Bin Hwangbo

Real-time Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Mediastinal Staging of Non-Small Cell Lung Cancer: How Many Aspirations Per Target Lymph Node Station?

OBJECTIVE The goal of this study was to determine the optimal number of aspirations per lymph node (LN) station during endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) for maximum diagnostic yield in mediastinal staging of non-small cell lung cancer (NSCLC) in the absence of rapid on-site cytopathologic examination. METHODS EBUS-TBNA was performed in potentially operable NSCLC patients with mediastinal LNs accessible by EBUS-TBNA (5 to 20 mm). Every target LN station was punctured four times. RESULTS We performed EBUS-TBNA in 163 mediastinal LN stations in 102 NSCLC patients. EBUS-TBNA confirmed malignancy in 41 LN stations in 30 patients. Two malignant LN stations were missed in two patients. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of EBUS-TBNA in predicting mediastinal metastasis were 93.8%, 100%, 100%, 96.9%, and 97.9%, respectively. Sample adequacy was 90.1% for one aspiration, and it reached 100% for three aspirations. The sensitivity for differentiating malignant from benign LN stations was 69.8%, 83.7%, 95.3%, and 95.3% for one, two, three, and four aspirations, respectively. The NPV was 86.5%, 92.2%, 97.6%, and 97.6% for one, two, three, and four aspirations, respectively. Maximum diagnostic values were achieved in three aspirations. When at least one tissue core was obtained by the first or second aspiration, the sensitivity and NPV of the first two aspirations were 91.9% and 96.0%, respectively. CONCLUSIONS Optimal results can be obtained in three aspirations per LN station in EBUS-TBNA for mediastinal staging of potentially operable NSCLC. When at least one tissue core specimen is obtained by the first or second aspiration, two aspirations per LN station can be acceptable.

Transbronchial and Transesophageal Fine-Needle Aspiration Using an Ultrasound Bronchoscope in Mediastinal Staging of Potentially Operable Lung Cancer

OBJECTIVE We performed this study to evaluate the role of transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) following endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the mediastinal staging of lung cancer. METHODS In this prospective study, we applied transbronchial and transesophageal ultrasonography using an ultrasound bronchoscope on patients with confirmed or strongly suspected potentially operable non-small cell lung cancer. Following EBUS-TBNA, EUS-B-FNA was used for mediastinal nodes that were inaccessible or difficult to access by EBUS-TBNA. The accessibility by EBUS-TBNA and EUS-B-FNA to mediastinal nodal stations having at least one node ≥ 5 mm was also checked. RESULTS In 150 patients, we performed EBUS-TBNA and EUS-B-FNA on 299 and 64 mediastinal nodal stations, respectively. Among 143 evaluable patients, EBUS-TBNA diagnosed mediastinal metastasis in 38 patients. EUS-B-FNA identified mediastinal metastasis in three additional patients. Surgery diagnosed mediastinal metastasis in four more patients. The sensitivity, negative predictive value, and diagnostic accuracy of EBUS-TBNA in the detection of mediastinal metastasis were 84.4%, 93.3%, and 95.1%, respectively. These values for the combined approach of EBUS-TBNA and EUS-B-FNA increased to 91.1%, 96.1%, and 97.2%, respectively, although the differences were not statistically significant (P = .332, P = .379, and P = .360, respectively). Among 473 mediastinal nodal stations having at least one node ≥ 5 mm that were evaluated, the proportion of accessible mediastinal nodal stations by EBUS-TBNA was 78.6%, and the proportion increased to 84.8% by combining EUS-B-FNA with EBUS-TBNA (P = .015). CONCLUSION Following EBUS-TBNA in the mediastinal staging of potentially operable lung cancer, the accessibility to mediastinal nodal stations increased by adding EUS-B-FNA and an additional diagnostic gain might be obtained by EUS-B-FNA. TRIAL REGISTRATION clinicaltrials.gov, NCT00741247.

