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The evaluation of mediastinal lymphadenopathy and masses poses a diagnostic challenge because of a myriad of possible etiologic causes; their proximity to numerous vital structures and the difficulty of access for biopsy. Computed tomography is an excellent modality for the initial evaluation of mediastinal lymph nodes (LNs). Tissue diagnosis is of paramount importance to confirm the diagnosis of mediastinal lymphadenopathy. Of various modalities including CT-guided biopsy, mediastinoscopy is considered a gold standard for tissue acquisition, but it is associated with considerable morbidity. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive method of sampling of mediastinal LNs and its role has been established in malignant cause of LN enlargement. However, its role in diagnosing benign diseases has not been studied much. In a cross-sectional observational study, we performed EBUS-TBNA of 116 patients, and the sample was evaluated by various pathological modalities. Most common LN sampled was subcarinal (68%). MTB gene Xpert was positive in 45 cases, and resistance was detected in 3 cases. Most common diagnosis was tuberculous lymphadenitis (67.9%). Only five of our patients had post-operative bronchospasm, while four had peri-operative hypoxia, which was managed with oxygen therapy. EBUS-TBNA is an excellent modality for sampling mediastinal LNs, which is very safe and can be done on an OPD basis. [ABSTRACT FROM AUTHOR]

Abstract EBUS-guided transbronchial mediastinal cryobiopsy (TBMC) has emerged as a promising biopsy tool for diagnosing hilar and mediastinal pathologies. However, several fundamental technical aspects of TBMC remain unexplored. This study aims to determine the optimal number of cryo-passes and freezing time of the ultrathin cryoprobe in EBUS-TBMC concerning specimen size and procedural diagnostic yield. We conducted a retrospective chart review of patients with mediastinal and hilar lesions who underwent EBUS-TBMC between January 2021 and April 2023 across three hospitals in Malaysia. A total of 129 EBUS-TBMC procedures were successfully completed, achieving an overall diagnostic yield of 88.4%. Conclusive TBMC procedures were associated with larger specimen sizes (7.0 vs. 5.0 mm, p

Introduction: Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) has a cardinal role in the diagnosis and staging of non-small cell lung cancer (NSCLC), providing an accurate nodal staging in a less invasive way than surgical biopsy. The aim of this study was to assess the diagnostic accuracy of EBUS-TBNA in the pre-operative NSCLC mediastinal staging, as well as to evaluate EBUS-TBNA specificity and sensibility in our cohort. Methods: We retrospectively analyzed data of NSCLC patients who underwent EBUS-TBNA followed by major pulmonary resection between January 2020 and December 2022. EBUS-TBNA was performed in patients with NSCLC (central T ≤ 3 cm, peripheral/central T > 3 cm), following the ESTS guidelines. The target nodes were selected on the basis of their radiologic/metabolic characteristics. Each procedure was conducted together with rapid on-site cytological evaluation (ROSE). Results: Twenty-five patients were included (M/F = 17/8). At least three needle passages on each target lymph node were performed. No complications during or after the procedures occurred. We found a 100% correspondence between ROSE on the sampled nodes and postoperative pathologic findings. An upstaging occurred in three cases (12%) because of the involvement of stations 5 and 6 (not accessible via EBUS), while the only case of downstaging (N2 → N0, 4%) was probably due to intercurrent neoadjuvant chemotherapy. In all cases, EBUS-TBNA has proved to achieve a diagnostic procedure on the target nodes. Conclusions: EBUS-TBNA is a safe and effective procedure that offers high sensitivity and specificity when performed together with ROSE, which improves the accuracy of sampling. Doubt on nodal stations 5 and 6 involvement should be settled by other techniques. [ABSTRACT FROM AUTHOR]

EBUS-guided transbronchial mediastinal cryobiopsy (TBMC) has emerged as a promising biopsy tool for diagnosing hilar and mediastinal pathologies. However, several fundamental technical aspects of TBMC remain unexplored. This study aims to determine the optimal number of cryo-passes and freezing time of the ultrathin cryoprobe in EBUS-TBMC concerning specimen size and procedural diagnostic yield. We conducted a retrospective chart review of patients with mediastinal and hilar lesions who underwent EBUS-TBMC between January 2021 and April 2023 across three hospitals in Malaysia. A total of 129 EBUS-TBMC procedures were successfully completed, achieving an overall diagnostic yield of 88.4%. Conclusive TBMC procedures were associated with larger specimen sizes (7.0 vs. 5.0 mm, p < 0.01). Specimen size demonstrated a positive correlation with diagnostic yield (p < 0.01), plateauing at specimen size of 4.1–6.0 mm. A significant positive correlation was also observed between the number of cryo-passes and both specimen size (p < 0.01) and diagnostic yield (p < 0.05). Diagnostic yield plateaued after 2–3 cryo-passes. In contrast, longer freezing times trended towards smaller specimens and lower diagnostic yield, though not reaching statistical significance. The highest diagnostic yield was recorded at the 3.1–4.0 s freezing time. The safety profile of TBMC remains favourable, with one case (0.8%) of pneumothorax and nine cases (7%) of self-limiting bleeding. In our cohort, TBMC performance with 2–3 cryo-passes and a 3.1–4.0 s freezing time to achieve a total aggregate specimen size of 4.1–6.0 mm appeared optimal. Further prospective studies are needed to validate these findings. [ABSTRACT FROM AUTHOR]

Lung cancer is the leading cause of cancer-associated death globally. Staging provides classification of the anatomic extent of cancer that is used consistently worldwide. Lung cancer staging is necessary for prognostication, to inform treatment options, and to allow accurate representation in clinical trials. Staging also separates operable from inoperable disease. Since its introduction in the 1970s, the Tumor, Node and Metastasis (TNM) Staging System has undergone significant revisions, with the latest version, the eighth edition, being effective internationally since 2017. Advances in bronchoscopic and thoracoscopic technologies have expanded procedures to diagnose lung cancer and accurately define the anatomic stage. Understanding the advantages and disadvantages of available methods for staging lung cancer is critical to clinician decision making. In patients with lung cancer without distant metastases, the staging of mediastinal lymph nodes determines treatment options. To minimize the risk and cost, the most appropriate method of staging should identify the highest disease stage while carrying acceptable risk. Minimally invasive endoscopic needle techniques to stage the mediastinum are the first choice to assess for metastases in accessible lymph node stations. Surgical techniques are generally reserved for specific clinical situations, including following negative endoscopic needle techniques when suspicion for nodal involvement is high and to assess endoscopically inaccessible lymph nodes. This review provides a concise account of TNM staging of non-small cell lung cancer (NSCLC) and overview of procedures available for the staging of lung cancer.

Key message The visualization of black pigment during EBUS‐TBNA suggests a relapse of melanoma. This case highlights the value of EBUS‐TBNA in diagnosing metastatic melanoma, particularly when the macroscopic appearance of the aspirate suggests the diagnosis.

