Comparative yield of EBUS-TBNA with EBUS-IFBTLP for diagnosis of mediastinal lymphadenopathy.

BACKGROUND: Patients with mediastinal lymph node enlargement (MLNE) are diagnosed depending on lymph node biopsy. Whereas, how to obtain larger tissue masses from mediastinal lymph nodes and improve the diagnostic yield of the disease remains to be investigated. OBJECTIVES: Aiming to assess the diagnostic value of endobronchial ultrasound-guided intranodal forceps biopsy via transbronchial laser photoablation (EBUS-IFB-TLP) in patients with MLNE. DESIGN: A prospective, self-controlled study. METHODS: This study was conducted on 67 MLNE patients requiring a lymph node biopsy for diagnosis at the Henan Provincial People's Hospital and the Fuwai Central China Cardiovascular Hospital in China, from January 2020 to December 2022. Each patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA group) and EBUS-IFB-TLP (EBUS-IFB-TLP group) on the same mediastinal lymph node for biopsies. The operation time, diagnostic efficiency, and complication rates of the two biopsy methods were compared. RESULTS: The number of diagnosed patients in the EBUS-IFB-TLP and the EBUS-TBNA groups was 65 (97.0%) and 57 (85.1%), respectively (p = 0.021). In the EBUS-IFB-TLP group, 28 cases (96.6%) were diagnosed with lung cancer and were classified into different epithelial types. In the EBUS-TBNA group, there were 27 cases (93.1%) diagnosed with lung cancer, of which 26 (89.7%) were classified into different epithelial types. There were 37 (97.4%) and 30 (78.9%) non-lung cancer patients diagnosed in the EBUS-IFB-TLP and EBUS-TBNA groups, respectively (p = 0.039), while 27 cases (96.4%) of sarcoidosis in the EBUS-IFB-TLP group and 20 cases (71.4%) of sarcoidosis in the EBUS-TBNA group were diagnosed (p = 0.016). The percentages of intraoperative mild to moderate bleeding complications were 23.9% (16/67) and 14.9% (10/67) in the EBUS-IFB-TLP and in the EBUS-TBNA groups, respectively (p = 0.109). CONCLUSION: This study demonstrated that EBUS-IFB-TLP could be a feasible and effective method in the diagnosis of patients with MLNE, presenting an analogous safety profile compared with EBUS-TBNA. Further studies are needed to verify the diagnostic performance of EBUS-IFB-TLP for MLNE.

A new way of obtaining a larger biopsy sample in patients with enlarged lymph nodes in the chestWhy was the study done?Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) allows doctors to look at a patient's lungs using a tiny camera (called a bronchoscope). A needle is found at the tip of the bronchoscope and is used to take samples (biopsies) from the lymph nodes in the chest. Lymph nodes are small structures that help filter foreign substances in the body, for example cancer cells. The enlarged (big) lymph nodes are often caused by cancer. Researchers are still trying to work out how to obtain large samples from the lymph nodes which could lead to a better diagnosis.What did the researchers do?We explored a new method called endobronchial ultrasound-guided intranodal forceps biopsy based on transbronchial laser photoablation (EBUS-IFB-TLP) to be used in diagnosing patients who have enlarged lymph nodes. EBUS-IFB-TLP is performed under the guidance of endndobronchial ultrasound, the laser fiber is inserted through the bronchoscope to act on the airway wall, creating a hole in the target lymph node, a biopsy forcep was inserted into the lymph node through the biopsy hole. We used both methods on each patient in this study and compared them.What did the researchers find?More patients were diagnosed with enlarged lymph nodes when using the EBUS-IFB-TLP method, but there were milder to moderate bleeding complications.What do the findings mean?This study shows that EBUS-IFB-TLP could be use in the diagnosis of enlarged lymph nodes.

Mature Cystic Teratoma of Anterior Mediastinum in a Child: A Case Report and Literature Review.

