Endoscopic Needle Research Articles

A Radial Clutch Needle for Facile and Safe Tissue Compartment Access.

Efficient and safe access to targeted therapeutic sites is a universal challenge in minimally invasive medical intervention. Percutaneous and transluminal needle insertion is often performed blindly and requires significant user skill and experience to avoid complications associated with the damage of underlying tissues or organs. Here, we report on the advancement of a safer needle with a radial mechanical clutch, which is designed to prevent overshoot injuries through the automatic stopping of the needle once a target cavity is reached. The stylet-mounted clutch system is inexpensive to manufacture and compatible with standard hypodermic or endoscopic needles, and therefore can be adapted to achieve safe access in a myriad of minimally invasive procedures, including targeted drug delivery, at-home and in-hospital intravenous access, laparoscopic and endo- and trans-luminal interventions. Here, we demonstrate the clutch needle design optimization and illustrate its potential for rapid and safe minimally invasive cannulation.

1694 Endoscopic Ultrasonography With Fine-Needle Aspiration in the Diagnosis of Metastatic Rectal Adenocarcinoma in Left Atrium

INTRODUCTION: Endoscopic ultrasonography(EUS) of the mediastinum with the use of fine needle aspiration(FNA) or biopsy can be used to characterize lesions that are within or adjacent to the esophageal wall, posterior and inferior mediastinum with minimal risk to the patient. EUS is an underutilized tool for identifying mediastinal masses and can help guide clinical decision making in patients with concerning lesions found on non-invasive imaging modalities. CASE DESCRIPTION/METHODS: A 71-year-old male with history of adenocarcinoma of the rectum with metastases to the liver and lung was treated with surgical resection and adjuvant chemotherapy. Patient responded well and was under regular surveillance when a new irregularly shaped abnormal soft tissue density measuring approximately 5.4 × 3.0 cm adjacent to the aorta and esophagus appearing to invade into the left atrium (Figure 1a) was found on a CT scan and confirmed on PET imaging. These findings favored rectal metastatic disease over thrombus but could not definitively rule out a new carcinoma. For that reason, an endoscopic ultrasonography was performed to determine the nature of the mass. A curvilinear array echoendoscope was used to visualize a 36 × 30 mm exophytic lesion within the left atrium which extended into the posterior mediastinum (Figure 2). Using Doppler to identify a vessel-free path, a 25-gauge needle was passed under ultrasound guidance through the esophagus and directly into the mass with the use of an endoscopic fine needle biopsy (FNB) device for three passes. Histopathological examination confirmed adenocarcinoma (Figure 3) and immunophenotype was compatible with colorectal primary which ruled out a pulmonary adenocarcinoma. DISCUSSION: The patient was determined to not be a surgical candidate due to the location of the mass and high risk nature of the surgery. The multidisciplinary team’s consensus was to repeat chemo-adjuvant therapy since he had responded so well previously. He received treatment and had follow up imaging six months after EUS diagnosis which showed decrease in size (Figure 1b) and activity of the mass. He is planned to have have stereotactic body radiation therapy to further decrease the size of the atrial mass. This case demonstrated how EUS with the use of FNA is a helpful tool in the prompt evaluation and confirmation of a mediastinal mass which allowed all physician’s involved in the care of the patient to develop and implement a treatment plan quickly. Watch the video: http://bit.ly/2Giu99S.

2812 Impact of Rapid On-Site Evaluation (ROSE) on Endoscopic Ultrasound-Guided FNA of Pancreatic Cysts: A Five-Year Comparative Study Between Two Academic Institutions

