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Objective: EBUS‐TBNA is a method of acquiring tissue samples from intrathoracic lymph nodes and central intrathoracic tumours in patients suspected of having lung cancer. Rapid on‐site evaluation (ROSE) denotes assessing tissue samples during EBUS (or bronchoscopy), providing instant feedback on sample adequacy and provisional cytomorphological diagnosis. Sector multidisciplinary team (MDT) discussion can then make informed treatment decisions, with confirmatory immunohistochemistry being finalised before provision of final treatment. Currently, impact of ROSE on length of time patients spend on the lung cancer diagnostic pathway remains unclear. Methods: We retrospectively evaluated the impact of ROSE on the length of time between patients' EBUS/bronchoscopy procedures and discussion at sector MDT, referred to as time to treatment decision (TTD), at our institution. Additionally, we assessed impact of ROSE on number of passes (number of times nodes/masses were sampled) per procedure. Results: The mean TTD was 77.9% shorter (p = 0.001) with ROSE present than when absent. Patients who received ROSE spend 34.3% less time (p = 0.028) on lung cancer diagnostic pathway overall. There was a significant reduction in number of passes in non‐malignant nodes with ROSE present (2.23) than when absent (3.14) (p < 0.001). With ROSE present there was a significantly greater number of passes at malignant sites (5.07) than non‐malignant sites (2.23) (p < 0.001). Conclusions: These findings support conclusions made in our institution's previous study, that utilisation of ROSE reduces TTD. ROSE also allows safe advancement through nodes with low suspicion of malignant involvement, focusing time on sampling nodes/masses of greater suspicion. [ABSTRACT FROM AUTHOR]

Lung cancer is among one of the most commonly diagnosed malignancies and is the leading cause of cancer-related mortality in both men and women globally, with an estimated 1.8 million deaths annually. Moreover, it is also the leading cause of cancer related deaths in the United States (U.S.), with an estimated 127,000 deaths annually. Approximately 50% of patients who undergo chest Computed Tomography (CT) are found to have a pulmonary nodule (PN), albeit 95% of these PNs are subsequently found to be benign. Further complicating the challenge of timely detection of lung cancer, is made more difficult by the fact that most patients are totally asymptomatic in early stage of disease. However, given that sponsored studies by National Cancer Institute (NCI) and other organizations showed a 20% reduction in lung cancer specific mortality with low dose CT scanning in patients at risk, it is reasonable to assume that clinicians will confront this clinical scenario more frequently. Consequently, due to these significant findings, the United States Preventive Services Task Force (USPSTF) recommended annual screening of high-risk patients. Therefore, as result of these recommendations, 240,000 new lung cancers were diagnosed in the U.S. in 2020, with an estimated 238,000 new cases in 2023. Given the multitude of challenges, the practice guidelines and recommendations for the management of these PNs are often tailored to available resources and trained personnel familiar with the various techniques and technologies. This review will discuss the evolution of various advancements when tissue biopsy is required: from sputum cytology, nonguided bronchoscopy, percutaneous CT guided biopsy, guided advanced bronchoscopic techniques such as endobronchial ultrasound (EBUS), radial Endobronchial Ultrasound (rEBUS) to the latest advancement of robotic-assisted bronchoscopy (RAB). Furthermore, as many of the aforementioned techniques require anesthesia, as integral members of the multidisciplinary team, anesthesiologists are often in the unique position of facilitating diagnosis and subsequent treatment by other subspecialists when providing anesthetic care for these patients with PNs. Additionally, the common anesthetic considerations and implications for the preoperative, intraoperative, and postoperative periods will be elucidated further, with special emphasis on the unique considerations for RABs. Combined hybrid procedures with RAB, EBUS and surgery will also be reviewed, as they offer potential reduction in time of diagnosis to definitive treatment. Lastly, the strategies employed to mitigate some of the commonly encountered challenges faced by anesthesiologists when caring for these patients will also be reviewed. [ABSTRACT FROM AUTHOR]

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard-of-care modality for evaluating mediastinal lymph nodes and masses. The EBUS bronchoscope may also be introduced through the oesophageal route to perform sampling of accessible lesions, a technique described as transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA). Because of the central oesophageal approach, EUS-B-FNA provides easy access to the left para-tracheal, subcarinal and para-oesophageal lymph nodes. In addition, the left adrenal gland (LAG) can also be imaged and sampled during the EUS-B-FNA procedure. In patients with suspected lung cancer, accurate staging is essential. Adrenal metastasis is relatively common and may often be a solitary metastatic site. We describe three cases where EUS-B-FNA was performed to safely sample the enlarged LAG in suspected lung cancer. We also review the literature on the performance characteristics of EUS-B-FNA for LAG aspiration. [ABSTRACT FROM AUTHOR]

Abstract Background Research in treatment of non-small cell lung cancer (NSCLC) has shown promising results with stereotactic ablative radiotherapy (SABR) of oligometastatic disease, wherein distant disease may be limited to one or a few distant organs by host factors. Traditionally, PET/CT has been used in detecting metastatic disease and avoiding futile surgical intervention, however, sensitivity and specificity is limited to only 81 and 79%, respectively. Mediastinal staging still identifies occult nodal disease in up to 20% of NSCLC patients initially thought to be operative candidates. Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive tool for the staging and diagnosis of thoracic malignancy. When EBUS is combined with endoscopic ultrasound using the same bronchoscope (EUS-B), the diagnostic sensitivity and negative predictive value increase to 84 and 97%, respectively. Endoscopic staging in patients with advanced disease has never been studied, but may inform treatment if a curative SABR approach is being taken. Methods This is a multi-centre, prospective, cohort study with two-stage design. In the first stage, 10 patients with oligometastatic NSCLC (lung tumour ± hilar/mediastinal lymphadenopathy) with up to 5 synchronous metastases will be enrolled An additional 19 patients will be enrolled in the second stage if rate of treatment change is greater than 10% in the first stage. Patients will be subject to EBUS or combined modality EBUS/EUS-B to assess bilateral lymph node stations using a N3 to N2 to N1 progression. Primary endpoint is defined as the rate of change to treatment plan including change from SABR to conventional dose radiation, change in mediastinal radiation field, and change from curative to palliative intent treatment. Discussion If a curative approach with SABR for oligometastatic disease is being explored, invasive mediastinal staging may guide treatment and prognosis. This study will provide insight into the use of endoscopic mediastinal staging in determining changes in treatment plan of NSCLC. Results will inform the design of future phase II trials. Trial registration Clinicaltrials.gov identifier NCT04852588. Date of registration: April 19, 2021. Protocol version: 1.1 on December 9, 2021.