Mediastinal mature cystic teratomas are rare benign germ cell tumors that predominantly affect children. Despite their low incidence, they present unique diagnostic and management challenges. Early recognition and appropriate surgical intervention are crucial for optimal outcomes. This case report aims to highlight the importance of prompt diagnosis and management of mediastinal mature cystic teratomas in pediatric patients. We present the case of a 10-year-old female patient who presented with persistent chest pain and dyspnea. Imaging studies, including a chest X-ray and contrast-enhanced chest CT scan, revealed a large, well-circumscribed anterior mediastinal mass with calcifications. The patient underwent a right thoracotomy, resulting in the excision of a 6 × 5 × 5 cm mature cystic teratoma. Histopathological examination confirmed the diagnosis. The patient had an uneventful recovery and was discharged in stable condition. Mediastinal mature cystic teratomas pose diagnostic challenges due to their nonspecific symptoms and heterogeneous imaging characteristics. Differential diagnosis includes other mediastinal masses containing fat and calcifications. Surgical excision is the preferred treatment, although complete removal can be challenging due to adhesions to neighboring structures. Close follow-up is necessary to monitor for recurrence and complications. Mediastinal mature cystic teratomas are rare tumors with variable clinical presentations. Early detection and surgical intervention are crucial for optimal outcomes. These tumors should be included in the list of differential diagnoses for mediastinal masses in pediatric patients.

Role of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and Gene Xpert.

BACKGROUND: Mediastinal tubercular lymphadenitis is form of extrapulmonary tuberculosis [EPTB]. Clinical presentations are non-specific and diagnosis remains great clinical challenge. Microbiological and or histopathological evidences need to be present in order make diagnosis secure before initiation of anti-tubercular therapy (ATT). Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) provides tissue samples and aids management of this difficult to diagnosed entity. Current study describe role of EUS-FNA and Gene Xpert (GXP) in mediastinal tubercular lymphadenitis. METHODS: Retrospective analysis of 72 patients with mediastinal lymphadenopathy who underwent EUS-FNA were carried out. Linear echoendoscope was used for evaluation mediastinum. EUS echo features of LNs were studied. Twenty two-G needle used was for aspiration tissue sample from pathologic lymph nodes (LNs). FNA samples were analysed by cytology, Acid-Fast Bacilli (AFB) staining and GXP study. All procedures were uneventful without any complications. RESULTS: Forty two patients were diagnosed as tuberculosis (TB) following first EUS-FNA setting. Six patients underwent repeat EUS-FNA procedure following which another 3 were diagnosed as TB while remaining 3 started on empirical ATT based on additional supportive evidences. Forty five patients showed granulomatous inflammation on cytological analysis, AFB positivity noted in 16 (33.33%) patients while GXP in 26 (57.78%) patients. Rifampicin resistance detected in 3 ((6.25%) patients. All patients were followed clinico-radiologically for response to treatment. CONCLUSION: Tuberculous lymphadenitis is the most common cause of mediastinal lymphadenopathy in TB endemic countries. EUS-FNA provides microbiological and histopathological/cytological evidences in this difficult to diagnosed EPTB and thereby avoids empirical ATT.

An update on the minimally invasive diagnosis of lymphoma for the chest physicians.

Mediastinal lymphadenopathy has a broad differential diagnosis which includes lymphoma. The current preferred biopsy technique for mediastinal lymph nodes is transbronchial needle aspiration which has mixed results in terms of sensitivity, specificity and diagnostic yields; there are also limitations with subtyping lymphomas with needle aspiration alone which can be a barrier to determine management strategies. Invasive mediastinal lymph node sampling such was with mediastinoscopy provides higher yields and preserved lymph node architecture for both diagnosis and subtyping of lymphoma but carries a higher risk of morbidity and complications. Novel techniques that may increase the diagnostic yield of bronchoscopy in the diagnosis of lymphoma are core biopsy needles, intranodal forcep biopsy, and intranodal cryobiopsy. The evidence is limited due to a relatively small number of cases, so further research is needed to standardize best practices for the bronchoscopic diagnosis of lymphoma. Pleural effusions in lymphoma can be present in up to 30 % of cases with the majority being non-Hodgkins's lymphoma. The presence of exudative effusion in the setting of an existing or prior diagnosis of lymphoma should raise clinical suspicions. Other less common subtypes of lymphoma presenting as primary pleural effusions are explored as well.

EBUS-TBNA in mediastinal staging of non-small cell lung cancer: comparison with pathological staging.

OBJECTIVE: Although EBUS-TBNA combined with EUS-FNA or EUS-B-FNA stands as the primary approach for mediastinal staging in lung cancer, guidelines recommend mediastinoscopy confirmation if a lymph node identified on chest CT or showing increased PET scan uptake yields negativity on these techniques. This study aimed to assess the staging precision of EBUS/EUS. METHODS: We conducted a retrospective study comparing the clinical staging of non-small cell lung cancer patients undergoing EBUS/EUS with their post-surgery pathological staging. We analyzed the influence of histology, location, tumor size, and the time lapse between EBUS and surgery. Patients with N0/N1 staging on EBUS/EUS, undergoing surgery, and with at least one station approached in both procedures were selected. Post-surgery, patients were categorized into N0/N1 and N2 groups. RESULTS: Among the included patients (n = 47), pathological upstaging to N2 occurred in 6 (12.8%). Of these, 4 (66.7%) had a single N2 station, and 2 (33.3%) had multiple N2 stations. The adenopathy most frequently associated with upstaging was station 7. None of the analyzed variables demonstrated a statistically significant difference in the occurrence of upstaging. PET scan indicated increased uptake in only one of these adenopathies, and only one was visualized on chest CT. CONCLUSIONS: Upstaging proved independent of the studied variables, and only 2 patients with negative EBUS/EUS would warrant referral for mediastinoscopy. Exploring other noninvasive methods with even greater sensitivity for detecting micrometastatic lymph node disease is crucial.

