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Convex probe endobronchial ultrasound transbronchial needle aspirations (CP-EBUS-TBNAs) and radial probe endobronchial ultrasound transbronchial lung biopsies (RP-EBUS-TBLBs) can be performed under moderate sedation or general anesthesia. Moderate sedation is more convenient, however patient discomfort may result in inadequate tissue sampling. General anesthesia ensures better patient cooperation but requires more logistics and also carries sedation risks. We aim to describe the diagnostic yield and safety of CP-EBUS-TBNAs and RP-EBUS-TBLBs when performed under moderate sedation at our center. All patients who underwent CP-EBUS-TBNA and/or RP-EBUS-TBLB under moderate sedation, between January 2015 and May 2017, were reviewed. Primary outcomes were defined in regard to the diagnostic yield and safety profile. A total of 336 CP-EBUS-TBNAs and 190 RP-EBUS-TBLBs were performed between January 2015 and May 2017. The mean sedation doses used were 50 mcg of intravenous fentanyl and 2.5 mg of intravenous midazolam. The diagnostic yield of the CP-EBUS-TBNAs and RP-EBUS-TBLBs were 62.5% and 71.6%, respectively. Complication rates were low with: transient bleeding 11.9%, transient hypoxia 0.5%, and pneumothorax 0.1%. None required escalation of care, post procedure. Performing CP-EBUS-TBNAs and RP-EBUS-TBLBs under moderate sedation is safe and provides good diagnostic yield. These procedures should, therefore, be considered as first-line sampling techniques.

Pulmonary embolism (PE) is a common diagnosis made in the emergency department (ED). Although CT angiogram remains the preferred diagnostic modality, sometimes it is not possible to obtain due to hemodynamic instability, renal failure, pregnancy, etc. Bronchoscopy with endobronchial ultrasound (EBUS) has been used for the evaluation of mediastinal and hilar lesions. The proximity of pulmonary vasculature to mediastinal and hilar structures can aid in utilizing EBUS for bedside diagnosis and future monitoring of pulmonary embolism. This case describes a patient who presented with cardiac arrest, likely secondary to a massive pulmonary embolism, and later underwent bronchoscopy with EBUS that demonstrated the pulmonary emboli.

Background Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is a minimally invasive, reliable technique for sampling mediastinal lymph nodes (LNs). Liquid‐based cytology (LBC) is widely used for cervical cancer screening because it provides reliable and feasible results. The present study aimed to evaluate effectiveness of the combination of EBUS‐TBNA and LBC in the diagnosis of mediastinal lymphadenopathy. Methods A total of 602 LNs that were retrospectively analyzed were sampled in 442 patients who underwent EBUS‐TBNA between January 2014 and December 2016. The histopathological result of TBNA tissue or cell blocks was considered as the gold standard to evaluate diagnostic utility of LBC and conventional smears (CS) for the diagnosis of mediastinal lymphadenopathy. Results Of the 602 LNs, 265 were mediastinal LN metastases from lung cancer, four were lymphoma, and 333 were benign. The sensitivity of LBC and CS in the diagnosis of mediastinal LN metastases from lung cancer was 72.8% and 63%, respectively, and the specificity was 98.5% and 97%, respectively. The positive predictive values for LBC and CS were 97.5% and 94.4%, respectively, whereas the negative predictive values were 82.2% and 76.9%, respectively. The accuracy of LBC and CS was 88% and 83.7%, respectively. The diagnostic value of LBC was significantly higher than that of CS (P = .001). Conclusions The combination of EBUS‐TBNA and LBC is a highly reliable and feasible procedure that optimizes diagnostic utility for the diagnosis of lung cancer and mediastinal LN staging.