Abstract Background Endobronchial ultrasound‐guided (EBUS) transbronchial needle aspiration (TBNA) has significantly improved the diagnostic workup for intrathoracic lymphadenopathies. More recently, EBUS intranodal forceps biopsy (IFB) has been developed in an attempt to maximize diagnostic yield by providing additional tissue. In this study, we aimed to assess the improvement of diagnostic yield with EBUS‐TBNA combined with EBUS‐IFB, compared to EBUS‐TBNA alone. Methods Consecutive patients who had 19‐G EBUS‐TBNA and EBUS‐IFB from August 30, 2018, to September 28, 2021, were included. Four senior pathologists retrospectively analyzed, independently and blindly, first, only the EBUS‐TBNA samples (cell block), then, at least 1 month later, both samples from EBUS‐TBNA and from EBUS‐IFB together. Results Fifty patients were included in the study and 52 lymph nodes were analyzed. Diagnostic yield was 77% (40/52) for EBUS‐TBNA alone and 94% (49/52) when combined with EBUS‐IFB (p = 0.023). Malignancy was diagnosed with EBUS‐TBNA combined with EBUS‐IFB in 25/26 cases (96%), versus 22/26 (85%) with EBUS‐TBNA alone (p = 0.35); and 4/5 (80%) versus 2/5 (40%) for lymphoma specifically. Kappa interobserver agreement was 0.92 for EBUS‐IFB and 0.87 for EBUS‐TBNA alone. Nonmalignant condition was diagnosed with EBUS‐TBNA combined with EBUS‐IFB in 24/26 cases (92%), versus 18/26 (69%) for EBUS‐TBNA alone (p = 0.07). Conclusion The use of EBUS‐IFB combined with 19‐G EBUS‐TBNA improves the mediastinal lymph node diagnostic yield However the benefit appears to be mainly restricted to nonmalignant histology.

Mediastinal masses present a diagnostic challenge due to their similar imaging characteristics, making distinguishing between noninfectious and infectious processes or malignancies difficult. A mediastinal abscess can result in severe life-threatening infections if left untreated. Traditional treatment approaches involve surgical debridement and drainage; however, emerging endobronchial techniques, such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), offer a less-invasive means of diagnosing and managing abscesses. Herein, we describe a case of a young male patient who exhibited nonspecific symptoms, including pleuritic chest pain, shortness of breath, and fever. Imaging revealed a mediastinal mass with granuloma formation. EBUS-TBNA successfully drained the abscess, and microbiology analysis confirmed the growth of Streptococcus intermedius. Subsequently, his symptoms resolved, and follow-up imaging demonstrated the resolution of the mass and associated calcifications. Further research is warranted to assess the role of EBUS-TBNA in benign mediastinal masses with granuloma formation. [ABSTRACT FROM AUTHOR]

Endobronchial Ultrasound (EBUS) has been widely used to stage lung tumors and to diagnose mediastinal diseases. In the last decade, this procedure has evolved in several technical aspects, with new tools available to optimize tissue sampling and to increase its diagnostic yield, like elastography, different types of needles and, most recently, miniforceps and cryobiopsy. Accordingly, the indications for the use of the EBUS scope into the airways to perform the Endobronchial Ultrasound–TransBronchial Needle Aspiration (EBUS-TBNA) has also extended beyond the endobronchial and thoracic boundaries to sample lesions from the liver, left adrenal gland and retroperitoneal lymph nodes via the gastroesophageal tract, performing the Endoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In this review, we summarize and critically discuss the main indication for the use of the EBUS scope, even the more uncommon, to underline its utility and versatility in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Endobronchial ultrasound‐guided (EBUS) transbronchial needle aspiration (TBNA) has significantly improved the diagnostic workup for intrathoracic lymphadenopathies. More recently, EBUS intranodal forceps biopsy (IFB) has been developed in an attempt to maximize diagnostic yield by providing additional tissue. In this study, we aimed to assess the improvement of diagnostic yield with EBUS‐TBNA combined with EBUS‐IFB, compared to EBUS‐TBNA alone. Methods: Consecutive patients who had 19‐G EBUS‐TBNA and EBUS‐IFB from August 30, 2018, to September 28, 2021, were included. Four senior pathologists retrospectively analyzed, independently and blindly, first, only the EBUS‐TBNA samples (cell block), then, at least 1 month later, both samples from EBUS‐TBNA and from EBUS‐IFB together. Results: Fifty patients were included in the study and 52 lymph nodes were analyzed. Diagnostic yield was 77% (40/52) for EBUS‐TBNA alone and 94% (49/52) when combined with EBUS‐IFB (p = 0.023). Malignancy was diagnosed with EBUS‐TBNA combined with EBUS‐IFB in 25/26 cases (96%), versus 22/26 (85%) with EBUS‐TBNA alone (p = 0.35); and 4/5 (80%) versus 2/5 (40%) for lymphoma specifically. Kappa interobserver agreement was 0.92 for EBUS‐IFB and 0.87 for EBUS‐TBNA alone. Nonmalignant condition was diagnosed with EBUS‐TBNA combined with EBUS‐IFB in 24/26 cases (92%), versus 18/26 (69%) for EBUS‐TBNA alone (p = 0.07). Conclusion: The use of EBUS‐IFB combined with 19‐G EBUS‐TBNA improves the mediastinal lymph node diagnostic yield However the benefit appears to be mainly restricted to nonmalignant histology. [ABSTRACT FROM AUTHOR]

Echobronchoscope-guided transbronchial needle aspiration (EBUS-TBNA) is mainly used as the transbronchial approach to hilar/mediastinal lymph nodes or lesions, for diagnostic or staging purposes. Moreover, the role of linear EBUS-TBNA as a diagnostic tool for central intrapulmonary lesions adjacent to the trachea or the major bronchi is also well established. However, since the tip of the ultrasound probe at the distal end of the echobronchoscope is very thin, it can be wedged through smaller peripheral bronchi, reaching the distal parenchyma and allowing for peripheral pulmonary lesion sampling. The main aim of this retrospective study was to evaluate the diagnostic yield and the safety of EBUS-TBNA in the diagnosis of pulmonary peripheral nodules. The database of the Interventional Pulmonology Unit of Azienda Ospedaliero-Universitaria delle Marche (Ancona, Italy) was evaluated to identify peripheral pulmonary nodules approached by EBUS-TBNA. Thirty patients with a single peripheral pulmonary nodule located peripherally to the subsegmental bronchi of the lower lobes and adjacent to a small bronchus greater than 3 mm in diameter were included in this study. The nodule was visible using endoscopic ultrasound in 28 patients and the diagnosis was obtained via EBUS-TBNA in 26 cases (12 adenocarcinoma, 5 typical carcinoid tumors, 4 hamartoma and 5 metastatic lesions). The diagnostic yield was 86.6% for all 30 patients and 92.8% if only the 28 patients in which the lesion was visualized via echobronchoscopy were considered. No relevant adverse events were observed. We conclude that EBUS-TBNA may be an effective and safe option to sample pulmonary peripheral nodules in selected patients with lower lobe peripheral pulmonary lesions adjacent to small bronchi greater than 3 mm in diameter and reachable with the EBUS-TBNA probe. [ABSTRACT FROM AUTHOR]

