Conventional transbronchial needle aspiration is promising for identifying EGFR mutations in lung adenocarcinoma.

BACKGROUND: Conventional transbronchial needle aspiration (TBNA) is advantageous for the one-step diagnosis and staging of lung adenocarcinoma under topical anesthesia and conscious sedation. We examined its efficacy for identifying EGFR mutations. METHODS: Forty-seven patients with proven or suspected lung adenocarcinoma indicated for hilar-mediastinal lymph node (LN) staging between June 2011 and December 2017 were enrolled. The cellblock was prepared using the plasma-thrombin method. TaqMan PCR was used to detect mutations. Considering cost effectiveness, only the sample with the highest tumor cell fraction in the same patient was chosen for analysis. RESULTS: TBNA provided positive results of malignancy in 27 patients. Seventeen patients (63.0%) had cellblocks eligible for mutation testing. Bronchial biopsy (n = 6), neck LN fine needle aspiration (n = 1), and brushing (n = 1), provided higher tumor cell fractions for analysis in eight patients. TBNA was the exclusive method used in nine patients (19.1%). For patients with an inadequate TBNA cellblock, bronchial biopsy (n = 5), neck LN fine needle aspiration (n = 3), computed tomography-guided transthoracic needle biopsy (n = 1), and brushing (n = 1) were used for analysis. Modification to specimen processing to prevent exhaustion by cytology after June 2016 improved the adequacy of cellblock samples (9/10, 90% vs. 8/17, 47.1%; P = 0.042). CONCLUSIONS: These findings suggest the promising role of conventional TBNA and highlight the challenges of doing more with less in an era of precision medicine.

Clinical outcomes of chemical pleurodesis using a minocycline.

BACKGROUND: Pleurodesis is often used to prevent the re-accumulation of a malignant pleural effusion (MPE). Intrapleural urokinase (IPUK) therapy facilitates lung re-expansion for patients with loculated MPE or a trapped lung that allows subsequent pleurodesis. MPE management has been traditionally regarded as a symptomatic treatment. We tried to evaluate their impact on patient survival. METHODS: There were 314 consecutive patients with symptomatic MPE that underwent minocycline pleurodesis with ( n = 109) and without ( n = 205) the antecedent IPUK therapy between September 2005 and August 2015, who were recruited for the pleurodesis outcome and survival analysis. RESULTS: The rate of successful pleurodesis was similar between the simple pleurodesis group and the IPUK therapy group followed by the pleurodesis group (69.0% versus 70.5%; p = 0.804). The patients who succeeded pleurodesis had a longer survival rate than those who failed in either the simple pleurodesis group (median, 414 versus 100 days; p < 0.001) or the IPUK therapy followed by pleurodesis group (259 versus 102 days; p < 0.001). The survival differences remained when the lung and breast cancer patients were studied separately. CONCLUSION: Successful pleurodesis translated into a better survival rate that promotes performing pleurodesis on lung re-expansion. The apparent shorter survival of the patients with loculated MPE or trapped lung, and those that did not respond to the IPUK therapy, lowered the probability of the survival benefit through the simple physical barrier by the fibrin formation to prevent the tumor spreading. The successfully induced inflammatory response by minocycline is supposed to prohibit the tumor invasion and metastasis. Further studies are warranted to clarify the mechanism and provide opportunities to develop novel therapeutic strategies.

Comparison of 19-gauge eXcelon and WANG MW-319 transbronchial aspiration needles.

Conventional transbronchial needle aspiration (TBNA) using 19-gauge needles can obtain larger histological specimens for hilar-mediastinal diagnosis. A new 19-gauge eXcelon needle was introduced in Taiwan in July 2012. We prospectively enrolled patients with hilar-mediastinal lesions and pathology results of suspected benign origin or lymphoproliferative processes, to perform TBNA using a 19-gauge eXcelon needle, between July 2012 and December 2012. The results were compared with historical control of TBNA using a WANG MW-319 needle between January 2011 and June 2012. The procedure was performed by the same pulmonologist, and rapid on-site cytologic evaluation was used. The 19-gauge eXcelon needle was used in nine patients with 15 lymph nodes aspirated, with a mean diameter of 23.3 ± 10.7 mm. The mean number of needle passes was 2.7 ± 1.4, with a diagnostic accuracy of 77.8%. The MW-319 needle was used in 12 patients with 18 lymph nodes aspirated, with a mean diameter of 21.3 ± 5.7 mm. The mean number of needle passes was 2.2 ± 0.4, with a diagnostic accuracy of 75.0%. Neither technical nor major clinical complications were noted in either group. We concluded that the 19-gauge eXcelon needle was as safe and effective as the MW-319 needle. A more adequate specimen could be obtained and fewer needle passes were required with the MW-319 needle, although the difference did not reach significance.

