Endobronchial Ultrasound Fine Needle Aspiration Research Articles

P-OGC22 Incidence and relevance of clinically indeterminate non-regional lymph nodes in the treatment of oesophageal cancer

Abstract Background Metastatic involvement of non-regional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare, but has important implications for prognosis and management. The management of non-regional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimetre nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up, and clinical significance of non-regional clinically indeterminate FDG avid lymph nodes. Methods A single centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted. Patients with mid- or distal oesophageal cancer with non-regional FDG avid nodes were identified. Subsequent work-up, management, and outcomes were retrieved from electronic health records. Results Reports for 1189 PET-CT scans were reviewed. A total of 79 patients met the inclusion criteria. Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery, and underwent further assessment. The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine needle aspiration (US-FNA) in 100% of cases. 15/18 (83.3%) of samples were benign and proceeded to surgery. Outcomes for patients who proceeded to surgery were similar to other cohorts. None had pathology suggesting false negative lymph node sampling. Conclusions EBUS and US-FNA are effective means of sampling clinically indeterminate non-regional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued.

Incidence and relevance of clinically indeterminate nonregional lymph nodes in the treatment of oesophageal cancer.

Metastatic involvement of nonregional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare but has important implications for prognosis and management. The management of nonregional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimeter nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up and clinical significance of nonregional clinically indeterminate FDG avid lymph nodes. A single-centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted. Patients with mid- or distal oesophageal cancer with nonregional FDG avid nodes were identified. Subsequent work-up, management and outcomes were retrieved from electronic health records. Reports for 1189 PET-CT scans were reviewed. A total of 79 patients met the inclusion criteria. Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery and underwent further assessment. The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine-needle aspiration (US-FNA) in 100% of cases. 15/18 (83.3%) of samples were benign and proceeded to surgery. Outcomes for patients who proceeded to surgery were similar to other cohorts. None had pathology suggesting false-negative lymph node sampling. EBUS and US-FNA are effective means of sampling clinically indeterminate nonregional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued. Nonregional clinically indeterminate lymph nodes represent a diagnostic dilemma in oesophageal cancer staging. Additional investigations in the form of endobronchial ultrasound are effective at providing additional staging information, and can substantially influence patient care.

Paraneoplastic sarcoidosis: a review.

Sarcoidosis is occasionally seen in association with malignancy, both at the time of cancer diagnosis or during follow up. The purpose of this study is to identify patients with paraneoplastic sarcoid, their associated malignancies and disease characteristics. We identified 289 patients diagnosed histologically with sarcoidosis over a 6-year period in one centre, from 2010 to 2016. Fifty of these patients had a prior or concomitant diagnosis of cancer. 17.3% of sarcoid cases had an associated malignancy. The most common malignancies were Gastrointestinal (20%), Haematological (18%), Lung (12%), Gynaecological (12%) and Head and Neck cancer (12%). 74% of sarcoid cases had pulmonary disease with sarcoid diagnostic tissue obtained most frequently via endobronchial ultrasound fine needle aspiration (68%). Most sarcoid cases (66%) were diagnosed within the first year of their malignancy diagnosis. Careful consideration needs to be given to the possibility that potential cancer recurrences suspected on imaging studies may indeed be sarcoid reactions.

Combined Endosonographic Mediastinal Lymph Node Staging in Positron Emission Tomography and Computed Tomography Node-Negative Non–Small-Cell Lung Cancer in High-Risk Patients

