|Year : 2017 | Volume
| Issue : 1 | Page : 6-9
Application value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and treatment of mediastinal and pulmonary diseases
Wenkui Sun1, Qian Qian2, Xinwu Xiao3, Yong Song3
1 Department of Respiratory and Critical Care Medicine, Jinling Hospital, School of Medicine, Nanjing University; Department of Respiration Disease, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
2 Department of Respiratory, Nanjing Chest Hospital, Southeast University, Nanjing, Jiangsu, China
3 Department of Respiratory and Critical Care Medicine, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
|Date of Submission||04-Dec-2016|
|Date of Acceptance||10-Mar-2017|
|Date of Web Publication||21-Mar-2017|
Department of Respiratory and Critical Care Medicine, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu
Department of Respiratory and Critical Care Medicine, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu
Source of Support: None, Conflict of Interest: None
Aim: This study aims to investigate the value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis and treatment of mediastinal and pulmonary diseases. Methods: The clinical data of 52 patients who were hospitalized in the Department of Respiratory and Critical Care Medicine at Jinling Hospital from July 2014 to February 2015 with documented EBUS-TBNA was obtained. Results: Positive results of EBUS-TBNA biopsy were statistically compared to the final diagnosis. A total of 82 specimens from 52 patients were obtained through EBUS-TBNA biopsy. Out of 52, 45 patients had concurrent surgical pathology, including 33 malignant lesions and 12 benign lesions. There were 7 patients with false-negative results, including 1 case of pulmonary sclerosing hemangioma, 4 cases of lung cancer, and 2 cases of tuberculosis. The sensitivity of EBUS-TBNA in this study was 85.2%, accuracy of 85.4%, positive predictive value of 100%, and negative predictive value of 7.7%. There were no serious complications. Conclusion: EBUS-TBNA is a safe and minimally invasive method for the diagnosis of mediastinal and pulmonary diseases. It may also have utility as a therapeutic option during the diagnostic process of some diseases.
Keywords: Cyst, endobronchial ultrasound, lung cancer, mediastinum, sarcoidosis
|How to cite this article:|
Sun W, Qian Q, Xiao X, Song Y. Application value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and treatment of mediastinal and pulmonary diseases. Transl Surg 2017;2:6-9
|How to cite this URL:|
Sun W, Qian Q, Xiao X, Song Y. Application value of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and treatment of mediastinal and pulmonary diseases. Transl Surg [serial online] 2017 [cited 2017 Aug 21];2:6-9. Available from: http://www.translsurg.com/text.asp?2017/2/1/6/202647
| Introduction|| |
The mediastinum is a complex structure, containing many important organs and tissues. Thoracoscopy and mediastinoscopy have been the primary diagnostic techniques for biopsy of lesions in the mediastinum. However, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has gained popularity because of simplicity; it is minimally invasive and causes less complication.
Conventional-TBNA (c-TBNA) has already shown to be effective for mediastinal lung cancer staging. The technique is still underutilized. Since the development of c-TBNA, many methods have been used with TBNA to improve the diagnostic yield, such as rapid on-site evaluation and a recommendation for at least three separate needle passes per sampling site. The guidance of fluoroscopy, computed tomography (CT), or EBUS has also been shown to increase the yield.
EBUS was introduced to bronchoscopy almost a decade ago, enabling real-time guidance of TBNA of mediastinal and hilar structures as well as parabronchial lung masses. The diagnostic yield of c-TBNA varies widely, ranging from 20% to 89%. The yield of c-TBNA is related to the size and location of the lesion, as well as the individual experience of the physician. The diagnostic value of EBUS-TBNA is higher when compared to c-TBNA.
EBUS-TBNA is not universally available in most community hospitals compared to c-TBNA, due to technical and financial issues. This paper reports the clinical application of EBUS-TBNA in the diagnosis and treatment of mediastinal and pulmonary disease.
| Methods|| |
The clinical data of 52 patients who were hospitalized at Jinling Hospital from July 2014 to February 2015 were reviewed. All patients underwent the EBUS-TBNA procedure. There were 36 males and 16 females, aged 21-78 (whose average age is 57 ± 13 years old).
All patients received CT examination before the EBUS-TBNA. Seven cases were diagnosed with mediastinal or hilar lymphadenopathy alone. There were four pure pulmonary lesions and 41 cases of hilar or mediastinal adenopathy combined with a pulmonary lesion. Either transthoracic needle biopsy or open-/video-assisted thoracoscopic lung biopsy was performed as an alternative to ENUS-TBNA.
Evaluation included clinical history, physical examination, laboratory tests (complete blood count, liver, and renal function tests), chest radiography, and CT of the chest. CT was used for evaluation of intrathoracic lymph node stations and size, and assessment of parenchymal abnormalities.
