Endobronchial Ultrasound-guided Fine Needle Aspiration Research Articles

Minimally Invasive with Maximal Yield: A Narrative Review of Current Practices in Mediastinal Lymph Node Staging in Non-Small Cell Lung Cancer.

Background: Lung cancer remains the leading cause of cancer deaths in the United States despite declining incidence and improved outcomes because of advancements in early detection and development of novel therapies. Accurate mediastinal lymph node staging is crucial for determining prognosis and guiding treatment decisions, particularly for non-small cell lung cancer (NSCLC). Materials and Methods: A systematic search of PubMed was conducted to identify English language articles published between January 2010 and January 2024 focusing on preoperative lymph node staging in adults with NSCLC. Case series, observational studies, randomized trials, guidelines, narrative reviews, systematic reviews, and meta-analyses were included. Results: Various imaging modalities, surgical and nonsurgical procedures for mediastinal lymph node staging were reviewed, including positron emission tomography with computed tomography, cervical mediastinoscopy, video-assisted cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy, endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA), transesophageal endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), and computed tomography-guided percutaneous lymph node biopsy. EBUS-FNA emerged as the preferred initial staging procedure because of its high sensitivity and low complication rate. Combining it with other procedures or confirmatory testing may be helpful in determining appropriate treatment. Conclusions: Although cervical mediastinoscopy remains a valuable confirmatory procedure in select cases, its role as a first-line staging modality is diminishing with the widespread adoption of EBUS-FNA and EUS-FNA. The combination of EBUS-FNA and EUS-FNA allows access to nearly all mediastinal lymph node stations with high diagnostic accuracy. Future research may further refine the selection criteria for invasive mediastinal staging procedures, ultimately optimizing patient outcomes in the management of NSCLC.

Accuracy of endobronchial ultrasound (EBUS) in the staging of lung cancer - A comparison of staging EBUS with postoperative pathological nodal staging.

Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-TBNA) has replaced mediastinoscopy as the preferred investigation for evaluating mediastinum in staging lung cancer. There is little evidence of mediastinal staging by EBUS-TBNA from India. To study endobronchial ultrasound's diagnostic accuracy in staging lung cancer. We retrospectively analysed patients operated on for lung cancer where EBUS was performed preoperatively for mediastinal staging. We compared the histological findings obtained from different mediastinal lymph nodes (LNs) by EBUS-TBNA with the pathology of the same LNs obtained after surgical dissection as the reference standard. Seventy-six patients underwent curative surgery for lung cancer. The diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of EBUS-TBNA in predicting mediastinal metastasis were 93.9%, 40%, 99%, 80% and 94.6%, respectively. Of the 115 LNs sampled, EBUS-TBNA was false negative in six nodes, resulting in an up-staging of six patients. EBUS-TBNA has a high diagnostic accuracy for lung cancer staging.

Expression of TLE1 in a Carcinoid Tumor of the Lung With Spindle Cell Morphology-A Potential Diagnostic Pitfall.

Tumors of the lung with a spindle cell morphology require consideration of many entities in the differential diagnosis, including metastases. Ancillary immunohistochemical stains but also molecular studies are typically required to arrive at the proper diagnosis. We present a case of a 71-year-old woman with multiple lung nodules, mediastinal lymphadenopathy, and a history of uterine cancer who underwent endobronchial ultrasound-guided fine needle aspiration and biopsy of the lung and mediastinal lymph nodes. A sampling of the lung lesion showed a cytologically bland neoplasm with spindle cell morphology, lacking necrosis or brisk mitotic activity. In conjunction with the cytomorphology, strong and diffuse Transducin-like enhancer of split 1 (TLE1) reactivity in the tumor cells initially raised the diagnosis of synovial sarcoma; however, subsequent results of additional testing showed strong and diffuse expression with AE1/AE3, CK 8/18, TTF-1, synaptophysin and chromogranin and focal or negative staining with a large number of other antibodies. This warranted a diagnosis of a carcinoid tumor. This is the first report of TLE1 staining in a carcinoid tumor of the lung. Therefore, when evaluating tumors of the lung with spindle cell morphology in which the differential diagnosis may include both carcinoid tumor and synovial sarcoma, TLE1 expression should be interpreted with caution and in conjunction with an expanded immunohistochemical staining panel.

The Performance of Rapid On-site Evaluation (ROSE) and Supplemental Cytology Preparations in Endobronchial Ultrasound-Guided Fine Needle Aspiration on Lung and Mediastinal Lymph Node Biopsies: An Institutional Retrospective Snapshot Review

The Performance of Rapid On-site Evaluation (ROSE) and Supplemental Cytology Preparations in Endobronchial Ultrasound-Guided Fine Needle Aspiration on Lung and Mediastinal Lymph Node Biopsies: An Institutional Retrospective Snapshot Review

Evaluation of automated sample preparation system for lymph node sampling.

Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-FNA) has revolutionized the diagnostic and staging approach to non-small cell carcinoma and thoracic lymphadenopathy. However, obstacles to efficacy of rapid on-site evaluation (ROSE) of the samples include variability in sample quality and slow and cumbersome process in the procedure room leading to extended procedure time. The purpose of this pilot study was to evaluate the feasibility and specimen quality of lymph node biopsies prepared through a novel automated system for automated fixation, drying and staining compared to standard slide preparation method. We performed a prospective, single-center pilot feasibility study of patients undergoing EBUS. Samples were split into conventional standard of care (SOC) slide preparation and preparation using the device ("instrument"). Pathologists compared the SOC slides to the slides prepared by the automated system and assessed the following metrics: nuclear and cytoplasmic quality, presence of debris/artifact, staining quality, creation of a monolayer, and ease of adequacy/diagnosis assessment. A score between 1 (lowest quality) and 3 (highest quality) was assigned to the above metrics. Sixty patients were recruited. One to three lymph nodes were sampled for each patient for a total of 72 samples collected. The mean scores of each assessment category showed no statistical difference between the two preparation techniques except for improved monolayer creation in the instrument samples. Thirty of thirty-one (96.8%) paired samples in the final analysis showed diagnostic equivalency between the automated slides and conventional slides; the discordant pairing was reported to be suspicious on the instrument sample and atypical on the SOC. Study results suggest that slides prepared by the automated system are of adequate quality for adequacy assessment with diagnostic concordance when compared to SOC slides.

Long-Term Follow-Up Results of Granulomatous Lymphadenitis Diagnosed by Endobronchial Ultrasound-Guided Fine-Needle Aspiration Biopsy.

Introduction Endobronchial ultrasound-guided fine-needle aspiration biopsy (EBUS-FNAB) is a minimally invasive method used to obtain cytological or histological specimens of masses and lymphadenopathies (LAP) adjacent to the trachea and bronchi. Granulomas, which represent a chronic inflammatory response and occur for a variety of reasons, like a 'sarcoid-like reaction', cause LAPs. In this study, it was aimed to evaluate the long-term follow-up results of granulomatous lymphadenitis diagnosed with EBUS-FNAB and to investigate whether granulomatous lymphadenopathies were precursors of malignancies that occurred during the follow-up period. Material and methods The medical records of 123 patients who underwent EBUS-FNAB and were diagnosed with granulomatous lymphadenitiswere retrospectively reviewed. Age, gender, acid-fast bacilli (ARB) staining, tuberculosis culture and tuberculosis polymerase chain reaction (PCR) culture results were examined by FNAB, and the procedure indications of all patients diagnosed with granulomatous lymphadenitis were recorded. The long-term health records of 52 patients could not be accessed. Data were collected from 71 patients. The progression, regressionor stable conditions of LAPs in the long-term radiological follow-up of at least two years and the treatment conditions of diagnosis after biopsywere examined. Results One hundred twenty-three patients were included in the study. Rapid onset evaluation (ROSE) was performed in 93 (75.6%) patients. In 62 (66.6%) of the 93 patients, the smear results were consistent with granulomatous reaction at baseline. Malignancy was present in seven patients (5.6%) at the time of the procedure. In two patients (1.62%), tuberculous lymphadenitis was diagnosed by a positive tuberculosis culture. The long-term follow-up results were not obtained in 52 (42.7%)patients included in the study. At the long-term follow-up of six patients' LAPs with known malignancies, three of them regressed, one of them progressed, and two of them remained stable after chemoradiotherapy. Methylprednisolone treatment was started in eight patients with the diagnosis of sarcoidosis. While LAP remained stable in five patients, regression was observed in three patients. Idiopathic LAPs remained stable in 24 of 55 patients who received no treatment and regressed spontaneously in 31 of them. One of the patients was diagnosed with lymphoma, and the otherpatient was diagnosed with primary lung cancer in the long-term follow-up. Conclusion In cases where tuberculosis is suspected, not only cytomorphology but also microbiological confirmation is important. Granulomatous lymphadenitis can be detected both in the disease course of patients with a history of malignancy and as a precursor to undiagnosed malignancy. So the diagnosis of granulomatous lymphadenitis is a clinicopathological diagnosis that must be followed up in patients without symptoms or other findings.

The Performance of an Extended Next Generation Sequencing Panel Using Endobronchial Ultrasound-Guided Fine Needle Aspiration Samples in Non-Squamous Non-Small Cell Lung Cancer: A Pragmatic Study