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. [ABSTRACT FROM AUTHOR]

Breast cancer is the most prevalent cancer among women worldwide. Despite significant advancements in breast cancer treatments over the past decade, late recurrence, a hallmark of breast cancer, remains a major challenge for oncologists. In this case report, we present an atypical presentation of late breast cancer recurrence as a peri-bronchial lesion manifesting as dysphagia 14 years after completing treatment for primary breast cancer. Radiological imaging revealed a peri-bronchial lesion and a subcutaneous nodule in the left mastectomy bed. This case posed a diagnostic dilemma for the attending physicians in distinguishing between late breast cancer recurrence and the possibility of two synchronous primary malignancies. The patient was ultimately diagnosed with metastatic breast cancer with histological confirmation. This case underscores the importance of correlating clinical presentation, radiological images, histopathology examinations and immunohistochemical results to ensure a comprehensive and accurate diagnosis., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Tseu et al.)

Introduction: Pulmonary endoscopy occupies a central role in Interventional Pulmonology and is frequently the mainstay of diagnosis of respiratory disease, in particular lung malignancy. Older techniques such as rigid bronchoscopy maintain an important role in central airway obstruction. Renewed interest in the peripheral pulmonary nodule is driving major advances in technologies to increase the diagnostic accuracy and advance new potential endoscopic therapeutic options., Areas Covered: This paper describes the role of pulmonary endoscopy, in particular ultrasound in the diagnosis and staging of lung malignancy. We will explore the recent expansion of ultrasound to include endoscopic ultrasound - bronchoscopy (EUS-B) and combined ultrasound (CUS) techniques. We will discuss in detail the advances in the workup of the peripheral pulmonary nodule.We performed a non-systematic, narrative review of the literature to summarize the evidence regarding the indications, diagnostic yield, and safety of current bronchoscopic sampling techniques., Expert Opinion: EBUS/EUS-B has revolutionized the diagnosis and staging of thoracic malignancy resulting in more accurate assessment of the mediastinum compared to mediastinoscopy alone, thus reducing the rate of futile thoracotomies. Although major advances in the assessment of the peripheral pulmonary nodule have been made, the role of endoscopy in this area requires further clarification and investigation.

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been used to diagnose and stage lung cancer. Acquire™ Pulmonary and Expect™ Pulmonary dedicated EBUS-TBNA needles were introduced as the Franseen and Lancet needles, respectively. It is still unclear whether the Franseen or Lancet needles yield a higher quality specimen especially focusing on next-generation sequencing-based molecular testing., Methods: A single-center, prospective study performed at the Chiba University Hospital randomly assigned patients to two groups: Group A, wherein the first and second EBUS-TBNA were performed using Lancet and Franseen needles, respectively, and Group B, wherein the first and second EBUS-TBNA were performed using Franseen and Lancet needles, respectively. Each specimen was compared and analyzed pathologically. The primary outcome was the histological tissue area except blood clot and the cellularity of each sample. We also examined the success rate of molecular testing., Results: Twelve patients who underwent EBUS-TBNA between November 2022 and February 2023 were enrolled in this study. The tissue area of the specimens obtained by the Franseen and Lancet needles was 13.3 ± 6.4 mm2 and 10.6 ± 6.3 mm2, respectively (P = .355). The tumor cellularity in the specimens obtained using the Franseen and Lancet needles was 54.0 ± 30.3 and 46.2 ± 36.3%, respectively (P = .608). The success rate of molecular testing using the single-pass sample by Franseen needle was 85.7 and 57.1% by Lancet needle. No serious complications were reported., Conclusions: The Franseen needle tended to show a greater amount of specimen with higher tumor cellularity than the Lancet needle which may contribute higher success rate of molecular testing. Further studies must be conducted to validate the results of this study., Key Findings: What is known and what is new?  What is the implication, and what should change now?, (© The Author(s) 2024. Published by Oxford University Press.)

Lung cancer remains the most common cause of cancer-related deaths in the United States. Traditional treatment of non-small cell lung cancer has included surgical resection for suitable candidates with early stage (I/II) disease and various chemoradiotherapeutic regimens used for advanced disease, for which prognosis has been poor. Since the early 2000s, there has been a revolution in the diagnosis and treatment of non-small cell lung cancer driven by improved diagnostic techniques and therapies targeted to druggable oncogenic drivers or manipulation of the immunologic milieu in the tumor microenvironment. With this has come a need for frequently updated comprehensive data regarding response to treatment and acquired resistance to targeted therapies. In this article, we aim to provide a concise review of the state-of-theart in lung cancer workup in 2021, with a focus on how molecular data now informs treatment decisions. With the burgeoning use of immunotherapeutic approaches, we will also discuss some of the complications seen, and briefly discuss their management. [ABSTRACT FROM AUTHOR]

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.

Aim: The initial mutation status of non-small cell lung cancer (NSCLC) is important for guiding treatment. However, re-biopsy is needed to determine the new mutation status in patients receiving targeted therapy or who develop resistance during first-line therapy. Endobronchial ultrasound (EBUS) is an important tool to obtain adequate tissue for molecular analyses. Materials and Methods: We used a clinical database of 349 patients who were previously included in a multi-center study. Adequacy of tissue collected, new molecular profile, and treatment regimens were evaluated. Results: A total of 50 patients (median age of 60 ± 9 years) received biopsy by EBUS. The success rate was 36% (n = 18), and repeat re-biopsy was performed for patients with anthracosis (n = 32). In 18 patients, only one lymph node station was sampled. Initial histopathology was adenocarcinoma in 28 patients, squamous cell carcinoma (SCC) in 18 patients, and not otherwise specified (NOS) in four patients. No correlation was found between initial treatment type and success rate of the procedure (p = 0.101). After re-biopsy in six patients (five of whom had newly detected mutations), targetable mutations were detected for T790M (n = 2), EGF-Rexon 19 (n = 1), c-Met (n = 1), and EGFR-21 (n = 2). Conclusion: : In cases of resistance to treatment, re-biopsy should be performed to detect different gene amplifications. Re-biopsy with EBUS is an effective method for an appropriate progressive lesion. [ABSTRACT FROM AUTHOR]

A 65-year-old male with a history of multiple myeloma and melanoma presented to the hospital with shortness of breath and lightheadedness. He was subsequently diagnosed with mild superior vena cava (SVC) syndrome due to a metastatic melanoma mediastinal mass. While melanoma frequently metastasizes to the lungs, the occurrence of SVC syndrome resulting from metastatic melanoma is exceedingly rare compared to other malignancies like lung cancer. Consequently, data on the incidence or prevalence of SVC syndrome caused by metastatic melanoma are sparse and variable. This case particularly underscores the rarity of melanoma causing SVC syndrome, as evidenced by the oncology team's request to perform a second biopsy to confirm the diagnosis. This case also highlights the need for a tailored diagnostic and management approach, providing valuable insights into the diverse presentations of melanoma and enriching the medical literature on this subject., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jafri et al.)

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.