INTRODUCTION: Endoscopic Ultrasound Guided-Fine Needle Aspiration (EUS-FNA) is considered the modality of choice for diagnosing intermediate pancreatic lesions. Rapid-on site evaluation (ROSE), when performed by a cytopathologist, has been suggested to improve the diagnostic yield of EUS-FNA. Prior studies were inconsistent regarding the benefit of ROSE. In our study, we evaluated the diagnostic yield of EUS-FNA in the presence of an on-site cytopathologist providing real-time feedback to the endoscopist compared to EUS-FNA alone in two academic hospitals. METHODS: We conducted a 2010-2015 retrospective chart review of all EUS-FNA performed at two academic medical centers (UT and UR). The policy at UT is to perform all EUS-FNA with ROSE, whereas it is not routinely done at UR. Cases where included when surgical pathology was available. Patients’ demographics, pancreatic cyst characteristics and EUS techniques were analyzed. EUS-FNA were considered valuable when it provided a classifying cytopathologic diagnosis. Student T-test and Analysis of Variance (ANOVA) were performed when appropriate for descriptive purposes. RESULTS: Forty-five cases (13 at UT, 32 at UR) were identified. EUS FNAs coupled with ROSE (UT) rendered 100% (13/13) valuable diagnoses, while those done with no cytopathologist on site (UR) had valuable diagnosis in 37.5% of the cases (12/32, P < 0.0001). The sensitivity of EUS-FNA at UT was 85% compared to 33% at UR. There was no statistically significant difference in gender, age, site or size of the tumor. The mean number of needle passes at UT was 1.9 (range 1-6) vs. 1.1 (range 1-3) at UR. The majority of needles used were 19G (55%) at UT vs 22G (83%) at UR (P < 0.001). Only one patient at UR had a minor cyst bleeding to the main pancreatic duct that required no therapeutic action. CONCLUSION: The results highlight the advantage of bed-side cytopathologist interaction with the endoscopist during EUS-FNA of pancreatic cysts. Absence of malignant cells despite suspicious ultrasound findings may have prompted more needle passes. The use of 19G needle may have improved outcomes with no significant increase of complications. In addition to the small sample size and the retrospective nature, the study is limited by the variability in personnel experience (endoscopists and cytopathologists) and the techniques used, indicating that further studies are necessary to confirm these findings.

MicroRNA-296-5p Promotes Cell Invasion and Drug Resistance by Targeting Bcl2-Related Ovarian Killer, Leading to a Poor Prognosis in Pancreatic Cancer

Background/Aims: Pancreatic ductal adenocarcinoma (PDAC) is characterized by aggressive invasion, early metastasis, and resistance to chemotherapy, leading to a poor prognosis. To clarify the molecular mechanism of these malignant characteristics, we performed a genome-wide microRNA (miRNA) array analysis utilizing micro-cancer tissues from patients with unresectable PDAC (stage IV), obtained by endoscopic ultrasound-fine needle aspiration (EUS-FNA). Methods: The expression profiles of 2,042 miRNAs were determined using micro-cancer tissues from 13 patients with unresectable PDAC obtained by EUS-FNA. The relationship between individual miRNA levels and overall survival (OS) was analyzed. Possible target genes for miRNAs were bioinformatically analyzed using the online database miRDB. Pancreatic cancer cell lines PANC-1, MIA PaCa-2, and PK-8 were transfected with miRNA mimic or small interfering RNA, and cell invasion, epithelial-mesenchymal transition (EMT), and apoptosis markers were examined. miRNA and mRNA expressions were examined by quantitative polymerase chain reaction. Results: Of 2,042 miRNAs, the 10 that exhibited the lowest correlation coefficient (p ≤ 0.005) between miRNA expression level and OS among the patients were identified. The miRDB and expression analysis in cancer cell lines for the 10 miRNAs identified miR-296-5p and miR-1207-5p as biomarkers predictive of shorter survival (p < 0.0005). Bioinformative target gene analysis and transfection experiments with miRNA mimics showed that Bcl2-related ovarian killer (BOK), a pro-apoptotic gene, is a target for miR296-5p in pancreatic cancer cells; transfection of miR-296-5p mimic into PANC-1, MIA PaCa-2, and PK-8 cells resulted in significant suppression of BOK mRNA and protein expression. These transfectants showed significantly higher invasion capability compared with control cells, and knock down of BOK in pancreatic cancer cells similarly enhanced invasion capability. Transfectants of miR-296-5p mimic also exhibited aberrant expression of EMT markers, including vimentin and N-cadherin. Moreover, these transfectants showed a significantly lower apoptosis rate in response to 5-fluorouracil and gemcitabine with a decrease of BOK expression, suggesting a role of miR-296-5p in drug resistance. Conclusion: These results suggest that miR-296-5p is a useful biomarker for a poor prognosis in patients with PDAC, and that the miR-296-5p/BOK signaling axis plays an important role in cell invasion, drug resistance, and EMT in PDACs.