Background: Peripheral bronchoscopy is often performed to biopsy peripheral pulmonary lesions. Despite technological advancements to improve reach and access to the lung periphery, the diagnostic yield of peripheral bronchoscopy has been inconsistent, and challenging, particularly for lesions that are adjacent to peripheral bronchi. Current biopsy instruments are reliant on the catheter or scope to align properly with targeted lesions. Objectives: This study evaluates the feasibility of using a steerable biopsy needle to gain access to peripheral tumor targets in a cadaveric model. Methods: Simulated tumor targets 10–30 mm in axial diameter were placed into human cadavers. Bronchoscopy was performed using a 4.2 mm OD flexible bronchoscope, CT-anatomic correlation, and multi-planar fluoroscopy for lesion localization. Once at the targeted location, a steerable needle was deployed and the needle position was determined to be in the central zone, peripheral zone, or outside of the lesion by cone beam CT imaging. If the needle position was within the lesion, a fiducial marker was deployed to mark the needle position, and the needle was articulated and/or rotated in an attempt to place another fiducial marker into a different location within the same lesion. If the needle was outside of the lesion, the bronchoscopist was provided with two additional attempts to gain access to the lesion. Results: Fifteen tumor targets were placed with a mean lesion size of 20.4 mm. The majority of lesions were located in the upper lobes. One fiducial marker was placed in 93.3% of lesions and a second fiducial marker was successfully placed in 80% of lesions. A fiducial marker was placed within the central zone in 60% of lesions. Conclusion: The steerable needle was successfully placed within 93% of targeted lesions 10–30 mm in diameter in a cadaveric model, with the ability steer the instrument into another portion of the lesion in 80% of cases. The ability to steer and control needle positioning toward and within peripheral lesions may complement existing catheter and scope technology during peripheral diagnostic procedures. [ABSTRACT FROM AUTHOR]

Background: Aspirations without a tissue core are common in endobronchial ultrasound-guided transbronchial needle aspiration procedures. However, the diagnostic value of all-shot aspirations and no-tissue-core aspirations is unclear. Patients and Methods: A retrospective analysis of patients who underwent endobronchial ultrasound-guided transbronchial needle aspiration with the description of all-shot or no-tissue-core aspirations was conducted at a tertiary hospital between January 2017 and March 2021. Patients' pathologic and clinical diagnoses were retrieved and compared between all-shot patients (all aspirations had a tissue core) and no-tissue-core patients (at least one aspiration had no tissue core). Results: Among all 505 patients with 1402 aspirations, 356 (70.5%) patients, and 1184 (84.5%) aspirations were all-shot. Pathologic diagnosis after endobronchial ultrasound-guided transbronchial needle aspiration revealed neoplasms in 46.1% of all-shot patients, but 33.6% of no-tissue-core patients (odds ratio, 1.69; 95% confidence interval, 1.14-2.52; P =.009). Final clinical diagnosis revealed malignancy in 53.1% of all-shot patients, but 37.6% of no-tissue-core patients (odds ratio, 1.88; 95% confidence interval, 1.27-2.78; P =.001). In 133 patients with pathologic nonspecific findings, a clinical diagnosis of malignancy was proven in 25 of 79 (31.6%) of all-shot patients, but only 6 of 54 (11.1%) of no-tissue-core patients (odds ratio, 3.70; 95% confidence interval, 1.40-9.79; P =.006). Conclusions: Patients with all-shot aspirations in endobronchial ultrasound-guided transbronchial needle aspiration are more likely to have the pathologic and clinical diagnosis of malignancy. More measures should be taken to exclude malignancy in all-shot patients when the endobronchial ultrasound-guided transbronchial needle aspiration was nondiagnostic. [ABSTRACT FROM AUTHOR]

Endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) have changed the landscape of pulmonology. Mediastinal structures beyond the confines of airway walls are visualized in real-time with EBUS, leading to improved accuracy of tissue sampling and diagnostic yield. With the development of various needle sizes ranging from 25-G to 19-G, the sampling of lymph nodes is becoming easier and more commonplace. Yet, certain conditions such as sarcoidosis and lymphoma may still be difficult to diagnose via EBUS-TBNA. Furthermore, in the age of targeted therapy, there are more demands on EBUS-TBNA samples for molecular marker testing and next-generation sequencing. Here, we present a complementary methodology, EBUS-guided intranodal forceps biopsy (EBUS-IFB), for tissue acquisition that may help address these deficiencies. Specifically, we aim to propose indications, contraindications, outline approaches in performing IFB, and provide an overview of the data for this complementary technique.

Key message Conventional transbronchial needle aspiration (cTBNA) remains a basic technique that must be part of the bronchoscopists expertise. In cases where EBUS is not available, cTBNA must be kept in mind: ‘the old bull knows best’.

Background: Endobronchial ultrasound (EBUS)-guided intranodal forceps biopsy (IFB), a diagnostic bronchoscopic technique for intrathoracic lymphadenopathy, is performed following EBUS-guided transbronchial needle aspiration (TBNA). The current EBUS-IFB technique is complex and provides small sample volumes. We modified this technique to allow the use of standard-sized forceps. Objectives: The aim of this study was to assess the feasibility of the modified EBUS-IFB technique, which combines standard-sized forceps with standard EBUS-TBNA equipment. Method: This retrospective analysis included consecutive patients scheduled for EBUS-TBNA with attempted additional IFB between July 2020 and March 2021. The feasibility indices of IFB, technical success rate, diagnostic accuracy, and major complications were retrospectively investigated. We performed semi-quantitative evaluation of the histological specimens and univariable analyses to identify factors associated with IFB failure. Results: During the study period, 295 patients underwent 307 EBUS-TBNAs; 195 cases were included in the analyses. Target lesions were mainly mediastinal lymph nodes (134 cases, 68.7%); the most frequent sites were #7 (61 cases) and #4R (50 cases). The median lesion size was 16.1 mm, the technical IFB success rate was 90.8%, and the diagnostic accuracy of the TBNA and IFB combination was 99.5%. One patient was lost to follow-up. Univariable analyses did not identify any factors involved in technical IFB failure. Major complications of pneumonia and pneumothorax occurred in 2 cases (1.0%). The median histological score was significantly higher in the IFB group than in the TBNA group (1.67 vs. 1.50, p = 0.032). Conclusions: Modified EBUS-IFB, combining standard-sized forceps with common EBUS-TBNA equipment, is feasible with few major complications. [ABSTRACT FROM AUTHOR]