Endobronchial ultrasound (EBUS)-guided mediastinal cryobiopsy is a novel technique that increases the accuracy of diagnosing most pathologies that affect the mediastinum. Although EBUS-guided transbronchial needle aspiration (EBUS-TBNA) is the first choice in the diagnosis of mediastinal pathology, mediastinal cryobiopsy offers a larger and higher quality biopsy with minimal artifacts and no crushing when compared to conventional cytological samples obtained through EBUS-TBNA. It is particularly valuable in pathologies where EBUS-TBNA has diagnostic limitations, such as lymphoproliferative diseases, benign granulomatous conditions like sarcoidosis and silicosis, some rare infectious processes, metastases from rare non-pulmonary tumors, and in advanced stages of non-small cell lung cancer (NSCLC) where immunohistochemistry and molecular analysis are essential for personalized treatment. Therefore, mediastinal cryobiopsy seems to play a crucial role in these challenging scenarios. However, there is ongoing debate in the field of interventional pulmonology regarding the best approach for obtaining a mediastinal cryobiopsy. Some interventional pulmonologists use a high-frequency needle knife to create an incision in the tracheobronchial wall adjacent to the mediastinal lesion before inserting the cryoprobe, while others use a needle to create a pathway to the target area. There are also variations in the use of endoscopic or ultrasound imaging for guidance. In this article, we aim to review the current literature on different methods of performing mediastinal cryobiopsy and share our own clinical experience and methodology in a systematic way for its implementation in a safe, fast, and effective way., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-23-65/coif). The authors have no conflicts of interest to declare., (2024 Mediastinum. All rights reserved.)

Sarcoidosis is a multisystem inflammatory disorder with unclear etiology and can often pose a diagnostic challenge. A tissue diagnosis is often necessary to illustrate the non-caseating granulomas on histopathology. This review aims to synthesize current evidence related to tissue diagnosis of sarcoidosis using various bronchoscopic techniques. We start by discussing standard bronchoscopic techniques which have remained the cornerstone of diagnostic workup such as bronchoalveolar lavage (BAL), endobronchial biopsy (EBB), conventional transbronchial needle aspiration (cTBNA) and transbronchial lung biopsy (TBLB) followed by newer modalities that incorporate real-time image guidance using endobronchial and endoscopic ultrasound. Although BAL, EBB, and TBLB have been employed as a diagnostic tool for several decades, their sensitivity and diagnostic yield is inferior to ultrasound-based endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). More recently, convincing evidence has also emerged to support the diagnostic accuracy and tissue yield of transbronchial lung cryobiopsy which will also be discussed in this review. These advances in bronchoscopic equipment and techniques over the last 2 decades have made it possible to obtain tissue samples using minimally invasive techniques thus avoiding invasive open lung biopsy and the risks that inherently follow. Up-to-date knowledge of these modalities is imperative for ensuring evidence-based medicine and improving patient-centric outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Radiotherapy is a standard treatment modality in cancer therapy, particularly for lung cancer. Diffusing alpha-emitters Radiation Therapy sources (hereafter, "Alpha DaRTs") are fixed with Ra-244 (half-life =3.6 days) that releases alpha-emitting atoms into the tumor tissue to an effective range of a few millimeters., Methods: The feasibility, usability, and safety of Alpha DaRTs deployment and implantation via bronchoscopy into the lung parenchyma and mediastinum in a big animal model of healthy swine was studied in two phases: (I) inert and (II) active Alpha DaRTs deployment. The Alpha DaRTs were inserted in both individual and cluster patterns based on a predefined plan. Swine health was monitored throughout the study. The usability of bronchoscopic deployment and implantation was evaluated using a user questionnaire. The movement and migration of the Alpha DaRTs were assessed. Necropsy was performed, and lungs were evaluated via gross pathology and histopathology., Results: A total of 158 Alpha DaRTs were inserted successfully in the lung parenchyma and mediastinum of five swine in two phases. It was possible to deliver and place the Alpha DaRTs in clusters of no more than 4 mm distance between the Alpha DaRTs. No adverse event or change in the health and general condition of animals was observed. Hematologic evaluation did not show any clinically significant abnormality related to the Alpha DaRTs. Histopathology demonstrated local mild inflammatory changes, minimal fibrosis, and dystrophic mineralization with giant cells. Minimal movement and no migration of Alpha DaRTs were observed., Conclusions: Bronchoscopic deployment of Alpha DaRTs in the lung parenchyma and mediastinum of the porcine animal is feasible, precise, and safe., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-23-639/coif). All authors report that this study was funded by Alpha Tau Medical. A.S. (Ali Sadoughi) has been compensated for the expenses of educational and training events by Merit Medical, Olympus, Siemens, AcuityMD and Boston Scientific, served on advisory board for Mauna Kea, received consulting fee from Alpha Tau Medical and Olympus, and has stock option at Alpha Tau. N.O. received research funds from AstraZeneca and Merck and received consulting fees from AstraZeneca, Genentech and Merck. The authors have no other conflicts of interest to declare., (2024 Translational Lung Cancer Research. All rights reserved.)

Background: The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in staging mediastinal and hilar lymph nodes in non-small cell lung cancer (NSCLC) is well established. However, evidence of its diagnostic utility in other pathologies-such as lymphoma-remains inadequate. This retrospective observational study aims to determine the diagnostic yield of EBUS-guided miniforceps biopsy (EBUS-MFB) compared to EBUS-TBNA in both malignant and nonmalignant conditions., Methods: We conducted a retrospective cross-sectional chart review of all adult patients referred for EBUS at our institution between January 2019 and December 2022. All patients who underwent both EBUS-TBNA and EBUS-MFB were included, with some patients also undergoing transbronchial cryobiopsy. Patients without pathology reports available were excluded., Results: The combination of EBUS-MFB and EBUS-TBNA had the highest percentage of diagnostic results both in the overall cohort (34.4%) and in patients who did not undergo transbronchial cryobiopsy (46.2%). EBUS-MFB alone yielded more diagnostic results compared to EBUS-TBNA. Transbronchial cryobiopsy was the sampling method with the highest percentage of diagnostic results in the cryobiopsy group (64.5%). Statistical analysis revealed a significant difference in diagnostic yield between EBUS-MFB and EBUS-TBNA (P<0.001), with EBUS-MFB showing a higher diagnostic yield overall. EBUS-MFB had a significantly higher diagnostic yield than EBUS-TBNA in benign cases, in patients diagnosed with sarcoidosis, but not in malignant disease., Conclusions: Our study suggests that combining EBUS-MFB with EBUS-TBNA can improve the diagnostic yield, particularly in benign cases and sarcoidosis. These findings support the potential superiority of adding EBUS-MFB over EBUS-TBNA alone and highlight the need for further randomized control trials to validate these results. The retrospective nature of this study and certain limitations, such as the lack of adequate longer-term follow-up, selection and operator biases, and the absence of rapid on-site evaluation (ROSE) in some cases, should be considered when interpreting the results. Nonetheless, this study contributes to the growing evidence for the utility of EBUS-MFB in improving the diagnostic yield of EBUS procedures in specific clinical scenarios., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-884/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Background and Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe, and well-established method for diagnosing and staging lung cancer and other conditions associated with mediastinal lymphadenopathy. Efforts have been made to enhance the material adequacy of EBUS-TBNA, including the recent introduction of EBUS-guided transbronchial mediastinal cryobiopsy (EBUS-TMC). This advancement facilitates the acquisition of larger and better-preserved tissue samples from the mediastinum. We evaluated the diagnostic accuracy and safety of EBUS-TMC in the diagnosis of malignant lesions and its effectiveness in relation to benign conditions, such as tuberculosis and sarcoidosis., Methods: We searched the PubMed ® database for relevant English articles published up to July 1, 2023. Subsequently, we conducted a comprehensive bibliographic analysis with a particular emphasis on diagnostic yield, safety profile, and procedural technicalities., Key Content and Findings: Our narrative review, comprising seven publications, emphasizes the significance of EBUS-TMC as an effective technique for obtaining diagnostic tissue in malignant and benign conditions while maintaining an excellent safety profile. Furthermore, its capability for obtaining larger tissue samples facilitates molecular and immunological analysis in non-small cell lung cancer., Conclusions: EBUS-TMC exhibits significant efficacy with regard to obtaining diagnostic tissue in malignant and benign conditions. However, further studies are needed to evaluate uncertainties regarding the selection of suitable cases and technical intricacies., Competing Interests: Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-23-34/coif). M.O. reports receiving speaker fees from Olympus Corporatio and AMCO Inc. as a guest speaker at academic medical meetings. The other author has no conflicts of interest to declare., (2024 Mediastinum. All rights reserved.)