Diagnostic Utility of Clinical, Laboratory, Radiology Findings to Predict Malignant Outcome in Endoscopic Ultrasound Guided-Fine Needle Aspirations of Solid Pancreatic Lesions with Atypical Results

Diagnostic Utility of Clinical, Laboratory, Radiology Findings to Predict Malignant Outcome in Endoscopic Ultrasound Guided-Fine Needle Aspirations of Solid Pancreatic Lesions with Atypical Results

Comparison of Endoscopic Ultrasound Biopsy Needles for Endoscopic Ultrasound-Guided Liver Biopsy.

Background/AimsTo compare the performance of latest commercially available endoscopic ultrasound biopsy needles. MethodsSix latest commercially available needles were tested on a freshly harvested bovine liver; the tested needles included three 19 G, one 20 G, and two 22 G needles. Five biopsies were performed per needle with 10 mL of wet suction. The primary outcome was the number of complete portal tracts (CPTs) per needle aspirate. The secondary outcomes were the mean specimen length and mean fragment length. Analysis of variance and Tukey’s test were applied. ResultsAll 19 G needles and the 20 G needle yielded similar mean CPTs and were superior to the SharkCore 22 G needle (p<0.001 adjusted for multiplicity). There was no statistically significant difference in total specimen length among the three 19 G needles and the 20 G needle tested. The two 22 G needles performed similarly with respect to the number of CPTs, mean fragment length, and mean specimen length (adjusted p=0.07, p=0.59, and p=0.10, respectively). ConclusionsThe specimen adequacy was similar among the 3 latest commercially available 19 G needles. The endoscopist may choose a larger-bore needle based on availability without concerns of specimen adequacy. Further studies are needed to assess the ease of needle use in various anatomical locations and to confirm the optimal needle design.

Concise Commentary: Antibiotic Prophylaxis for Endoscopic Needle Aspiration of Pancreatic Cystic Lesions: Bursting the Bubble?

Concise Commentary: Antibiotic Prophylaxis for Endoscopic Needle Aspiration of Pancreatic Cystic Lesions: Bursting the Bubble?

Sodium hydroxide-induced esophageal stricture via an endoscopic injection needle: a novel rabbit model of corrosive injury

Purpose: Benign strictures of the esophagus are commonly encountered in clinical practice and are difficult to manage conservatively. This study aimed to establish a novel animal model of benign esophageal stricture by using corrosive-induced injury in rabbits with an injection of sodium hydroxide (NaOH) via a self-made endoscopic injection needle.Materials and Methods: Corrosive injury of the esophagus was induced in 10 rabbits by administration of 1 mL of 1.5% NaOH using a laryngoscope with a self-made endoscopic injection needle. The self-made injection needle was fabricated by modification of the core of an endoscopic injection needle. The laryngoscope examination was performed at 2 weeks and 4 weeks after induction of corrosive injury; esophagography was also performed at 4 weeks to assess esophageal stricture. All animals were euthanized at the end of the fourth week; the esophagus was removed, and stained sections were examined microscopically.Results: Laryngoscope examination at 2 weeks showed ulceration. At the end of fourth week, laryngoscopy, radiological, and gross examinations showed successful induction of esophageal stricture in all animals, without any complication. The mean stricture index at the end of fourth week was 49.54±3.61%; the mean length of stricture was 18 .0±2.5mm. Microscopic examination revealed focal ulceration and submucosal thickening secondary to fibrosis.Conclusion: Rabbit esophageal stricture induced using laryngoscopy with endoscopic injection of a small amount of low-concentration sodium hydroxide is a technically simple, safe, and reproducible method for creation of an animal model of esophageal stricture. This model can be useful for developing new treatment methods for esophageal stricture.