Introduction/BackgroundSamples from endobronchial ultrasound-guided fine needle aspiration (EBUS-TBNA) are frequently used for next generation sequencing (NGS) in patients with non-small cell lung cancer (NSCLC) to look for genetic driver mutations. The objective of the current study was to evaluate the performance of extended NGS panels using EBUS-TBNA samples in a real-world setting and identify factors associated with the success of NGS. Materials and MethodsThis study included all patients who underwent EBUS and were diagnosed with non-squamous NSCLC with mediastinal metastasis from 2016 to 2019 at the University of Pennsylvania. We reviewed demographic information, imaging studies, procedure reports, pathology and NGS reports. Logistic regression was used to analyze factors associated with the success of NGS panels. ResultsThe success rates of NGS using EBUS-TBNA samples were 92.5%, and 91.5% for DNA and RNA NGS panels respectively. Samples from higher N stage (N2 and N3 lymph nodes) and with higher tumor cellularity (>25%) resulted in higher success rate for DNA NGS. The effect of tumor cellularity remained borderline significant after entering multivariable logistic regression. The short-axis diameter of the sampled lymph node on CT scan, FDG-avidity on PET CT and >3 EBUS passes per lymph node during the procedure were not associated with NGS success. ConclusionBoth DNA and RNA extended-panel NGS had high performance using EBUS-TBNA samples. Sampling more advanced nodal stations and obtaining samples with higher tumor cellularity were associated with higher success rate of DNA NGS. Other imaging or procedural factors did not affect NGS performance.

Endobronchial Ultrasound-Guided Fine Needle Aspiration (EBUS-FNA) in the Diagnosis of Mediastinal Disease in Less Than or Equal To 50-Year-Old Patients

Endobronchial Ultrasound-Guided Fine Needle Aspiration (EBUS-FNA) in the Diagnosis of Mediastinal Disease in Less Than or Equal To 50-Year-Old Patients

Telecytology Versus Conventional Rapid On-site Evaluation for Endobronchial Ultrasound-Guided Fine Needle Aspiration: A Single Institution’s Experience

Telecytology Versus Conventional Rapid On-site Evaluation for Endobronchial Ultrasound-Guided Fine Needle Aspiration: A Single Institution’s Experience

Performance of Telecytology in Endobronchial Ultrasound-Guided Fine Needle Aspiration on Mediastinal Lymph Node Staging: An Institutional Review

Performance of Telecytology in Endobronchial Ultrasound-Guided Fine Needle Aspiration on Mediastinal Lymph Node Staging: An Institutional Review