Abstract: Background and objective: Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) has emerged as a minimally invasive technique for diagnosing intrathoracic malignancies and some benignancies; however, there are no data available on the utility of EBUS‐TBNA for the diagnosis of non‐specific inflammatory intrathoracic lymphadenitis. Methods: A prospective analysis was performed from 104 patients with enlarged lymphadenopathy suspected of non‐specific lymphadenitis referred for EBUS‐TBNA between October 2009 and March 2012. Rapid on‐site cytological evaluation was not adopted. Microbiological tests were carried out in all patients. Patients were excluded from the study if there was other diagnosis being defined. Results: One hundred ninety‐one lesions were aspirated in 94 patients with enlarged mediastinal/hilar lymph nodes within reach of EBUS‐TBNA, which were diagnosed as non‐specific intrathorcacic lymphadenitis by pathology and clinical follow‐up. According to EBUS‐TBNA pathologies, 94 patients were categorized into four kinds: (i) inflammatory cell infiltrates and/or noncaseating necrosis in 38 cases; (ii) granuloma formed by epithelioid cells and/or fiber hyperplasia in 13 cases; (iii) lymph node tissue/lymphocyte without obvious abnormal lesions in 41 cases; (iv) inadequate sample in 2 cases. Bacterial and/or fungal smears and cultures were carried out in all 94 patients (100%), with pathogens being found in 4 (4.3%) cases. All patients (100%) underwent acid‐fast staining and culture for mycobacterium tuberculosis to exclude tuberculosis. No procedure‐related complication was observed. Conclusions: EBUS‐TBNA can provide pathological and microbiological evidences for diagnosing non‐specific inflammatory intrathoracic lymphadenopathy, and it is a safe and effective first‐line investigation for ruling out malignancies and other benign diseases. [ABSTRACT FROM AUTHOR]

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.

Biopsying lung tumours with endobronchial access in patients with respiratory impairment is challenging. However, fine needle aspiration with the endobronchial ultrasound-endoscope via the oesophagus (EUS-B-FNA) makes it possible to obtain tissue samples without entering the airways. Safety of EUS-B-FNA in these patients has not earlier been investigated prospectively. Therefore, this study aimed at assessing feasibility and safety of EUS-B-FNA from centrally located tumours suspected of thoracic malignancy in patients with respiratory insufficiency. The study is a prospective observational study. Patients with indication of EUS-B-FNA of centrally located tumours and respiratory impairment defined as modified Medical Research Council (mMRC) dyspnoea scale score of ≥3, saturation ≤90% or need of continuous oxygen supply were included prospectively in three centres. Any adverse events (AEs) were recorded during procedure and 1-hour recovery. AEs were defined as hypoxemia (saturation <90% or need for increased oxygen supply) or any kind of events needing intervention. Late procedure-related events were recorded during 30-day follow-up. Between April 1, 2020 and January 30, 2021, 16 patients were included. No severe AEs (SAEs) occurred, but AEs were seen in 50% (n=8) and 13% (n=2) of the patients during procedure and recovery respectively. AEs included hypoxemia corrected with increased oxygen supply and in two cases reversal of sedation. Late procedure-related events were seen in 13% (n=2) and included prolonged need of oxygen and one infection treated with oral antibiotics. In this cohort, EUS-B-FNA of centrally located tumours was safe and feasible in patients with respiratory impairment, when examined in the bronchoscopy suite. A variety of mostly mild and manageable complications may occur, a few even up to 30 days post-procedure., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-1705/coif). ISC received unrestricted research grants from the following funds: the Danish Respiratory Society, Neye Fonden, Dagmar Marshalls Fond and Else og Mogens Wedell Wedellsborgs Fond. The other authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a first-line approach for diagnosing hilar and mediastinal lymph node metastasis. Endobronchial ultrasound (EBUS) elastography is an imaging technique for describing the elasticity of intrathoracic lesions. However, the reported accuracy of EBUS elastography needs to be improved. In this study, we aimed to explore the diagnostic value of EBUS elastography for differentiating between benign and malignant hilar and mediastinal lymph nodes., Methods: We conducted a single-center, retrospective study enrolling consecutive patients who received EBUS elastography followed by EBUS-TBNA at the Chinese PLA General Hospital from October 2015 to October 2022. The pathological results of EBUS-TBNA confirmed by 6-month follow-up were used as the gold standard. The ultrasound elastography parameters of lymph nodes included strain rate, stiff area ratio, and elasticity score, along with the conventional ultrasound characteristics such as short axis diameter, shape, margin, echogenicity distribution and intensity, and blood flow. The diagnostic performance of these parameters was compared, and conjointly analyzed using multivariate logistic regression. Bootstrapping resampling was applied for internal validation of the regression model., Results: A total of 83 patients were enrolled with an average age of 57 years, and 66.3% of patients were male. In total, 131 lymph nodes were punctured, among which 79 (60.3%) were malignant. All the conventional ultrasound characteristics were significantly different between benign and malignant lymph nodes. All the ultrasound elastography parameters of malignant lymph nodes were markedly higher than those of benign lymph nodes. Multivariate logistic regression analysis showed that the margin, echogenicity intensity, blood flow, short axis diameter, and stiff area ratio were the main factors affecting the lymph node property. The diagnostic accuracy, sensitivity, and specificity were 91.8% [95% confidence interval (CI): 85.4-96.0%], 94.4% (95% CI: 86.4-98.5%), and 88.0% (95% CI: 75.7-95.5%), respectively. Bootstrap resampling validation showed a concordance index (C-index) of 0.949. The calibration plot indicated good agreement between the predicted and observed results., Conclusions: EBUS elastography is a promising approach for differentiating between benign and malignant lymph nodes. The combination of conventional EBUS and elastography can improve diagnostic efficacy, provide reliable complementary information, and guide the implementation of EBUS-TBNA more accurately., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-23-241/coif). The authors have no conflicts of interest to declare., (2023 Quantitative Imaging in Medicine and Surgery. All rights reserved.)