EBUS was performed as previously described in detail. A bronchoscope (BF-UC180F, Olympus Medical, Japan) with a dedicated ultrasound image processor (model EU-ME1, Olympus Medical, Japan) was introduced. The exact location of the target lymph nodes and their relationship to the tracheobronchial tree was noted.
Procedures of endobronchial ultrasound-guided transbronchial needle aspiration
Before the procedure, we identified the precise puncture position with the aid of either enhanced CT or positron emission tomography-computed tomography (PET/CT). All bronchoscopy procedures were performed by experienced faculty. Preprocedural medications included nebulized 2% lidocaine (5 mL), topical 2% lidocaine jelly applied to the nasal cavity, and 2% lidocaine aerosol sprayed over the vocal cords. Monitored care was provided during the procedure.
We performed conventional bronchoscopy examination on all patients. Additional anesthesia was applied to both trachea and bronchus. Ultrasonic bronchoscopy examination with the water sac in place was performed. The bronchoscope was inserted to the puncture point through either the nasal or oral cavity. The ultrasonographic features such size, shape, and Doppler blood flow distribution, of enlarged hilar and mediastinal lymph nodes, as well as visible pulmonary lesions, were recorded.
EBUS-TBNA (at least three passes per node) was performed on those lymph glands and pulmonary lesions whose diameter ≥5 mm. All TBNA specimens were obtained using a dedicated, disposable, 21-gauge needle (NA-201 SX-4021A, Olympus Medical, Japan). In this study, the puncture sites were as follows: 2 R, 2 L, 3 R, 3 L, 4 R, 4 L, 7, 11 R, 11 L, and sites of sampled pulmonary lesions.
During the procedure, the length of the needle was determined (2–3 cm), and the needle sheath advanced to the microscope until the meniscus was seen. Under the guidance of ultrasound, the puncture needle was quickly inserted into lesion and the core removed. Negative pressure was achieved with syringe suction. The puncture needle needs to repeated move back and forth in lymph node 20–30 times for suction. Then, biopsy needle was withdrawn back into casing pipe. The syringe and normal saline was used to flush out the samples in needle cavity. Specimens were placed in 10% formaldehyde solution. Cell smears were fixed with 95% ethanol. Patients were observed for both intra- and post-operative hemoptysis.
| Results|| |
Out of 52, 45 patients who received the EBUS-TBNA type biopsy, 33 of them were diagnosed with malignant lesions. The lesions spanned a wide spectrum to include 18 cases of adenocarcinoma, 4 cases of squamous carcinoma, 9 cases of the small cell carcinoma, one neuroendocrine carcinoma, and one case of spindle-cell tumor. Twelve patients were diagnosed with benign lesions including 5 with tuberculosis, 4 with sarcoidosis, 2 with mediastinal cysts, and one case of respiratory anthracosis. Among the 7 patients without a diagnosis by core needle biopsy, 2 cases were separately diagnosed as pulmonary sclerosing hemangioma and lung cancer, 2 were diagnosed with pulmonary tuberculosis, and 3 were diagnosed with lung cancer through puncture [Table 1].
|Table 1: Diagnostic yields with endobronchial ultrasound-guided transbronchial needle aspiration|
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In total, 82 tissue cores were obtained through EBUS-TBNA biopsy, including 78 lymph node samples and 4 pulmonary lesion samples. The lymph node sites were as follows: 4 in the 2 R group, 2 in the 2 L group, 5 in the 3 R group, 2 in the 3 L group, 27 in the 4 R group, 17 in the 4 L group, 15 in the 7 group, 2 in the 11 R group, and 4 in the 11 L group. Based on 82 core biopsies, one was true negative, 12 were false negative, 69 were true positive, and none were falsely positive. In this study, the sensitivity of EBUS-TBNA sampling was 85.2% (69/81), the accuracy was 85.4% (70/82). The positive predictive value was 100% (69/69), and the negative predictive value was 7.7% (1/13). The average number of needle passes was 3. Five patients were noted to have blood-stained sputum and recovered with conservative treatment. No other complications related to the procedure or to bronchoscopy were observed with the use of EBUS-TBNA. All patients tolerated the treatment well.
| Discussion|| |
The diagnosis of mediastinal disease is difficult because of the location and complexity of the residing structures. Although CT, magnetic resonance imaging (MRI), PET/CT, and other imaging exams have relatively high sensitivity for mediastinal disease, pathology is the gold standard for diagnosis.