Su1202 ENDOSCOPIC ULTRASOUND FINE NEEDLE ASPIRATION VERSUS FINE NEEDLE BIOPSY IN SOLID LESIONS: A MULTICENTER RETROSPECTIVE ANALYSIS

Endoscopic ultrasound guided-fine needle aspiration (EUS-FNA) has been a preferred technique for tissue sampling for several years. To overcome limitation of FNA cytology, fine needle biopsy (FNB) has recently been developed with the promise of histological tissue samples. The main objective of this study is to compare the accuracy of FNB versus FNA in determining the diagnosis of solid lesions.

The role of rapid on-site evaluation on diagnostic accuracy of endoscopic ultrasound fine needle aspiration for pancreatic, submucosal upper gastrointestinal tract and adjacent lesions.

Our aim was to assess adequacy and diagnostic accuracy of endoscopic ultrasound-fine needle aspiration (EUS-FNA) specimens with or without rapid on-site evaluation (ROSE) from pancreatic, upper gastrointestinal tract (UGIT) and adjacent masses. A retrospective cohort study based on patients' files who underwent EUS-FNA in Galilee Medical Center in a 4years period. Number of needle passes, repeated EUS and ROSE effect on tissue adequacy and diagnostic accuracy were reported. One-hundred sixty-one patients were included. Ninety-three patients (57.7%) underwent EUS-FNA without ROSE (group A) compared to 68 patients (42.3%) with ROSE (group B). The most common location was in the pancreas (55% in group A vs 81% in group B). Addition of ROSE yielded a significantly higher specimen adequacy (65% in group A vs 92.6% in group B (Chi-Square<0.0001, OR 6.72, 95% CI 2.45-18.38). The matching rate (accuracy) between ROSE diagnosis and final histopathological diagnosis was noticed in 61 out of 68 patients (89.7%, 95% CI 0.7993-0.9576). The Kappa coefficient correlations of matching rate between ROSE and final histopathological diagnosis of all lesion and in pancreatic lesions were 0.7558, (95% CI 0.625-0.887) and 0.7814, (95% CI 0.639-0.924), respectively. EUS-FNA with ROSE significantly improve specimen adequacy and was associated with high diagnostic accuracy.

Sa1707 – Using Endoscopic Fine Needle Biopsies of Pancreatic Ductal Adenocarcinoma for Immunotherapy Precision Medicine

Sa1707 – Using Endoscopic Fine Needle Biopsies of Pancreatic Ductal Adenocarcinoma for Immunotherapy Precision Medicine

Unplanned but proven obsolescence for 19 G endoscopic ultrasound needles.

Unplanned but proven obsolescence for 19 G endoscopic ultrasound needles.

Soft Palate Modification Using a Collagen Crosslinking Reagent for Equine Dorsal Displacement of the Soft Palate and Other Upper Airway Breathing Disorders.

The mechanical properties of the soft palate can be associated with breathing abnormalities. Dorsal displacement of the soft palate (DDSP) is a naturally occurring equine soft palate disorder caused by displacement of the caudal edge of the soft palate. Snoring and a more serious, sometimes life-threatening, condition called obstructive sleep apnea (OSA) are forms of sleep-related breathing disorders in humans which may involve the soft palate. The goal of this study was to investigate the effect of injecting the protein crosslinker genipin into the soft palate to modify its mechanical properties for the treatment of equine DDSP with potential implications for the treatment of snoring and OSA in humans. Ex vivo experiments consisted of mechanical testing and a wind tunnel study to examine the effect of genipin on the mechanical properties, displacement, and vibration of equine soft palates. A pilot in vivo study was completed using DDSP and control horses to test the safety and effectiveness of injecting a genipin reagent into the soft palate. The wind tunnel testing demonstrated a greater than 50% decrease in transient deformation and a greater than 33% decrease in steady-state vibrations for all doses of genipin tested. Ultimate tensile stress, yield stress, and Young's modulus were higher in the genipin-treated distal soft palate specimens by 52%, 53%, and 63%, respectively. The pilot in vivo study showed a reduction of snoring loudness in all DDSP horses and elimination of DDSP in at least one of three horses. The difficulty of using a 1-meter-long endoscopic injection needle contributed to a consistent overinjection of the equine soft palates, causing excessive stretching (pillowing) and related degradation of the tissue. These ex vivo and in vivo results demonstrated reduced vibration amplitude and flaccidity and increased strength of genipin-treated soft palates, suggesting that genipin crosslinking could become an effective and safe treatment for soft palate related breathing abnormalities.