Positron emission tomography (PET) with computed tomography (CT) is routinely utilized to investigate lymph node (LN) metastases in non-small-cell lung cancer. However, it is less sensitive in normal-sized LNs. This study was performed in order to define the prevalence of mediastinal LN metastases discovered on combined endosonography by endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration in patients with a radiologically normal mediastinum. This study consists of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database. Patients were identified from a cohort between January 2009 and December 2014. One hundred and sixty-one patients with biopsy-proven, non-small-cell lung cancer were identified in whom both the preendosonography CT and PET-CT were negative for mediastinal LN metastases. Combined endosonography (EBUS + EUS-FNA) was performed in all patients. Z test was used for statistical analysis. A P value of <0.05 was considered statistically significant. A total of 161 consecutive patients were included. Patients were staged if they had central tumor, tumor size >3 cm, N1 lymph node involvement on PET-CT/CT, or if there was low SUV (<2.5) in the primary tumor. A total of 416 lymph nodes were biopsied in the 161 patients using combined endosonography; 147 with EBUS and 269 with EUS. Mean and median number of lymph nodes biopsied per patient using combined EBUS/EUS was 2.5 and 3, respectively (mean and median EBUS: 0.91 and 2.5; mean and median EUS 1.6 and 3). Endosonographic staging upstaged 13% of patients with radiologically normal lymph nodes in the mediastinum, hilum, lobar, and sublobar regions (confidence interval 8.22-19.20). Twenty-one out of 161 patients (13%) with radiologically normal mediastinum were positive on combined EBUS/EUS staging. Out of 21 patients upstaged on endosonography, 15 (71%) had tumor size >3 cm. Six (28%) had occult N1 disease. Thirteen (61%) had occult N2 disease and 2 (9%) had adrenal involvement. None of the upstaged patients had N1 LN involvement on PET-CT or CT scan. Combined endosonographic lymph node staging should be considered in the pretreatment staging of high-risk patients with non-small-cell lung cancer in the presence of radiologically normal mediastinal lymph nodes due to the significant rate of radiologically occult lymph node metastases.

Evolution of a rapid onsite evaluation (ROSE) service for endobronchial ultrasound guided (EBUS) fine needle aspiration (FNA) cytology in a UK Hospital: A 7 year audit

Endobronchial ultrasound fine needle aspiration (EBUS FNA) is a well-established procedure for the diagnosis and staging of lung cancer. We review our provision of this service at the Royal Devon and Exeter NHS Foundation Trust and the role of rapid onsite evaluation (ROSE) with the increasing demand for molecular markers in this era of personalized medicine. A review of the changes in the Endoscopy clinic over the 7years from the introduction of EBUS at the end of 2010 until 2017 was carried out. This included the availability of material obtained for diagnosis, accurate subtyping, and molecular testing. We also assessed the success of molecular genetics DNA techniques from EBUS material versus formalin fixed paraffin embedded tissue (FFPE). A total of 1218 EBUS cases with ROSE were reported between 2011 and 2017 Percentage diagnostic rates were calculated as 83, 82, 84, 92, 93, 94, and 92 for 2011, 2012, 2013, 2014, 2015, 2016, and 2017, respectively. Availability of material for immunocytochemistry ranged from 86 to 100% over the 7years. Molecular testing was successfully performed for EGFR in 89-100% of requested cases and ALK testing in 87-100% of requested cases. EBUS sourced material gave on average twice the amount of DNA and fewer amplicon repeats per patient compared to FFPE material. ROSE at EBUS FNA provides access to suitable material for molecular testing with increased yields in the form of needle washings for EGFR with FFPE materials for ALK and PDL1 testing.

BRAF Mutated Tall Cell Papillary Carcinoma Lung Metastasis Following Thyroidectomy

SESSION TITLE: Metastatic and Other Primary Lung Tumors SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: BRAF Mutated Tall Cell Papillary Carcinoma is a rare tumor infrequently presented as lung metastasis. Although Papillary Carcinoma is one of the most frequent Thyroid Cancers, BRAF-Tall Cell Variant carries the worst prognosis. CASE PRESENTATION: A 65-year-old male former 12-pack year smoking history and total thyroidectomy as a child presents for evaluation of hematochezia. He has no prior history of radiation exposure or familial history of thyroid cancer. Supplemental thyroid replacement therapy was started at age 21 due to clinical hypothyroidism. Residual thyroid glandular tissue was not visible on CT scan or ultrasound studies. Abdominal and pelvic computed tomography (CT) scan demonstrated the incidental finding of a 1.2 cm non-calcified lobulated and speculated pulmonary nodule. Positron Emission Test (PET) Scan demonstrated maximum SUV uptake of 11.0 in mediastinal and pretracheal structures. Mediastinoscopy aborted after experiencing intraoperative bleeding complications. Endobronchial Ultrasound Trans-bronchial fine needle aspiration (EBUS-TB FNA) was was non-diagnostic. Exploratory thoracotomy with right middle lobe wedge resection and mediastinal lymph node dissection was performed. Surgical biopsy diagnosed a poorly differentiated tall cell papillary carcinoma, BRAF positive mutation. DISCUSSION: BRAF is a important oncoprotein responsibile for the MAPK-pathway output. Its role suppresses the expression of genes required for iodide incorporation. Due to poor iodide uptake, radioactive iodine is not useful diagnostically or therapeutically in tall cell variant disease. CONCLUSIONS: BRAF-mutated classical or tall-cell-variant papillary thyroid carcinomas have a high frequency of lymph-node metastases and recurrence after thyroidectomy. These associated carcinomas have a poor response to radioiodine therapy due to the high MAPK-pathway output, which is driven by the BRAF V600E oncoprotein. This case demonstrates the difficulty with diagnosis of mediastinal lymphadenopathy and rare presentation of tall cell variant papillary cell carcinoma as lung metastasis. Reference #1: American Cancer Society: Cancer Facts and Figures 2016. Atlanta, Ga: American Cancer Society, 2016. Reference #2: Gimm, O., Rath, F. W. and Dralle, H. (1998), Pattern of lymph node metastases in papillary thyroid carcinoma. Br J Surg, 85: 252-254. doi:10.1046/j.1365-2168.1998.00510.x Reference #3: Xing M, Westra WH, Tufano RP, et al. BRAF mutation predicts a poorer clinical prognosis for papillary thyroid cancer. J Clin Endocrinol Metab 2005;90:6373-9. DISCLOSURE: The following authors have nothing to disclose: Brandon Hooks No Product/Research Disclosure Information