The diagnosis of peripheral pulmonary lesions (PPLs) remains a challenge for physicians. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been applied in the diagnosis of PPLs, but its diagnostic rate varies widely. The systematic review and meta-analysis was conducted to figure out the accuracy and safety of EBUS-TBNA in the diagnosis of PPLs. We searched the PubMed and Embase databases for relevant studies published from January 1, 2000 to December 30, 2021 and used PICO (Participants, Intervention, Comparison, and Outcome) to worked out the diagnostic rate of EBUS-TBNA in PPLs. Two reviewers independently performed the data extraction and assessed study quality. Statistical analysis was carried out via R software. In 7 studies of totally 510 patients of PPLs, the overall EBUS-TBNA diagnosis yield is 0.75 (95% CI 0.67–0.84) by the random effect model. EBUS-TBNA showed a higher accuracy of 0.64 (95% CI 0.53–0.74) compared to 0.46 (95% CI 0.19–0.72) of endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB) when EBUS probe is adjacent to lesions. In the case of malignant lesions, the diagnostic rate of EBUS-TBNA is 0.79 (95% CI 0.72–0.88). Combined EBUS-TBNA with conventional bronchoscopy procedures showed the highest diagnostic yield (0.83 (95% CI 0.79–0.87)). Collectively, EBUS-TBNA should be performed firstly in patients with PPLs suspected to lung cancer especially when the EBUS probe was adjacent to the lesions. No serious procedure-related complications were observed. [ABSTRACT FROM AUTHOR]

Abstract Background This study aimed to compare the lymph node core tissue lengths obtained via mediastinal or hilar lymphadenopathy using the complementary “rotation aiding” and conventional Jab technique. Methods We prospectively measured the lymph node core tissue length in patients who sequentially underwent the Jab and rotation aiding (RA) techniques between October 2012 and December 2014. Wilcoxon signed‐rank test was used to compare the core tissue length and grade of diagnostic cells obtained by each technique. McNemar's test was used to compare the proportion of adequate cellularity (≥grade 2) between the aspiration techniques. Results The core tissue length of 61 lymph nodes from 43 patients (mean age: 63 years, range: 16–86 years) was analyzed. Pathological findings were consistent with malignant lesions in 25 (41%) patients and benign lesions in 36 (59%). The most common diagnosis in benign lymph nodes was reactive, followed by tuberculosis and sarcoidosis. We obtained longer core tissue with RA technique than with the Jab technique (83.2 ± 12.7 vs. 60.1 ± 10.1 mm; p = 0.02). There was a significant increase in cellularity grade and proportion of ≥grade 2 cells with the RA technique than with the Jab technique (2.39 ± 1.08 vs. 1.84 ± 1.14; p

Background: There is a lack of data on the prevalent practices of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in India. Aim: To study the current practices of EBUS-TBNA in India. Methods: This survey was an online questionnaire designed on the Google forms interface. The survey included various questions related to demographics, sedation, analgesia and anesthesia, technical aspects, and infection control related to the procedure of EBUS-TBNA. Results: Data from 134 respondents (mean age: 42.2 years) were analyzed. Most (97.8%) were pulmonologists or physicians, and a majority (94.8%) practicing in either a private multi-specialty setting or medical college. 40.3% had received procedure training at a formal training program. Mild/moderate sedation was the most common strategy (70.1%). Midazolam (76.7%), Fentanyl (76.0%), followed by propofol (46.5%), were the most frequent drugs, and 82.8% preferred combination sedation. 26.1% used cricothyroid lignocaine injection, and the use of 1% or 2% lignocaine for spray-as-you-go administration was similar. The oral route was preferred, while the laryngeal mask airway was the most common airway conduit under general anesthesia. Suspected granulomatous mediastinal lymphadenopathy (TB/sarcoidosis) (67.2%), followed by lung cancer (32.8%), were the most common indications of EBUS-TBNA. 81.3% performed EBUS-TBNA for lung cancer staging. 21 G needle was preferred (64.9%), and vacuum suction was common (80.6%). 55.2% routinely performed ROSE. Alcohol fixed glass slide smears were the most common method (93.1%) for cytological preparation. 49.3% also performed EUS-B-FNA. 76.9% routinely obtained endo bronchial biopsy and transbronchial lung biopsy in patients with suspected sarcoidosis. Elastography was infrequently used. Nearly three-fourths (77.6%) reused EBUS needles. Conclusion: There is practice variability in the multiple aspects related technical performance of EBUS-TBNA. Evidence-based guidelines addressing the multiple technical aspects are required to standardize the practice of EBUS-TBNA.

BackgroundTransbronchial needle aspiration (TBNA) is a sampling tool that has demonstrated a higher accuracy in the diagnosis of peripheral pulmonary lesions (PPL) compared to other techniques. However, there are no studies investigating the value of TBNA in defining the genotype of peripheral lung cancer.ObjectiveTo evaluate the accuracy of TBNA in defining the molecular characteristics of peripheral lung cancer.MethodsConsecutive patients who underwent TBNA for the diagnosis of a PPL at the Pulmonary Unit of the Azienda Ospedali Riuniti of Ancona (Italy) between January 2020 and September 2022 were included in the study. TBNA was performed under fluoroscopic guidance and the additional support of an ultrasound miniprobe, with an ultrathin bronchoscope with a flexible 21G needle. Samples were smeared on glass slides for cytological evaluation and flushed in 10% neutral-buffered formalin for cell-blocks.Results154 patients were enrolled:55 were diagnosed with adenocarcinoma and 21 with squamous cell carcinoma. TBNA correctly diagnosed 43/55 (78.2%) patients with adenocarcinoma and 17/21 (81.0%) patients with squamous cell carcinoma, with a sensitivity of 77.5%. Complete genotyping for guiding targeted therapies was obtained in 52 patients (86.6%).ConclusionsTBNA is a valid tool for the diagnosis of PPL, allowing a correct diagnosis and a complete genotyping of the tumors in a considerable proportion of patients.

Accurate staging for non-small cell lung cancer (NSCLC) is essential to guide therapy. While computed tomography (CT) and positron emission tomography (PET) scan can indicate whether mediastinal lymphadenopathy is present, histologic confirmation is required to complete the staging evaluation. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique associated with similar diagnostic yield and improved postoperative pain and complication rates compared to mediastinoscopy. We share the surgical technique for EBUS-TBNA based on our experience. An 81-year-old man underwent EBUS-TBNA for concurrent tissue diagnosis and mediastinal staging of a hypermetabolic left lower lobe mass and subcarinal lymph node. Our patient had no perioperative complications and was discharged home on the same day. Histologic evaluation demonstrated squamous cell carcinoma in the left lower lobe and subcarinal lymph node. EBUS-TBNA provides histologic confirmation of suspicious mediastinal lymph nodes seen on imaging. Clinicians should consider EBUS-TBNA as a mediastinal staging modality for patients with NSCLC.