Cystic lesions of the pancreas : Differential diagnostics and treatment

Cystic space-occupying lesions of the pancreas represent incidental findings in most cases. As there is apotential risk of malignant transformation further evaluation of the lesions as well as afollow-up of these patients is usually recommended. Before this work-up is initiated the clinical situation of the patient as awhole and comorbidities, age and personal preferences have to be taken into account. So far there are no biomarkers that reliably predict the risk of malignant transformation. Imaging by magnetic resonance tomography (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) is more accurate than computed tomography to identify worrisome features. During follow-up, endoscopic ultrasound (EUS) can be used as complementary method to MRI/MRCP. Using contrast enhancement or endoscopic fine needle aspiration (EUS-FNA) may influence the therapeutic strategy in some patients. Whereas for some cystic pancreatic lesions consensus has been reached, varying recommendations exist for intraductal papillary mucinous neoplasms (IPMN). There is consensus that in main-duct as well as in mixed-type IPMN surgery is recommended. The management of branch-duct type IPMN, however, remains controversial. Amultidisciplinary expert panel including gastroenterologists, visceral surgeons, radiologists and pathologists is essential to discuss all cases of patients with cystic pancreatic lesions and to guarantee an optimal, patient-centered treatment recommendation.

EUS-guided FNA in Diagnosing Pancreatic Lesions: Strength and Cytological Spectrum.

Introduction:Early and accurate diagnosis is paramount for improving the therapeutic efficacy of pancreatic cancers. Endoscopic ultrasonography–fine needle aspiration (EUS-FNA) cytology has come up with the advantage of an early and accurate diagnosis of pancreatic cancers. This study was conducted to analyze the spectrum of pancreatic lesions cytology, and appraise the diagnostic accuracy of EUS-FNA cytology for pancreatic solid and cystic lesions.Materials and Methods:This retrospective study includes 288 EUS-guided pancreatic FNA cases. Clinical data, laboratory tests, cytopathology, histopathology, and imaging reports were retrieved. The final diagnosis was based on EUS-FNA cell block and/or pathology in surgical specimens, with immunohistochemistry support. The results of EUS-guided FNA were compared with the final diagnoses to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).Results:Among 288 EUS-guided pancreatic FNA cases, 175 (62.0%) were malignant. The mean age was 57.8 ± 13.5 years and 50.1 ± 13.7 years, and the mean size of the lesion was 4.1 ± 1.8 cm and 2.2 ± 1.1 cm in malignant and benign groups, respectively. Sensitivity, specificity, PPV, and NPV of EUS-FNA cytology for solid malignant lesions were 98.3%, 95.1%, 98.3%, and 95.1%, and those for cystic lesions were 88%, 92.3%, 100%, and 100%. Diagnostic accuracy of EUS-FNA cytology for solid and cystic pancreatic lesions is 97.4% and 95.0%, respectively. In conclusion of the above; diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation and immunohistochemistry Diagnosis of pancreatic solid and cystic malignancy can be assigned from a composite of the EUS-FNA cytology, cell block preparation, and immunohistochemistry.

