Sanjay Agrawal

Mediastinal staging procedures in lung cancer: EBUS, TBNA and mediastinoscopy

Purpose of review There is increasing awareness of minimally invasive endoscopic techniques for mediastinal staging in lung cancer. Traditionally, cervical mediastinoscopy has been utilized. Endobronchial ultrasound-guided fine needle aspiration (EBUS) has recently emerged as a potential alternative. Recent findings EBUS has sensitivity for lung cancer which is at least equivalent (if not superior) to cervical mediastinoscopy. However, cervical mediastinoscopy remains superior to EBUS and other techniques in its high negative predictive value. More recent data suggest EBUS may have a role in presurgical staging of radiologically normal subcentimetre nodes and its negative predictive value may be equivalent to surgical staging. Ongoing comparative studies between EBUS and cervical mediastinoscopy may well clarify relative performance and cost analyses. Summary Currently, insufficient data are present to recommend replacing cervical mediastinoscopy with EBUS for lung cancer staging; the negative predictive value of EBUS requires validation. However, EBUS can be recommended for initial staging as a minimally invasive option provided negative results are followed by cervical mediastinoscopy. This would also allow cervical mediastinoscopy to be reserved for re-staging. Conventional transbronchial needle aspiration has a limited role only as a first-line staging procedure but may aid diagnosis. In the future, EBUS may have a role in presurgical staging of the radiologically normal mediastinum and re-staging if prior staging is done by cervical mediastinoscopy.

A performance and theoretical cost analysis of endobronchial ultrasound-guided transbronchial needle aspiration in a UK tertiary respiratory centre

BACKGROUNDnNew innovative techniques can improve patient care but may not be appropriately funded. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) offers a minimally invasive mediastinal staging and diagnostic method for suspected lung cancer.nnnAIMnWe report the performance and cost analysis of a newly established EBUS service in a prospective real world cohort of patients to assess the impact of Payment by Results (PbR).nnnDESIGNnProspective cohort study.nnnMETHODSnFifty-four patients between June 2008 and April 2009 underwent EBUS for evaluation of unexplained mediastinal lymphadenopathy on CT. Cost analysis was performed from local Trust financial data and 2008-09 tariffs.nnnRESULTSnEBUS had an 89% sensitivity, 75% negative predictive value and 92% accuracy for malignancy. EBUS coding was inaccurate in 15.6% of cases. The actual cost of an EBUS is 1252-1433 pounds but is coded as a standard bronchoscopy (561 pounds). EBUS reduces health community costs by 107824 pounds/year, as a result of a Primary Care Trust cost saving of 113968 pounds/year and a Trust cost deficit of 6144 pounds/year. Coding inaccuracies further alter the Primary Care Trust costs.nnnCONCLUSIONnMedical innovation is fundamental to improved patient care. EBUS can potentially reduce morbidity for lung cancer patients and save health community costs. However, with PbR the service provider delivers this at a loss as the tariffs do not reflect innovation and because of coding inaccuracies. We suggest tariffs for innovative procedures need to reflect the true cost.

A Prospective Study of Conventional Transbronchial Needle Aspiration: Performance and Cost Utility