Simple Summary: Endobronchial ultrasound (EBUS) features help differentiate between benign and malignant lymph nodes (MLNs) during transbronchial needle aspiration (TBNA). B-, power/color Doppler, and elastography modes are used during EBUS-TBNA. However, only few studies have assessed them simultaneously. This study evaluated multi-EBUS features (B-, power/color Doppler, and elastography modes) and established a novel scoring system. Multivariable analysis revealed that short axis (>1 cm), heterogeneous echogenicity, absence of central hilar structure, presence of coagulation necrosis sign, and blue-dominant elastographic images were independent predictors of MLNs. At three or more EBUS features predicting MLNs, our scoring system had high sensitivity and specificity (77.9 and 91.8%, respectively). The area under the receiver operating curve (AUC) was 0.894 (95% confidence interval (CI): 0.868–0.920), higher than that of B-mode features alone (AUC: 0.840 (95% CI: 0.807–0.873)). Our novel scoring system could predict MLNs more accurately than B-mode features alone. Endobronchial ultrasound (EBUS) features with B-, power/color Doppler, and elastography modes help differentiate between benign and malignant lymph nodes (MLNs) during transbronchial needle aspiration (TBNA); however, only few studies have assessed them simultaneously. We evaluated the diagnostic accuracy of each EBUS feature and aimed to establish a scoring system to predict MLNs. EBUS features of consecutive patients and final diagnosis per lymph node (LN) were examined retrospectively. In total, 594 LNs from 301 patients were analyzed. Univariable analyses revealed that EBUS features, except for round shape, could differentiate MLNs from benign LNs. Multivariable analysis revealed that short axis (>1 cm), heterogeneous echogenicity, absence of central hilar structure, presence of coagulation necrosis sign, and blue-dominant elastographic images were independent predictors of MLNs. At three or more EBUS features predicting MLNs, our scoring system had high sensitivity (77.9%) and specificity (91.8%). The area under the receiver operating curve (AUC) was 0.894 (95% confidence interval (CI): 0.868–0.920), which was higher than that of B-mode features alone (AUC: 0.840 (95% CI: 0.807–0.873)). The novel scoring system could predict MLNs more accurately than B-mode features alone. Multi-EBUS features may increase EBUS-TBNA efficiency for LN evaluation. [ABSTRACT FROM AUTHOR]

Endobronchial Ultrasound (EBUS) has been widely used to stage lung tumors and to diagnose mediastinal diseases. In the last decade, this procedure has evolved in several technical aspects, with new tools available to optimize tissue sampling and to increase its diagnostic yield, like elastography, different types of needles and, most recently, miniforceps and cryobiopsy. Accordingly, the indications for the use of the EBUS scope into the airways to perform the Endobronchial Ultrasound–TransBronchial Needle Aspiration (EBUS-TBNA) has also extended beyond the endobronchial and thoracic boundaries to sample lesions from the liver, left adrenal gland and retroperitoneal lymph nodes via the gastroesophageal tract, performing the Endoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In this review, we summarize and critically discuss the main indication for the use of the EBUS scope, even the more uncommon, to underline its utility and versatility in clinical practice.

Echobronchoscope-guided transbronchial needle aspiration (EBUS-TBNA) is mainly used as the transbronchial approach to hilar/mediastinal lymph nodes or lesions, for diagnostic or staging purposes. Moreover, the role of linear EBUS-TBNA as a diagnostic tool for central intrapulmonary lesions adjacent to the trachea or the major bronchi is also well established. However, since the tip of the ultrasound probe at the distal end of the echobronchoscope is very thin, it can be wedged through smaller peripheral bronchi, reaching the distal parenchyma and allowing for peripheral pulmonary lesion sampling. The main aim of this retrospective study was to evaluate the diagnostic yield and the safety of EBUS-TBNA in the diagnosis of pulmonary peripheral nodules. The database of the Interventional Pulmonology Unit of Azienda Ospedaliero-Universitaria delle Marche (Ancona, Italy) was evaluated to identify peripheral pulmonary nodules approached by EBUS-TBNA. Thirty patients with a single peripheral pulmonary nodule located peripherally to the subsegmental bronchi of the lower lobes and adjacent to a small bronchus greater than 3 mm in diameter were included in this study. The nodule was visible using endoscopic ultrasound in 28 patients and the diagnosis was obtained via EBUS-TBNA in 26 cases (12 adenocarcinoma, 5 typical carcinoid tumors, 4 hamartoma and 5 metastatic lesions). The diagnostic yield was 86.6% for all 30 patients and 92.8% if only the 28 patients in which the lesion was visualized via echobronchoscopy were considered. No relevant adverse events were observed. We conclude that EBUS-TBNA may be an effective and safe option to sample pulmonary peripheral nodules in selected patients with lower lobe peripheral pulmonary lesions adjacent to small bronchi greater than 3 mm in diameter and reachable with the EBUS-TBNA probe.

Key message: The visualization of black pigment during EBUS‐TBNA suggests a relapse of melanoma. This case highlights the value of EBUS‐TBNA in diagnosing metastatic melanoma, particularly when the macroscopic appearance of the aspirate suggests the diagnosis. [ABSTRACT FROM AUTHOR]

When evaluating mediastinal/hilar lymphadenopathy (LAD) or masses, guidelines recommend endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) as an initial technique for tissue analysis and diagnosis. However, owing to the small sample size obtained by needle aspiration, its diagnostic yield (DY) is limited. EBUS transbronchial forceps biopsy (TBFB) used as a complimentary technique to EBUS-TBNA might allow for better histopathological evaluation, thus improving DY. In this retrospective bicentric study, we assessed the DY and safety of an EBUS-guided 1.5 mm mini-forceps biopsy combined with EBUS-TBNA for the diagnosis of mediastinal/hilar LAD or masses compared to EBUS-TBNA alone. In total, 105 patients were enrolled. The overall DY was 61.9% and 85.7% for TBNA alone and EBUS-TBNA combined with EBUS-TBFB, respectively (p < 0.001). While the combined approach was associated with a significantly higher DY for lung cancer diagnosis (97.1% vs. 76.5%, p = 0.016) and sarcoidosis (85.2% vs. 44.4%, p = 0.001), no significant differences in DY were calculated for subgroups with smaller sample sizes such as lymphoma. No major adverse events were observed. Using a 1.5 mm mini-forceps is a safe and feasible technique for biopsy of mediastinal or hilar LAD or masses with superior overall DY compared to EBUS-TBNA as a standalone technique. [ABSTRACT FROM AUTHOR]

Key message: Conventional transbronchial needle aspiration (cTBNA) remains a basic technique that must be part of the bronchoscopists expertise. In cases where EBUS is not available, cTBNA must be kept in mind: 'the old bull knows best'. [ABSTRACT FROM AUTHOR]

In our day-to-day practice, as a pulmonologist, the mediastinal lymphadenopathy is a common finding, the cause of which is difficult to diagnose. Although in endemic countries like India, tuberculosis is the common cause, there are also other causes which are associated with it. Therefore, it is important to get a tissue diagnosis before we arrive at a conclusion.

