Endobronchial Ultrasound Procedures Research Articles

Prediction of malignancy in mediastinal lymph nodes during endobronchial ultrasound: A comparative validation study.

In this study, we aimed to compare the diagnostic performances of three existing prediction tools in visually identifying a malignant lymph node. Between April 2016 and January 2021, a total of 827 lymph nodes of 259 patients (211 males, 48 females; mean age: 61.1±7.2 years; range, 41 to 79 years) who underwent endobronchial ultrasound procedure for diagnosis and/or staging of lung cancer and diagnosis of mediastinal lymphadenopathy of unknown origin were retrospectively analyzed. This external validation study was designed to compare the diagnostic yields of the prediction tools developed by Shafiek et al., Alici et al., and Canada Lymph Node Score (CLNS). Endobronchial ultrasoundguided transbronchial needle aspiration results and predictions were compared to gold-standard tool. Overall, endobronchial ultrasound-guided transbronchial needle aspiration had a sensitivity, specificity, positive and negative predictive value, and accuracy of 95.6%, 100%, 100%, 97.6%, and 98.4%, respectively. Diagnostic performances of proposed tools were quite remarkable. Among them, Alici algorithm had a higher sensitivity and negative predictive value, which were matched by excellent specificity and positive predictive value offered by CLNS ≥3 and Shafiek tool. The area under the curve value of CLNS ≥3 was higher than Shafiek tool and CLNS ≥2. Conventional prediction tools relying on simple real-time sonographic features were found to be consistent by the means of diagnostic performance in this external validation dataset. Despite being inferior to cytology, their superior performance was proven with defined individual strengths and weaknesses.

Endobronchial ultrasound-guided re-biopsy of non-small cell lung cancer with acquired resistance after EGFR tyrosine kinase inhibitor treatment.

Few studies assessed the use of endobronchial ultrasound (EBUS)-guided re-biopsy for detecting the T790M mutation after epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) failure. A total of 2996 EBUS procedures were performed during the study period (January 2019-June 2022). In total, 44 consecutive patients who underwent EBUS-guided re-biopsy (56 procedures) for detecting the T790M mutation were analyzed. The success rates and T790M mutation frequencies were analyzed according to the re-biopsy site and EBUS method. Multivariate logistic regression analyses were used to identify factors affecting the likelihood of the T790M mutation. The success rates for the mutation analyses using EBUS with a guide-sheath (EBUS-GS), EBUS guided transbronchial needle aspiration (EBUS-TBNA), and EBUS-GS with EBUS-TBNA for re-biopsy were 80.6% (29/36), 93.3% (14/15), and 100% (5/5), respectively. Patients who underwent lymph node biopsy using EBUS-TBNA had an increased rates of the T790M mutation compared with those undergoing lung biopsy using EBUS-GS (EBUS-TBNA, 60.0%; EBUS-GS with EBUS-TBNA, 40.0%; EBUS-GS, 11.1%; p < 0.001). In multivariate analysis, the use of a first-generation EGFR-TKI (odds ratio [OR], 4.29; 95% confidence interval [CI], 1.05-17.58; p=0.043) was associated with occurrence of the T790M mutation. Re-biopsy of the metastatic site tended to be associated with a higher T790M mutation rate. Mild hemoptysis occurred in 3.6% (2/56) of the patients. EBUS-guided re-biopsy can be used for detecting the T790M mutation in patients who failed EGFR-TKI therapy. The T790M mutation frequency differed according to the re-biopsy site. The use of a first-generation EGFR-TKI was an independent predictor of the T790M mutation.

Fast investigative lung cancer pathway and endobronchial ultrasound procedure supported by rapid on-site evaluation.