Application of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Following Integrated PET/CT in Mediastinal Staging of Potentially Operable Non-small Cell Lung Cancer

BACKGROUND The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) following integrated PET/CT scanning in mediastinal staging of non-small cell lung cancer (NSCLC) has not been assessed. METHODS We prospectively evaluated the diagnostic values of PET/CT scanning and EBUS-TBNA for mediastinal staging in 117 patients with potentially operable NSCLC with accessible mediastinal lymph nodes (diameter range, 5 to 20 mm) by EBUS-TBNA. Subgroup analysis according to histologic type was performed. RESULTS Of 30 cases of mediastinal metastasis, 27 were confirmed by EBUS-TBNA and 3 were confirmed by surgery. EBUS-TBNA results confirmed all cases with true-positive PET/CT scan findings and six of nine cases with false-negative PET/CT scan findings. The sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of EBUS-TBNA in the detection of mediastinal metastasis were 90.0%, 100%, 100%, 96.7%, and 97.4%, respectively. For PET/CT scans, the values were 70.0%, 59.8%, 37.5%, 85.2%, and 62.4%, respectively (p = 0.052; p < 0.001; p < 0.001; p = 0.011; p < 0.001, respectively). In adenocarcinoma (n = 55), EBUS-TBNA detected four of six cases with false-negative PET/CT scan findings, and the NPV was higher for EBUS-TBNA than for PET/CT scans (94.6% vs 77.8%, respectively; p = 0.044). In squamous cell carcinoma (n = 53), the NPV of EBUS-TBNA and PET/CT scans were similarly high (97.9% vs 96.3%, respectively; p = 0.689). CONCLUSIONS EBUS-TBNA was an effective invasive method following PET/CT scanning in the mediastinal staging of potentially operable NSCLC. In mediastinal PET/CT scan-positive cases, EBUS-TBNA was an excellent tool for detecting mediastinal metastasis. Even in mediastinal PET/CT scan-negative cases, EBUS-TBNA can be useful for confirming mediastinal metastases, especially in adenocarcinoma.

EBUS-centred versus EUS-centred mediastinal staging in lung cancer: a randomised controlled trial

Background The impact of procedure sequence and primary procedure has not been studied in the combined application of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in lung cancer staging. Methods In a randomised controlled trial, 160 patients with histologically confirmed or strongly suspected potentially operable non-small cell lung cancer were enrolled (Group A, n=80, EBUS-centred; Group B, n=80, EUS-centred). EBUS-TBNA and EUS-FNA with an ultrasound bronchoscope were used as the first procedures in Groups A and B, respectively, and secondary procedures (EUS-FNA in Group A, EBUS-TBNA in Group B) were added. Results Diagnostic values were evaluated in 148 patients (74 in each group). In Groups A and B the diagnostic accuracy (93.2% (95% CI 87.5% to 99.0%) vs 97.3% (95% CI 93.6% to 101.0%), p=0.245) and sensitivity (85.3% (95% CI 68.9% to 95.0%) vs 92.0% (95% CI 74.0% to 99.0%), p=0.431) in detecting mediastinal metastasis were not statistically different. In Group A, adding EUS-FNA to EBUS-TBNA did not significantly increase the accuracy (from 91.9% to 93.2%, p=0.754) or sensitivity (from 82.4% to 85.3%, p=0.742). In group B, adding EBUS-TBNA to EUS-FNA increased the accuracy (from 86.5% to 97.3%, p=0.016) and sensitivity (from 60.0% to 92.0%, p=0.008). There were no intergroup differences in procedure time, cardiorespiratory parameters during procedures, complications or patient satisfaction. Conclusions Using a combination of EBUS-TBNA and EUS-FNA in mediastinal staging, we found that diagnostic values and patient satisfaction were not different between the EBUS-centred and EUS-centred groups. However, the necessity for EBUS-TBNA following EUS suggests that EBUS-TBNA is a better primary procedure in endoscopic mediastinal staging of potentially operable lung cancer. Trial Registration number ClinicalTrials.gov number NCT01385111.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of lung cancer