Background: This study aimed to compare the lymph node core tissue lengths obtained via mediastinal or hilar lymphadenopathy using the complementary "rotation aiding" and conventional Jab technique. Methods: We prospectively measured the lymph node core tissue length in patients who sequentially underwent the Jab and rotation aiding (RA) techniques between October 2012 and December 2014. Wilcoxon signed‐rank test was used to compare the core tissue length and grade of diagnostic cells obtained by each technique. McNemar's test was used to compare the proportion of adequate cellularity (≥grade 2) between the aspiration techniques. Results: The core tissue length of 61 lymph nodes from 43 patients (mean age: 63 years, range: 16–86 years) was analyzed. Pathological findings were consistent with malignant lesions in 25 (41%) patients and benign lesions in 36 (59%). The most common diagnosis in benign lymph nodes was reactive, followed by tuberculosis and sarcoidosis. We obtained longer core tissue with RA technique than with the Jab technique (83.2 ± 12.7 vs. 60.1 ± 10.1 mm; p = 0.02). There was a significant increase in cellularity grade and proportion of ≥grade 2 cells with the RA technique than with the Jab technique (2.39 ± 1.08 vs. 1.84 ± 1.14; p < 0.001, 78.7% vs. 52.5%; p = 0.002), regardless of the pathological diagnosis. Conclusions: RA technique facilitated more lymph node samples in terms of core tissue length and cellularity than the Jab technique. [ABSTRACT FROM AUTHOR]

Background: There is a lack of data on the prevalent practices of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in India. Aim: To study the current practices of EBUS-TBNA in India. Methods: This survey was an online questionnaire designed on the Google forms interface. The survey included various questions related to demographics, sedation, analgesia and anesthesia, technical aspects, and infection control related to the procedure of EBUS-TBNA. Results: Data from 134 respondents (mean age: 42.2 years) were analyzed. Most (97.8%) were pulmonologists or physicians, and a majority (94.8%) practicing in either a private multi-specialty setting or medical college. 40.3% had received procedure training at a formal training program. Mild/moderate sedation was the most common strategy (70.1%). Midazolam (76.7%), Fentanyl (76.0%), followed by propofol (46.5%), were the most frequent drugs, and 82.8% preferred combination sedation. 26.1% used cricothyroid lignocaine injection, and the use of 1% or 2% lignocaine for spray-as-you-go administration was similar. The oral route was preferred, while the laryngeal mask airway was the most common airway conduit under general anesthesia. Suspected granulomatous mediastinal lymphadenopathy (TB/sarcoidosis) (67.2%), followed by lung cancer (32.8%), were the most common indications of EBUS-TBNA. 81.3% performed EBUS-TBNA for lung cancer staging. 21 G needle was preferred (64.9%), and vacuum suction was common (80.6%). 55.2% routinely performed ROSE. Alcohol fixed glass slide smears were the most common method (93.1%) for cytological preparation. 49.3% also performed EUS-B-FNA. 76.9% routinely obtained endo bronchial biopsy and transbronchial lung biopsy in patients with suspected sarcoidosis. Elastography was infrequently used. Nearly three-fourths (77.6%) reused EBUS needles. Conclusion: There is practice variability in the multiple aspects related technical performance of EBUS-TBNA. Evidence-based guidelines addressing the multiple technical aspects are required to standardize the practice of EBUS-TBNA. [ABSTRACT FROM AUTHOR]

Mediastinal masses are relatively uncommon. Surgical approach is often needed to diagnose mediastinal masses. Using endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) toward approaching a mediastinal mass has yet to be established. Here, we present a case of successful diagnosis of thymic cancer with the use of EBUS-TBNA. [ABSTRACT FROM AUTHOR]

Background: Even though studies have indicated the usefulness and safety of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA), elderly patient data are limited due to the small sample sizes. Aim: We aimed to evaluate usage and safety of EBUS-TBNA in elderly population. Methods: This single-center retrospective study was conducted with patients who underwent an EBUS-TBNA procedure between September 2011 and December 2019. The patients were categorized into two groups: those aged 65 years or older (elderly group) and those younger than 65 years (younger group). Results: 2444 patient data, 1069 of which were in the elderly group, were analyzed. The cytological examination of EBUS-TBNA identified specimen adequacy in 96.8% of patients. One hundred and thirty patients (5.3%) experienced complications, with similar complication rates recorded in both the elderly and younger groups (5.4% vs 5.2%, p: 0.836). Logistic regression analyses revealed that age, and presence of hypertension, diabetes mellitus, coronary artery disease and malignancy are associated significantly with complication-related EBUS-TBNA. For the lymph nodes with a final diagnosis of malignancy, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of EBUS-TBNA revealed a diagnostic performance in excess of 90% except for metastasis and lymphoma. Conclusion: EBUS-TBNA can be considered a safe and effective technique in patients aged 65 years and over. [ABSTRACT FROM AUTHOR]

Background: Diagnosis of isolated mediastinal tuberculosis (TB) can be challenging. Endobronchial ultrasound (EBUS) increases the diagnostic yield by direct sonographic visualization of mediastinal and hilar lymph nodes. With the advent of molecular techniques such as Gene Xpert, their addition to the cytology and cultures increases the diagnostic yield and detection of rifampicin resistance (RR) which helps change the effective therapeutic regimen immediately. Materials and Methods: Prospective analysis of all patients undergoing EBUS-guided transbronchial needle aspiration (EBUS-TBNA) with a clinical possibility of TB in isolated mediastinal lymphadenopathy patients at a tertiary care referral center between June 2016 and January 2018. All patients had at least five passes from each node of which two passes from each lymph node sampled in 2 ml of saline for culture and Gene Xpert for microbiologic, pathologic, and molecular analysis as per hospital protocol. Results: Out of 60 patients, 44 were diagnosed to have mediastinal tuberculous lymphadenitis, 8 sarcoidosis, 2 malignancies, and 6 reactive lymphadenitis. TBNA cytology was positive in 40/44 patients (90.9%), out of which 18 patients were culture positive with the sensitivity of 100%, specificity 47.6%, positive predictive value (PPV) 45%, and negative predictive value (NPV) 100%, (P value 0.011). TBNA acid-fast bacilli (AFB) smear was positive in 20/44 patients (45.45%) out of which 12 were culture positive, with sensitivity of 67%, specificity 80.95%, PPV 60%, NPV 85% (P value 0.011). TBNA Gene Xpert was positive in 30/44 patients (68.2%), out of which 6 (13.63%) showed RR-TB and two were cytology negative. Sixteen patients where culture positive with sensitivity of 88.89%, specificity 66.67%, PPV 53.33%, NPV 93.33% (P value of 0.005). TBNA AFB culture was positive in 18/44 patients (40.9%). Conclusion: EBUS-TBNA is an effective and safe diagnostic tool for intrathoracic TB, especially for mediastinal tuberculous lymphadenitis. The combination of various tests increases the diagnostic yield. Mediastinal nodal aspirates traditionally believed to be paucibacillary can still be captured by Gene Xpert.