EBUS is a well-established tool for diagnosis and staging of lung cancer in a fast track investigative pathway. However, impact of ROSE in conjunction with EBUS on reduction of time to treatment decision (TTD) for cancer patients is less well known. Our aim was to determine TTD which was defined as the number of working days from EBUS procedure to the discussion at sector lung multidisciplinary team meeting (MDT). Moreover, concordance of ROSE with final diagnosis was evaluated. A retrospective analysis was performed of a prospective data collection in a busy teaching hospital over a four months study period (September to December 2018). Data from 112 patients was analyzed. There were 61 (54%) males. Mean age was of 70 years (range 43-91). WHO performance status was 0 in 20 (23%), 1 in 57 (51%), 2 in 22 (20%) and 3 in 7 (6%) patients. In total 522 needle passes were performed from 242 sampling sites. Average working days to discuss at MDT after optimal EBUS sampling was 2.087 (range 0-13 working days). ROSE concordance with final cytological diagnosis was 98.4%. The number of needle passes per site for adequate sample and diagnosis in malignant (4.929) vs non-malignant (2.776) involvement was significantly different (p value <0.0001). There was 100% sample adequacy for preliminary diagnosis, immunohistochemistry and predictive molecular testing. ROSE supported fast-investigative pathway by reducing the time to treatment decision (TTD) making at MDT. High concordance with final cytological diagnosis makes it an effective tool to inform meaningful decision making.

Regional single-queue scheduling platform for specialist diagnostics in the lung cancer pathway: accelerating cancer recovery from the COVID-19 pandemic

Lung cancer is the single biggest cause of cancer death. The diagnostic pathway can be complex, including specialist cancer diagnostics that are not performed at every hospital. One such example...

Should We Start With Navigation or Endobronchial Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations

Should We Start With Navigation or Endobronchial Ultrasound Bronchoscopy?: Insights From Monte Carlo Simulations

Effectiveness of convolutional neural networks in the interpretation of pulmonary cytologic images in endobronchial ultrasound procedures.

BackgroundRapid on‐site cytologic evaluation (ROSE) helps to improve the diagnostic accuracy in endobronchial ultrasound (EBUS) procedures. However, cytologists are seldom available to perform ROSE in many institutions. Recent studies have investigated the application of deep learning in cytologic image analysis. As such, the present study analyzed lung cytologic images obtained by EBUS procedures, and employed deep‐learning methods to distinguish between benign and malignant cells and to semantically segment malignant cells.MethodsNinety‐seven patients who underwent 104 EBUS procedures were enrolled. Four hundred and ninety‐nine lung cytologic images obtained via ROSE, including 425 malignant and 74 benign, and most malignant were lung adenocarcinoma (64.3%). All the images were used to train a residual network model with 101 layers (ResNet101), with suitable hyperparameters selected to classify benign and malignant lung cytologic images. An HRNet model was also employed to mark the area of malignant cells. Automatic patch‐cropping was adopted to facilitate dataset preparation.ResultsMalignant cells were successfully classified by ResNet101 with 98.8% classification accuracy, 98.8% sensitivity, and 98.8% specificity in patch‐based classification; 95.5% classification accuracy in image‐based classification; and 92.9% classification accuracy in patient‐based classification. Malignant cell area was successfully marked by HRNet with a mean intersection over union of 89.2%. The automatic cropping method enabled the system to complete diagnosis within 1 s.ConclusionsThis is the first study to combine lung cytologic image deep‐learning classification with semantic segmentation. The model was optimized for high accuracy and the automatic cropping facilitates the clinical application of our model. The success in both lung cytologic images classification and semantic segmentation on our dataset shows a promising result for clinical application in the future.