In lung cancer accurate assessment of the mediastinal lymph node status is of paramount importance for the stage assignment as well as crucial for the therapeutic plan. TAC and positron emission tomography (PET) are valuable tools to achieve a preliminary picture of the mediastinal staging but Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) is considered the first choice for investigating mediastinal lymph nodes as recommended by updated guide-lines. Despite the EBUS-TBNA sensitivity is satisfactory, it is not high enough to exclude mediastinal lymph node metastases; therefore devices and technologies were implemented to increase its sensitivity. The purpose of this narrative review is to describe the tools aimed at correctly interpreting sonographic patterns during EBUS and maximizing the diagnostic accuracy of TBNA. The bibliographic research identified 354 articles potentially related to the purpose of the current review and after accurate reading we selected 21 articles. Eight articles focused on the sonographic features of lymph nodes found during EBUS, 2 papers considered the Doppler patterns and, finally, 18 studies analyzed the advantages of ultrasound elastography. Sonographic features, vascular patterns and ultrasound elastography have proved to be helpful in directing the operator to biopsy the most suspect lymph node, especially in patients with CT-negative and/or PET-negative mediastinum.

Background: Several studies have reported the efficacy of esophageal ultrasound-guided fine needle aspiration (EUS-FNA) for the detection of metastases in the left adrenal gland (LAG) in patients with lung cancer. Currently we have only limited evidence based on small studies on the usefulness of EUS-B [endobronchial ultrasound (EBUS) scope into the esophagus] to provide tissue proof of suspected LAG metastases. The objectives of this study are to investigate feasibility, safety and diagnostic yield of EUS-B-FNA in LAG analysis in patients with proven or suspected lung cancer.Methods: In two Danish hospitals, a systematic search in the electronic database for patients who underwent EUS-B-FNA of the LAG for suspected or proven lung cancer was performed retrospectively between January 1st, 2015 and December 31st, 2017. Computed tomography (CT), positron emission tomography-CT, endoscopy, pathology and follow-up data were acquired.Results: One hundred and thirty-five patients were included; the prevalence of biopsy proven LAG malignancy was 30% (40/135). A total of 87% (117/135) of EUS-B-FNA samples were adequate (i.e., containing adrenal or malignant cells). No complications were observed.Conclusions: We present the largest cohort of patients ever reported showing that EUS-B-FNA of the LAG is a safe and feasible procedure and should therefore be used for staging purposes in patients with lung cancer and a suspicious LAG.

Objectives: Peripheral lung nodules containing ground-glass opacity (GGO), which include both pure GGN (nodules that contain only GGO) and part-solid GGN (nodules that contain both GGO and consolidation), are difficult to diagnose by conventional transbronchial biopsy (TBB) because they are not visible by fluoroscopy. Recently developed endobronchial ultrasound (EBUS)-guided TBB is useful for diagnosing these nodules. This study was performed to clarify the contribution of EBUS to the diagnostic yield of TBB for peripheral lung nodules containing GGO. Methods: We retrospectively reviewed the medical records of 41 patients (21 male, 20 female; median age, 72 years) with peripheral lung pure GGN or part-solid GGN who underwent EBUS-guided TBB. Results: The median diameter of the target lesions was 18.6 mm (range, 8.8–46.7 mm). There were seven pure GGN lesions and 34 part-solid GGN lesions. The total diagnostic yield was 65.9% (27/41). EBUS images could be obtained (positive) in 30 (73.1%) patients. Among the clinical factors studied, only a positive EBUS finding was significantly associated with a higher diagnostic yield (p=0.018). Diagnostic yield tended to be higher in patients with a positive CT bronchus sign (presence of a bronchus leading directly to the target lesion) and increased consolidation-to-tumor ratio. Conclusions: EBUS-guided TBB is useful for diagnosing GGN or part-solid GGN. Obtaining positive EBUS findings is important for successful TBB for lesions containing GGO.

Due to the increasing role of endosonography [endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound-guided fine needle aspiration (EUS-FNA)] in the diagnosis of several lung diseases, the knowledge of technical aspects is mandatory to optimize the success of the procedure. Among those technicalities related to the procedure, the choice of a needle over another one-either in terms of dimension and type-may have a role in the diagnostic process, especially in some diseases such as lymphoproliferative disorders. In this review, we analyze the current knowledge about the biopsy needle for endosonography, providing also some hints for the future.