Abstract Background Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) has been become an important procedure for the diagnosis and staging of lung cancer. Our research identified the effects of different pathological preparation on the diagnosis of lung cancer for specimens obtained by biopsy. Methods Patients were clinically considered if lung cancer was accompanied by mediastinal or hilar lymph node enlargement between March 2014 and November 2017. Specimens obtained by EBUS-TBNA were treated by three methods: traditional smear cytology, liquid-based cytology (LBC) and histopathology. Results Of a total of 154 puncture sites from 153 patients, the total positive rate of combination for the three pathological treatment types (histopathology, direct traditional smear, and LBC) was 77.3%. The diagnostic positive rate for histopathology was 68.6%, direct traditional smear was 65.6%, and LBC was 60.4%; there was no significant differences among the three single pathological treatment types (P = 0.29), but there was a statistically significant difference between the combination of three treatments and any single pathological treatment type (P = 0.01). The diagnostic sensitivities of histopathology combined with traditional smear and histopathology combined LBC were 94.4 and 92.8%, respectively, the specificities and PPVs were both 100%, and the diagnostic accuracies were 95.5 and 94.2%, respectively; the sensitivities, specificities and diagnostic accuracies above were all higher than those of single specimen treatment and lower than those of the three combined. Conclusion When EBUS-TBNA is used for the diagnosis and staging of lung cancer, the use of histopathological sections combined with direct cytological smear should be sufficient and is the most economical choice.

Background The ProCore 25‐gauge needle is a novel specifically designed puncture needle for endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA), which may improve the puncture efficiency of the procedure while ensuring the diagnostic rate. The aim of the present study was to evaluate the diagnostic accuracy, mRNA yield, and complication rate of 25‐gauge needles compared to those of 22‐gauge needles in the evaluation of mediastinal and hilar lymphadenopathy. Methods A total of 39 patients undergoing EBUS‐TBNA at our institution were evaluated. All the procedures were performed by an experienced endoscopist formally trained in interventional pulmonology. Both the traditional 22‐gauge and ProCore 25‐gauge needles were used at each lymph node station. For all specimens obtained via EBUS‐TBNA, 50 μL was used to extract mRNA and detect the RNA concentration, whereas the other part was sent to the pathological evaluation. χ2 test and t‐test were performed to determine the differences between the two types of the needles. A P‐value of 0.05). No serious procedure‐related complications were reported. In addition, the mRNA concentration did not differ between the two types of needles (P > 0.05). Conclusion The ProCore 25‐gauge needle gained a similar diagnostic yield with less puncture time and frequency compared with the 22‐gauge needle.

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be limited by the inadequacy of intact tissues, especially in patients with lymphoma, sarcoidosis, and lymph node tuberculosis. A novel technique called transbronchial node biopsy (TBNB) by forceps or cryoprobe has been proposed and studied to improve specimen quality and diagnostic yield. We performed a systematic review of studies describing the safety and sensitivity of EBUS-TBNB versus EBUS-TBNA in diagnosing intrathoracic lymphadenopathy/masses., Methods: We systematically searched MEDLINE, Embase, Cochrane, and China National Knowledge Infrastructure to identify studies focusing on the application of EBUS-TBNB for diagnosis of intrathoracic lymphadenopathy. The quality of each study was evaluated using the QUADAS-2 tool. Using inverse-variance (I-V) weighting, we performed a meta-analysis of diagnostic yield estimations. We also reviewed the complications related to the procedure., Results: Thirteen studies were included in the final analysis. The meta-analysis yielded a pooled overall diagnostic yield of 77.80% (939/1,207) for EBUS-TBNA and 86.01% (834/958) for EBUS-TBNB, with an inverse-variance-weighted odds ratio of 3.13 (95% confidence interval [CI], 1.61-6.01; p = 0.0008) and I2 of 82%. The pooled diagnostic yield of EBUS-TBNB versus EBUS-TBNA for the diagnosis of malignancy (including primary lung cancer and extrapulmonary malignancy) was 84.53% (590/698) for EBUS-TBNA and 90.84% (476/524) for EBUS-TBNB, with an I-V-weighted OR of 2.33 (95% CI, 1.15-4.74; p = 0.02) and I2 of 64%. The pooled diagnostic yield of EBUS-TBNB versus EBUS-TBNA for the diagnosis of benignancy was 71.19% (252/354) for EBUS-TBNA and 86.62% (233/269) for EBUS-TBNB, with an I-V-weighted OR of 4.39 (95% CI, 2.00-9.65; p = 0.002) and I2 of 59%. The overall complications included bleeding (n = 11, 0.90%), pneumomediastinum (n = 6, 0.49%), pneumothorax (n = 6, 0.49%), pneumonia (n = 4, 0.33%), respiratory failure (n = 1, 0.08%), and haemoptysis (n = 1, 0.08%). The funnel plot analysis illustrated no major publication bias., Conclusions: EBUS-TBNB improves the overall diagnostic yield of sampling intrathoracic lymphadenopathy and mass lesions relative to EBUS-TBNA. The complication rate of EBUS-TBNB is higher than that of EBUS-TBNA but reportedly lower than that of surgical biopsies., (© 2024 S. Karger AG, Basel.)

Transbronchial needle aspiration (TBNA) is a commonly used sampling approach in the diagnosis of hilar and mediastinal lymphadenopathy as well as peripheral lesions. As a very important tool, the continued innovation of TBNA needles is a vital driving force for the development of the technique. Although TBNA plays an important role in interventional pulmonology, there are no clear standards guiding operators to choose an appropriate needle for their operation. In recent decades, with the advent of endobronchial ultrasound-guided TBNA (EBUS-TBNA), the real-time visualization of TBNA has been enabled. These modern TBNA needles, such as ViziShot2, FLEX 19G, Acquire FNB, and EchoTip ProCore, have made significant progress in specimen collection, convenience, and safety, though still remain grounded in the basic premise and initial upgrades to the original conventional TBNA (cTBNA) needles. This review introduced the developmental history of WANG cTBNA needles, and summarized the lessons of success and failure and the enlightenments for currently used EBUS- and other emerging TBNA needles, aiming to provide a significant reference for pulmonologists who lived through the cTBNA era and for junior physicians who start working in the EBUS-TBNA era. Despite its long history, TBNA is still playing significant roles in the diagnosis of pulmonary diseases. A deeper understanding from the historical perspectives would facilitate continued innovations in the field of TBNA and beyond., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Abstract Infectious complications after endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) are rare but serious. Here, we report a very rare case of delayed onset of mediastinitis with tracheomediastinal fistula after EBUS‐TBNA. Surgical debridement was performed, antibiotics were administered, and the postoperative course of the patient was good. Careful monitoring is needed to prevent the possible development of infectious complications after EBUS‐TBNA.

Abstract Background The critical management of advanced non-small-cell lung carcinoma (NSCLC), especially when complicated by severe airway stenosis, is difficult and often leads to high clinical risks and medical costs. Case presentation A 51-year-old previously healthy male was admitted to the Department of Respiratory and Critical Care Medicine, Taizhou People’s Hospital, in November 2018 for haemoptysis and difficulty breathing during a 15-d period. Following admission, chest computed tomography (CT) showed a large mass in the left hilum with atelectasis in the left upper lobe and obstructive pneumonia in the left lower lobe. Bronchoscopy revealed that the lesions occurred in the distal segment of the left main trachea, with occlusion of the left upper bronchus and significant narrowing of the lower bronchus. A basal mucosal biopsy of the lump tissue was performed after haemostasis treatment with sub-plasma coagulation (APC), and squamous lung carcinoma was confirmed. Following the final diagnosis, the patient was successfully treated with implantation of 125I radioactive seeds via transbronchial needle aspiration (c-TBNA) combined with chemotherapy. Conclusion We believe that implantation of 125I radioactive seeds via c-TBNA is an effective treatment for patients with advanced lung cancer and those presenting with severe and mixed main bronchus stenosis.