True Negative Predictive Value of Preoperative Staging Endosonography by Combined Endobronchial Ultrasound and Endoscopic Ultrasound in Non-Small Cell Lung Cancer

SESSION TITLE: Interventional Pulmonary Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: Complete endosonographic mediastinal staging modalities have become a new standard in the pre-operative staging of non-small cell lung cancer in some centers. This study was performed to understand the value of mediastinal lymph node (LN) sampling and dissection at time of pulmonary resection in the setting of a negative pre-operative staging endosonography by combined EBUS & EUS. METHODS: This study consisted of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database between January 2009 and December 2014. Two hundred and thirty-two consecutive patients with non-small cell lung cancer with negative results on lymph node staging by combined endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration (FNA) that subsequently underwent pulmonary resection or attempt at pulmonary resection were included. The endosonographic results were compared with the final pathological staging utilizing final pathology results of lymph nodes sampled during surgery. Chi-Square test was used for statistical analysis. A p-value of <0.05 was considered statistically significant. RESULTS: Twenty-five out of 232 patients with negative results on LN staging by combined EBUS / EUS - FNA had metastases in LNs sampled during pulmonary resection. 10 patients had N1 disease and 15 patients had N2 disease. The negative predictive value (NPV) of EBUS/EUS was 89.2% (p<0.01). Twenty-one out of these 25 patients who had surgical LN sampling at resection did not have the same station sampled pre-operatively by EBUS/ EUS. Therefore a direct comparison at surgical resection could not be made on these 21 patients. Eleven out of these 21 patients had Station 5 and Station 6 involvement and these stations are routinely difficult to sample using endoscopic modalities. If these 21 patients are omitted for comparison, only 4 out of 232 patients had false negative results by EBUS / EUS - FNA giving a true negative predictive value of 98.3% (p<0.01). 3 out of these 4 patients had N2 disease (Station 4L, 5 and 7) and 1 patient had N1 (Station 11R) disease detected at Pulmonary resection. CONCLUSIONS: Staging endosonography by combined EBUS & EUS in potentially resectable patients is associated with a high NPV. If pre-operative results of biopsy of a particular LN station by EBUS/EUS-FNA are negative, then sampling of the same station at surgery can potentially be omitted. LN stations not sampled by endosonography should be sampled at surgery. CLINICAL IMPLICATIONS: Can potentially change the practice and the way lymph node station sampling and dissection is done during pulmonary resection. This may reduce the operative time and avoid unnecessary dissection of the lymph nodes already biopsied at pre operative staging procedure. DISCLOSURE: The following authors have nothing to disclose: Pravachan Hegde, Vicky Thiffault, Vipul Jain, Akshatha Gowda, Pasquale Ferraro, Moishe Liberman No Product/Research Disclosure Information

The complimentary role of transbronchial lung cryobiopsy and endobronchial ultrasound fine needle aspiration in the diagnosis of sarcoidosis.