Background: Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is the standard for evaluating mediastinal and hilar lesions. EBUS-TBNA is limited by small volume of material obtained for immunohistochemistry (IHC) and ancillary studies important for oncological therapies. The Franseen Acquire TM needle is designed for EBUS-transbronchial needle core biopsy (TBNB) allowing larger core sizes with evidence in gastroenterology literature but little in pulmonology. This study reports the first Asia-Pacific experience of EBUS-TBNB and adequacy of samples for diagnosis and ancillary studies., Methods: A retrospective cohort study of EBUS-TBNB at the Royal Adelaide Hospital was conducted between December 2019 and May 2021. Diagnostic rate, adequacy for ancillary studies and complications were evaluated. Samples were flushed into formalin for histological processing with no rapid on-site cytological evaluation (ROSE). For suspected lymphoma, samples were flushed into HANKS for flow cytometry. Cases performed with the Olympus Vizishot TM during the same 18-month were similarly analysed., Results: One hundred and eighty-nine patients were sampled with the Acquire TM needle. Diagnostic rate was 174/189 (92.1%). Where reported [146/189 (77.2%)], average core aggregate sample size was 13.4 mm × 10.7 mm × 1.7 mm. For non-small cell lung cancer (NSCLC) cases, 45/49 (91.8%) had adequate tissue for programmed cell death-ligand 1 (PD-L1). 32/35 (91.4%) adenocarcinoma cases had sufficient tissue for ancillary studies. There was one false negative malignant lymph node at the first Acquire TM procedure. There were no major complications. One hundred and one patients were sampled with the Vizishot TM needle. Diagnostic rate was 86/101 (85.1%) with only 25/101 (24.8%) having reported tissue cores (P<0.0001 of Vizishot TM ) with the remaining samples processed via cell block., Conclusions: Acquire TM EBUS-TBNB diagnostic rate is comparable to historical data with >90% of cases having sufficient core material for ancillary studies. There appears to be a role for the Acquire TM alongside the standard of care for the work up of lymphadenopathy and particularly for lung cancer., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-1747/coif). PN has had presentation fees from Boston Scientific Australia relating to the content of this manuscript. PN has had consultancy fees from Olympus Medical Corporation Australia not relating to contents of this manuscript. The other authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

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. [ABSTRACT FROM AUTHOR]

Background: Multimodal transbronchial biopsy (TBB) may have improved diagnostic yield for peripheral pulmonary lesions suspected as lung cancer. Radial endobronchial ultrasound (R-EBUS) provides real-time imaging and confirmation of the location of the lesions. Cone-beam computed tomography (CBCT) can confirm that the forceps tip has reached the lesion before biopsy., Methods: Patients with peripheral pulmonary lesions and a positive computed tomography (CT) bronchus sign (based on slice thickness of 1 mm) were prospectively enrolled. An ultrathin bronchoscope (UTB) and R-EBUS probe were advanced to the target bronchus. Thereafter, forceps were advanced, and CBCT was performed. R-EBUS was performed for re-navigation, if possible. The obtained EBUS and CBCT images were classified into "within" (type 1), "adjacent to" (type 2), or "far from" (type 3), based on the probe or forceps tip., Results: For 20 lesions, the diagnostic yield was 85%. The primary EBUS images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. The primary CBCT images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. Primary EBUS and CBCT image types were equivalent in 14 cases. Of the 12 cases with type 1 primary EBUS image, 9 cases had a type 1 primary CBCT image, while 3 cases exhibited positional misalignment of the forceps tip. Re-navigation was required in 8 cases with types 2 and 3 primary CBCT images., Conclusions: CBCT-guided TBB using an UTB and EBUS may enable real-time positioning guidance and better re-navigation in the diagnosis of peripheral pulmonary lesions., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-1369/coif). H Takizawa serves as an unpaid editorial board member of Journal of Thoracic Disease. The other authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

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. [ABSTRACT FROM AUTHOR]

BACKGROUND There is no widely accepted rapid on-site evaluation (ROSE) reporting system for endobronchial ultrasound-guided transbronchial needle aspiration. At the University of Arkansas for Medical Sciences, ROSE reporting was unstructured. The goal was to evaluate, compare, and improve upon 2 structured approaches proposed in the literature. METHODS One hundred eighteen consecutive nodal aspirates were retrospectively reviewed by a pathology resident and a staff cytopathologist, both of whom were blinded to the original unstructured readings. Each reviewer interpreted every specimen with 2 different structured criteria proposed in the literature: criteria from the University of Minnesota (the Minnesota [MN] criteria) and criteria from the North Shore Long Island Jewish Health System (the New York [NY] criteria). The data allowed a comparison of the original unstructured ROSE system with the MN and NY scoring schemes and the final diagnosis. RESULTS Original on-site adequacy (OSA) had been assessed at 96%. Three cases were false-adequate according to the original unstructured approach; these had been called adequate on site, but a subsequent slide review including cell blocks did not show definite nodal tissue. OSA dropped to 86% with the MN criteria and to 85% with the NY criteria. No false-adequate on-site diagnoses would have been rendered with the application of either structured criteria. There were no significant differences between the MN and NY criteria with respect to the determination of OSA. An assessment of ease of application favored the NY criteria. With respect to diagnostic categories, each of the systems (MN and NY) was felt to have a category of value not used by the other system. CONCLUSIONS A standardized intra- and inter-institutional system for ROSE reporting is needed. On the basis of comparative analyses and consensus, modifications to prior criteria have been proposed in the hope of approaching this goal. Cancer (Cancer Cytopathol) 2015;123:362-72. © 2015 American Cancer Society [ABSTRACT FROM AUTHOR]