Mediastinoscopy is the gold standard for the diagnosis of mediastinal disease. However, it uses a surgical incision, has other intraoperative and postsurgical risks, and has limited ability to evaluate hilar nodes. All of these factors may contribute to limited applicability for mediastinal evaluation.
C-TBNA requires locate identification of the lesion by CT or enhanced CT, followed by correlation with the anatomical structures under the bronchoscope before attempting needle aspiration biopsy. It has the advantages of minimal trauma, but there is still has a degree of uncertainty with respect to a blind aspiration. In addition, the location of lymph nodes in question affects the ability to achieve a diagnosis., To overcome the shortcomings of C-TBNA, in 2002, Tengzewuyan and Anfuhehong successfully developed the ultrasonic bronchoscopy with a convex probe. It was applied to the real-time EBUS-TBNA. In 2008, this novel technology was introduced to China. Surgeons with bronchoscopic skills can usually master the key techniques of EBUS-TBNA after 10 cases of practices. This allows for a new method for the clinical diagnosis of mediastinal lesions and the pulmonary lesions beside the mediastinum.
In 2006, the research of Yasufuku et al. successfully applied EBUS-TBNA for staging lung cancer according to nodal basins. Subsequent clinical research also confirmed the ability of EBUS-TBNA to detect positive mediastinal lymph nodes as they relate to the staging of lung cancer. A meta-analysis of 1,299 cases of patients showed that the overall sensitivity of EBUS-TBNA applied to lung cancer staging was 93%, and specificity was 100%. The biopsy range of EBUS-TBNA is wider than that of mediastinoscopy. EBUS-TBNA is the only way of obtaining tissue from node stations 10 and 11. Moreover, it has a significant advantage over mediastinoscopy when being applied to station 7 nodes. The technique can be used to inspect other groups of mediastinal lymph nodes such as para-aortic nodes. Among the 37 cases of malignancy, 33 cases were identified by EBUS-TBNA, substantiating the importance of this technique. Therefore, when chest CT or PET/CT suggests the possibility of malignancy, particularly with mediastinal lymphadenopathy, EBUS-TBNA may be the preferred method for obtaining tissue.
EBUS-TBNA also has important diagnostic value for benign lesions. Studies confirmed that the diagnostic rate of EBUS-TBNA for sarcoidosis is 80%–90% and the sensitivity is 96%. The recent meta-analysis by Agarwal et al. showed that the accuracy is 79%. With EBUS, the lymphadenopathy related to sarcoidosis is characterized by nodules with separation and flat blood vessels. Primary mediastinal cysts are mainly caused by abnormal embryologic development and account for about 13%–18% of primary mediastinal tumors. Approximately, 90% of mediastinal cysts can be diagnosed by CT or MRI, using internal density and signal characteristics. Patients with atypical presentations often require an invasive examination in addition to the conventional methods. With EBUS, 2 mediastinal cysts in our group showed the pathognomonic anechoic character associated with large lesions (with internal diameters of 5.5–6.3 cm). By TBNA, we aspirated 90 mL and 120 mL, respectively, of clear yellow liquid. Analysis of the fluid by Gram-stain, acid-fast stain, and cytology was negative. Therefore, in addition to diagnostic information, EBUS-TBNA can also perform a therapeutic maneuver, in this case, decompression of symptomatic mediastinal cysts. This method is safer and more cost effective when compared to an operation. EBUS-TBNA also shows its clinical diagnostic value when it comes to other benign lesions. Among the 7 cases of tuberculosis in this group, 5 cases were diagnosed by EBU-TBNA. The clinical value of EBUS-TBNA in the setting of more rarely encountered lesions, such as anthracosis or pulmonary embolism, is yet to be determined.
When compared to both open thoracotomy and thoracoscopy, EBUS-TBNA has obvious advantages., In the past, the nature of the associated complications limited development in clinical surgery. Common complications include hemorrhage, infection, fever, pneumomediastinum, and pneumothorax. All of these risks can be mitigated by an experienced surgeon. Timely and standardized intraoperative and postoperative nursing care can reduce the occurrence of complications, such as infection and hemorrhage, to a certain degree. In our group, 5 cases had small amounts of blood in phlegm and recovered after receiving symptomatic treatment.
In conclusion, the study shows that EBUS-TBNA is a safe and minimally invasive method for the diagnosis of mediastinal and pulmonary diseases. In particular, it has a supportive role in the diagnosis and evaluation of mediastinal and hilar adenopathy as well as certain pulmonary parenchymal lesions accessible from the mediastinum.
Financial support and sponsorship
This study was supported by the National Nature Science Foundation of China (Grant No: 81500073) and the Nanjing Medical Science and Technology Development Project (Grant No: YKK13089).
Conflicts of interest
There are no conflicts of interest.
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