior vena cava syndrome (SVCS) requires a timely histopathological diagnosis for appropriate management. We prospectively evaluated the diagnostic yield and complications of transbronchial needle aspiration (TBNA) among patients with SVCS in a tertiary care university hospital. From February 1996 to April 2000, 27 consecutive patients referred with clinical SVCS without a prior diagnosis underwent flexible bronchoscopy and TBNA. The ultimate diagnoses were small cell carcinoma (SCLC) in 15 patients, non-small cell lung carcinoma (NSCLC) in 11, and non-Hodgkin lymphoma in one patient. TBNA was diagnostic in all 26 patients with bronchogenic carcinoma, but not in lymphoma, which was subsequently diagnosed via thoracotomy. The overall diagnostic yield of TBNA was 96%, and the 95% confidence interval (CI) of diagnostic yield was 80–100%. TBNA solely provided the diagnosis in nine patients with NSCLC (82%), and in seven with SCLC (47%), and confirmed the diagnosis established via forceps biopsy in ten patients. Age, gender, radiological involvement and TBNA site were comparable in cases with and without forceps biopsy. There was no major complication related to either flexible bronchoscopy or TBNA. We concluded that TBNA is safe and has a high diagnostic yield in SVCS caused by bronchogenic carcinoma.

Punción transbronquial en el carcinoma broncogénico con lesión visible: rendimiento y coste económico

Transbronchial needle aspiration (TBNA) is a bronchoscopic technique whose usefulness in diagnosing endobronchial lesions has not yet been clearly established. We aimed to determine whether the diagnostic yield of fiberoptic bronchoscopy could be increased, without a negative impact on diagnostic costs, if TBNA were used in combination with conventional diagnostic techniques (bronchial washings and bronchial brushings and forceps biopsy). The cases of 130 patients diagnosed with bronchogenic carcinoma with endoscopically visible lesions were analyzed retrospectively. All had undergone conventional diagnostic procedures; TBNA was also performed if the bronchoscopist considered it was indicated. The final cost was calculated in euros for each diagnosis as the sum of the cost of the procedures needed to reach the diagnosis, including both endoscopic procedures and others (transthoracic needle aspiration, lymph node biopsy). Diagnostic yield and costs in cases diagnosed using only conventional techniques were compared to the yield and costs in cases in which both conventional techniques and TBNA were used. TBNA was performed in 49 patients and provided the diagnosis in 85.7%. Conventional techniques led to cytological and histological diagnosis in 80.2% of the cases, and the combination of conventional techniques and TBNA gave a diagnosis in 89.7% (P=.01). Significant differences were observed in extrinsic compression (conventional 37.5%; conventional+TBNA 100%; P=.01), submucosal infiltration (conventional 54.6%; conventional+TBNA 85%; P=.03), and exophytic mass with necrosis (conventional 80%; conventional+TBNA 100%; P=.01). The mean (SD) cost of diagnosis was euros 381.60 (euros 156.53) using conventional techniques and euros 413.25 (euros 112.91) for conventional techniques in combination with TBNA. By adding TBNA, costs decreased for diagnoses of submucosal infiltration, exophytic mass with necrosis and extrinsic compression, although the saving was significant only for extrinsic compression. The diagnostic yield of TBNA is high for endoscopically visible bronchial anomalies suggesting neoplasm, particularly when the lesion is due to extrinsic compression, submucosal infiltration, or exophytic mass with necrosis.