Transbronchial lung cryobiopsy (TBLC) is a novel technique that has proved to be useful in diagnosing various interstitial lung diseases (ILD). The use of TBLC to diagnose sarcoidosis in an unselected patient population is unknown, and could be complimentary to endobronchial ultrasound fine needle aspiration (EBUS-FNA). A retrospective analysis of 36 patients in a single, tertiary-care, academic medical center was conducted to describe the yield of both EBUS-FNA and TBLC in the diagnosis of suspected sarcoidosis over a three year period. A grading system to evaluate the presence and extent of specific radiographic features on computed tomography chest imaging studies was compared to the results of EBUS-FNA and TBLC. Complications associated with the procedures were also noted. The overall diagnostic yield in our cohort (all pathologic diagnosis considered) was 80.6% (29 out of 36 patients had a definite pathologic diagnosis). Eighteen patients referred for possible sarcoidosis had a positive bronchoscopic specimen confirming the diagnosis of sarcoidosis. For those patients with a pathologic diagnosis of sarcoidosis, the diagnostic yield for EBUS-FNA and TBLC was 66.7% each (12 out of 18 patients), while the combined diagnostic yield for EBUS-FNA and TBLC increased to 100%. For all cases, the pneumothorax rate was 11.1%. TBLC appears to be a safe and complimentary technique to diagnose sarcoidosis and could be considered part of the diagnostic armamentarium in bronchoscopic centers.

Feasibility of endobronchial ultrasound fine-needle aspiration for massively parallel next-generation sequencing in cancer patients.

8535 Background: Next generation sequencing (NGS) is an important emerging tool in precision oncology, allowing identification of a growing number of clinically validated and investigational therapeutic molecular targets. A potential limitation is that some NGS assays require more DNA input than more limited molecular assays. Endobronchial ultrasound fine-needle aspiration (EBUS-FNA) is a minimally invasive procedure for sampling mediastinal and pulmonary lesions, but it is unknown if it provides adequate material for NGS. Methods: An IRB approved, retrospective review was performed of patients undergoing EBUS-FNA by thoracic surgeons at our institution 3/1/14 - 9/28/16. NGS was performed using an assay developed at our institution that detects mutations in up to 410 genes (MSK-IMPACT). Samples diagnostic for malignancy and with MSK-IMPACT requested were identified. Pathology and clinical data were drawn from the medical record and MSK-IMPACT results were examined. Results: 784 EBUS-FNA were done in the study period. MSK-IMPACT was requested on 115 positive samples. MSK-IMPACT was successful in 99 samples (86.1%), identifying an average of 12.7 mutations at a mean coverage depth of 806X. In 17 (17.2%) samples, tumor content was suboptimal ( &lt; 20% of nucleated cells), with fewer identified mutations than in cases with higher tumor content (6.8 vs 13.9, p = 0.01). NGS was performed on paraffin-embedded cell blocks in 93 cases (93.9%), and in 6 cases DNA extraction was performed from residual cytological material isolated from supernatant including cell-free DNA. Failures were attributable to low cell content (7), high contamination by benign cells (4) or both (1) and processing issues (4). No difference in surgical or radiologic parameters were identified for failed or suboptimal samples. Conclusions: In our practice, EBUS-FNA has a high rate of success for obtaining adequate tissue for NGS. Ability to utilize cell-free DNA for molecular studies – a new process in our lab – allows increased success of molecular testing in scant samples. Further studies may identify factors contributing to NGS failure and to improving success for samples with minimal cellularity.

Endosonography‑guided fine‑needle aspiration in the diagnosis of sarcoidosis: a randomized study.