Lung cancer is the leading cause of cancer-related deaths worldwide with an overall 5-year survival rate of 17% after diagnoses. Indeed many patients tend to have a very poor prognosis, due to being diagnosed at an advanced stage. Conversely patients who are diagnosed at an early stage have a 5-year survival >70%, indicating that early detection of lung cancer is crucial to improve survival. Although flexible bronchoscopy is a relatively non-invasive procedure for patients suspected of having lung cancer, only 29% of carcinoma in situ (CIS) and 69% of microinvasive tumors were detectable using white light bronchoscopy (WLB) alone. As a result, in the past two decades, new bronchoscopic techniques have been developed to increase the yield and diagnostic accuracy, such as autofluorescence bronchoscopy (AFB), narrow band imaging (NBI) and high magnification bronchovideoscopy (HMB). However, due to the low specificity and the limitation to detect only proximal bronchial tree, new probe-based technologies have been introduced: radial endobronchial ultrasound (R-EBUS), optical coherence tomography (OCT), confocal laser endomicroscopy (CLE) and laser Raman spectroscopy (LRS). To date, although tissue biopsy remains the gold standard for diagnosing malignant/premalignant airway disease and some techniques are still investigational, bronchoscopic technologies can be considered the safest and most accurate tools to evaluate both central and distal airway mucosa.

Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) has revolutionized the diagnosis and staging of lung cancer. Multiple studies support EBUS as a safe, cost-effective, and accurate method of diagnosing lung cancer. Even with the groundbreaking developments of immunotherapy and targeted therapy in advanced non-small cell lung cancer, EBUS-TBNA remains the optimal method for obtaining tissue for molecular testing. Since the advent of EBUS, there have been a multitude of needles and biopsy tools that have been developed, each with its own unique features that may make it suitable for various clinical situations. With needle sizes ranging from 19 gauge to 25 gauge, and both aspiration and biopsy needles, as well as mini-forceps available, there are now numerous tools to choose from. Over the past several years, EBUS has also gained new roles outside the realm of lung malignancy. EBUS now plays an important role in diagnosing other thoracic pathology, such as sarcoidosis and lymphoma, as well as facilitating treatment of both benign and malignant disease. As the use of EBUS has become more widespread, new tools have emerged to allow for EBUS to continue expanding its applicability. This review examines the evidence for the current equipment and novel tools that are being used in EBUS-guided biopsy.

Background and Objectives: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the procedure of choice for the evaluation of mediastinal/hilar lymph node enlargements. Granulomatous inflammation of the mediastinal/hilar lymph nodes is often identified on routine histology. In addition, mediastinal lymphadenopathy may be present with undiagnosed infection. We sought to determine the usefulness of routine cultures and histology for infectious etiologies in a fungal endemic area when granulomatous inflammation is identified. Materials and Methods: We identified 56 of 210 patients with granulomatous inflammation on EBUS-TBNA biopsies from October 2012 through October 2014. An onsite cytologist evaluated all biopsies and an additional TBNA pass for microbiologic stains and cultures were obtained in those with granulomatous inflammation. Results: Of the 56 patients with granulomatous inflammation, 20 patients had caseating (necrotizing) granulomas while noncaseating (nonnecrotizing) granulomas were detected in 36 of the remainder patients. In patients with caseating granulomas, fungal elements were identified in 6 of 20 (30%) patients (histoplasma; N = 5, blastomyces; N = 1) on Grocott methenamine silver (GMS) stain. Lymph node cultures identified 3 of 20 (20%) patients as being positive for Mycobacterium tuberculosis (N = 1), Histoplasma capsulatum (N = 1), and Blastomyces dermatitidis (N = 1). Among patients with noncaseating granulomas, only 2 out of 36 (5%) were positive for fungal elements on GMS stain, identified as Histoplasma, although the lymph node cultures remained negative. Conclusion: The incidence of granulomatous inflammation of mediastinal lymph nodes was 26.6% in our series. Of these patients, noncaseating granulomas were more common (64% vs. 36%). Infectious organisms, fungal or acid-fast bacilli (AFB), on either staining or lymph node culture were rarely identified in noncaseating granulomas, 5% and none, respectively. Caseating granulomas were more commonly associated with positive lymph node fungal stain and culture, 35% and 15%, respectively. In a fungal endemic area, lymph node staining and culture can be considered in cases with caseating granulomatous inflammation, if known at the time of biopsy.