Time between endobronchial ultrasound needle passes as a metric to monitor progress of trainees

ABSTRACT Background Methods to assess and track progress of new endobronchial ultrasound (EBUS) operators and trainees is desirable to ensure training goals and procedural competence are achieved. Relying on the diagnostic yield or on question-based assessments alone is not sufficient. This study examined the longitudinal change in times taken between needle passes (needle pass time; NPT) during EBUS lymph node sampling as a metric to monitor progress. Research Design and methods :The EBUS database of a tertiary hospital was accessed to extract data on the first 50 EBUS procedures for three trainees. The NPT was derived using PACS images that are stored to document every needle pass during an EBUS procedure and an average NPT was calculated. Results Between the three trainees, 157 procedures were carried out within the study period with 302 nodal stations sampled. The mean NPT (n = 204 stations) was 2:49 ± 0:49 mins. The mean node short axis diameter was 15.5 ± 8.7 mm. There was a negative correlation between node size and time per pass (r − 0.146, p = 0.045). The average NPT showed a negative correlation with procedure order through the first 50 procedures. Less variation between procedures was noted for the three trainees from the 30th procedure onward. On multivariate regression, NPT was significantly associated with procedure order regardless of station sampled or lymph node diameter. Conclusion NPT is novel, easy, and robust metric that can potentially help ensure EBUS trainees are advancing in a given training program.

The Effectiveness of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Patients With Undiagnosed Lung Cancer

Objectives: Conventional bronchoscopic techniques and computed tomography-guided transthoracic needle aspiration are widely used in the diagnosis of lung cancer. In some patients diagnosis can be challenging. Endobronchial ultrasound-guided transbronchial needle aspiration can be used in the diagnosis of lung cancer after procedures have failed to provide a diagnosis. We aimed to show the effectiveness of Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer in view of the literature and to share the experience from Turkey.&#x0D; Material and Methods: This was a retrospective study conducted between 2014 and 2019. Forty-five patients who were suspected of having lung cancer and underwent Endobronchial ultrasound because diagnosis was not confirmed using methods such as bronchoscopy, computed tomography transthoracic needle aspiration, and peripheral lymph node excision, were included in the study.&#x0D; Results: Three hundred sixty-eight Endobronchial ultrasound procedures were performed. Forty-five patients met the inclusion criteria and were included in the study. Using Endobronchial ultrasound, samples were taken from only mass in eight patients (17.8%), lymph nodes in 30 patients (66.7%), and mass + lymph node in seven (15.5%) patients. Minor complications were seen in five (11.1%) patients and no major complications were seen. Definitive diagnosis was obtained in 35 (77.7%) patients with Endobronchial ultrasound guided transbronchial needle aspiration. Non-small cell lung cancer was identified in 16 patients (45.7%), small cell lung cancer was seen in 15 (42.8%) patients. Seven of ten undiagnosed patients underwent surgical procedures.&#x0D; Conclusion: Endobronchial ultrasound, is an effective and safe method for diagnosing lung cancer after undiagnosed procedures. In selected cases, it can be the first choice for the diagnosis of lung cancer.