Background: Conventional transbronchial needle aspiration (TBNA) is a cheap, minimally invasive tool for lung cancer staging and diagnosis. Endobronchial ultrasound-guided TBNA (EBUS-TBNA) is more sensitive but is more expensive and less widely available. We describe a prospective analysis of TBNA diagnostic, staging and cost utility in a centre in the UK. Objectives: To illustrate the potential diagnostic, staging and cost utility of a low cost conventional TBNA service. Methods: A prospective analysis of 79 TBNA procedures over a 2-year period was performed looking at performance and cost utility in a ‘mixed’ cohort with variable pre-test probability of malignancy (year 1) followed by a high probability cohort (year 2). Results: TBNA avoided mediastinoscopy in 25% of the cases overall (37% in high probability vs. 13% in the ‘mixed’ cohort, p = 0.03). The overall prevalence of malignancy was 84%, sensitivity 79%, negative predictive value 58% and accuracy 85%. Diagnostic utility varied with pre-test probability and nodal station. TBNA down-staged 8% of lung cancer patients to receive surgery and confirmed the pre-treatment stage (inoperability) in 74%. TBNA led to theoretical cost savings of GBP 560 per patient. Conclusions: TBNA can achieve a high diagnostic sensitivity for cancer in high probability patients and stage the majority appropriately, thereby avoiding unnecessary mediastinoscopies and reducing costs. It may also down-stage a minority to have surgery. TBNA is cheap, routinely available and learnable. As EBUS-TBNA will take time to develop due to its costs, all respiratory centres should perform TBNA at flexible bronchoscopy in suspected lung cancer with accessible mediastinal adenopathy.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): Applications in chest disease

Endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) offers a minimally invasive option for staging the mediastinum in suspect lung cancer but also in the diagnosis of mediastinal lesions accessible from the airway. This review is aimed at centres considering establishing an EBUS service that may not be so familiar with the technique. It focuses primarily on technical aspects of EBUS‐TBNA, training issues, cost considerations, indications, advantages and disadvantages compared with other mediastinal sampling techniques as well as some reference to its performance in clinical studies.

Thoracic ultrasound prior to medical thoracoscopy improves pleural access and predicts fibrous septation

Background and objective:u2003 Medical thoracoscopy (MT) is indicated for the investigation of unexplained pleural exudates. Not all MT units create artificial pneumothoraces because of time. Difficult pleural space access and thick fibrous adhesions may prevent MT and pleurodesis, respectively. The potential role of thoracic ultrasound (TUS) pre‐MT has not been fully evaluated. We hypothesized TUS would reduce failure to access the pleural space and enable detection of thick fibrous adhesions.

A local anaesthetic video-assisted thoracoscopy service: prospective performance analysis in a UK tertiary respiratory centre

INTRODUCTIONnLocal anaesthetic video-assisted thoracoscopy (LAVAT) is a safe, reliable and therapeutic procedure used by respiratory physicians in the management of pleural disease, especially pleural malignancy. We describe a prospective analysis of a UK LAVAT service set up in a tertiary respiratory centre to complement an existing large surgical video-assisted thoracic surgery (VATS) service.nnnMETHODSnA prospective analysis of 125 LAVAT procedures over a 34-month period was performed looking at a variety of quality control endpoints comparing them to national thoracic surgical VATS standards.nnnRESULTSnTalc pleurodesis was effective in over 86% of cases and this did not significantly lengthen bed stay (median 4.5 days). Bed stay was also unchanged between the ages of 60-89 years. Over 77% of the 48 patients with proven metastatic pleural lung malignancy or mesothelioma received either surgical decortication or oncological treatment (palliative chemotherapy in 57%). In only 6% were biopsies not possible because of technical factors. LAVAT biopsies had a diagnostic accuracy of 97.4%, sensitivity 95.4%, specificity 100%, positive predictive value 100%, and negative predictive value 94.7%. Our complication rate was 4% and mortality rate 0.8%.nnnDISCUSSIONnOur LAVAT service meets surgical VATS standards for diagnosis and safety with a good pleurodesis efficacy rate. It complements our surgical VATS service, offering a pleural diagnostic service for patients with non-complex pleural exudates or too frail for VATS. Our data demonstrate there is a demand and potential for respiratory physicians dealing with pleural malignancy to develop LAVAT and enhance their local lung cancer and pleural diagnostic pathway.