Purpose: Although bronchoscopy has conventionally been performed using conscious sedation, advanced diagnostic techniques like endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), peripheral EBUS, and electromagnetic navigational bronchoscopy add to procedural complexity. The adaptation of these techniques by bronchoscopists of varied backgrounds is expanding. It is not clear how patients will tolerate these advanced procedures when they are performed using traditional conscious sedation. Methods: We prospectively studied patients that underwent diagnostic bronchoscopic procedures using conscious sedation over a 1-year period. The primary outcome was patient tolerability measured with four questions soliciting subjective responses. Secondary outcomes included required dosage of medications, thoroughness of the procedure, diagnostic yield, and occurrence of complications. Results: A total of 181 patients were enrolled. Compared to patients in whom conventional bronchoscopy with transbronchial biopsies were performed, there was no difference in patient tolerability using the advanced techniques. Although some of the advanced procedures added to the procedure time, the required amount of medication was within commonly accepted dosages. When EBUS-TBNA was performed, a mean of 2.8 lymph node stations per patient were sampled. A specific diagnosis was obtained in 55.9 % of patients who solely underwent EBUS-TBNA. The diagnostic yield increased to 75.7 % when a parenchymal abnormality prompted additional biopsies. One patient required sedation reversal. Complications were minimal. Conclusions: This study suggests that advanced diagnostic bronchoscopic procedures are well tolerated using conscious sedation with no compromise of thoroughness, diagnostic yield, or safety. This may be useful for bronchoscopists using these techniques who do not have ready access to general anesthesia. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Stage classification is important because it allows consistent definition of patient groups, and thus provides a foundation for comparison of outcomes. For patients with multiple pulmonary foci of lung cancer, however, the classification rules are ambiguous and confusing. Materials and methods: We surveyed experts and clinicians who regularly evaluate patients with lung cancer to see how similar or different their interpretation of the official stage classification was for such patients. Results: We found a great deal of inconsistency in how four clinical scenarios were classified. No method of classification was chosen by a majority when there were more than two choices allowed by the classification rules. In a scenario with pulmonary foci of cancer of different histologic types, 86% classified this as separate primary cancers and 14% as multifocal lung cancer. Conclusion: The marked variability in classification must be taken into account when interpreting reported outcomes of patients with multiple pulmonary foci of lung cancer. [Copyright &y& Elsevier]

Background: Radial endobronchial ultrasonography transbronchial biopsy with and without a guide sheath is a useful method for diagnosing peripheral pulmonary lesions (PPLs). However, the diagnostic yield and complications of radial endobronchial ultrasonography transbronchial biopsy for PPLs remains elusive in patients with interstitial lung disease (ILD)., Methods: We retrospectively analysed 431 patients (69 with and 362 without ILD) who underwent radial endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) for PPLs from April 1, 2011, to March 31, 2020. We investigated the diagnostic yield and complications of the procedure for PPLs and compared them between patients with and without ILD. We also evaluated the factors contributing to successful diagnosis., Results: The diagnostic yield of radial endobronchial ultrasonography in patients with ILD was significantly lower than in those without ILD (62.3% vs. 75.4%, P=0.024). Multivariate analysis showed that the presence of ILD as background lung [odds ratio (OR) =0.517], probe position within the lesion (OR =4.654), and the presence of solid lesion (OR =1.946) significantly affected the diagnostic yield of PPLs. There was a significant difference in the rate of pneumothorax between the patients with ILD and those without ILD (4.3% vs. 0.6%, P=0.031)., Conclusions: The presence of ILD as the background lung significantly affected the diagnostic yield of PPLs with radial EBUS-GS TBB. Regarding the complications, pneumothorax occurred more frequently in patients with ILD than in those without ILD., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-809/coif). TFCY serves as an unpaid editorial board member of Journal of Thoracic Disease from April 2022 to March 2024. The other authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

The current management of non--small cell lung cancer (NSCLC) requires pathological differentiation between adenocarcinoma and squamous cell carcinoma using immunohistochemistry and morphological analysis. Additionally, as novel therapies for specific genetic mutation and chromosomal rearrangement profiles in patients with adenocarcinoma are becoming more numerous and clinically available, adequate tissue acquisition and specimen processing have become crucial. Historically, tissue was obtained via mediastinoscopy or video-assisted thoracoscopy (VATS). However, 80% of patients with lung cancer are ultimately found to be nonsurgical candidates. More recently, endobronchial ultrasound-guided transbronchial needle aspiration (EBUSTBNA) has been shown to be a safe and potentially superior modality to obtain tissue for diagnosis, staging, and molecular profiling. The preparation of tissue specimens has also been the subject of study as differentmethods have been shown to increase cellular yield. This is of particular importance as the number of clinically significant targetable mutations and chromosomal rearrangements continues to grow and the need for more tissue increases. [ABSTRACT FROM AUTHOR]

Objective: Accurate pathologic restaging of N2 stations after neoadjuvant therapy in stage IIIA (N2) non–small cell lung cancer is needed. Methods: A prospective multi-institutional trial was designed to judge the feasibility of videothoracoscopy to restage the ipsilateral nodes in mediastinoscopy-proven stage IIIA (N2) non–small cell lung cancer after 2 cycles of platinum-based chemotherapy and/or 40 Gy or more of radiotherapy. The goals included biopsy of 3 negative N2 node stations or to identify 1 positive N2 node or pleural carcinomatosis. Results: Ten institutions accrued 68 subjects. Of the 68 subjects, 46 (68%) underwent radiotherapy and 66 (97%) underwent chemotherapy. Videothoracoscopy successfully met the prestudy feasibility in 27 patients (40%): 3 negative stations confirmed at thoracotomy in 7, persistent stage N2 disease in 16, and pleural carcinomatosis in 4. In 20 procedures (29%), no N2 disease was found, 3 stations were not biopsied because of unanticipated nodal obliteration. Thus, 47 videothoracoscopy procedures (69%, 95% confidence interval, 57%-80%) restaged the mediastinum. Videothoracoscopy was unsuccessful in 21 patients (31%) because the procedure had to be aborted (n = 11) or because of false-negative stations (n = 10). Of the 21 failures, 15 were right-sided, and 10 had a positive 4R node. The sensitivity of videothoracoscopy was 67% (95% confidence interval, 47%-83%), and the negative predictive value was 73% (95% confidence interval, 56%-86%) if patients with obliterated nodal tissue were included. The sensitivity was 83% (95% confidence interval, 63%-95%) and the negative predictive value was 64% (95% confidence interval, 31%-89%) if those patients were excluded. The specificity was 100%. One death occurred after thoracotomy. Conclusions: Videothoracoscopy restaging was “feasible” in this prospective multi-institutional trial and provided pathologic specimens of the ipsilateral nodes. Videothoracoscopy restaging was limited by radiation and the 4R nodal station. [Copyright &y& Elsevier]