Abstract Background Endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is minimally invasive technique used for diagnosis and/or staging of benign and malignant pulmonary and non-pulmonary disease. Previous studies have established the utility of EBUS-TBNA in narrowly defined indications and populations. In this pragmatic ‘real world’ study we have analysed the use of EBUS-TBNA for a variety of clinical presentations and its clinical application in conjunction with other invasive investigations. Methods All EBUS-TBNA procedures performed at Sir Charles Gardiner Hospital in 2012–2014 were reviewed retrospectively, using relevant hospital databases. Results A total of 327 patients underwent 337 EBUS-TBNA procedures. EBUS-TBNA procedures were used to diagnose a wide spectrum of benign and malignant conditions. The main application was in the diagnosis and staging of malignant conditions (70.6%), and in the diagnosis of benign conditions such as sarcoidosis 40 (12.2%), and silicoanthracosis 17 (5.2%). EBUS-TBNA was sufficient to diagnose and stage the disease as a single stand-alone invasive procedure in 191 (59.2%) patients. EBUS-TBNA was the final invasive procedure undertaken in 283 (87.6%) patients. Only 13.3% of non small cell lung cancer (NSCLC) patients who had EBUS-TBNA as a first investigation required multiple procedures compared to 51.1% of all NSCLC patients undergoing EBUS-TBNA. Overall sensitivity, specificity, NPV and diagnostic accuracy for EBUS-TBNA were 89.7, 100, 85.1 and 89.9%, respectively and three minor complications (0.9%) occurred as a result of the procedure. Conclusions EBUS-TBNA was undertaken for a wide variety of clinical conditions. Good diagnostic accuracy and safety profiles were demonstrated for the procedure, supporting its application as a first line investigation in the diagnosis and/or staging of a range of malignant and benign conditions. Our study was unique in its documentation of the use of EBUS-TBNA in a real-world setting in conjunction with other invasive modalities. EBUS-TBNA was utilised as a stand alone invasive procedure in more than half of the patients. Importantly, in NSCLC, when EBUS-TBNA was performed as primary diagnostic and staging investigation, less patients underwent subsequent invasive procedures.

Abstract Context Endoscopy plays an integral part in the evaluation of mediastinum. Transbronchial sampling can be done conventionally or guided with endobronchial ultrasonography (EBUS), which is a new tool that allows seeing beyond the airway. Following its invention, the use of conventional sampling has declined. Aims To evaluate the efficacy of EBUS-transbronchial needle aspiration (TBNA) in sampling mediastinal lesions after conventionally negative TBNA result and to compare EBUS-TBNA sampling in subcarinal and hilar sites versus paratracheal sites regarding diagnostic yield. Settings and design A prospective evaluation study was done. Patients and methods The study enrolled 52 patients with undiagnosed mediastinal lymphadenopathy or lesions. Subcarinal lesions were sampled by both conventional TBNA and EBUS-TBNA sampling (after negative conventional sampling results), and paratracheal lesions were sampled only with EBUS. Statistical analysis used Data were analyzed to test statistical significant difference between groups. Quantitative data were presented as mean±SD, and Student t test was used to compare between two groups. Results No complications were reported. Conventional subcarinal TBNA sampling was done in 37 cases, where sufficient sampling was seen in 67.6% of cases, was diagnostic in 16.2% and had sensitivity of 20%. EBUS-TBNA was done in 22 cases after negative conventional sampling result, and in additional 15 cases as an initial procedure during the study. EBUS diagnosed 89.2% of cases, with sensitivity of 97.1%. Diagnostic percent in EBUS targeting subcarinal/hilar sites was 81.8% whereas was 100% in paratracheal EBUS sampling. Conclusion Both modalities of sampling are safe. Diagnostic value of EBUS-TBNA exceeded much more than conventional sampling.

Background Conventional transbronchial needle aspiration (TBNA) is advantageous for the one‐step diagnosis and staging of lung adenocarcinoma under topical anesthesia and conscious sedation. We examined its efficacy for identifying EGFR mutations. Methods Forty‐seven patients with proven or suspected lung adenocarcinoma indicated for hilar‐mediastinal lymph node (LN) staging between June 2011 and December 2017 were enrolled. The cellblock was prepared using the plasma‐thrombin method. TaqMan PCR was used to detect mutations. Considering cost effectiveness, only the sample with the highest tumor cell fraction in the same patient was chosen for analysis. Results TBNA provided positive results of malignancy in 27 patients. Seventeen patients (63.0%) had cellblocks eligible for mutation testing. Bronchial biopsy (n = 6), neck LN fine needle aspiration (n = 1), and brushing (n = 1), provided higher tumor cell fractions for analysis in eight patients. TBNA was the exclusive method used in nine patients (19.1%). For patients with an inadequate TBNA cellblock, bronchial biopsy (n = 5), neck LN fine needle aspiration (n = 3), computed tomography‐guided transthoracic needle biopsy (n = 1), and brushing (n = 1) were used for analysis. Modification to specimen processing to prevent exhaustion by cytology after June 2016 improved the adequacy of cellblock samples (9/10, 90% vs. 8/17, 47.1%; P = 0.042). Conclusions These findings suggest the promising role of conventional TBNA and highlight the challenges of doing more with less in an era of precision medicine.

Background: Few studies have reported on the utility of ultrathin bronchoscopes (UTBs) for performing radial probe endobronchial ultrasound (EBUS). Herein, we describe our experience with UTB and conventional bronchoscope (CB) for performing radial EBUS. Materials and Methods: This was a retrospective study comparing the diagnostic yield of a prototype UTB (external diameter 3 mm, working channel diameter 1.7 mm) versus CBs (external diameter ≥4.9 mm) in performing radial EBUS for the evaluation of peripheral pulmonary lesions (PPLs). Fluoroscopic guidance was not available. Results: A total of 121 subjects (34, UTB; 87, CB; 69.4% males) with a mean (standard deviation [SD]) age of 55.2 (14.8) years underwent radial EBUS. The mean (SD) size of PPLs on computed tomography of the thorax was 22.2 (13.7) mm. The lesions were significantly smaller in the UTB group (16.4 vs 24.7 mm, P = 0.006). Eight lesions could be visualized within the lumen of the peripheral smaller bronchi with the UTB. The overall yield of radial EBUS was 52.9% and was similar in the two groups (UTB vs. CB, 55.9% vs. 51.7%; P = 0.7). The procedure time was significantly shorter in the UTB group. On multivariate logistic regression, the yield was similar in the two groups after adjusting for the size and location of the lesion and position of the radial probe in relation to the lesion. Conclusion: Despite smaller lesions, radial EBUS performed with the UTB was found to have similar efficacy to that performed with the CB. More lesions could be visualized endobronchially using the UTB making it an attractive alternative for performing radial EBUS.