Diagnostic yield and safety of EUS-FNA biopsy in sub-aortic and para-aortic lymph node stations with the trans-aortic approach: a case series and literature review

ABSTRACTBackground: Sub-aortic (station 5) and para-aortic (station 6) lymph nodes are not easily accessible due to the interposition of the aorta and the left pulmonary artery. Taking a biopsy from those stations could be of value when there are no other mediastinal lymph node stations or when biopsy in other sites failed to reach a diagnosis. Surgery is the gold standard technique in the evaluation of those stations; endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been proposed as a minimally invasive technique through the trans-aortic approach, with an acceptable diagnostic yield and safety profile.Objective: To evaluate diagnostic accuracy and safety of the trans-aortic EUS-FNA in lymph node stations 5 and 6.Methods: We reviewed all patients who underwent trans-aortic EUS-FNA from 2010 to 2017, for mediastinal lymph node enlargement or positron emission tomography/computed tomography (PET/CT) positivity (integrated 2-deoxy-2-fluoro-d-glucose). Demographic characteristics, lesion site and size, needle, final diagnosis, and complications were collected.Results: A total of 11 patients were included, 5 males, mean age 59 years. Samples were inadequate in two cases, a diagnosis of lung cancer was reached in four patients (two adenocarcinoma and two squamous cell carcinoma) and five cases were negative for malignancy (one confirmed by surgery, two were found to be cancer at percutaneous lung biopsy and transbronchial biopsy, one patient received a diagnosis of Langerhans cell histiocytosis by transbronchial lung cryobiopsy, and one patient was lost at follow-up). The sensitivity for malignancy was 57%, and the overall diagnostic accuracy was 45%. No complications occurred.Conclusions: Trans-aortic EUS-FNA could be proposed as a valuable and safe approach for taking biopsy from mediastinal lymph node stations 5 and 6.

Hypervascular lesions of the pancreas: Think before you act

BackgroundThe “classic” CT appearance of pancreatic neuroendocrine tumors (PNETs) is a solid, hypervascular lesion; however, non-PNET diagnoses may appear similar. In addition, some PNETs have a “non-classic” appearance. MethodsDemographic, imaging, endoscopic ultrasound-fine needle aspiration (EUS/FNA) results, and pathology data were analyzed for patients who underwent pancreatectomy for suspected or confirmed diagnosis of PNET from our institutional database. ResultsForty-three patients with a hypervascular lesion on CT had pancreatectomy for a pre-operative diagnosis of PNET. Final pathology revealed PNET in 30 (70%) and non-PNET diagnoses in 13 (30%). EUS/FNA had a sensitivity of 82% for the pre-operative diagnosis of PNET in patients with “classic” CT. Of 13 non-PNET diagnoses, 7 were benign. Among a total of 41 patients with a final diagnosis of PNET, 11 (27%) had “non-classic” CT (5 hypodense solid lesions, 3 isodense solid lesions, and 3 cystic lesions). Among these patients, EUS/FNA had a sensitivity of 100% in diagnosing PNET. ConclusionsConsideration of non-PNET diagnoses is important for patients with hypervascular lesions on CT. Appropriate pre-operative evaluation will optimize treatment plans.