NOT YOUR USUAL PULMONARY NODULE: CASE OF PULMONARY MALTOMA

SESSION TITLE: Pathology Identifying Chest Infections Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Marginal zone lymphoma (MZL) is a type of non-Hodgkin lymphoma (NHL) that represents a group of tumors arising from post-germinal center marginal zone B-cells and share a similar immunophenotype. Extra-nodal MZL arises in several epithelial tissues including, stomach, salivary glands, thyroid, and skin. We present a case of a female with a pulmonary MZL associated with chronic inflammation due to autoimmune and infectious etiology.CASE PRESENTATION: A 65-year-old female with a history of systemic lupus erythematosus (SLE), chronic bronchitis, recurrent Klebsiella pneumonia, and a 32-pack year smoking history, presented with chronic productive cough. Lung cancer screening with low dose computed tomography (CT) chest revealed a 2.3 x 1.6 cm lobulated irregular nodule in the right lower lobe. A positron emission tomography showed minimal FDG labeling of 1.5 SUV and no hilar or mediastinal adenopathy. Given high pretest probability of malignancy, navigational bronchoscopy and endobronchial ultrasound-guided fine-needle aspiration were done. Fine needle aspiration of the nodule and mediastinal lymph nodes were negative for malignancy and revealed acute on chronic inflammation. Bronchoalveolar lavage cultures grew Klebsiella pneumoniae and she received a course of antibiotics. A 6 month follow up CT chest showed interval growth of nodule to 3.3 cm x 2.6cm. Given concern for an indolent malignancy, a CT-guided needle biopsy was done, which revealed low-grade B-cell lymphoma, consistent with extra-nodal MZL of mucosa-associated lymphoid tissue (MALT). A subsequent esophagogastroduodenoscopy showed no evidence of gastric MALT or Helicobacter pylori infection. A bone marrow biopsy showed less than 10% involvement. She received 4 cycles of rituximab with a good response and a decrease in the size of pulmonary nodules.DISCUSSION: The incidence of pulmonary MALT (PMALT) is rare, occurring in about 0.1% of pulmonary tumors.[1] Clinical course is indolent and most patients have no pulmonary or constitutional symptoms. Radiographic appearance is variable, and lesions can appear as unilateral or bilateral alveolar opacities and nodules. Extra-gastric MZL is generally associated with an underlying autoimmune disease, but SLE as seen in our patient, is only seen in 3% of cases.[2] Rarely, in healthy adults increased prevalence has been observed among patients with chronic inflammation.[3] Although Helicobacter pylori is a known causative microorganism in gastric MALT, no microorganism has been confirmed as a contributing agent for PMALT. Like observations noted in other cases, our patient developed PMALT while having ensuing inflammation from chronic bronchitis and recurrent bacterial infections, highlighting a possible association between them.CONCLUSIONS: Pulmonary MZL is a rare indolent cancer that can be associated with chronic inflammatory conditions like autoimmune disorders and recurrent infections.Reference #1: Cadranel J, Wislez M, Antoine M. Primary pulmonary lymphoma. Eur Respir J. 2002 Sep;20(3):750-62. doi: 10.1183/09031936.02.00404102. PMID: 12358356Reference #2: Wöhrer S, Troch M, Streubel B, et al. MALT lymphoma in patients with autoimmune diseases: a comparative analysis of characteristics and clinical course. Leukemia. 2007;21(8):1812-1818. doi:10.1038/sj.leu.2404782Reference #3: Inadome Y, Ikezawa T, Oyasu R, Noguchi M. Malignant lymphoma of bronchus-associated lymphoid tissue (BALT) coexistent with pulmonary tuberculosis. Pathol Int. 2001;51(10):807-811. doi:10.1046/j.1440-1827.2001.01272.xDISCLOSURES: No relevant relationships by Varun BhallaNo relevant relationships by Jayashri Bhaskar SESSION TITLE: Pathology Identifying Chest Infections Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Marginal zone lymphoma (MZL) is a type of non-Hodgkin lymphoma (NHL) that represents a group of tumors arising from post-germinal center marginal zone B-cells and share a similar immunophenotype. Extra-nodal MZL arises in several epithelial tissues including, stomach, salivary glands, thyroid, and skin. We present a case of a female with a pulmonary MZL associated with chronic inflammation due to autoimmune and infectious etiology. CASE PRESENTATION: A 65-year-old female with a history of systemic lupus erythematosus (SLE), chronic bronchitis, recurrent Klebsiella pneumonia, and a 32-pack year smoking history, presented with chronic productive cough. Lung cancer screening with low dose computed tomography (CT) chest revealed a 2.3 x 1.6 cm lobulated irregular nodule in the right lower lobe. A positron emission tomography showed minimal FDG labeling of 1.5 SUV and no hilar or mediastinal adenopathy. Given high pretest probability of malignancy, navigational bronchoscopy and endobronchial ultrasound-guided fine-needle aspiration were done. Fine needle aspiration of the nodule and mediastinal lymph nodes were negative for malignancy and revealed acute on chronic inflammation. Bronchoalveolar lavage cultures grew Klebsiella pneumoniae and she received a course of antibiotics. A 6 month follow up CT chest showed interval growth of nodule to 3.3 cm x 2.6cm. Given concern for an indolent malignancy, a CT-guided needle biopsy was done, which revealed low-grade B-cell lymphoma, consistent with extra-nodal MZL of mucosa-associated lymphoid tissue (MALT). A subsequent esophagogastroduodenoscopy showed no evidence of gastric MALT or Helicobacter pylori infection. A bone marrow biopsy showed less than 10% involvement. She received 4 cycles of rituximab with a good response and a decrease in the size of pulmonary nodules. DISCUSSION: The incidence of pulmonary MALT (PMALT) is rare, occurring in about 0.1% of pulmonary tumors.[1] Clinical course is indolent and most patients have no pulmonary or constitutional symptoms. Radiographic appearance is variable, and lesions can appear as unilateral or bilateral alveolar opacities and nodules. Extra-gastric MZL is generally associated with an underlying autoimmune disease, but SLE as seen in our patient, is only seen in 3% of cases.[2] Rarely, in healthy adults increased prevalence has been observed among patients with chronic inflammation.[3] Although Helicobacter pylori is a known causative microorganism in gastric MALT, no microorganism has been confirmed as a contributing agent for PMALT. Like observations noted in other cases, our patient developed PMALT while having ensuing inflammation from chronic bronchitis and recurrent bacterial infections, highlighting a possible association between them. CONCLUSIONS: Pulmonary MZL is a rare indolent cancer that can be associated with chronic inflammatory conditions like autoimmune disorders and recurrent infections. Reference #1: Cadranel J, Wislez M, Antoine M. Primary pulmonary lymphoma. Eur Respir J. 2002 Sep;20(3):750-62. doi: 10.1183/09031936.02.00404102. PMID: 12358356 Reference #2: Wöhrer S, Troch M, Streubel B, et al. MALT lymphoma in patients with autoimmune diseases: a comparative analysis of characteristics and clinical course. Leukemia. 2007;21(8):1812-1818. doi:10.1038/sj.leu.2404782 Reference #3: Inadome Y, Ikezawa T, Oyasu R, Noguchi M. Malignant lymphoma of bronchus-associated lymphoid tissue (BALT) coexistent with pulmonary tuberculosis. Pathol Int. 2001;51(10):807-811. doi:10.1046/j.1440-1827.2001.01272.x DISCLOSURES: No relevant relationships by Varun Bhalla No relevant relationships by Jayashri Bhaskar

AN ALTERNATE APPROACH: TRANSESOPHAGEAL BRONCHOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION (EUS-B-FNA) TO ASSESS PLEURAL MESOTHELIOMA