[Changes in mediastinal lymph node sampling practices]. / Évolution des pratiques concernant l'exploration ganglionnaire médiastinale.

INTRODUCTION: While mediastinoscopy is considered the gold standard for mediastinal node sampling, it is to some extent being superseded by endobronchial ultrasound. The objective of this study was to evaluate the different practices in our center regarding mediastinal lymph node sampling in lung cancer patients. METHODS: Data were collected from patients having undergone mediastinal lymph node sampling by video-assisted-mediastinoscopy (VM) or by endobronchial ultrasound (EBUS) in our center between August 2020 and July 2023. The modalities of the two procedures and their diagnostic accuracy were analyzed, as was their evolution over time. RESULTS: The 362 patients comprised 217 who were sampled by EBUS and 145 by VM. Overall, the procedures became more frequent, with EBUS tending to supersede VM. The number of harvested lymph nodes gradually grew, and less unforeseen lymph node invasion and upstaging occurred. CONCLUSION: The arrival in our center of endobronchial ultrasound yielded an overall increase of lymph node sampling despite a decrease in the number of mediastinoscopy procedures performed. Reinforced compliance with guidelines is needed to improve the diagnostic accuracy of these techniques and to better ensure quality of care.

Technical tips, diagnostic yield and safety of endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used to diagnose and stage lung cancer. In clinical practice, cytology specimens from EBUS-TBNA may be low in cellularity, especially with necrotic lesions. Endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy (EBUS-TBMC) has recently become the preferred method for obtaining histology biopsy. This retrospective cohort study analysed the first 30 patients who have undergone EBUS-TBMC in a tertiary centre in Malaysia. EBUS-TBMC demonstrated a high diagnostic yield and good safety profile. All the samples obtained were adequate for the detection of driver alteration by next-generation sequencing.

An explorative analysis on the optimal cryo-passes and freezing time of the ultrathin cryoprobe in endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy.

EBUS-guided transbronchial mediastinal cryobiopsy (TBMC) has emerged as a promising biopsy tool for diagnosing hilar and mediastinal pathologies. However, several fundamental technical aspects of TBMC remain unexplored. This study aims to determine the optimal number of cryo-passes and freezing time of the ultrathin cryoprobe in EBUS-TBMC concerning specimen size and procedural diagnostic yield. We conducted a retrospective chart review of patients with mediastinal and hilar lesions who underwent EBUS-TBMC between January 2021 and April 2023 across three hospitals in Malaysia. A total of 129 EBUS-TBMC procedures were successfully completed, achieving an overall diagnostic yield of 88.4%. Conclusive TBMC procedures were associated with larger specimen sizes (7.0 vs. 5.0 mm, p < 0.01). Specimen size demonstrated a positive correlation with diagnostic yield (p < 0.01), plateauing at specimen size of 4.1-6.0 mm. A significant positive correlation was also observed between the number of cryo-passes and both specimen size (p < 0.01) and diagnostic yield (p < 0.05). Diagnostic yield plateaued after 2-3 cryo-passes. In contrast, longer freezing times trended towards smaller specimens and lower diagnostic yield, though not reaching statistical significance. The highest diagnostic yield was recorded at the 3.1-4.0 s freezing time. The safety profile of TBMC remains favourable, with one case (0.8%) of pneumothorax and nine cases (7%) of self-limiting bleeding. In our cohort, TBMC performance with 2-3 cryo-passes and a 3.1-4.0 s freezing time to achieve a total aggregate specimen size of 4.1-6.0 mm appeared optimal. Further prospective studies are needed to validate these findings.

Prevalence and quantity of lymph nodes at mediastinal stations in patients with lung cancer: lessons from 181 bilateral mediastinal lymphadenectomies.

