Therese Maria Henriette Naur

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Staging of Patients with Non-Small Cell Lung Cancer without Mediastinal Involvement at Positron Emission Tomography-Computed Tomography

Background: Staging of lung cancer is essential to the treatment, which is curative only in cases of localized disease. Previous studies have suggested that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is unnecessary when positron emission tomography-computed tomography (PET-CT) shows no mediastinal involvement. Objective: The aim of the study was to investigate how often EBUS-TBNA resulted in a clinically relevant upstaging in patients with lung cancer without mediastinal involvement at PET-CT. Methods: A total of 981 consecutive patients from 2009 to 2014 were referred for preoperative EBUS-TBNA. We included 167 patients with lung cancer without involvement of the mediastinum at PET-CT (115 N0 and 52 N1). Results: Of the 167 patients included, 10 (6.0%) were upstaged to N2 or N3 by EBUS-TBNA; 9 of these were originally classified as N1 at PET-CT. Therefore, 17.3% of the included N1 patients were upstaged to N2/N3 after EBUS-TBNA. This compares to only 0.9% of the N0 patients. After both EBUS-TBNA and PET-CT, 115 patients were operated, and 12 (10.4%) of these proved to be N2/N3. We calculated the sensitivity as 42.9%, the specificity as 99.0%, and the negative predictive value as 89.6%. Conclusions: The overall probability of a clinically relevant upstaging by EBUS-TBNA in patients judged as N0/N1 at PET-CT was 6.0%, compared to 0.9% in patients classified as N0 and 17.3% in patients classified as N1. The risk of overlooking N2/N3 disease after both PET-CT and EBUS-TBNA was 10.4%.

Impact of EBUS-TBNA on PET-CT Imaging of Mediastinal Nodes

Background: Positron emission tomography-computed tomography (PET-CT) with fluorine-18-fluorodeoxyglucose has a high sensitivity in detecting malignancy in patients suspected of lung cancer but a low specificity as inflammatory reactions can also result in metabolic activity. Furthermore, it is assumed that invasive pulmonary procedures with biopsies from benign lesions can induce metabolic activity resulting in false-positive results. However, this hypothesis lacks solid evidence. We aimed to evaluate how often endobronchial ultrasound (EBUS) with biopsies from benign lesions are followed by false-positive results. Methods: Patients with suspected or proven lung cancer admitted for invasive pulmonary procedures in a 6-year period were retrospectively reviewed. Patients who had at least 1 nonmalignant mediastinal lymph node (MLN) biopsied 1 to 13 days before PET-CT were included. The number of false-positive and true-negative results shortly after EBUS biopsy of nonmalignant MLN was reviewed. Results: Of 1025 patients, 216 patients were referred for PET-CT 1 to 13 days after biopsy. Of these, 107 patients had at least 1 MLN biopsied. From a total of 198 biopsied MLNs, we found 62% without metabolic activity (benign) and 38% with metabolic activity. In 5% the metabolic activity could be explained by an infection or inflammatory disorder, in 15% no cytologic follow-up was available, in 1% malignancy was confirmed at follow-up, and in 3% the patients were not possible to follow-up. In the remaining 14%, no other reasonable explanation for the metabolic activity was found other than the biopsy. Conclusions: EBUS with biopsy do not necessarily result in PET activity. Therefore, PET-positive results should always be taken seriously, even when PET is performed shortly after biopsies.

Importance of oesophageal ultrasound in mediastinal staging of lung cancer: Correspondence

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Endoscopic Ultrasound with Bronchoscope-Guided Fine Needle Aspiration for the Diagnosis of Paraesophageally Located Lung Lesions