SESSION TITLE: Tales in BronchoscopySESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: The use of transesophageal fine needle aspiration with an EBUS scope (EUS-B-FNA) is an emerging technique for biopsy of mediastinal lymph nodes and left adrenal glands by trained interventional pulmonologists. We report a case of paraoesophageal EUS-B-FNA of pleural thickening in a man with radiographic presentation of diffuse pleural thickening encasing the right lung.CASE PRESENTATION: A 76-year-old male with a history of prostate cancer presented to our ED following a syncopal event. Circumferential thickening of the right pleura along with pleural calcifications near the right diaphragm was found on CXR (Figure 1). CT of chest confirmed diffuse pleural thickening, encasing the right lung. Trace left pleural effusion with pleural calcifications were also present. Right lung contraction was present, causing minimal right mediastinal shift. The choice of an endoscopic approach with EUS-B-FNA was made because of its feasibility and location of pleural thickening which was in close proximity to the esophagus. Endobronchial ultrasound-guided transbronchial fine-needle aspiration was first performed to obtain samples from mediastinal and hilar lymph node stations. Following this, the EBUS scope was then inserted into the esophagus and advanced to the gastroesophageal junction. It was then pulled proximally with identification of liver. Next, the scope was then rotated clockwise and pulled proximally with identification of paraesophageal right pleural thickening. Using ultrasound guidance, 6 FNA biopsy samples were obtained.DISCUSSION: The use of EUS-B-FNA allows for ultrasound examination and biopsy of pleural tissue that was previously inaccessible by bronchoscopy. Notably, a recent meta-analysis showed a diagnostic yield of 90% when EUS-B-FNA and EBUS-TBNA are used concurrently for evaluation of mediastinal lymphadenopathy. A recent study found that experienced bronchoscopists can easily gain proficiency in EBUS-TBNA with minimal complications. In the current report we bring awareness for interventional pulmonologists to consider pleural biopsies using EUS-B-FNA as a feasible biopsy approach. More research is required to assess the difference in outcomes between conventional techniques for biopsying pleura. The mediastinal and hilar lymph nodes were benign, the pleural biopsy was non diagnostic. Patient underwent VATS for final diagnosis of epithelioid mesothelioma.CONCLUSIONS: EUS-B-FNA is a safe, effective, and worthwhile technique in the evaluation of mediastinal, left adrenal, and paraesophageal pleural tissue abnormalities.Reference #1: Ng, Jeffrey & Chan, Hiang Ping & Kee, Adrian & Khoo, Kay & See, Kay. (2021). Transitioning to Combined EBUS EUS-B FNA for Experienced EBUS Bronchoscopist. Diagnostics. 11. 1021. 10.3390/diagnostics11061021.Reference #2: Madan K, Mittal S, Madan NK, Tiwari P, Jain D, Arava S, Hadda V, Mohan A, Garg P, Guleria R. EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial. Clin Respir J. 2020 Nov;14(11):1076-1082. doi: 10.1111/crj.13244. Epub 2020 Aug 19. PMID: 32748463.Reference #3: Dhooria, S.; Aggarwal, A.N.; Gupta, D.; Behera, D.; Agarwal, R. Utility and Safety of Endoscopic Ultrasound with BronchoscopeGuided Fine-Needle Aspiration in Mediastinal Lymph Node Sampling: Systematic Review and Meta-Analysis. Respir. Care 2015, 60, 1040–1050.DISCLOSURES: No relevant relationships by Sailendra ChunduNo relevant relationships by Moiz JavedNo relevant relationships by Ali SaeedNo relevant relationships by Andrew Talon SESSION TITLE: Tales in Bronchoscopy SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: The use of transesophageal fine needle aspiration with an EBUS scope (EUS-B-FNA) is an emerging technique for biopsy of mediastinal lymph nodes and left adrenal glands by trained interventional pulmonologists. We report a case of paraoesophageal EUS-B-FNA of pleural thickening in a man with radiographic presentation of diffuse pleural thickening encasing the right lung. CASE PRESENTATION: A 76-year-old male with a history of prostate cancer presented to our ED following a syncopal event. Circumferential thickening of the right pleura along with pleural calcifications near the right diaphragm was found on CXR (Figure 1). CT of chest confirmed diffuse pleural thickening, encasing the right lung. Trace left pleural effusion with pleural calcifications were also present. Right lung contraction was present, causing minimal right mediastinal shift. The choice of an endoscopic approach with EUS-B-FNA was made because of its feasibility and location of pleural thickening which was in close proximity to the esophagus. Endobronchial ultrasound-guided transbronchial fine-needle aspiration was first performed to obtain samples from mediastinal and hilar lymph node stations. Following this, the EBUS scope was then inserted into the esophagus and advanced to the gastroesophageal junction. It was then pulled proximally with identification of liver. Next, the scope was then rotated clockwise and pulled proximally with identification of paraesophageal right pleural thickening. Using ultrasound guidance, 6 FNA biopsy samples were obtained. DISCUSSION: The use of EUS-B-FNA allows for ultrasound examination and biopsy of pleural tissue that was previously inaccessible by bronchoscopy. Notably, a recent meta-analysis showed a diagnostic yield of 90% when EUS-B-FNA and EBUS-TBNA are used concurrently for evaluation of mediastinal lymphadenopathy. A recent study found that experienced bronchoscopists can easily gain proficiency in EBUS-TBNA with minimal complications. In the current report we bring awareness for interventional pulmonologists to consider pleural biopsies using EUS-B-FNA as a feasible biopsy approach. More research is required to assess the difference in outcomes between conventional techniques for biopsying pleura. The mediastinal and hilar lymph nodes were benign, the pleural biopsy was non diagnostic. Patient underwent VATS for final diagnosis of epithelioid mesothelioma. CONCLUSIONS: EUS-B-FNA is a safe, effective, and worthwhile technique in the evaluation of mediastinal, left adrenal, and paraesophageal pleural tissue abnormalities. Reference #1: Ng, Jeffrey & Chan, Hiang Ping & Kee, Adrian & Khoo, Kay & See, Kay. (2021). Transitioning to Combined EBUS EUS-B FNA for Experienced EBUS Bronchoscopist. Diagnostics. 11. 1021. 10.3390/diagnostics11061021. Reference #2: Madan K, Mittal S, Madan NK, Tiwari P, Jain D, Arava S, Hadda V, Mohan A, Garg P, Guleria R. EBUS-TBNA versus EUS-B-FNA for the evaluation of undiagnosed mediastinal lymphadenopathy: The TEAM randomized controlled trial. Clin Respir J. 2020 Nov;14(11):1076-1082. doi: 10.1111/crj.13244. Epub 2020 Aug 19. PMID: 32748463. Reference #3: Dhooria, S.; Aggarwal, A.N.; Gupta, D.; Behera, D.; Agarwal, R. Utility and Safety of Endoscopic Ultrasound with BronchoscopeGuided Fine-Needle Aspiration in Mediastinal Lymph Node Sampling: Systematic Review and Meta-Analysis. Respir. Care 2015, 60, 1040–1050. DISCLOSURES: No relevant relationships by Sailendra Chundu No relevant relationships by Moiz Javed No relevant relationships by Ali Saeed No relevant relationships by Andrew Talon