Comparison between groove carcinoma and groove pancreatitis

Background/objectivesThe pancreatoduodenal groove (anatomical groove) is a potential space bordered by the head of the pancreas, duodenum, and common bile duct. Discerning between groove carcinoma (GC) and groove pancreatitis (GP) is often difficult, but clinically important. We retrospectively analyzed and compared the findings of computed tomography (CT), laboratory tests, and endoscopic ultrasound-fine needle aspiration (EUS-FNA) for GC and GP. MethodsGC (n = 36) and GP (n = 44) patients at Asan Medical Center from January 1, 2000, to May 31, 2017 were retrospectively reviewed. MDCT findings, baseline characteristics, laboratory test results, and EUS and EUS-FNA findings of GC and GP patients were compared. ResultsCT showed no significant difference in groove enhancement between the groups. Mass-like lesions, cystic groove lesions, and calcification were observed in 86.1% and 15.9%, 38.9% and 75%, and 2.8% and 29.5% of GC and GP patients, respectively. Patients were tested for total bilirubin (GC: 2.0 vs. GP: 0.6 mg/dL), cancer antigen 19-9 (CA19-9) (GC: 76 vs. GP: 12.5 U/mL), and carcinoembryonic antigen (GC: 2.4 vs. GP: 2 ng/mL). Three GP patients died, and one GP patient was diagnosed with GC. However, among 30 GC patients with at least 1-year follow-up, 20 died. In multivariate logistic regression, CA19-9, and mass-like lesion on multidetector CT (MDCT) were discriminating factors between GC and GP. Among 23 (10 GC, 13 GP) patients who underwent EUS-FNA, the diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy of EUS-FNA were 90%, 100%, 100%, 92.86%, and 95.65%, respectively. ConclusionsSeveral MDCT and laboratory findings favor GC over GP. EUS-FNA should be considered in patients with elevated CA19-9 levels and mass-like lesions on MDCT.

Ultrasonography of the Mediastinum: Techniques, Current Practice, and Future Directions.

In the everyday practice of respiratory physicians, ultrasound techniques play a key role by enabling several diagnostic and interventional procedures. The application of ultrasound to endoscopic procedures allows both a visualization and a guided sampling of mediastinal and hilar lymph nodes. Endobronchial ultrasound can be combined with transbronchial needle aspiration, and, similarly, endoscopic ultrasound can be combined with fine-needle aspiration to sample virtually all mediastinal nodal stations from the airways and the esophagus. Endobronchial ultrasound-transbronchial needle aspiration and endoscopic ultrasound-fine needle aspiration showed a complementary diagnostic yield, and, recently, endoscopic ultrasound with bronchoscope was introduced in clinical practice to perform a transesophageal needle aspiration by using an ultrasound bronchoscope. This technique allows a single operator to perform both transbronchial and transesophageal needle sampling with the same instrument during a single bronchoscopic procedure. Mediastinal staging impacts the management of patients affected by lung cancer, and the most recent guidelines clearly state that endobronchial ultrasound and endoscopic ultrasound should be the initial tissue sampling procedure over surgical staging. In addition, endoscopic ultrasound techniques demonstrated an excellent yield in diagnosing lymphoma and benign diseases, for example, sarcoidosis. The aim of this review was to discuss the current role and future perspectives of endosonography techniques available for the evaluation of the mediastinum. Special emphasis was placed on equipment and technical aspects, the diagnostic role, and future directions of development.

VATS-lymph node dissection, staging and restaging in advanced malignancy/the Munich experience

In NSCLC an accurate staging of the mediastinum and in particular its lymph nodes is mandatory to determine accurate therapy, prevent futile surgery and identify those patients who eventually will benefit from a multimodality treatment setting including pre-surgical induction therapy. This review provides an overview on current standards of mediastinal staging in NSCLC followed by the presentation of the authors’ institutional practice. While the introduction of integrated positron tomography and computed tomography (PET/CT) has significantly improved non invasive clinical staging, the invasive mediastinal staging was revolutionized by ultrasound-based endoscopic fine needle aspiration with an accuracy surpassing that of the pervious gold standard—cervical mediastinoscopy. After many decades, the dogma of a “clear or cleared off” mediastinum as a prerequisite for primary tumor resection in curative intention has been re-evaluated and consequently has fallen: if PET positive mediastinal nodes are considered resectable, patients are referred to initial surgery without further invasive staging or induction therapy in many centers; in those patients with unresectable N2 disease however, histological proof is still of high importance but invasiveness is kept as minimally as possible, starting with endoscopic techniques and only eventually accelerating to surgical ones like VAM and VATS. In contrast to any other staging tool, VATS allows for a combination or cascade of diagnostic (re-)staging and therapeutic resection within a single procedure: the initial evaluation of histology and respectability of the mediastinal lymph nodes during a diagnostic systematic or selective mediastinal dissection is eventually followed by the anatomical tumor resection.