BACKGROUND: This study evaluated the prevalence and quantity of lymph nodes at particular stations of the mediastinum in patients with lung cancer. These data are important to radiologists, pathologists, and thoracic surgeons because they can serve as a benchmark when assessing the completeness of lymph node dissection. However, relevant data in the literature are scarce. METHODS: Data regarding the number of lymph nodes derived from two randomised trials of bilateral mediastinal lymph node dissection, the BML-1 and BML-2 study, were included in this analysis. Detectable nodes at particular stations of the mediastinum and the number of nodes at these stations were analysed. RESULTS: The mean number of removed nodes was 28.67 (range, 4-88). Detectable lymph nodes were present at stations 2R, 4R, and 7 in 93%, 98%, and 99% of patients, respectively. Nodes were rarely present at stations 9 L (33%), and 3 (35%). The largest number of nodes was observed at stations 7 and 4R (mean, 5 nodes). CONCLUSION: The number of mediastinal lymph nodes in patients with lung cancer may be greater than that in healthy individuals. Lymph nodes were observed at stations 2R, 4R, and 7 in more than 90% of patients with lung cancer. The largest number of nodes was observed at stations 4R and 7. Detectable nodes were rarely observed at stations 3 and 9 L. TRIAL REGISTRATION: ISRCTN 86,637,908.

[EBUS-guided cryobiopsy in the diagnosis of mediastinal lesions - step by step]. / EBUS-gestützte Kryobiopsie mediastinaler Läsionen ­ Schritt für Schritt.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the gold standard in the diagnosis of mediastinal and hilar lesions. For certain purposes, such as the diagnosis and subtyping of lymphoproliferative disorders or molecular pathology, a larger amount of intact sample material is required. EBUS cryobiopsy is a new and efficient tool for this purpose. As it is a new approach, there is still no standardised workflow. In this review, we present the procedure step by step as it is performed at the Ruhrlandklinik in Essen.

Hodgkin lymphoma: hypodense lesions in mediastinal masses.

Hypodense volumes (HDV) in mediastinal masses can be visualized in a computed tomography scan in Hodgkin lymphoma. We analyzed staging CT scans of 1178 patients with mediastinal involvement from the EuroNet-PHL-C1 trial and explored correlations of HDV with patient characteristics, mediastinal tumor volume and progression-free survival. HDV occurred in 350 of 1178 patients (29.7%), typically in larger mediastinal volumes. There were different patterns in appearance with single lesions found in 243 patients (69.4%), multiple lesions in 107 patients (30.6%). Well delineated lesions were found in 248 cases (70.1%), diffuse lesions were seen in 102 cases (29.1%). Clinically, B symptoms occurred more often in patients with HDV (47.7% compared to 35.0% without HDV (p = 0.039)) and patients with HDV tended to be in higher risk groups. Inadequate overall early-18F-FDG-PET-response was strongly correlated with the occurrence of hypodense lesions (p < 0.001). Patients with total HDV > 40 ml (n = 80) had a 5 year PFS of 79.6% compared to 89.7% (p = 0.01) in patients with HDV < 40 ml or no HDV. This difference in PFS is not caused by treatment group alone. HDV is a common phenomenon in HL with mediastinal involvement.

Endobronchial ultrasound-guided transbronchial fine needle aspiration of mediastinal lymphadenopathy: Diagnostic performance and clinical implications of the World Health Organization reporting system.

INTRODUCTION: Lymph node fine-needle aspiration cytology (LN-FNAC) is a common, rapid, minimally invasive and cost-effective diagnostic method. For mediastinal lymph nodes, endobronchial ultrasound (EBUS) guided LN-FNAC is a first-line investigation and has an indispensable role in the diagnosis and staging of patients with suspected lung cancer. Recently, a new WHO system has been proposed for classification of LN-FNAC heralding five different diagnostic categories; insufficient, benign, atypical, suspicious for malignancy and malignant. The aim of this study was to evaluate the diagnostic accuracy and risk of malignancy (ROM) of these categories in EBUS-guided LN-FNAC from mediastinal lymph nodes. METHOD: We evaluated 2110 consecutive mediastinal lymph nodes during this one-year retrospective study. Corresponding radiological images and histologic material were used as ground truth to calculate accuracy, sensitivity, specificity and ROM. RESULTS: The WHO system showed an overall accuracy of 93.7% with a sensitivity of 83.0% and a specificity of 97.5%. The positive predictive value was 92.3% and the negative predictive value 94.2%. The overall ROM for each category in the WHO classification system was 12.8% for the inadequate, 2.4% for the benign, 47.4% for the atypical, 81.0% for the suspicious for malignancy and 93.6% for the malignant category. CONCLUSION: The results of the present study indicate that the new WHO system entails a high diagnostic accuracy regarding EBUS-guided LN-FNAC assessment of mediastinal lymph nodes and supports its integration into clinical practice. Application of the WHO system standardizes risk assessment thus facilitating communication between cytopathologists and clinicians and minimizes the need for histopathological analysis.