The optimal approach of EBUS-FNA rapid on-site evaluation (ROSE): a five-year experience from a large academic medical center.

Rapid on-site evaluation (ROSE) performed during endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) has shown significant value. However, ROSE may not be available for some pulmonary centers. Performing ROSE can be challenging and stressful due to time constrains for preparing, staining and reviewing the cytology slides between passes. A retrospective cytology report review of EBUS-FNA procedures performed between October 2014 and May 2019 revealed 516 cases that were included in the study. The number of passes for each procedure was documented. The adequacy rates were assessed at 4 different study points; ≤3 passes, ≤5 passes, at odd passes only, and the even passes only. The study groups results were compared to the overall ROSE and the final cytology adequacy. The overall ROSE interpretation was adequate in 370 (71.7%) and inadequate in 146 (28.3%). After reviewing the Papanicolaou stained slides and cell blocks, the final cytology results were adequate in 473 (91.7%) and inadequate in 43 (8.3%) of the cases. The number of passes per procedure ranged from 1 to 17. Our results showed that ROSE evaluation of the first 5 passes during the EBUS-FNA procedure could achieve the similar adequacy rate compared to the overall ROSE evaluation of all the passes. To achieve the most benefits of ROSE and to reduce the procedure time for EBUS-FNA, we recommend performing ROSE for ≤5 passes depending on the adequacy, and save all additional passes for cell blocks preparation if more than 5 passes are attempted.

Mediastinal Nodal Staging Performance of Combined Endobronchial and Esophageal Endosonography in Lung Cancer Cases: A Systematic Review and Meta-Analysis.

By searching lliteratures till January 5, 2022, we evaluated the role of the mediastinal nodal staging of endobronchial ultrasound-guided fine-needle aspiration (EBUS) and endoscopic ultrasound-guided fine-needle aspiration (EUS) in lung cancer. A total of 20 studies with 2,961 patients were included in this study. The pooled sensitivity, specificity, PLR, and NLR for EBUS were 0.79, 0.97, 27.29, and 0.25, respectively. EUS showed staging performance similar to EBUS. The staging performance was significantly improved when combining EBUS + EUS.

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.

