Abiramy Jeyabalan

Impact of needle gauge on characterization of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) histology samples.

Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is a minimally invasive mediastinal node sampling technique used for lung cancer staging and diagnosis of mediastinal lesions. The four published studies assessing sampling with 21‐G or 22‐G needles conflict. The study objective is to evaluate the diagnostic utility of 21‐G versus 22‐G EBUS‐TBNA needles, and the ability to subcharacterize both benign and malignant lesions using histopathological assessment only.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Patient Satisfaction under Light Conscious Sedation

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an increasingly used mediastinal sampling technique. Many centres use conscious sedation in an ambulatory setting to optimise the flow of patients, save costs and shorten recovery time. The only EBUS-TBNA patient satisfaction study published so far used deep conscious sedation with propofol. To our knowledge, ours is the largest prospective study evaluating the experience of patients undergoing EBUS-TBNA using light conscious sedation without propofol. Objectives: To evaluate the patient tolerability of EBUS-TBNA under mild conscious sedation. Methods: Eighty-two consecutive patients between January 2011 and November 2011 requiring EBUS-TBNA under light conscious sedation for either mediastinal staging of lung cancer or the diagnosis of suspected mediastinal disease due to malignancy or granulomatous disease were invited to complete a questionnaire after the intervention. The collection of data included the diagnostic yield, the number and size of nodes sampled and the dose of sedative medication administered. Results: The average dose of sedative agents administered was 59.4 μg fentanyl and 3.2 mg midazolam. The sensitivity of EBUS-TBNA for the cancer staging, cancer diagnosis and granulomatous disease cohorts was 90.0, 94.1 and 87.5%, respectively. The most commonly reported symptom was a cough in 65 (93%) patients. Of these patients, 46 (71%) described the severity as being mild. All but 9 patients (61/70 or 87%) stated that they would definitely or probably undergo a repeat EBUS-TBNA. Conclusions: This single-centre UK study confirms that EBUS-TBNA under light conscious sedation is a well-tolerated procedure maintaining the expected diagnostic performance, with patients reporting a high degree of satisfaction with both the test and the information received beforehand.

S22 The Effect Of Needle Gauge On Characterisation Of Histology Samples At Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA)

Introduction Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal node sampling technique used for lung cancer staging and diagnosis of malignant and benign lesions. Sampling is done with either 21-gauge (21G) or 22-gauge (22G) needles. There are only two published (non-UK) studies which have evaluated the effect of EBUS-TBNA needle gauge on diagnosis.1,2 Neither study demonstrated a difference in diagnostic yield but one study suggested better preservation of histological structure with the 21G needle.1 The aim of this retrospective UK study was to evaluate the diagnostic utility of 21G versus 22G EBUS-TBNA needles. Our hypothesis was that the 21G needle would allow greater histological characterisation of non-small cell lung cancer (NSCLC) and benign mediastinal lesions. Methods A retrospective analysis was performed from 185 patients referred for EBUS-TBNA between 2011 to 2012. EBUS-TBNA was performed as previously described under conscious sedation.3 21G or 22G (Olympus ViziShot, NA-201SX-4021 and NA-201SX-4022) was used at the discretion of the operator. Pathologists were blinded to needle gauge. Contingency table statistical analysis was performed (GraphPad Prism version 5) to compare diagnostic utility of 21G and 22G EBUS-TBNA needles and ability to subcharacterise NSCLC and benign lesions. Results Performance data (table 1) showed non-inferior diagnostic utility for 21G and 22G needles. Subgroup analysis of benign 21G tissue samples revealed superior characterisation (especially for sarcoidosis) compared to 22G samples (30/37, 81%, versus 17/33, 52%, p=0.008). Similarly, characterisation of NSCLC was superior in 21G samples versus 22G samples (28/33, 85%, versus 25/41, 61%, p=0.02). Conclusion This UK single centre retrospective study suggests 21G EBUS-TBNA needles are superior in characterising benign lesions (especially sarcoidosis) and NSCLC Making a positive benign diagnosis avoids the need to perform mediastinoscopy; additionally, identification of lung adenocarcinoma allows appropriate epidermal growth factor receptor mutation testing and targeted oncological therapy. References Nakajima T, Yasufuku K, Takahashi, Shingyoji M, Hirata T, Itami M, Matsui Y, Itakura M, Ilzasa T, Kimura H. Comparison of 21-gauge and 22-gauge aspiration needle during endobronchial ultrasound-guided transbronchial needle aspiration. Respirology (2011); 16: 90–94. Oki M, Saka H, Kitagawa C, Kogure Y, Murata N, Ichihara, Mortamni S, Ando M. Randomized study of 21-gauge versus 22-gauge endobronchial ultrasound-guided transbronchial aspiration needles for sampling histology specimens. J Bronchol Intervent Pulmonol (2011); 18:306–310. Medford AR, Agrawal S, Free CM, Bennett JA. A performance and theoretical cost analysis of endobronchial ultrasound-guided transbronchial needle aspiration in a UK tertiary respiratory centre. QJM (2009); 102(12):859–64. Abstract S22 Table 1 EBUS-TBNA Needle Sensitivity (%) Specificity (%) Positive Predictive value (%) Negative Predictive Value (%) Prevalence (%) Accuracy (%) 21Gn=88 (48%) 90 100 100 88 58 94 22Gn=97 (52%) 91 100 100 85 66 94 Combinedn=185 90 100 100 86 62 94