Prikazan je mogući anestezijski postupak za dijagnostički endobronhijski ultrazvuk. (EBUS). EBUS je specifi čna pretraga za dijagnostiku novonastale hilarne i/ili medijastinalne limfadenopatije te tumora pluća. Anestezija olakšava izvođenje ovog dijagnostičkog postupka bolesniku i liječniku. Iz dosadašnjih studija vidljivo je da su u primjeni različite tehnike anestezije. Postupak se može izvesti u sedaciji primjenom lokalnog anestetika i općoj anesteziji. Kod primjene sedacije lokalnim anestetikom bolesnik diše spontano, a u općoj anesteziji se dišni put održava laringealnom maskom ili orotrahealnim tubusom. Bolesniku u dobi od 57 godina, tjelesne težine (TM) 94 kg, ASA I (The American Society of Anesthesiologists), uredne plućne funkcije, bez poznatih alergija, indicirana je dijagnostička pretraga EBUS zbog povećanih limfnih čvorova u medijastinumu. Dijagnostička pretraga EBUS izvodi se na udaljenom radilištu koji je opremljen anesteziološkim uređajem Datex-Ohmeda S5 Aespire 1990. godine i monitorom Philips IntelliVue MP60. te smo anestezijski postupak prilagodili postojećim uvjetima. Monitorira se srčana frekvencija, elektrokardiogram (EKG), broj respiracija, krvni tlak, te postotak zasićenja hemoglobina kisikom pulsnim oksimetrom. Postavljena je intravenska kanila čija se prohodnost održava infuzijom 500 mL 0,9 % NaCl. Nakon lokalne anestezije 1-2 mL 1 %-tnim lidokainom orofaringealnog područja bolesnik je sediran midazolamom (2,5 mg), n-fentanilom (5 mcg) te propofolom (bolus 100 mg i doza održavanja kontinuirano 4 mg /min). Nakon fl eksibilne bronhoskopije kroz nos od 5 minuta nastavlja se EBUS kroz usnik u trajanju od 22 minute. Dijagnostički postupak ukupno je trajao 27 minuta. Za vrijeme anestezije bolesnik je bio respiracijski i hemodinamski stabilan, diše spontano uz suplementaciju smjese zrak/kisik 1 : 1 volumnim modalitetom maksimalnog volumena 700 mL i frekvencije maksimalno 33/min. S takvom modifi - kacijom se postigla zadovoljavajuća ventilacija i zasićenost kisikom koja je na periferiji iznosila 94±4 %. Sistolički krvni tlak je iznosio 157±7 mm Hg, a dijastolički 78±9 mm Hg. Srčana frekvencija bila je 88±8/min. Bolesnik se nakon učinjenog dijagnostičkog zahvata uredno probudio. Anestezija je protekla bez komplikacija., A possible anesthetic procedure for diagnostic endobronchial ultrasound (EBUS) is presented. EBUS is a specifi c search for the diagnosis of newly emerged hilar and/or mediastinal lymphadenopathy and lung tumors. Anesthesia facilitates the performance of this diagnostic procedure for the patient and the physician. From previous studies, it is apparent that various anesthetic techniques are employed. The procedure can be performed in sedation with the application of local anesthetic and general anesthesia. When using local anesthetic sedation, the patient breathes spontaneously, general anesthesia maintains the respiratory tract with a laryngeal mask or an orotracheal tube. In the patient aged 57, body mass 94 kg, with regular pulmonary function according to ASA classifi cation, without known allergies, the EBUS diagnostic scan was indicated for increased lymph nodes in the mediastinum. Diagnostic EBUS is run on a remote site equipped with the Datex-Ohmeda S5 Aespire anesthetic device and the Philips IntelliVue MP60 monitor, and we adjusted the anesthetic process to the existing conditions. Heart rate, electrocardiogram, number of breaths, blood pressure, percentage of hemoglobin, oxygen saturation and pulse oximetry were monitored. Intravenous cannula was placed and infusion of 500 mL of 0.9% NaCl maintained. Following local anesthesia with 1-2 mL 1% lidocaine in the oropharyngeal area, the patient was sedated with midazolam (2.5 mg), n-fentanyl (5 mcg) and propofol (bolus 100 mg and continuous maintenance dose of 4 mg/min). After fl exible bronchoscopy through the nose for 5 min, the EBUS was continued through the mouth for 22 min. The diagnostic procedure took a total of 27 min. During anesthesia, the patient was respiratory and hemodynamically stable. The patient breathed spontaneously with the addition of air/oxygen mixture 1:1, with a modality of 700 mL maximum volume and maximum frequency of 33/min. Such modifi cation achieved satisfactory ventilation and oxygen saturation at the periphery of 94±4%. Systemic blood pressure was 157±7 mm Hg and diastolic pressure 78±9 mm Hg. Heart rate was 88±8 min. After completing the diagnostic procedure, the patient woke up neatly. Anesthesia was without complications.

