Mahendran Chetty

Endobronchial ultrasound-transbronchial needle aspiration and its practical application

Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) has emerged over the past decade as one of the most exciting and innovative developments in the field of respiratory medicine. This procedure allows sampling of mediastinal lymph nodes and masses in both malignant and benign disease and overcomes some of the disadvantages associated with mediastinoscopy and blind transbronchial needle aspiration. We describe the clinical use, indications for and limitations of EBUS-TBNA along with several illustrated clinical examples.

Endobronchial ultrasound transbronchial needle aspiration at Aberdeen Royal Infirmary: the initial experience

Sir, Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a more convenient, quicker and less expensive alternative to mediastinoscopy for sampling mediastinal lymph nodes and masses. Since its introduction, it has become well established as a further tool at the disposal of chest physicians by which to accurately diagnose and stage patients with suspected lung cancer and in the evaluation of those with mediastinal lymphadenopathy of uncertain aetiology.1,2 Although its benefits, especially when compared to other investigative tools in lung cancer are well studied, far less is known regarding ‘real-life’ outcomes during its initial introduction. We therefore wished to highlight the demographics, results and diagnostic sensitivity of EBUS-TBNA in the first consecutive 100 patients in whom this procedure …

The changing vista of pleural effusion management: Indwelling pleural catheters (IPC)

A 90yearold woman presented with a 3month history of progressive breathlessness and weight loss. Computed tomography demonstrated a large right pleural effusion with collapse of right lower and middle lobes, pleural enhancement and thickening suggestive of T1cN0M1a lung cancer. The patient was admitted for chest drain insertion, fluid drainage (>2 L), talc slurry pleurodesis then discharged 4 days later. Fluid immunocytochemistry revealed features in keeping with pulmonary adenocarcinoma. A tyrosine kinase inhibitor was offered but declined. One month later, the patient reported progressive breathlessness and chest Xray demonstrated recurrence of a large hydropneumothorax with probable underlying “trapped”/ nonexpanded lung (Figure 1). She was admitted for an indwelling pleural catheter (IPC) as a day case procedure whereby a unidirectional smallbore silicon tube was tunnelled into the pleural space and secured subcutaneously (Figures 2 and 3). This enabled pleural fluid to be drained thrice weekly by the patients’ carers (district nurse) after minimal training. Six weeks later, the patient remained symptom free and reported no concerns.

A patient with concurrent primary lung cancer and lymphoma diagnosed using endobronchial ultrasound

Sir, Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is an effective tool in the diagnosis and staging of the mediastinum in suspected primary lung cancer.1,2 We describe a patient who was found to have two separate malignant conditions using EBUS-TBNA. A 70-year-old man with 125 pack-year smoking history presented with 4 weeks of breathlessness, cough, haemoptysis, weight loss and no night sweats. Chest computerized tomography revealed right lower lobe collapse, extensive mediastinal lymphadenopathy (right hilar: 27 mm, right paratracheal: 31 mm) and right …

Recurrent breast cancer and endobronchial ultrasound-transbronchial needle aspiration

A 67 years old female with previous breast cancer and a 40-pack year smoking history presented with recurrent lower respiratory tract infections on a background of chronic obstructive pulmonary disease. Despite a normal chest X-ray, the history of recurrent infections led to a high resolution computed tomography scan to exclude structural lung disease. This showed subcarinal lymphadenopathy, multiple nodules in the right lung and suggestion of lymphangitis. She proceeded to have EBUS-TBNA of the enlarged paratracheal and subcarinal lymph nodes. Cytology was consistent with the diagnosis of recurrent metastatic breast carcinoma. The patient went on to receive Letrozole and radiotherapy. EBUS-TBNA is typically used to both diagnose and stage suspected lung cancer, usually in a solitary procedure. However, it is also useful in patients with undiagnosed mediastinal and hilar lymphadenopathy. This case adds to the paucity of literature whereby EBUS-TBNA was used as a quick and effective tool by which recurrent breast cancer was diagnosed.

Endobronchial ultrasound guided transbronchial needle aspiration: a novel way to diagnose metastatic urological cancer

Sir, Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) is a relatively non-invasive technique—usually performed as a day case under light sedation—whereby mediastinal and hilar lymph nodes can be safely sampled under direct vision. It was first described in the early 1990s and since the beginning of the 21st century its popularity and use has spread across the world. EBUS-TBNA is performed using an ultrasound transducer that is integrated into a flexible fibreoptic bronchoscope which in turn permits biopsies to be taken under direct vision and thereby overcomes many of the problems associated with mediastinoscopy and blind TBNA. We present two cases whereby patients underwent this procedure and the diagnosis of metastatic urological cancer was made. A 73-year-old male former cigar smoker presented with progressive breathlessness, haemoptysis and …

Endobronchial ultrasound guided transbronchial needle aspiration--a sensitive and cost effective method of sampling mediastinal lymph nodes.