M11 Adequacy of 22 and 21 Gauge EBUS-TBNA histology samples for genotyping of primary lung adenocarcinoma

Introduction Epidermal growth factor receptor (EGFR) gene mutations in non-small cell lung cancer have been shown to confer improved responsiveness to tyrosine kinase inhibitors. NICE recommends tyrosine kinase inhibitors as first line therapy in patients with locally advanced or metastatic tumours with EGFR gene mutations. Evidence from a multicentre retrospective study of 119 patients undergoing EBUS-TBNA to obtain cell block samples showed that EGFR mutation analysis was possible in 89.9% (107/119)1. Similar results 32/36 (88.8%) have been observed in a smaller more recent study2. The aim of this single centre prospective study was to evaluate the adequacy of EBUS-TBNA histology specimens using both 21G and 22G needles in confirmed primary lung adenocarcinoma. Methods A prospective analysis was performed on 250 consecutive patients undergoing EBUS-TBNA between 2009 and 2013. 21G or 22G needles (Olympus ViziShot, NA-201SX-4021 and NA-201SX-4022) were used by operator discretion. A minimum of 2 passes were carried out per nodal station. Samples were fixed in formalin and prepared for histopathological analysis. The proportion of confirmed primary lung adenocarcinoma samples in which EGFR mutation testing was feasible was determined. Results Primary lung adenocarcinoma was confirmed in 45 patients (18%). EGFR mutation analysis was attempted in 35 of these patients and was possible in 34 (97.1%). EGFR mutation was present in 3 patients (8.8%). Conclusions This single centre study demonstrates both 22G and 21G EBUS-TBNA samples are adequate for EGFR mutation analysis with no clear superiority in contrast to recent data suggesting disease phenotyping may be superior using a 21G needle when analysed by histopathology. We speculate that higher sample usability rates for mutation analysis may have been facilitated by the use of histological specimens however further larger studies are required to confirm this hypothesis. References Navani N, Brown JM, Nankivell M et al. Suitability of endobronchial ultrasound-guided transbronchial needle aspiration specimens for subtyping and genotyping of non-small cell lung cancer: a multicentre study of 774 patients. AJRCCM (2012); 185(12): 1316–22 Esterbrook G, Anathhanam S, Plant PK. Adequacy of endobronchial ultrasound transbronchial needle aspiration samples in the subtyping of non-small cell lung cancer. Lung Cancer (2013); 80(1): 30–4.

Isolated colorectal mediastinal metastasis

A 52-year-old man was referred for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) having been found to have isolated asymptomatic right paratracheal adenopathy. He had previously had a sigmoid colectomy in 2008 for Dukes B carcinoma (pathological staging pT3 N0). One year later, he was found to have a lesion in the right lobe of the liver, which was successfully downsized with chemotherapy and resected. Subsequent serial follow-up computed tomography scans identified an enlarging isolated right 20 mm paratracheal …

A node or not a node; that is the question?

A 40-year-old woman was referred to the respiratory assessment clinic with a history of sudden onset, right-sided, posterior chest pain. The pain was noted to be exacerbated by respiratory excursion. She had a history of well-controlled asthma and seronegative arthritis for which she was being treated with methotrexate and depomedrone. No specific abnormal examination findings were found, vital signs were normal and a d-dimer was noted to be negative. A chest radiograph (CXR) suggested abnormal soft tissue in the right paratracheal area. Computed tomography (CT) pulmonary angiogram showed no evidence of pulmonary …

Post-bronchoalveolar lavage pneumothorax.

A 54-year-old man underwent fibreoptic bronchoscopy (FOB) for further investigation of chronic cough and weight loss in the context of a right upper lobe lesion most evident on computed tomography (CT; Figure 1A and B). The patient was a heavy smoker without a formal diagnosis of chronic obstructive pulmonary disease (COPD). FOB, as expected, showed no endobronchial lesion. Bronchoalveolar lavage (BAL) with 120 ml …

Endobronchial Ultrasound in the Diagnostic Evaluation of Sarcoidosis

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal sampling technique which combines the use of ultrasound with conventional bronchoscopy in order to visualise and sample structures adjacent to the tracheo-bronchial tree such as mediastinal and hilar lymph nodes. The technique is commonly used in the staging and diagnosis of lung cancers but can also be used for the diagnosis of benign conditions affecting the mediastinum including sarcoidosis.