INTRODUCTION There are no widely accepted standards for the diagnosis of sarcoidosis. OBJECTIVES The aim of this study was to assess the relative diagnostic yield of endobronchial ultrasound fine-needle aspiration (EBUS -FNA) and endoscopic ultrasound fine needle aspiration (EUS -FNA), and to compare them with standard diagnostic techniques such as endobronchial biopsy (EBB), transbronchial lung biopsy (TBLB), transbronchial needle aspiration (TBNA), and mediastinoscopy. PATIENTS AND METHODS This was a prospective randomized study including consecutive patients with clinical diagnosis of stage I or II sarcoidosis. EBB, TBLB, and TBNA were performed at baseline in all patients. Subsequently, patients were randomized to group A (EBUS -FNA) or group B (EUS -FNA). Next, a crossover control test was performed: all patients with negative results in group A underwent EUS -FNA and all patients with negative results in group B underwent EBUS -FNA. If sarcoidosis was not confirmed, mediastinoscopy was performed. RESULTS We enrolled 106 patients, of whom 100 were available for the final analysis. The overall sensitivity and accuracy of standard endoscopic methods were 64% each. When analyzing each of the standard endoscopic methods separately, the diagnosis was confirmed with EBB in 12 patients (12%), with TBLB in 42 patients (42%), and with TBNA in 44 patients (44%). The sensitivity and accuracy of each endosonographic technique were significantly higher than those of EBB+TBLB+TBNA (P = 0.0112 vs P = 0.0134). CONCLUSIONS The sensitivity and accuracy of EBUS -FNA and EUS -FNA are significantly higher than those of standard endoscopic methods. Moreover, the sensitivity and accuracy of EUS -FNA tend to be higher than those of EBUS -FNA.

A Case Report of False Positive FDG- PET/CT Mediastinal Lymph Node in Oesophageal Adenocarcinoma Revealed to be an Anthracotic and Anthracosilicotic Spindle Cell Pseudotumor (AASCP)

Anthracotic and anthracosilicotic spindle cell proliferation (AASCP) is a rare reactive proliferative entity of phagocytic histiocytes which can affect hilar and mediastinal lymph nodes. Fluorodeoxyglucose-positron emission tomography (FDG-PET) has been used for the clinical diagnosis and staging of oesophageal adenocarcinoma. We report the first case of AASCP exhibiting false positivity on FDG-PET imaging. A 76-year-old man with distal esophageal adenocarcinoma underwent PET/CT for staging revealing a positive mediastinal lymph node involvement. The patient underwent Endobronchial Ultrasound Fine Needle Aspiration Biopsy (EBUS-FNA) followed by an oesophagectomy with lymph node dissection. The histological diagnosis of the mediastinal lymphadenopathy was AASCP. In mediastinal lymph nodes of esophageal adenocarcinoma, AASCP could be a cause of false-positivity on FDG-PET imaging.

Pros: should a patient with stage IA non-small cell lung cancer undergo invasive mediastinal staging?

Mediastinal lymph node involvement is an important prognostic factor in patients with non-small cell lung cancer (NSCLC). The American and European guidelines for preoperative mediastinal lymph node staging agree in which situations a pre-surgical exploration of the mediastinum is required in order to avoid futile pulmonary resections (1,2). Invasive mediastinal staging with cyto-histological confirmation is indicated when computed tomography (CT) shows enlarged mediastinal or hilar lymph nodes, when positron emission tomography (PET) shows an increase uptake in the mediastinum or hilum, when the tumour is centrally located and when the tumour size is more than 3 cm, especially in adenocarcinoma with high 18F-Fluorodeoxyglucose (FDG) uptake. In general, a minimally invasive technique (endobronchial or endoesophageal ultrasound fine needle aspiration) is indicated of first choice, but when negative, a surgical exploration of the mediastinum (mainly a video mediastinoscopy) is required. In some particular situation, like clinical (c) staged N1 tumours, with normal mediastinum on imaging techniques, it was suggested to proceed directly to surgical resection when preoperative endosonography was negative. However, this issue has been analyzed, concluding that in cN1 NSCLC, endosonography alone has an unsatisfactory sensitivity to detect mediastinal involvement and, therefore, a confirmatory video mediastinoscopy is mandatory when endoscopic techniques show a negative result (3). Although stage cIA NSCLC is the main situation in which invasive mediastinal staging might be omitted, this paper will analyze the established indications and other particular situations in which performing a pre-surgical mediastinal staging in this group of patients can add a benefit in terms of accurate staging.