HUMAN T-CELL LYMPHOTROPIC VIRUS TYPE 1-ASSOCIATED ADULT T-CELL LEUKEMIA/LYMPHOMA AND PROGRESSION TO HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A CASE REPORT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Human T-cell lymphotropic virus type 1 (HTLV-1) was the first human retrovirus to be discovered [1]. Its infection can lead to adult T-cell leukemia/lymphoma (ATLL). Hemophagocytic lymphohistiocytosis (HLH) is a syndrome with a mortality of 95% caused by overstimulation of the immune system [2,3,4]. This case report presents a male with HTLV-1—associated ATLL who developed HLH. CASE PRESENTATION: A 75 year-old Haitian male with a 22 pack-year smoking history presented to our hospital after a pre-syncopal episode with a 10 day history of pleuritic chest pain. Labs were significant for leukocytosis of 26.2 *10^9/L with lymphocyte predominance. Chest x-ray showed bilateral pleural effusions. Cytometry of the pleural fluid showed an aberrant population of CD4(+) T lymphocytes consistent with post-thymic T-cell lymphoma and atypical T lymphocytes, positive for CD45RO, CD25, and TCRab and negative for CD26 and CD56, consistent with ATLL. Bronchoscopy with endobronchial ultrasound-guided fine needle aspiration of lymph node stations 4R, 7, and 11L revealed aberrant T-cells. TCR gene rearrangement and HTLV-1 western blot confirmed ATLL due to HTLV-1. He was started on CHOP and brentuximab, but was readmitted weeks later with encephalopathy and acute hypoxic respiratory failure. CMV viremia was confirmed via serum PCR and ganciclovir was initiated. Labs were significant for elevated ferritin 9,464 ng/mL, triglycerides 162 mg/dL, D-dimer 549 ng/mL, low fibrinogen 150 mg/dL, and worsening cytopenia with hematocrit 27.1% and platelets 58*10^9/L. Bone marrow biopsy demonstrated histiocytes with engulfed erythroid cells, confirming HLH. The patient was treated with dexamethasone, but was too unstable for etoposide and died 12 days after readmission. DISCUSSION: Lymphoma is the third most common cause of malignant pleural effusion (MPE) and patients have an overall survival of 3-12 months after diagnosis [5]. Diagnostic tests for ATLL are usually done with serum and rarely from MPE, as was done in this case [6]. Signs of HTLV-1—associated ATLL include marked leukocytosis with atypical lymphocytes, rash, and lymphadenopathy [1]. Our patient did not have a rash, but had other signs and symptoms consistent with the presentation of HTLV-1—associated ATLL. HLH likely occurred from progression of HTLV-1—associated ATLL, but CMV viremia or chemotherapy could have contributed. The diagnosis of HLH is difficult because symptoms are nonspecific, requiring a high index of suspicion [7]. The optimal treatment for HLH is still unknown and a multidisciplinary approach is essential. CONCLUSIONS: This case demonstrates HLTV-1—associated ATLL that initially presented as MPE, and was a subsequent trigger for HLH. REFERENCE #1: Rodriguez-Zuniga MJM, Corte-Franco F, Qujiano-Gomero E. Adult T-Cell Leukemia/Lymphoma. Review of the Literature. Actas Dermosifiliogr. 2018;109(5):399-407 REFERENCE #2: Atteritano M, David A, Bagnato G, et al. Haemophagocytic syndrome in rheumatic patients. A systematic review. Eur Rev Med Pharmacol Sci. 2012;16(10):1414-1424 REFERENCE #3: Bindra BS, Garcia de de Jesus K, Cisneros O, Jorge VM, Kaur H. Hemophagocytic Lymphohistiocytosis: Management and Special Consideration in Human Immunodeficiency Virus Positive Patients with Immune Reconstitution Syndrome. Cureus. 2019;11(8):e5402 DISCLOSURES: No relevant relationships by Michael Bender, source=Web Response No relevant relationships by Liane Emerson, source=Web Response No relevant relationships by Chaim Rube, source=Web Response

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.

SYNCHRONOUS ORAL SQUAMOUS CELL CARCINOMA (SCC) AND LUNG ADENO-CARCINOMA—THE VALUE OF SCREENING CHEST COMPUTED TOMOGRAPHY (CT): A CASE SERIES

Background Lung cancer is present in 1.1% of patients with oral (head and neck) SCC. Guidelines recommend that all patients with head and neck SCC receive chest computed tomography (CT) as part of their diagnostic and surgical evaluation, given that smoking is an established risk factor for cancer of both sites. The diagnosis of a synchronous lung cancer will alter the treatment of the patient. Case 1 An 85-year-old man with a 60 pack-year smoking history presented with a T1N0M0 floor of mouth SCC. His ECOG performance status was 1. CT demonstrated a 23-mm spiculated mass in the right upper lung lobe. Positron emission tomography demonstrated avidity in the lung mass (SUV 7.8), as well as multiple mildly avid associated lymph nodes. Lung biopsy demonstrated an infiltrative adenocarcinoma. Endobronchial ultrasound-guided fine-needle aspiration biopsies of the lymph nodes were unremarkable. The patient underwent stereotactic radiation therapy for lung cancer and is awaiting definitive surgery for his oral cancer. Case 2 A 53-year-old man with a 50 pack-year smoking history presented with a T3N2 floor of mouth SCC. CT and positron emission tomography demonstrated a 44-mm apical mass of the left lung, invading the mediastinum. Treatment of the oral SCC was deferred until confirmatory biopsy with a view to management of the suspected lung cancer. Conclusions These cases highlight the value of chest CT chest as part of the comprehensive evaluation of patients presenting with oral (head and neck) cancer. Lung cancer is present in 1.1% of patients with oral (head and neck) SCC. Guidelines recommend that all patients with head and neck SCC receive chest computed tomography (CT) as part of their diagnostic and surgical evaluation, given that smoking is an established risk factor for cancer of both sites. The diagnosis of a synchronous lung cancer will alter the treatment of the patient. An 85-year-old man with a 60 pack-year smoking history presented with a T1N0M0 floor of mouth SCC. His ECOG performance status was 1. CT demonstrated a 23-mm spiculated mass in the right upper lung lobe. Positron emission tomography demonstrated avidity in the lung mass (SUV 7.8), as well as multiple mildly avid associated lymph nodes. Lung biopsy demonstrated an infiltrative adenocarcinoma. Endobronchial ultrasound-guided fine-needle aspiration biopsies of the lymph nodes were unremarkable. The patient underwent stereotactic radiation therapy for lung cancer and is awaiting definitive surgery for his oral cancer. A 53-year-old man with a 50 pack-year smoking history presented with a T3N2 floor of mouth SCC. CT and positron emission tomography demonstrated a 44-mm apical mass of the left lung, invading the mediastinum. Treatment of the oral SCC was deferred until confirmatory biopsy with a view to management of the suspected lung cancer. These cases highlight the value of chest CT chest as part of the comprehensive evaluation of patients presenting with oral (head and neck) cancer.