Background FDG-PET–CT-based selective lymph node (LN) irradiation is standard using 3D-conformal techniques for locally advanced NSCLC. With newer techniques (intensity-modulated/volumetric-arc therapy (IMRT/VMAT)), the dose to non-involved adjacent LN decreases, which raises the question whether FDG-PET–CT-delineation is still safe. We therefore evaluated the impact of adding linear endosonography with needle aspiration (E(B)US-NA) to FDG-PET–CT in selective nodal irradiation. Methods Based on literature data on sensitivity and specificity of E(B)US-NA in FDG-PET–CT-staged NSCLC, false negative (FN) rates for different constellations of CT, PET and E(B)US-NA were calculated. The algorithm was tested on consecutive patients with N2/N3 disease referred for radiotherapy in Leuven and Maastricht. Results An algorithm determining when to include LN in the GTV is proposed, based on data from 5 meta-analyses. Adding E(B)US-NA to FDG-PET–CT decreases the FN-rate, but for PET-positive and E(B)US-negative LN, FN rates are still 14–16%. In Leuven 520 LN were analyzed, in Maastricht 364 LN; with E(B)US-NA a geographical miss was avoided in 2 (2/40=5%) and 1 (1/28=4%) patients, respectively. Conclusions E(B)US-NA in addition to FDG-PET–CT for mediastinal staging decreases the risk of a geographical miss with 4–5%. The impact of this small decrease on survival is unknown. The proposed algorithm may guide the radiation oncologist when to include LN in the nodal GTV.

Background and Objectives: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has a well-established role in the diagnosis and staging of lung cancer. This technology is also widely used for the diagnosis of mediastinal masses and cysts as well as other inflammatory disorders such as sarcoidosis. However, the utility of this procedure in the diagnosis and subclassification of lymphoproliferative disorders (LPDs) is not clear. We performed a systematic review to evaluate EBUS-TBNA use in LPDs. Materials and Methods: PubMed, EMBASE, MEDLINE, Cochrane Library Plus, and ISI Web of Knowledge were searched for studies of clinical trials in English reporting diagnostic performance of EBUS-TBNA in lymphoma until September 2014. The overall sensitivity, negative predictive value (NPV), and diagnostic accuracy were evaluated. Results: Six trials involving 346 patients with suspected lymphoma were included. The overall sensitivity, NPV, and diagnostic accuracy ranged 38%-91%, 83%-96.4%, and 91%-97%, respectively. Further invasive surgery was needed only in 13-43% of the patients. None of the studies included in the present review reported important complications. Conclusion: Current evidence suggests that EBUS-TBNA can be used as an initial evaluation for patients with suspected lymphoma. Additional surgical procedures may be necessary if a sample is inadequate or negative with high suspicion of lymphoma. Further multicenter trials are needed to evaluate the diagnostic yield of EBUS-TBNA in lymphoma patients.