PURPOSE We performed this study to evaluate the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the pathologic diagnosis of lung cancer including lung masses as well as lymph nodes as targets. METHODS We retrospectively reviewed 126 patients who underwent EBUS-TBNA to diagnose radiologically suspected lung cancer. The patients had masses or lymph nodes that were highly suspicious for malignancy and accessible by EBUS-TBNA. RESULTS EBUS-TBNA was performed on 195 lesions (lymph nodes, n=151; lung masses, n=44). In 61 cases, other diagnostic methods had failed previous to EBUS-TBNA. In 118 patients, no definite endobronchial mucosal tumor invasion was observed. In eight patients with endobronchial tumor invasion, EBUS-TBNA was chosen due to tumor bleeding, necrosis, or difficult location for endobronchial biopsy. EBUS-TBNA confirmed 105 lung cancers, five other malignancies and six specific benign cases, demonstrating a diagnostic yield of 92.1% (116/126). Nine cases were diagnosed by other methods (lung cancer, n=2; other malignancies, n=2; benign cases, n=5). One case that was not confirmed by any diagnostic method was considered false negative. The sensitivity and diagnostic accuracy of EBUS-TBNA in the diagnosis of lung cancer were 97.2% (105/108) and 97.6% (123/126), respectively. CONCLUSIONS EBUS-TBNA targeting lymph nodes or masses highly suspicious for malignancy demonstrated high diagnostic value in the diagnosis of lung cancer. EBUS-TBNA is recommended for these cases, especially when other diagnostic methods have failed or are difficult.

Transoesophageal needle aspiration using a convex probe ultrasonic bronchoscope

Background and objective:  Although endoscopic ultrasound‐guided fine needle aspiration can be helpful when combined with bronchoscopic procedures, endoscopic ultrasound‐guided fine needle aspiration is not available as a conjunctive procedure with bronchoscopy at many institutions. This study evaluated the feasibility and the additional role of transoesophageal fine needle aspiration using a convex probe ultrasonic bronchoscope (EUS‐B‐FNA).

F-18 fluorodeoxyglucose and F-18 fluorothymidine positron emission tomography/computed tomography imaging in a case of neurosarcoidosis.

Purpose: F-18 fluorothymidine (FLT) PET/CT is considered more specific for malignancy than F-18 fluorodeoxyglucose (FDG) PET/CT. This case report presents F-18 FLT and F-18 FDG scans of a patient with neurosarcoidosis. Materials and Methods: We describe a 34-year-old man who presented with myelopathic symptoms and signs. The patients evaluation included serological tests for systemic autoimmunity, CSF analysis, magnetic resonance imaging of the spinal cord and brain, abdominal CT, whole-body F-18 FDG and F-18 FLT PET/CT, and high-resolution chest CT. The patient finally underwent transbronchial mediastinal lymph node biopsy for definite diagnosis. Results: The neurologic symptoms were relapsing and remitting. Magnetic resonance imaging demonstrated corresponding abnormal lesions in the spinal cord. Under a tentative diagnosis of multiple sclerosis, the patient was treated with beta-interferon, which showed no beneficial effect. Abdominal CT for evaluation of unexplained abdominal discomfort revealed abdominal lymphadenopathies. F-18 FDG PET/CT showed multiple symmetrical intense accumulations of F-18 FDG on mediastinal and abdominal lymph nodes, whereas only faint to mild F-18 FLT accumulations were observed. Biopsy of mediastinal lymph nodes indicated nontuberculous granulomatous disease. A final diagnosis of neurosarcoidosis was made, and his clinical symptoms and signs were markedly improved by immunosuppressive treatment. Conclusions: Multiple F-18 FDG-avid lymphadenopathies with mild F-18 FLT uptake can be characteristic findings of sarcoidosis. The combination of F-18 FDG and F-18 FLT PET/CT can be helpful in differentiating granulomatous inflammatory diseases such as neurosarcoidosis from malignancy and in localizing the most appropriate biopsy site of active sarcoidosis.