Mediastinal Lesions Unassociated with Lung Carcinoma Diagnosed by Endobronchial Ultrasound Transbronchial Fine Needle Aspiration (EBUS-TBNA)

Mediastinal Lesions Unassociated with Lung Carcinoma Diagnosed by Endobronchial Ultrasound Transbronchial Fine Needle Aspiration (EBUS-TBNA)

A Prospective Clinical Trial of Telecytopathology for Rapid Interpretation of Specimens Obtained During Endobronchial Ultrasound–Fine Needle Aspiration

Cytopathologic interpretation of endobronchial ultrasound with fine needle aspiration (EBUS-FNA) samples by a pathologist can be time-consuming and costly, and an onsite cytopathologist may not always be readily available. A telecytopathology system was instituted and evaluated to examine the effect on operative time for EBUS. A prospective study was performed of sequential patients undergoing EBUS-FNA for the evaluation of mediastinal lymphadenopathy. Specimens for the control group were transported to the pathology laboratory, followed by remote cytologic interpretation. In a subsequent cohort, a telecytopathology system was used with intraoperative transmission of real-time live video microscopy to a remote cytopathologist (TCP group). The primary outcome was time to confirmation of cytology results. Of 46 patients entered into the study, 23 underwent traditional analysis (control group), and 20 were analyzed using telecytopathology (TCP group). Lung cancer was the most common malignancy in both groups (12 TCP, 12 control). There was no difference in mean number of lymph node stations sampled (1.3 TCP vs 1.8 control, p = 0.76). Use of TCP was associated with fewer needle passes (4.9 vs 7.3, p = 0.02) and fewer slides for interpretation (8.4 vs 13.5, p = 0.01) per procedure. Time to result confirmation was significantly shorter in the TCP group (19.0 vs 46.7 minutes, p < 0.001). A diagnostic specimen was obtained in 70% of patients in the TCP group compared with 65% in the control group (p = 0.5). False-negative rates in patients undergoing EBUS-FNA and mediastinoscopy were similar between the two groups (0 in TCP vs 2 in control, p = 0.49). Mean procedural costs (excluding cost of the telecytology system and operating room time) were equivalent between the two groups ($888 TCP vs $887 control). Telecytopathology provides rapid interpretation of EBUS-FNA samples with diagnostic accuracy comparable to traditional methods, shortens procedure time, and is a more efficient model for delivery of on-site EBUS-FNA interpretation.

Using Flow Cytometry for the Diagnosis of Lung Neuroendocrine Carcinoma With Samples From Endobronchial Ultrasound Fine Needle Aspiration and Pleural Fluid

Using Flow Cytometry for the Diagnosis of Lung Neuroendocrine Carcinoma With Samples From Endobronchial Ultrasound Fine Needle Aspiration and Pleural Fluid

Combined endoscopic ultrasonography and endobronchial ultrasound-fine-needle aspiration for evaluation of mediastinal lymph nodes

Endoscopic ultrasonography (EUS) and endobronchial ultrasound-fine-needle aspiration (EBUS-FNA), is an accurate technique for evaluation of mediastinal lymph nodes (MLN) and stadification of lung cancer. The aims of the study are to evaluate the feasibility and the efficacy of the combined technique compared with mediastinoscopy for the diagnosis of MLN. All patients with suspected malignant MLN and/or lung lesion identified by positron emission tomography-computed tomography underwent combined EUS-EBUS-FNA. The combined procedure was performed in outpatients under general anesthesia for EUS and sedation by intravenous midazolam for EBUS when performed separately, using linear-array echoendoscopes. The MLN were punctured during the EUS and EBUS-FNA procedures with a 22 gauge needle. Thirty-four patients underwent consecutively EUS and EBUS-FNA between September 2011 and November 2013 (8 women, 26 men, mean age of 65.9 year, range: 51-83). Combined EUS-EBUS-FNA was performed in a single time procedure in 26 patients (mean time 50 min) and in two different times in eight patients (mean delay 3 days). Twenty-five malignant and 9 inflammatory lesions were diagnosed. Mediastinoscopy was performed in nine patients and confirmed in eight patients the initial combined EUS-EBUS-FNA diagnosis. The diagnosis was obtained in 91.2% with EUS-FNA, 70.6% with EBUS-FNA and 97% when combined procedure was performed. The overall sensitivity, specificity, positive and negative predictive values of EUS-EBUS-FNA for diagnosing malignancy were 96.5%, 100%, 100% and 90% respectively. No complications related to the procedure were observed. Combined EUS-EBUS-FNA represents an accurate technique in the diagnosis of MLN, can be done in a single time procedure and has the advantage of being less invasive than mediastinoscopy.