DIPHENHYDRAMINE AS ADJUNCTIVE THERAPY DURING MODERATE SEDATION FOR ENDOBRONCHIAL ULTRASOUND

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Endobronchial ultrasound (EBUS) and real-time guidance of transbronchial needle aspiration (TBNA) has become a widely adopted tool in evaluation of intrathoracic lymphadenopathy for malignant or non-malignant disease. EBUS has been shown to have comparable diagnostic yield and safety profile when done with either moderate sedation (MS) or deep sedation (DS). The purpose of this study was to assess the use of diphenhydramine in bronchoscopies and specifically EBUS/TBNA. METHODS: Patient data was collected via chart review of all bronchoscopies done at the Kansas City VA Medical Center between July 2018 and June 2019. Only procedures done under MS were included. Sedation medications used were fentanyl and midazolam. The use of intravenous diphenhydramine, dose and timing was at the discretion of the proceduralist. RESULTS: A total of 165 bronchoscopies were performed under MS; 84 were EBUS procedures. Of the EBUS patients, 81 (96.4%) patients were male; mean age was 66.4±10.7. No patients had a documented history of chronic opioid use.Midazolam and fentanyl were used for induction and maintenance of sedation in all EBUS patients. The mean doses were 5.3±3.3 mg of midazolam and 203.9±52.1 mcg of fentanyl. Diphenhydramine was used in 62 (73.8%) of EBUS procedures. Twenty (32.3%) patients received diphenhydramine at induction compared to 42 (67.7%) who only received it during the procedure. The mean dose of diphenhydramine was 41.5±12.7 mg.Comparing EBUS in which any diphenhydramine was used to cases in which it was not, there was no significant difference in the cumulative doses of midazolam (5.6±3.5 vs. 4.5±2.5mg, p=0.161) and fentanyl (204.8±57.6 vs. 201.1±33.2mcg, p= 0.777). The time to adequate sedation was significantly higher in patients who received diphenhydramine (11.1±4.9 vs. 8.6±2.9 min, p=0.006). Procedure time (64.0±25.1 vs 61.4±20.2 min, p=0.660) and recovery time (81.4±32.4 vs. 81.3±47.9 min, p=0.995) were not significantly different.Compared to no use at all, any diphenhydramine use (at induction or during the procedure) was associated with a lower fentanyl dose per minute (4.2±2.6 vs. 7.2±5.0 mcg/min, p<0.001) and a trend towards a lower midazolam dose per minute although not statistically significant (0.1±0.1 vs. 0.2±0.6 mg/min, p=0.271). CONCLUSIONS: Use of diphenhydramine in our cohort was associated with a mean of 3.0 mcg/min lower fentanyl dose, equivalent to an average fentanyl dose reduction of 193mcg per procedure. Further randomized controlled trials with a protocol for sedation including diphenhydramine or placebo would be the next endeavor to fully evaluate this hypothesis. CLINICAL IMPLICATIONS: Diphenhydramine appears to reduce fentanyl requirements and therefore should be considered as adjuctive therapy for moderate sedation in EBUS procedures. DISCLOSURES: No relevant relationships by Abdallah Abboud, source=Web Response No relevant relationships by Sonia Castillo, source=Web Response

Risk/caution of vitamin D insufficiency for quarantined athletes returning to play after COVID-19

Flexible bronchoscopy plays a major role in the diagnosis and staging of lung cancer. One of the most important advances in this field is the development of endobronchial ultrasound (EBUS),...

Integration of Bronchoscopic Transesophageal Ultrasound Examination of the Left Adrenal Gland into Routine Lung Cancer Staging Workup: A Prospective Trial

Background: Endobronchial ultrasound (EBUS) with transbronchial needle aspiration increases the diagnostic yield of lung cancer staging. The left adrenal gland (LAG) is a common site for lung cancer metastasis. The modality of transesophageal examination with an EBUS bronchoscope (EUS-B) routinely for LAG has not been assessed. Objective: The aim of this study was to prospectively assess if evaluation and tissue sampling of the LAG could routinely be implemented in an EBUS procedure. Methods: Patients referred for EBUS between March and August 2017 had assessment of the LAG via EUS-B. Fine-needle aspiration (FNA) was performed in cases with a suspicious LAG. The detection rate, procedure time, and learning curve of four experienced EBUS-bronchoscopists was assessed, plus the diagnostic accuracy and complication rate of FNA. Results: In total, 313 consecutive patients were included. The overall LAG detection rate was 87.5%. After the initial learning curve, the detection rate for all four bronchoscopists was >93%. The detection rate did not correlate with any patient characteristics. EUS-B-FNA revealed nine LAG metastases, with a sensitivity, specificity, and accuracy of 75%, 100%, and 99%, respectively. The mean EUS-B operation time was 194.4 s, with 594.8 s for FNA. There were no FNA-associated complications. Conclusions: Evaluation of the LAG with EUS-B could routinely be included in an EBUS procedure if necessary. A high detection rate can be achieved after an initial learning period. FNA of the LAG was feasible and safe. EUS-B of the LAG could be integrated into the usual EBUS/EUS-B procedure in lung cancer staging workup.

Performance of endobronchial-ultrasound guided miniforceps biopsy of targeted mediastinal and hilar lesions.