Background and Objective: Endobronchial ultrasound (EBUS) is a minimally invasive endobronchial technique, which uses ultrasound along with a bronchoscope to visualize the airway wall and structures that are adjacent to it. Indications for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are samplings of mediastinal, hilar lymph nodes, and tumors adjacent to airway walls. EBUS-TBNA has been used in our clinic since 2009. The aim of the study is to evaluate the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of cytological and histological specimens, and the safety of EBUS-TBNA in an unselected patient population that has been referred to our hospital. Materials and Methods: We have retrospectively analyzed the medical documentation of 215 patients who had EBUS-TBNA performed in our clinic from April 2009 to February 2014. Results: There were 215 patients who underwent EBUS-TBNA. A total of 296 lymph nodes were sampled. EBUS-TBNA was diagnostic in 176 (81.9%) cases of cytological, 147 (68.4%) cases of histological, and 191 (88.9%) cases of the combined evaluation. In the lung cancer patients, EBUS-TBNA cytology had a sensitivity of 72.9% and histology of 72.9%, and in the sarcoidosis group, it had a cytology of 55.8% and histology of 64.5%. As all positive cytology and histology specimens were assumed to be true positive, specificity and positive predictive value (PPV) were 100%. The sensitivity and diagnostic accuracy was significantly higher when cytology and histology specimens were combined, compared with cytology or histology results evaluated separately (p < 0.05) (for lung cancer 84.1% and for sarcoidosis 78.8%). The sensitivity and diagnostic accuracy of EBUS-TBNA procedures increased significantly over time, with increased experience. There were no complications with EBUS-TBNA in our clinical practice. Conclusions: EBUS-TBNA had a high diagnostic yield and was safe in the diagnosis of lung cancer and sarcoidosis. It was most informative when cytology and histology were combined. The informative value of EBUS-TBNA histology increased with our experience.

Background: Mediastinal lymphadenopathy (ML) presents a diagnostic challenge. The technique to sample the lymph nodes has evolved from conventional "blind" transbronchial needle aspiration (TBNA) to the present day endobronchial ultrasound (EBUS)-guided procedure that improves the accuracy of sampling. Objective: This study was undertaken to evaluate the utility of "rapid on-site evaluation" (ROSE) in EBUS-guided TBNA (EBUS-TBNA) for the diagnosis of ML. Patients and Methods: This prospective study included 80 patients who underwent EBUS-TBNA for computed tomography/positron emission tomography (CT/PET) diagnosed ML over a 4-month period at a single tertiary care center. All 80 of these patients underwent histopathological evaluation (HPE) in addition to cytology. Three out of these 80 (3.7%) patients were excluded in view of inadequate material on EBUS-TBNA. After the sampling of nodes was done, the slides were stained with rapid hematoxylin and eosin (H&E) and then on-site evaluation was done. The tissue derived was also processed for HPE in all cases. Results: ROSE revealed granuloma in 27 patients and malignancy in 14 patients, and the remaining patients showed nonspecific inflammation. Concomitant histopathology revealed granuloma in 34 patients and malignancy in 14 patients. Considering HPE as gold standard, the overall sensitivity and specificity of EBUS-TBNA for diagnosis were 85.4% and 89.6%, respectively. For malignancy alone, the sensitivity and specificity were 100% and 98.4%, respectively. Conclusion: This novel approach is safe, has good diagnostic yield, and has an excellent potential in assisting safe and accurate diagnostic interventional bronchoscope.

Background and objectives There is a paucity of data concerning the impact of the sedation technique used for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) on diagnostic accuracy. The aim of this retrospective study was to compare the diagnostic accuracy of EBUS-TBNA in deep and moderate sedations, and to investigate other possible determinants of diagnostic accuracy in three lymph node locations (mediastinal, subcarinal, and hilar). Materials and methods The first consecutive patients at our institution undergoing EBUS-TBNA for selective sampling in deep sedation were compared with the first consecutive patients in moderate sedation between 2006 and 2014. Diagnoses based on EBUS-TBNA were compared with those on surgical or radiological follow-up. Results In a total of 232 patients, the overall diagnostic accuracy for correct diagnosis at the mediastinal, subcarinal, and hilar locations irrespective of the sedation technique was 91%, 93%, and 92%, respectively. At the three mentioned lymph node locations, overall diagnostic accuracy of EBUS-TBNA in deep sedation compared to moderate sedation was 88.5% and 95.5% (P = 0.3), 93.2 and 93.6% (P = 0.9), and 88.6 and 94.0% (P = 0.4), respectively. Conclusions The sedation technique does not seem to influence the diagnostic accuracy of EBUS-TBNA.