To the Editor: We read with interest the article by Lange et al. describing the outcome of their first consecutive 100 patients undergoing endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) (1). In particular, we were surprised by the fact that a diagnosis was only made in 27% and sensitivity was only 61%. These findings are at odds with our own initial experience of EBUS-TBNA carried out at Aberdeen Royal Infirmary in 150 consecutive patients. All procedures were performed under light sedation using intravenous midazolam and fentanyl by two experienced bronchoscopists (GPC and MC); patients had been either referred directly to them for consideration of this procedure or discussed at a lung multidisciplinary team (MDT) meeting. Of the 150 patients [62% men, mean age 63 years (range 22–88)], 206 lymph nodes ⁄ mediastinal masses were sampled with a median of five passes. Lymphoid material was obtained in 139 (93%) and a cytological abnormality identified in 111 (74%). Of the remaining 39 patients, no lymphoid material was sampled in 11 and lymphoid material was obtained in 28 with no cytological abnormality. Of the latter, 12 were subsequently considered to be true negatives; this was based on MDT consensus decision, follow-up imaging or negative mediastinoscopy. Our overall diagnostic sensitivity for EBUSTBNA was therefore 82% (77%, in the first 50 patients, 84% in the next 50 patients and 84% in the final 50 patients). This in turn suggests that the top of the learning curve is reached somewhere between 50 and 100 patients. Moreover, also at odds with the findings of Lange et al., results from randomised controlled trials evaluating EBUS-TBNA have suggested a diagnostic sensitivity of > 90% (2,3). Arguably however this impressive sensitivity is partly because many of the centres involved in such trials are highly experienced in the procedure and patients are carefully selected according to predefined study entry criteria. Furthermore, ‘‘real-life’’ data in 77 consecutive patients with isolated mediastinal lymphadenopathy indicated that EBUS-TBNA only failed to provide a diagnosis in 13% (4). Factors that may have resulted in a low sensitivity in patients evaluated by Lange et al. (1) are as follows:

An incidental finding in a preoperative chest radiograph.

An 88 year old woman who had never smoked was found to have a left lower zone mass on chest radiography before elective total knee replacement for osteoarthritis. Other than weight loss, she had no other symptoms. Her medical history included hypertension and anterior resection for Dukes’s A rectal cancer complicated by postoperative deep vein thrombosis eight years earlier; she had no history of tuberculosis. Cardiorespiratory and abdominal examinations (other than a scar) were normal; performance status was 1. Routine blood tests and carcinoembryonic antigen were normal and negative, respectively. Chest and abdominal computed tomography was performed (figs 1⇓ and 2⇓), with abnormalities noted only within the thorax. Fig 1 Computed tomography of the chest Fig 2 Computed tomography of the chest (at a different level from that of fig 1) ### 1 What does performance status measure? #### Short answer The Eastern Co-operative Oncology Group/World Health Organization performance status is used widely in patients with cancer to measure their general wellbeing and ability to perform (or otherwise) daily living activities. #### Long answer Performance status is often used as a general guide to help …

A breathless man with diffuse chest pain

A 63 year old white man was referred to hospital with a two month history of left sided diffuse chest pain, weight loss, and progressive breathlessness on exertion. He was a retired joiner and had a 20 pack year history of smoking. He had not recently travelled abroad. He was taking bendroflumethiazide for hypertension. On examination, his blood pressure and heart rate were normal, respiratory rate was 14 beats per minute, and oxygen saturation was 97% on air. He had no clubbing, pedal oedema, or lymphadenopathy. Respiratory examination showed dullness and reduced breath sounds in the left lower and middle zones. Cardiac and abdominal examinations were normal. Chest radiography showed a moderate left sided pleural effusion, and electrocardiography was normal. Renal function, biochemistry, and bone profile were normal. Straw coloured pleural fluid was aspirated under ultrasound guidance; subsequent analysis showed total protein of 44 g/l (total serum protein 68 g/l), glucose 5.3 mmol/l, and lactate dehydrogenase 423 U/l, with no malignant cells or microbial growth.

Cough and breathlessness not responding to inhalers

A 29 year old unemployed woman who had never smoked was referred to the outpatient clinic with a 10 month history of non-productive cough, breathlessness, and chest tightness. Her exercise tolerance had reduced dramatically from breathlessness on exertion to symptoms at rest over six months. She had been treated for asthma in the community for six months before attendance, although inhalers had conferred little improvement in symptoms. She lived alone and had kept budgies for several years. She did not have cyanosis or clubbing. Her pulse rate was 80 beats/min regular, blood pressure was 124/88 mm Hg, and her heart sounds were normal. On auscultation she had vesicular breath sounds with fine inspiratory bilateral basal crackles. Routine haematological and biochemical parameters were normal. Her urinalysis was negative. Chest radiography showed diffuse bilateral air space consolidation, and electrocardiography was normal. Her forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were 1.8 l (predicted 3.3 l) and 2.1 l (3.9 l), respectively. ### Short answers