Safety of interventional bronchoscopy through complication review at a cancer center.

BACKGROUND AND AIMS: There have been rapid advances in the area of interventional bronchoscopy over the past 15 years, but associated complications have been rarely discussed. A longitudinal evaluation of the same operator's performance at a cancer center is reported. METHODS: A detailed record review of diagnostic and therapeutic bronchoscopy between January 1997 and March 2013 was conducted. RESULTS: Among the 1358 diagnostic bronchoscopies, there were nine major complications requiring premature termination and three pneumothoraces found during follow-up (0.88%). An escalation in the level of care was required for four patients with massive bleeding, asthma attack, sedation intoxication and myocardial ischemia, respectively. Six cases occurred after brushing (0.71%), and five cases before any sampling procedure was conducted. The complication rate was highest for peripheral lesions (1.03%). Among the 109 therapeutic bronchoscopies, no major patient-specific complication occurred except for excessive granulation tissue formation following metallic stenting in one patient with benign tracheal stenosis. CONCLUSION: The complication rate with regard to bronchoscopy is comparable with historical controls according to the related literature, and their occurrence appears to be sporadic, not relevant to patient characteristics and mostly related to the bronchoscopy itself rather than the introduction of new techniques. Bronchoscopy remains safe along with technical innovations. However, risk recognition and effective prevention is essential.

Education and experience improve the performance of transbronchial needle aspiration: a learning curve at a cancer center.

STUDY OBJECTIVES: Transbronchial needle aspiration (TBNA) is an indispensable part of the pulmonologist's armamentarium, although it continues to be woefully underutilized despite its demonstrated safety and usefulness. We herein review our experience with the procedure. MATERIALS AND METHODS: All TBNAs were conducted according to standard techniques using 21-gauge cytology needles or 19-gauge histology needles connected to a flexible bronchovideoscope. All procedures were conducted at a 180-bed cancer center, and results were analyzed retrospectively. The mediastinum and hilar lymph node mapping system proposed by Wang was followed exclusively. RESULTS: From September 1999 to March 2003, inclusively, 90 of 549 patients undergoing diagnostic bronchoscopy were selected for TBNA: 66 patients for hilar-mediastinal lymphoadenopathies, and 24 patients for submucosal and/or peribronchial lesions. A total of 87 hilar-mediastinal lymph node stations were sampled, with a mean of 2.2 needle passes for each. Seventy-eight patients revealed a malignant diagnosis. TBNA provided positive results for malignancy for 59 patients. Sarcoidosis, mediastinal bronchogenic cyst, and mediastinal tuberculous adenitis were identified for another three patients, respectively. The diagnostic yield was 68.2% (45 of 66 patients) for hilar-mediastinal lesions, and 70.8% (17 of 24 patients) for submucosal and peribronchial lesions. The sensitivity was 75% (45 of 60 patients) for hilar-mediastinal lesions, and 80.9% (17 of 21 patients) for submucosal and peribronchial lesions. The overall accuracy of the procedure for returning a correct diagnosis was 75.9% (66 of 87 patients). Higher yields for patients featuring small-cell lung cancer were noted. Fifteen patients presenting mediastinal lesions attained to a specific pathologic diagnosis using TBNA despite normal-appearing airways. TBNA was the exclusive means of diagnostic sampling for 27 patients. Twenty-two patients had previously undergone a nondiagnostic bronchoscopy at other hospitals. Diagnosis and mediastinal staging was accomplished in one procedure for 19 patients exhibiting non-small cell lung cancer. The number of TBNA procedures performed per unit time rose steadily during the test period. The TBNA yield and sensitivity for the detection of hilar-mediastinal lymphoadenopathies increased significantly (p = 0.03) during the study period. The presence of the cytotechnologist during the TBNA procedure provided direct, immediate feedback pertaining to the quality of specimens acquired. With such rapid on-site examination of TBNA-derived specimens, there was a trend with borderline significance (p = 0.06) toward a decreasing frequency of inadequately acquired tissue specimens when using this technique. CONCLUSIONS: TBNA performance was able to be improved over time. Increased specimen yield and sampling sensitivity over a 43-month period suggested the impact of enhanced training interventions and experience. Rapid on-site examination was also indispensable for the promotion of diagnostic accuracy. The progressive acquisition of skills as regards the use of cytology needles for TBNA purposes should precede the use of a histology needle for such biopsy purposes. For selected cases, the use of the 19-gauge histology needle increased the diagnostic yield of TBNA. It is to be hoped that increased experience with the TBNA technique and focused education regarding its performance will enhance its utilization by bronchoscopists and the spread of its acceptance.