[Cost-effectiveness and safety of mediastinal transbronchial cryobiopsy guided by endobronchial ultrasonography (CRYO-EBUS) in 110 cases]. / Rentabilidad y seguridad de la criobiopsia transbronquial mediastínica guiada por ultrasonografía endobronquial (CRYO-EBUS) en 110 casos.

INTRODUCTION: Transbronchial needle aspiration guided by endobronchial ultrasonography (EBUSTBNA) has the disadvantage of sometimes offering samples of an unsuitable size for an accurate histo-molecular diagnosis. Transbronchial mediastinal cryobiopsy (CRYOEBUS) is a very novel and additional technique to EBUS-TBNA that allows us to obtain larger and quality samples, improving diagnostic performance. MATERIAL AND METHODS: Descriptive study of 110 patients with lesions and/or mediastinal lymphadenopathy who underwent EBUS-TBNA and CRYO-EBUS in a single procedure. Our objective was to analyze the diagnostic profitability and safety of the technique. RESULTS: CRYO-EBUS obtained samples of 0.42cm on average compared to 0.14cm obtained by EBUS-TBNA. The overall diagnostic performance of the techniques was 60% for EBUS-TBNA and 94.5% for CRYO-EBUS. Furthermore, the latter was more sensitive for the diagnosis of both malignant and benign diseases. With a very high security profile. CONCLUSIONS: The CRYO-EBUS technique is cost-effective and safe, and is superior to EBUS-TBNA. Future studies may confirm our findings.

Minimally Invasive with Maximal Yield: A Narrative Review of Current Practices in Mediastinal Lymph Node Staging in Non-Small Cell Lung Cancer.

Background: Lung cancer remains the leading cause of cancer deaths in the United States despite declining incidence and improved outcomes because of advancements in early detection and development of novel therapies. Accurate mediastinal lymph node staging is crucial for determining prognosis and guiding treatment decisions, particularly for non-small cell lung cancer (NSCLC). Materials and Methods: A systematic search of PubMed was conducted to identify English language articles published between January 2010 and January 2024 focusing on preoperative lymph node staging in adults with NSCLC. Case series, observational studies, randomized trials, guidelines, narrative reviews, systematic reviews, and meta-analyses were included. Results: Various imaging modalities, surgical and nonsurgical procedures for mediastinal lymph node staging were reviewed, including positron emission tomography with computed tomography, cervical mediastinoscopy, video-assisted cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy, endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA), transesophageal endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), and computed tomography-guided percutaneous lymph node biopsy. EBUS-FNA emerged as the preferred initial staging procedure because of its high sensitivity and low complication rate. Combining it with other procedures or confirmatory testing may be helpful in determining appropriate treatment. Conclusions: Although cervical mediastinoscopy remains a valuable confirmatory procedure in select cases, its role as a first-line staging modality is diminishing with the widespread adoption of EBUS-FNA and EUS-FNA. The combination of EBUS-FNA and EUS-FNA allows access to nearly all mediastinal lymph node stations with high diagnostic accuracy. Future research may further refine the selection criteria for invasive mediastinal staging procedures, ultimately optimizing patient outcomes in the management of NSCLC.

Large atypical lipomatous tumour of the neck with mediastinal extension managed by transcervical excision.

Tumours of adipose tissue origin are relatively rare in the head and neck. Here, we report a case of an unfamiliar lipomatous lesion that involved the neck and mediastinum. A nil-comorbid man in his 40s presented with a slowly progressive anterior neck swelling of 3 years, which was diagnosed as lipoma by histopathological sampling. Computed tomography demonstrated the lesion to be involving parapharyngeal and retropharyngeal spaces with mediastinal extension. The lesion was removed by the transcervical approach. The final histology of the excised specimen, with immunohistochemistry for mouse double minute 2 (MDM2) and p16, suggested an atypical lipomatous tumour (ALT). This report accentuates the occurrence of this rare neoplasm in the neck, which often mimics lipoma clinically. Although radiology can demonstrate suggestive features, histology with MDM2 and/or p16 positivity can confirm the diagnosis of ALT as against the lipoma. A successful transcervical excision, despite the deeper extension of the lesion between the critical structures of the neck and mediastinum, demonstrates the non-infiltrating nature of the tumour.