A phase II study of nintedanib in patients with relapsed small cell lung cancer

OBJECTIVES Nintedanib is an oral triple angiokinase inhibitor. This study was conducted to evaluate the efficacy and safety of nintedanib in patients (pts) with relapsed/refractory small cell lung cancer (SCLC). PATIENTS AND METHODS Pts with an ECOG PS from 0 to 2 who exhibited progression after one or two prior chemotherapy or chemo/radiotherapy were enrolled. Pts received nintedanib 200mg BID daily in a 4-week cycle until progression or intolerable toxicity. The primary end point was the objective response rate (ORR). A two-stage design was employed. To continue to stage 2, ≥2 responders out of 22 pts were required. RESULTS From Dec 2011 to June 2014, 24 pts were enrolled. Twenty-two pts completed treatment and were evaluable for response. The median follow-up was 9.7 (0.5-19.8) months. The median age was 64 (46-77) years. Twenty-two pts were male. Six pts had sensitive relapse. Eight pts received one prior chemotherapy. A median of one (range 1-5) cycle was administered. One pt had a partial response, and seven pts exhibited stable disease. The ORR was 5% (95% confidence interval [CI], 0.1-22.8). Median progression-free survival was 1.0 (95% CI, 0.9-1.1) month, and overall survival was 9.8 (95% CI, 8.4-11.2) months. The response criteria to proceed to full accrual were not met. The most frequent drug-related adverse events (AE) included hepatic enzyme elevation (86%), anemia (73%), anorexia (59%), and nausea (50%). Most AEs were mild and manageable. Grade 3 hepatic enzyme elevation occurred in 5 pts (23%). CONCLUSIONS Nintedanib exhibited only limited activity with a manageable AE profile in relapsed or refractory SCLC (NCT01441297).

Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is becoming a standard method for invasive mediastinal staging and for the diagnosis of paratracheal and peribronchial lesions. It is essential to understand the technical aspects of EBUS-TBNA to ensure safe and efficient procedures. In this review, we discuss the practical aspects to be considered during EBUS-TBNA, including anesthesia, manipulation of equipment, understanding mediastinal ultrasound images, target selection, number of aspirations needed per target, sample handling, and complications.

Transient pulmonary eosinophilia incidentally found on low-dose computed tomography: findings in 40 individuals.

Purpose: To describe computed tomography (CT) findings of transient pulmonary eosinophilia (TPE) incidentally found on low-dose CT (LDCT) and to identify suggestive CT features helpful in initial diagnosis. Materials and Methods: We retrospectively reviewed LDCT scans in 40 individuals who met criteria for having TPE. There were 35 men and 5 women (age range, 32-62 years; mean, 48.5 ± 9 years). Initial LDCT scans were assessed as either (a) nodules, further characterized as either solid, solid associated with a halo of ground-glass attenuation, or pure ground-glass lesions as well as by number, size, and location or (b) ill-defined foci of parenchymal consolidation. Results: A range of focal parenchymal abnormalities (n = 78) were identified-both single (48%) and multiple (52%). Most of these proved to be either solid nodules with discrete ground-glass halos (72%), or poorly defined solid nodules exhibiting a variety of differing morphologies (24%). Ill-defined foci of consolidation were noted in 3 cases (4%). The lesions were predominantly located in the lower lung zone (73%) with peripheral distribution (92%). Conclusions: Transient pulmonary eosinophilia most often manifests as solid nodules with associated ground-glass halos. Awareness of TPE should serve to limit the number of mistaken diagnoses of early lung cancer.