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an important tool in the diagnosis of mediastinal and hilar pathology. We describe our experience with EBUS-TBNA performed in a teaching institution primarily under conscious sedation. Methods: Patients who underwent EBUS-TBNA were included in this retrospective review. We focused on the diagnostic yield of EBUS-TBNA in relationship to the nature of the mediastinal or hilar lesions (suspected malignancy vs. benign disease), incremental 25 procedures aliquots, lymph node (LN) station, LN size, and the number of needle aspirations per LN station. Results: Of the 212 patients who underwent EBUS-TBNA, 200 patients had adequate follow-up information and were included in this analysis. The procedure was performed under conscious sedation in 97 % of patients and 133 patients (67 %) were suspected to have malignancy before the procedure. A total of 690 TBNAs were performed from 294 LN stations. The mean number of LN stations sampled per procedure was 1.47 ± 0.6. The mean number of TBNAs per LN station was 2.35 ± 0.91. The mean number of TBNAs per procedure was 3.45 ± 1.2. The overall sensitivity, specificity, negative predictive value (NPV), and diagnostic accuracy for all procedures were 87.41 % (CI 80.76-91.99), 100 % (CI 93.12-100), 75.36 % (CI 64.04-84.01), and 90.91 % (CI 85.92-94.25), respectively. The NPV increased significantly after the initial 25 procedures and remained high thereafter. EBUS-TBNA was more accurate (96.12 % (CI 91.25-98.33)) with higher NPV (90.74 % (CI 80.09-95.98)) in patients with suspected malignancy compared with patients with suspected benign disease (79.31 % (CI 67.23-87.75), 20 % (7.05-45.19)). Samples from relatively smaller LN (>5 to ≤20 mm) and from all analyzed LN stations were similarly accurate with high sensitivity and NPV. Conclusions: EBUS-TBNA allows safe real-time sampling of mediastinal and hilar lesions under conscious sedation with high diagnostic accuracy. The NPV is high and increased significantly after the initial 25-50 procedures. This is comparable to available surgical techniques, including mediastinoscopy, when malignancy is suspected. The NPV for specific benign disease remains low in our experience. The diagnostic yield is not affected by the LN station, size, or the number of passes per LN station. [ABSTRACT FROM AUTHOR]

Background: Accurate mediastinal staging of lung cancer patients is critical for determining appropriate treatment. Mediastinoscopy and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration are the most commonly utilized techniques. Limited data exist on training and practice trends among thoracic surgeons. We aimed to determine training and practice patterns and find whether there is a paradigm shift in mediastinal staging after the introduction of EBUS into practice among thoracic surgeons in the United States., Methods: 28-question survey was constructed querying demographic, training, and practice patterns with mediastinoscopy and EBUS and was sent to practicing thoracic surgeons in the United States. Descriptive statistics were used to summarize quantitative data., Results: Ninety-eight responded with a 93% completion rate. Eighty-seven percent of respondents received training in EBUS and 70% perform EBUS routinely. All respondents believe EBUS should be incorporated into thoracic surgery training curriculums. Majority of those who prefer EBUS feel EBUS is safer than mediastinoscopy, allows access to lymph nodes stations or lesions inaccessible by mediastinoscopy and prefer EBUS to avoid re-do mediastinoscopy and in irradiated mediastinum. Majority of those who prefer mediastinoscopy reported they perform more accurate staging compared to EBUS, that mediastinoscopy is more accurate in diagnosing lymphoma or sarcoidosis and that frozen section can be done at the same interval as resection. Among surgeons who prefer EBUS, 94% biopsy 3 or more lymph node stations, 86% routinely biopsy hilar (N1) nodes while 8% never biopsy N1 nodes. Of surgeons who prefer mediastinoscopy. Ninety-seven percent biopsy 3 or more lymph node stations, only 27% routinely biopsy N1 nodes and 70% never biopsy N1 nodes., Conclusions: EBUS is used frequently by thoracic surgeons in their practice for mediastinal staging. Methods of obtaining proficiency in EBUS widely varied among surgeons. In addition to mediastinoscopy, dedicated EBUS training should be incorporated into thoracic surgery training curriculums., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-183/coif). The authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

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Background: Ultrathin bronchoscope (UTB) with a 3.0-mm outer diameter and a 1.7-mm working channel currently appeared as a potential tool for better biopsy and diagnosis of peripheral pulmonary lesions (PPLs) by accessing more distal bronchus. However, published research is primarily limited to diagnosis value of UTB for PPLs with fluoroscopy, the value of UTB compared with thin bronchoscope (TB) without fluoroscopy guidance has not been determined yet., Methods: We design a prospective, randomized, controlled, non-inferior, multicenter study aiming to evaluate the diagnostic value and safety of UTB for PPLs with the guidance of virtual bronchoscopic navigation (VBN) combined with endobronchial ultrasound (EBUS) without fluoroscopy by comparing to TB. The study aims to enroll 578 patients presenting for evaluation of PPLs at five clinical sites in China. Subjects will be randomized to UTB-VBN-EBUS group, TB-VBN-EBUS-guide sheath (GS) group, and TB-VBN-EBUS-non-GS group. Primary endpoint is the diagnostic yield of PPLs. The total examination time, duration of finding lesions, the proportion of lesions visible by radial EBUS, factors affecting the diagnostic yield, difference in the bronchus level reached with the bronchoscope, difference in diagnostic yield, and complication rate will be determined as secondary endpoints. The primary endpoint will be followed-up at least 6-month post-procedure and 1-month post-procedure for safety endpoint., Discussion: Study enrollment began in March 2021. Our preliminary experience reveals that UTB is a powerful tool in the diagnosis of PPLs even without fluoroscopy. The results of the current study will compensate the limitations of the previous research, further provide evidence of UTB in diagnosing PPLs without fluoroscopy., Trial Registration: ClinicalTrials.gov NCT04571476. Registered on 30 September 2020., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-20/coif). All authors report funding from Olympus (Beijing) sales and service Co., Ltd., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a commonly performed minimally invasive technique for diagnosing mediastinal pathologies. Currently, many needle types are being developed to improve the accuracy of the final diagnosis. Our study aimed to assess the possible advantages and disadvantages between the 22-gauge ProCore ® needle and the standard 22-gauge needles., Methods: In this prospective study, we enrolled a group of 363 EBUS-TBNA patients. For each patient, we used either the ProCore ® needle or the standard one. We used the ProCore ® needle in 51 patients and the standard needle in 312 patients. When a diagnosis could not be made, it was subsequently established with a surgical biopsy. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the biopsy for both needle types., Results: By using EBUS-TBNA, a diagnosis was established in 306 patients (84.3%). The rates of the final diagnoses in ProCore ® and standard needle groups were 92.2% and 83.0% (P=0.14), respectively. The sensitivity, specificity, PPV, and NPV for ProCore ® vs. standard needles did not differ and were 89.2% vs. 79.3%, 100.0% vs. 95.7%, 100.0% vs. 98.5%, and 77.8% vs. 57.3%, respectively. A total of 57 patients required mediastinoscopy or surgical biopsy to obtain a final pathology. However, this number was not significantly different between the needles [ProCore ® (7.8%) vs. standard (17%), P=0.26]., Conclusions: Both types of needles demonstrated very high diagnostic efficiency for malignancy, and there was no significant advantage of the ProCore ® over the standard needle., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1594/coif). The authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: Current massive pulmonary embolism (PE) animal models use central venous access to deliver blood clots, which have features of random clot distribution and potentially fatal hemodynamic compromise. A clinically relevant preclinical model for generating pulmonary emboli in a more controlled fashion would be of value for a variety of research studies, including initial evaluation of novel therapeutic approaches. Endobronchial ultrasound-guided transbronchial needle injection (EBUS-TBNI) is a newly established approach for peri-tracheal/bronchial targets. The purpose of the present work was to establish a minimally invasive PE model in swine via a transbronchial approach., Methods: In anesthetized Yorkshire pigs, a 21-G EBUS-guided transbronchial needle aspiration (EBUS-TBNA) needle was introduced into the pulmonary artery under EBUS guidance. Autologous blood clots were administered into the right and left lower pulmonary arteries sequentially (PE1 and PE2, respectively). Hemodynamic and biochemical responses were evaluated., Results: Ten pigs were evaluated; all 20 blood clots (6.3±1.9 mL) were successfully injected. After injection, mean pulmonary artery pressure (mPAP; mmHg) increased (baseline: 16.6±5.6 vs. PE1: 24.5±7.6, P<0.0001 vs. PE2: 26.9±6.7, P<0.0001), and a positive correlation was observed between clot volume and change in mPAP (PE1: r=0.69, P=0.025; PE1 + PE2: r=0.60, P=0.063). Mean arterial pressure (MAP; mmHg) (baseline: 57.5±5.1 vs. PE1: 59.0±9.1, P=0.918 vs. PE2: 60.9±9.6, P=0.664) remained stable. No complications were observed., Conclusions: EBUS allows minimally invasive, precise, and reliable generation of pulmonary emboli in pigs. This model may serve as an important tool for new PE-related diagnostic and therapeutic research., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1242/coif). KY reports that this work was supported by a research grant from Olympus Corporation, and KY is a consultant for Olympus. The other authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Abstract: We report a case of lung adenocarcinoma presenting as pure ground glass opacity (GGO) and diagnosed by bronchoscopy with the use endobronchial ultrasound with a guide sheath (EBUS-GS). The lesion was indistinguishable by real-time fluoroscopy but simultaneous endobronchial ultrasound scanning of the involved lung segment showed a hyperechoic shadow that was subtly more intense than a typical snowstorm appearance when scanning normal alveolar tissue. Transbronchial biopsy from this area revealed adenocarcinoma with lepidic growth. On hindsight, it was the aforementioned ultrasound pattern that helped us decide the sampling site for EBUS-GS guided TBB when fluoroscopy was equivocal. We hypothesize that this pattern is specific for GGO and we name it the Blizzard Sign. [Copyright &y& Elsevier]