Single Bronchoscope Combined Endoscopic-Endobronchial Ultrasound-Guided Fine-Needle Aspiration for Tuberculous Mediastinal Nodes

We fully support the use of a single linear endobronchial ultrasound (EBUS) bronchoscope for both endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fi ne-needle aspiration (EUS-FNA) of mediastinal lymph nodes, as reported in the recent CHEST article by Herth et al. 1 Having initially established and reported our own results with EBUS-TBNA for both malignant and benign disease, 2 , 3 we have more recently moved to performing EUS-FNA and EBUS-TBNA with a single linear EBUS bronchoscope for benign and malignant nodes. We would like to add the particular utility of EUS-FNA in nonmalignant disease as well as the more common utility in malignant disease. In our fi rst fi ve combined EBUS-TBNA EUS-FNA procedures via a single EBUS bronchoscope, three patients with suspected TB (enlarged subcarinal and hilar nodes but no parenchymal lung disease) had TB diagnosed (caseous granulomatous histologic results with positive TB culture) from the EUS-FNA only (with only one positive histologic examination and culture from EBUS-TBNA, and all negative on BAL). In addition, the antibiotic sensitivities from mediastinal lymph node culture are helpful to ongoing management of the TB. (The remaining two cases were for suspected malignancy, metastatic renal cell carcinoma and non-small cell lung cancer, which were confi rmed at EBUS-TBNA and EUS-FNA of subcarinal nodes). We have also found EUS-FNA more tolerable to some patients than EBUS-TBNA, particularly those with pronounced cough despite adequate conscious sedation and those with poor lung function and signifi cant comorbid lung disease. This can be particularly helpful if Station 7 is a target or there is a paraesophageal lymph node. Obviously, the cost savings of another EUS scope are also welcome in resource-rationed health-care systems. In summary, combined EUS-FNA EBUS-TBNA is likely to become more commonplace for all the above reasons but should not be overlooked in the diagnosis of benign disease accessible by this technique.

Retrospective analysis of Healthcare Resource Group coding allocation for local anaesthetic video-assisted ‘medical’ thoracoscopy in a UK tertiary respiratory centre

BACKGROUNDnCorrect service costing is essential but may not always be done accurately.nnnAIMnTo assess the accuracy of Healthcare Resource Group (HRG) coding allocation for patients undergoing local anaesthetic video-assisted thoracoscopy (LAVAT) against predicted codes under Payment by Results (PbR).nnnDESIGNnSingle centre retrospective study. Tertiary respiratory centre in Leicestershire.nnnMETHODSnOne hundred twenty-five patients undergoing LAVAT from July 2005 to July 2008.nnnMAIN OUTCOME MEASURESnPredicted and actual revenue per LAVAT episode based on predicted and actual HRG codes allocated.nnnRESULTSnAmong 125 patients undergoing LAVAT, the actual HRG code matched the predicted code in only 39 cases (31.2%), odds ratio (OR) 0.002, 95% confidence intervals (CIs) 0.0001-0.03, P < 0.0001. In 51 cases (40.8%), this resulted in a median (interquartile range) excess of PbR revenue of 574 pounds (574-1366) per episode; a total estimated overspend of 29,274 pounds. In 35 cases (28.0%), this resulted in a median underspend of --1093 pounds (-1285 to -851) per episode; a total estimated underspend of 38,529 pounds, with a total estimated financial error of 67,529 pounds. The net median (interquartile range) difference for PbR-related revenue was 0 pounds (-89 to + 574). Factors associated with coding discrepancy were longer length of stay (OR = 2.52, 95% CIs = 1.09-5.81, P = 0.03) and talc pleurodesis (OR = 2.25, 95% CI = 1.01-4.99, P = 0.06).nnnCONCLUSIONnHRG coding allocation errors occur frequently. The potential financial implications of this are significant for providers and commissioners. Future strategies are required at multiple levels (NHS Trust, Primary Care Trust and Department of Health) to minimize future discrepancies and financial error.

Current Status of Medical Pleuroscopy

Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional pulmonologists. It allows diagnosis of unexplained effusion, while at the same time allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse interstitial disease or associated peripheral lung abnormality in the presence of effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or chronic pancreatic pain. This article reviews the technical aspects and range of applications of MP.