Diagnostic Algorithm in Patients with Superior Vena Cava Syndrome and Efficacy of Cervical Mediastinoscopy

Background: Superior vena cava syndrome (SVCS) is the result of the direct obstruction of the superior vena cava by malignancy and/or mediastinal lymphadenopathy. Our aim is to propose a diagnostic algorithm for undiagnosed superior vena cava syndrome patients and compare the diagnostic value, mortality and morbidity rates in patients diagnosed by mediastinoscopy.Methods: Ninety-seven patients with SVCS underwent diagnostic management starting with the least invasive technique and proceeding to more advanced and invasive methods between January 2000 and June 2013. Seventy one (73%) patients received histopathologic diagnosis using local biopsy, endobronchial biopsy by fiberoptic bronchoscopy and/or endobronchial ultrasound (EBUS) and CT-guided fine needle aspiration biopsy. Twenty six patients out of 97 patients who had superior vena cava syndrome underwent cervical mediastinoscopy for definitive diagnosis. Four patients (three male and one female) received histopathologic diagnosis using EBUS with the use of this method in our institution after 2010.Results: Of 26 patients who underwent cervical mediastinoscopy, 11 had small cell lung carcinoma, six had squamous cell lung carcinoma, three had adenocarcinoma, two had lymphoma, one had thymoma, one had tuberculosis, one had seminoma and one had chronic fibrous mediastinitis. Definitive tissue diagnosis was obtained in all patients. No peri-operative mortality was recorded. One patient had minor bleeding which was controlled without additional surgical intervention.Conclusions: We propose a diagnostic algorithm in undiagnosed patients with superior vena cava syndrome. We conclude that cervical mediastinoscopy is a safe, fast and effective technique to establish pathologic diagnosis, and directs the physicians to apply the appropriate treatment in clinically diagnosed superior vena cava syndrome when less invasive techniques have been unsuccessful.

Infection of a Bronchogenic Cyst After Ultrasonography-Guided Fine Needle Aspiration

Standard recommendation for therapy of benign mediastinal cysts is surgery. Endobronchial ultrasound fine needle aspiration (EBUS-FNA) has been used by some researchers as a diagnostic tool. This approach may be associated with severe life-threatening complications. We describe a case of life-threatening purulent pericardial effusion with tamponade by infection of a bronchogenic cyst after EBUS-FNA.

Using Flow Cytometry for the Diagnosis of Small Cell Lung Carcinoma by Endobronchial Ultrasound Fine Needle Aspiration

Using Flow Cytometry for the Diagnosis of Small Cell Lung Carcinoma by Endobronchial Ultrasound Fine Needle Aspiration

Endobronchial ultrasound fine‐needle aspiration biopsy of pulmonary non–small cell carcinoma with subclassification by immunohistochemistry panel

With the introduction of new treatment modalities and guidelines, it is important to subclassify primary pulmonary non-small cell carcinoma (NSCCA). Subsequent treatment and testing is dependent on accurate subclassification. Endobronchial ultrasound fine-needle aspiration (EBUS FNA) is used for primary evaluation and diagnosis, and can provide a cell block for ancillary testing. EBUS FNA cases from primary pulmonary NSCCA with an immunohistochemical (IHC) panel performed on a cell block with concomitant surgical pathology biopsy were analyzed. Cell block preparations underwent an IHC panel including monoclonal antibodies for napsin A (nap-A), thyroid transcription factor (TTF-1), p63, and cytokeratin 5/6 (CK5/6). A total of 81 cases from 81 patients were identified. Of these, 69 cases (85%) were provided a specific diagnosis of adenocarcinoma (ADCA) or squamous cell carcinoma (SCCA) on the EBUS FNA. In 12 cases (15%), a diagnosis of NSCCA, not otherwise specified was provided. For specific subclassifications, there were 35 ADCA cases, 34 SCCA cases, and 12 NSCCA, not otherwise specified cases. For ADCA, nap-A showed granular cytoplasmic staining and TTF-1 nuclear staining. For SCCA, CK5/6 showed cytoplasmic staining and p63 nuclear staining. Surgical pathology concomitant material was present in 29 of 81 cases with 18 correlations and 11 noncorrelations. With new treatment guidelines for patients with primary pulmonary NSCCA, specific diagnosis is increasingly important. EBUS FNA with cell block provided a specific subclassification of NSCCA in 85% of cases when used in conjunction with a specific IHC panel including nap-A, TTF-1, CK5/6, and p63.