Sex-associated differences in non-small cell lung cancer in the new era: is gender an independent prognostic factor?

BACKGROUND: Women with non-small cell lung cancer (NSCLC) appear to have better survival. This study aimed to evaluate sex differences in NSCLC in recent years. The true effect of gender on the overall survival was analyzed taking other prognostic factors into account. METHODS: A cohort of consecutive NSCLC patients was prospectively enrolled from January 2002 to December 2005, and followed-up until December 2006. They were clinically and pathologically staged and underwent homogenous treatment algorithms. Demographics, histology, and disease stage between sexes were compared. The clinical prognostic factors to be analyzed in addition to gender included stage, age, smoking history and histology. The overall survival of females and males within relevant subgroups defined by smoking history and histology was also compared. RESULTS: Of the 738 patients, 695 were analyzed with a definite stage (94.2%; 315 females and 380 males), which was similar in both sexes. Females were younger (median age: 59.5 years vs. 65.0 years; P<0.001) and more likely to have adenocarcinoma (81% vs. 60.5%; P<0.001). Patients with earlier stage, younger patients, never-smokers and females had better overall survival in univariate analyses and no significant survival difference was noted between adenocarcinoma and squamous cell carcinoma. Multivariate analyses demonstrated age, smoking history and gender to have a hazard ratio 1.46 (95% confidence interval, CI 1.21-1.76; P<0.001), 1.27 (95% CI 0.97-1.65; P=0.082), and 1.18 (95% CI 0.90-1.55; P=0.226), respectively. Subgroup analyses revealed the survival of never-smoker males with adenocarcinoma was similar to that of females. CONCLUSIONS: There are sex-related differences in the clinico-pathologic characteristics and survival of NSCLC patients. The survival advantages of females could be attributed to the younger age and lower smoking prevalence. Never-smokers with adenocarcinoma should be given special attention regardless of sex as they imply better survival with different treatment outcomes.

Transbronchial needle aspiration accurately diagnoses subcentimetre mediastinal and hilar lymph nodes detected by integrated positron emission tomography and computed tomography.

OBJECTIVE AND BACKGROUND: Integrated PET and CT (PET/CT) is accurate in detecting hilar-mediastinal metastases. However, it has a moderate positive predictive value, necessitating pathological verification, especially in situations in which the result would make a difference to treatment. This study aimed to evaluate the performance of transbronchial needle aspiration (TBNA) for hilar-mediastinal lesions suspicious on PET/CT. METHODOLOGY: A retrospective study was conducted on 19 patients with a total of 25 positive hilar-mediastinal lymph nodes localized on PET/CT. Standard TBNA technique with rapid on-site cytopathology was performed. RESULTS: The mean short-axis diameter of the positive lymph nodes identified on PET/CT was 9.9 +/- 3.0 mm. The sensitivity, specificity and diagnostic accuracy of PET/CT-guided TBNA were 81.8%, 100% and 84%, respectively. The number of needle passes to successful lymph node aspiration or a diagnosis of cancer was 2.36 +/- 0.49. Nine of the 25 positive lymph nodes (36%) on PET/CT were smaller than 1.0 cm. The accuracy and sensitivity of TBNA for these subcentimetre nodes was 88.9% and 87.5%, respectively. TBNA replaced surgical sampling in 15 patients (78.9%) with positive lymph nodes on PET/CT. In seven non-small cell lung cancer patients, diagnosis and staging were possible in the one procedure. No complications were encountered. CONCLUSION: PET/CT can identify small malignant lymph nodes that can then be successfully biopsied by TBNA with on-site cytopathology.