Performance of endobronchial-ultrasound guided miniforceps biopsy of targeted mediastinal and hilar lesions.

Endosonographic evaluation of the mediastinum through the i-gel O2 supraglottic airway device.

Endobronchial ultrasound (EBUS) is an endoscopic diagnostic procedure combining flexible fibrobronchoscopy with ultrasound techniques; it allows transbronchial needle aspiration biopsy for the diagnosis and staging of mediastinal masses. We present our preliminary experience with the use of the i-gel O2 supraglottic airway device for management of EBUS procedures. An observational study on 39 patients who underwent EBUS under general anesthesia was performed. Airways were managed with i-gel O2 by anesthesiologists unfamiliar with it. Data collected included patient characteristics, i-gel O2 positioning, mechanical ventilation, procedure, and complications occurring during and after the EBUS. The i-gel airway was successfully positioned during the first attempt in 34/39 cases (87.2%). No failed positioning was recorded. The EBUS scope easily passed through the i-gel in all patients and in 14 (35.6%) cases it was also inserted through the esophagus allowing the examination or fine needle aspiration of paraesophageal lymph nodes. In one case, during the EBUS procedure, the i-gel was dislocated but easily put in place again. During EBUS, air leakages were significant in 2 cases (5.1%) and minimal in 14 cases (35.9%). A brief self-solved laryngospasm and a bronchospasm during bronchoscopy were recorded. After recovery, no patients had dysphagia; mild odynophagia and pharyngodinia were referred by 2 (5.1%) and 12 (30.1%) patients, respectively. The i-gel O2 airway is easy to position and manage even for anesthesiologists unfamiliar with it. This supraglottic airway device is suitable for a complete endosonographic evaluation of the mediastinum.

Utility of Endobronchial Ultrasound in Assessment of Intrathoracic Lesions in Paediatric Patients

Introduction: In adults, linear endobronchial ultrasound (EBUS) is the preferred modality to sample intrathoracic adenopathy and radial EBUS is a useful tool to biopsy peripheral pulmonary nodules. Utility in children is less well known. Objectives: The objective of this study was to review the EBUS experience of two specialist centres to better define the current role of EBUS in paediatric practice. Methods: A retrospective record review of EBUS procedures undertaken in patients aged 0–17 years at the Royal Children’s Hospital (Melbourne, Australia) and Thoraxklinik (Heidelberg, Germany) was performed. Data extracted included patient demographics, clinical presentation, bronchoscope (size and model), EBUS technique used, pathologic results, need for further invasive investigation, and complications. Results: Between 2008 and 2017, ten EBUS procedures were performed (6 linear EBUS and 4 radial EBUS). No complications were reported. Linear EBUS was performed on subjects who were between 4 and 15 years old, with a 100% diagnostic yield. Radial EBUS was non-diagnostic in three cases of non-malignant disease. In one case, it was used successfully for imaging alone. Conclusion: Both linear and radial EBUS are safe and feasible in children. Diagnostic yield of linear EBUS was 100%. Radial EBUS did not demonstrate utility, likely reflecting the pathologies of underlying parenchymal masses in paediatric populations.

A Multicenter Study on the Utility of EBUS-TBNA and EUS-B-FNA in the Diagnosis of Mediastinal Lymphoma