Background: Diagnosing centrally located lung tumors without endobronchial abnormalities and not located near the major airways is a diagnostic challenge. Tumors near or adjacent to the esophagus can be aspirated and detected with esophageal ultrasound (EUS) using gastrointestinal endoscopes. Objective: To assess the feasibility and diagnostic yield of endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA) in paraesophageally located lung tumors and its added value to bronchoscopy and endobronchial ultrasound (EBUS). Methods: Retrospective, multicenter international study (from January 1, 2015 until January 1, 2018) of patients with suspected lung cancer, undergoing bronchoscopy, EBUS, and endoscopic ultrasound bronchoscopy (EUS-B) in one session by a single operator (pulmonologist), in whom the primary lung tumor was detected and aspirated by EUS-B. In the absence of malignancy following endoscopy, transthoracic ultrasound needle aspiration, clinical and radiological follow-up of at least 6 months was performed. The yield and sensitivity of EUS-B-FNA and its added value to bronchoscopy and EBUS was assessed. Results: 58 patients were identified with the following diagnosis: non-small-cell lung cancer (n = 43), small-cell lung cancer (n = 6), mesothelioma (n = 2), metastasis (n = 1), nonmalignant (n = 6). The yield and sensitivity of EUS-B-FNA for detecting lung cancer was 90%. In 26 patients (45%), the intrapulmonary tumor was exclusively detected by EUS-B. Adding EUS-B to conventional bronchoscopy and EBUS increased the diagnostic yield for diagnosing lung cancer in paraesophageally located lung tumors from 51 to 91%. No EUS-B-related complications were observed. Conclusion: EUS-B-FNA is a feasible and safe technique for diagnosing centrally located intrapulmonary tumors that are located near or adjacent to the esophagus. EUS-B should be considered in the same endoscopy session following nondiagnostic bronchoscopy and EBUS.

Training and certification in endobronchial ultrasound-guided transbronchial needle aspiration

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) plays a key role in the staging of lung cancer, which is crucial for allocation to surgical treatment. EBUS-TBNA is a complicated procedure and simulation-based training is helpful in the first part of the long learning curve prior to performing the procedure on actual patients. New trainees should follow a structured training programme consisting of training on simulators to proficiency as assessed with a validated test followed by supervised practice on patients. The simulation-based training is superior to the traditional apprenticeship model and is recommended in the newest guidelines. EBUS-TBNA and oesophageal ultrasound-guided fine needle aspiration (EUS-FNA or EUS-B-FNA) are complementary to each other and the combined techniques are superior to either technique alone. It is logical to learn and to perform the two techniques in combination, however, for lung cancer staging solely EBUS-TBNA simulators exist, but hopefully in the future simulation-based training in EUS will be possible.

Simulation in bronchoscopy: current and future perspectives

Objective To provide an overview of current literature that informs how to approach simulation practice of bronchoscopy and discuss how findings from other simulation research can help inform the use of simulation in bronchoscopy training. Summary We conducted a literature search on simulation training of bronchoscopy and divided relevant studies in three categories: 1) structuring simulation training in bronchoscopy, 2) assessment of competence in bronchoscopy training, and 3) development of cheap alternatives for bronchoscopy simulation. Conclusion Bronchoscopy simulation is effective, and the training should be structured as distributed practice with mastery learning criteria (ie, training until a certain level of competence is achieved). Dyad practice (training in pairs) is possible and may increase utility of available simulators. Trainee performance should be assessed with assessment tools with established validity. Three-dimensional printing is a promising new technology opening possibilities for developing cheap simulators with innovative features.

Ultrasound-guided Lung Biopsy in the Hands of Respiratory Physicians: Diagnostic Yield and Complications in 215 Consecutive Patients in 3 Centers

Background:The aim of the study was to determine the diagnostic yield and prevalence of complications of ultrasound-guided transthoracic needle aspiration biopsies (US-TTNAB) performed by respiratory physicians after implementation of the procedure in an everyday clinical setting at 3 different centers. Methods:Patients were included if they during the period from January 2012 to August 2014 had a registered US-TTNAB procedure code or if a US biopsy registration form had been filled out at either of the participating centers. Histology or cytology results were used as a reference test for diagnoses that could be made based on these results. Reference test for the remaining diagnoses was clinical follow-up. The diagnostic yield of US-TTNAB was defined as the proportion of patients in which the result of the US-TTNAB was consistent with the reference test. Results:A total of 215 patients in which a primary US-TTNAB had been performed were identified. The most common biopsy sites were lungs and pleurae with a total of 164 (76.3%) patients and 31 patients (14.4%), respectively. US-TTNAB diagnostic yield was 76.9% (95% CI, 70.3%-83.4%) for malignant diagnoses and 47.6% (95% CI, 31.9%-63.4%) for nonmalignant diagnoses. The most common complications of US-TTNAB were pneumothorax (2.5%; 95% CI, 0.03%-4.6%) and pain at the biopsy site (2%; 95% CI, 0.04%-3.9%). No fatalities related to US-TTNAB were observed. Conclusion:US-TTNAB performed by respiratory physicians is a safe procedure with a low risk of complications and the diagnostic yield to establish a malignant diagnosis is acceptable.