Endobronchial and/or Endoesophageal Bronchoscopic Ultrasound-Guided Fine Needle Aspiration in the Diagnosis of Mediastinal and Hilar Diseases of Unknown Etiologies

<i>Introduction:</i> Diagnosis of mediastinal and hilar lesions represents a problematic issue for long ago, not only due to various structures that occupy this space but also difficult accessibility to such lesions. Mediastinal endosonography – guided FNA is emerged as a new minimally invasive modality for diagnosis of such lesions. <i>Objectives: </i>to evaluate the role of endobronchial and/ or endoesophageal -bronchoscopic ultrasound-guided fine needle aspiration in the diagnosis of mediastinal and hilar diseases of unknown etiologies. <i>Methods:</i> This Prospective observational study was carried out at Tanta University Educational Hospital and Kobri Elkobba Military Hospitals; from December 2017 to December 2019 on thirty patients (19 males; 11 females, age range 17-82 years) presented with undiagnosed mediastinal and or hilar lesions. All patients were subjected to clinical examination, radiological assessment including Chest-X-Ray, CT Chest. Laboratory investigations: CBC, blood urea, serum creatinine and coagulation profile. Twenty-six patients were subjected only to endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsies and four patients were subjected to endoscopic ultrasound using EBUS scope-guided fine- needle aspiration (EUS-B-FNA) after EBUS-TBNA, using Pentax Endobronchial ultrasound and a fine needle (22- Gauge). The procedure was done under local anesthesia and conscious sedation ROSE technique was applied for some cases. <i>Results:</i> Definitive diagnosis was reached in twenty-nine cases, achieving diagnostic yield (96.67%). Malignant lesions were the predominant category; twenty (66.67%), while nine (30%) were diagnosed as benign lesions and one (3.33%) case remained un diagnosed. Also, immunohistochemistry played an important role to reach definitive diagnosis in six cases without further sampling. About (12/30; 40%) of patients were passed without any complications while the others recorded controlled complications without any serious events. <i>Conclusion: </i>EBUS and EUS-B-FNA are minimally invasive, complementary and cost effective procedures with high diagnostic yield for mediastinal and hilar lesions. Addition of immunohistochemistry raises diagnostic value of this procedure.

Invasive methods for the diagnosis and management of intrathoracic extramedullary hematopoiesis: A literature review

BackgroundExtramedullary hematopoiesis is defined as hematopoiesis occurring outside of the bone marrow. It usually compensates insufficient bone marrow function or ineffective erythropoiesis and is observed mostly in hematological disorders. Most common locations of extramedullary hematopoiesis are the spleen, the liver and the lymph nodes. Intrathoracic extramedullary hematopoiesis is rare presenting as bilateral lobulated masses of lower paravertebral regions. This review summarizes the role of invasive techniques in the diagnosis and management of intrathoracic EMH and its complications. MethodsAn electronic search in PubMed and Google Scholar was conducted with the keywords “intrathoracic extramedullary hematopoiesis” AND “surgery” OR “video-assisted thoracic surgery (VATS)” OR “medical thoracoscopy” OR “biopsy” OR “thoracotomy” OR “image-guided biopsy” OR “median sternotomy”, within 1970 to 2020 with the limitation of English language to include those articles reporting data on invasive techniques in intrathoracic extramedullary hematopoiesis. ResultsOverall, 93 articles were originally identified using our search criteria and from the reference list of the previously identified documents. Following elimination of duplicates, 29 were excluded after title, abstract or full text screening, since they did not report the use of invasive techniques in the diagnosis and management of intrathoracic extramedullary hematopoiesis. ConclusionsAlthough in some cases radiological features are typical for the diagnosis of intrathoracic extramedullary hematopoeisis, invasive methods such as bronchoscopy with transbronchial biopsy, ιmage-guided fine needle aspiration, endobronchial ultrasound-guided fine needle aspiration of the mass and mediastinoscopy, medical thoracoscopy, median sternotomy, video-assisted thoracoscopic surgery and thoracotomy, are essential for definite diagnosis and management.