There is conflicting data on the utility of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) for the detection and subtyping of lymphomas. Herein, we present our experience with EBUS-TBNA in suspected lymphoma. This was a multicenter retrospective study of subjects with suspected lymphoma who underwent EBUS-TBNA (July 2011 to June 2017). The performance characteristics of EBUS-TBNA were calculated separately for suspected new-onset and recurrent lymphoma as well as for subtyping. We also analyzed the factors predicting the yield of EBUS-TBNA in suspected lymphoma. Among the 4803 EBUS procedures performed, 92 (1.9%) subjects had either suspected or proven lymphoma; 48 were finally diagnosed to have lymphoma. The diagnostic sensitivities of EBUS-TBNA in new-onset and recurrent lymphomas were 72.7% and 73.3%, respectively. Only 24.2% (8/33) subjects with new-onset lymphoma could be appropriately subtyped. This low yield was possibly due to inadequate material for cell block in 10 subjects, and performance of immunophenotyping and flow cytometry in only 5 and 1 subjects, respectively. Among the suspected cases of recurrence, EBUS-TBNA was sufficient for management in 81.8% (18/22). On a multivariate analysis, no factor (rapid onsite evaluation, needle size, number of lymph nodes sampled, passes per node, and size of the largest lymph node sampled) predicted the diagnostic yield. EBUS-TBNA is a useful investigation in the diagnostic algorithm of suspected lymphoma as it helps avoid other invasive diagnostic procedures. The sensitivity of EBUS-TBNA in subtyping new-onset mediastinal lymphoma depends on the adequacy of cell aspirate and the judicious utilization of pathologic techniques.

Invasive mediastinal staging for resected non–small cell lung cancer in a population-based cohort

ObjectivesInvasive mediastinal nodal staging is recommended before curative-intent resection in patients with non–small cell lung cancer deemed at risk for mediastinal lymph node involvement. We evaluated the use and survival effect of preoperative invasive mediastinal nodal staging in a population-based non–small cell lung cancer cohort. MethodsWe analyzed all curative-intent resections for non–small cell lung cancer from 2009 to 2018 in 11 hospitals in 4 contiguous Dartmouth Hospital Referral Regions, comparing patients who did not have invasive mediastinal nodal staging with those who did. ResultsPreoperative invasive nodal staging was used in 22% of 2916 patients, including mediastinoscopy only in 13%, minimally invasive procedures only in 6%, and both approaches in 3%. Sixty-three percent of patients at risk for nodal disease (tumor size ≥3.0 cm/T2-T4; N1-N3 by computed tomography or positron-emission tomography-computerized tomography criterion) did not undergo invasive staging; among those who did not have invasive testing, 47% had at least 1 of the 3 clinical indications. Mediastinoscopy yielded a median of 3 lymph nodes and 2 nodal stations; 17% of mediastinoscopies and 31% of endobronchial ultrasound procedures yielded no lymph node material. Patients not invasively staged were more likely to have no nodes (6% vs 2%; P < .0001) and no mediastinal nodes (20% vs 11%; P < .0001) examined at surgery. Invasive staging was associated with significantly better survival (P = .0157). ConclusionsMore than a decade after the 2001 American College of Surgeons Patient Care Evaluation report, preoperative invasive nodal staging remains underused and of variable quality, but was associated with survival benefit in high-risk patients.

Development and Pilot Testing of an Assessment Tool for Performance of Invasive Mediastinal Staging

To develop and evaluate a surgical trainee competency assessment instrument for invasive mediastinal staging, including cervical mediastinoscopy and endobronchial ultrasound (EBUS), a comprehensive instrument was developed, the Thoracic Competency Assessment Tool-Invasive Staging (TCAT-IS), using expert review and simulated and clinical pilot-testing. Validity and reliability evidence were collected, and item analysis was performed. Initially, a 27-item instrument was developed, which underwent expert review with members of the Canadian Association of Thoracic Surgeons (n= 86) in 2014 to 2015 (response rate, 57%). TCAT-IS was refined to 29 items in 4 competency areas: preoperative, general operative, mediastinoscopy, and EBUS. Further refinements were made based on simulated use. The final version was then used to assess competency of 5 thoracic trainees performing invasive mediastinal staging in live patients. Participants were assessed during 20 mediastinoscopy and 8 EBUS procedures, with 47 total assessments completed. Reliability (Cronbach's alpha= 0.94), interrater reliability (κ= 0.80), and correlation with an established global competency scale (κ= 0.75) were high. The most difficult items were "set up and adjust EBUS equipment" and "identify vascular anatomy (EBUS)." Feedback questionnaires from trainees (response rate, 80%) and surgeons (response rate, 100%) were consistently positive regarding user friendliness, utility as an assessment tool, and educational benefit. Participants believed the tool "facilitated communicating feedback to the trainee with specific areas to work on." TCAT-IS is an effective tool for assessing competence in invasive staging and may enhance instruction. This initial test establishes early validity and reliability evidence, supporting the use of TCAT-IS in providing structured, specific, formative assessments of competency.