Background: Thoracic lymph node (LN) evaluation is essential for the accurate diagnosis of lung cancer and deciding the appropriate course of treatment. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered a standard method for mediastinal nodal staging. This study aims to build a deep convolutional neural network (CNN) for the automatic classification of metastatic malignancies involving thoracic LN, using EBUS-TBNA., Methods: Patients who underwent EBUS-TBNAs to assess the presence of malignancy in mediastinal LNs during a ten-month period at Severance Hospital, Seoul, Republic of Korea, were included in the study. Corresponding LN ultrasound images, pathology reports, demographic data, and clinical history were collected and analyzed., Results: A total of 2,394 endobronchial ultrasound (EBUS) images of 1,459 benign LNs from 193 patients, and 935 malignant LNs from 177 patients, were collected. We employed the visual geometry group (VGG)-16 network to classify malignant LNs using only traditional cross-entropy for classification loss. The sensitivity, specificity, and accuracy of predicting malignancy were 69.7%, 74.3%, and 72.0%, respectively, and the overall area under the curve (AUC) was 0.782. We applied the new loss function to train the network and, using the modified VGG-16, the AUC improved to a value of 0.8. The sensitivity, specificity, and accuracy improved to 72.7%, 79.0%, and 75.8%, respectively. In addition, the proposed network can process 63 images per second on a single mainstream graphics processing unit (GPU) device, making it suitable for real-time analysis of EBUS images., Conclusions: Deep CNNs can effectively classify malignant LNs from EBUS images. Selecting LNs that require biopsy using real-time EBUS image analysis with deep learning is expected to shorten the EBUS-TBNA procedure time, increase lung cancer nodal staging accuracy, and improve patient safety., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-21-870/coif). SIO and JSK have been full-time employees of Waycen Inc. during this study. KNK has been the CEO of Waycen Inc. during this study. The other authors have no conflicts of interest to declare., (2022 Translational Lung Cancer Research. All rights reserved.)

Background: As lung cancers arising in a background of idiopathic pulmonary fibrosis (IPF) are known to show high malignancy grades, early pathologic diagnosis of peripheral pulmonary lesions (PPLs) is important. Meanwhile, the risk of complications associated with diagnostic procedures is high, which prompted us to investigate the role of bronchoscopy, a relatively safe diagnostic procedure. Therefore, we conducted this study to evaluate the usefulness of bronchoscopy for the diagnosis of PPLs in patients with IPF., Methods: Data of consecutive patients with IPF who underwent bronchoscopy under radial endobronchial ultrasound (R-EBUS) guidance for PPLs at our institution between April 2014 and March 2019 were retrospectively reviewed. IPF was defined as usual interstitial pneumonia (UIP) or probable UIP, in accordance with the classification in the latest global guidelines. The diagnostic outcomes and the factors independently related to the diagnostic yield were analyzed., Results: A total of 92 patients were included in the analysis. The median (range) size of the target PPLs was 27.1 (11.4-75.3) mm, and the diagnostic yield was 82.6%. Multivariable analysis identified a larger size [P=0.017; odds ratio (OR), 5.33; 95% confidence interval (CI), 1.29-22.01], positive bronchus sign (P=0.035; OR, 4.99; 95% CI, 1.12-22.18), and not involved with UIP/probable UIP pattern (P=0.023; OR and 95% CI, unmeasurable) as being associated with a significantly higher diagnostic yield. Meanwhile, none of the patients developed acute exacerbation of IPF or pneumothorax following the diagnostic bronchoscopy., Conclusions: Bronchoscopy using R-EBUS was safe and showed an acceptable diagnostic yield for PPLs, even in patients with IPF., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jtd-21-1067). YM reports grants from National Cancer Center Research and Development Fund, grants from Grant-in-Aid for Scientific Research on Innovative Areas, grants from Hitachi, Ltd., personal fees from Olympus, personal fees from Erbe Elektromedizin GmbH, personal fees from AMCO Inc., outside the submitted work. TT reports grants from Japan Agency for Medical Research and Development, grants from Foundation for Promotion Cancer Research, personal fees from Nippon Medical School Foundation, personal fees from Hamamatsu University School of Medicine, outside the submitted work. The other authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

The indications and utility of flexible bronchoscopy have expanded over the past few decades with major innovations in design and development of new tools for endobronchial interventions and image-guided tissue sampling techniques. This review highlights the application of advanced diagnostic bronchoscopy (including endobronchial ultrasound and CT navigational techniques), cryotherapy and the use of one-way endobronchial valves for persistent air leak in the pediatric setting. [ABSTRACT FROM AUTHOR]