Ultrasonographic characteristics of lymph nodes as predictors of malignancy during endobronchial ultrasound (EBUS): A systematic review

ObjectivesThe primary objective of this study is to systematically review all pertinent literature related to the use of ultrasonographic features to predict malignancy in mediastinal lymph nodes seen during endobronchial ultrasound (EBUS) procedures. Materials and MethodsTwo independent reviewers completed the search and review (PubMed, EMBASE, Medline, and Cochrane databases) of the resulting titles and abstracts. Following full-text screening, thirteen articles met the inclusion criteria. Heterogeneity prevented any meta-analysis, instead a narrative review was completed. Results from each included article are categorized by the following ultrasonographic features: shape, echogenicity, margin status, central necrosis, short axis length, and central hilar structure. Diagnostic tools are also described in detail. ResultsAbsence of a central hilar structure and heterogeneous echogenicity were often associated with malignancy; however, consensus was not achieved amongst the included articles. The remaining ultrasonographic features were not consistently associated with malignancy or benign disease status, suggesting a need for prospective analysis. Four diagnostic tools were also assessed. These tools demonstrate that a combination of ultrasonographic features may accurately predict lymph node malignancy rather than a single feature. ConclusionAnalysis of ultrasonographic features may prevent the need for repeat EBUS procedures when initial biopsy results are inconclusive. However, prospective external validation of these features is required to determine their true predictive capability. PROSPERO registration number: CRD42017068468.

The Impact of the Eighth TNM Classification for Lung Cancer on the Endobronchial Ultrasound Procedure

The Impact of the Eighth TNM Classification for Lung Cancer on the Endobronchial Ultrasound Procedure

Prevalence of nodal metastases in lymph node stations 8 & 9 in a large UK lung cancer surgical centre without routine pre-operative EUS nodal staging

IntroductionEndoscopic ultrasound (EUS) allows access to the inferior mediastinal lymph node stations (8 and 9) which are beyond the reach of endobronchial ultrasound (EBUS). The addition of EUS to EBUS procedures requires cost and resource investment. This study sought to describe the prevalence of station 8/9 nodal metastases from intra-operative lymph node sampling in a UK region where routine pre-operative EUS is not available. MethodsA retrospective review of all lung cancer resections at the University Hospital South Manchester from 2011 to 2014. Surgical variables, pre-operative PET variables and survival outcomes were collected and analysed. Results1421 surgical resections were performed in the study period. Lymph node stations 8 and/or 9 were sampled in 52% (736/1421) of patients. Overall, there were 34 patients with lymph node metastases at station 8/9. This represents 2.4% of the study populations and 4.6% of patients in whom stations 8/9 were sampled intra-operatively. Of those patients with station 8/9 metastases, 65% (22/34) had multi-station N2 disease and the majority of the additional N2 disease was present in EBUS-accessible areas (lymph node stations 2, 4 and 7). Two percent (16/736) of patients in whom station 8/9 lymph nodes were sampled intra-operatively had N2 disease that was only accessible endoscopically with EUS. There was no significant difference in overall survival in patients with pathological N2 disease stratified according to whether stations 8/9 were involved or not. ConclusionsThe prevalence of lymph node metastases in stations 8/9 in this UK surgical centre where routine pre-operative EUS is not performed is low at approximately 5%. Given the identification of N2 disease in two-thirds of these patients can potentially be achieved through EBUS alone, this questions whether the resource implications of EUS are justified by the impact on patient management.