Inheritance and innovation of the diagnosis of peripheral pulmonary lesions.

As the leading cause of cancer-related deaths worldwide, early detection and diagnosis are crucial to reduce the mortality of lung cancer. To date, the diagnosis of the peripheral pulmonary lesions (PPLs) remains a major unmet clinical need. The urgency of diagnosing PPLs has driven a series of development of the advanced bronchoscopy-guided techniques in the past decades, such as radial probe-endobronchial ultrasonography (RP-EBUS), virtual bronchoscopy navigation (VBN), electromagnetic navigation bronchoscopy (ENB), bronchoscopic transparenchymal nodule access (BTPNA), and robotic-assisted bronchoscopy. However, these techniques also have their own limitations. In this review, we would like to introduce the development of diagnostic techniques for PPLs, with a special focus on biopsy approaches and advanced guided bronchoscopy techniques by discussing their advantages, limitations, and future prospects.

Comparison of operation time, efficacy and safety between through-the-scope stent and over-the-while stent in malignant central airway obstruction: a multi-center randomized control trial.

Background: Self-expandable metallic (SEM) airway stents are an important approach to treating malignant central airway obstruction (CAO). Standard over-the-while (OTW) stent needs the guidance of a guide-wire. It should be implanted under flouroscopy or the guidance of bronchoscope visualization. In this study, we evaluated the operation time and safety between OTW stent and a novel through-the-scope (TTS) SEM airway stent. Methods: In this multi-center, randomized, parallel-group superiority study, malignant CAO patients were enrolled randomly assigned (2:1) to the TTS stent implantation group (TTS group) or the standard OTW stent group (OTW group) in six sites across China. The entire process of all surgical procedures was recorded by video. Primary endpoint was the operation time of the airway stent implantation and secondary endpoint was the success rate of the stent implantation as well as its efficacy and safety. Results: From May 15, 2017, to December 30, 2018, 148 patients were enrolled from the six sites. We analyzed 134 patients (including 91 patients from the TTS group and 43 patients from the OTW group) according to the per-protocol set. There were no significant differences in the ages, genders, underlying diseases, and stenosis sites between the two groups. The operation time in the TTS group was significantly shorter than that in the OTW group (104±68 vs. 252±111 seconds, P<0.001). Compared to the OTW group, the efficacy of stent implantation (97.80% vs. 90.70%, P=0.093) and rate of first-time successful stent implantation (78.02% vs. 74.42%, P=0.668) were higher in the TTS group, but did not reach statistically significance. The rates of granulation (28.57% vs. 41.86%, P=0.128) and restenosis (15.38% vs. 30.23%, P=0.064) in the TTS group were slightly lower as compared with the OTW group without achieving statistical significance. Conclusions: The TTS stent implantation procedure time was significantly shorter than that of the OTW airway stent with similar efficacy and complications, which might reduce the risk and flexibility of stent implantation. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IOR-17011431.

Multi-Dimensional Display of Wang's Lymph Node Map Using Virtual Bronchoscopic Navigation System.

Background: Transbronchial needle aspiration (TBNA) is a classical technique for diagnosing mediastinal-hilar lymph node enlargement. However, the diagnostic value of conventional TBNA (cTBNA) is limited in small lymph nodes. Methods: Here, we generated an innovative multi-dimensional virtual lymph node map on top of Wang's lymph node map using a Lungpoint Virtual Bronchoscopic Navigation System. Results: The virtual bronchoscopic navigation (VBN) system was combined with computed tomography (CT) images to generate extrabronchial, endobronchial, sagittal, coronal as well as horizontal views of the 11 intrathoracic lymph node stations and their adjacent tissues and blood vessels. We displayed the specific puncture site of each lymph node station. The 11 stations were divided into four groups: right mediastinal stations, left mediastinal stations, central mediastinal stations and hilar stations. Conclusion: The VBN system provides a precise view of the intrabronchial landmarks, which may increase the diagnostic accuracy of intrathoracic lymph node adenopathy and assist bronchoscopists with practicing TBNA.

Randomized controlled trial to evaluate the utility of suction and inner-stylet of EBUS-TBNA for mediastinal and hilar lymphadenopathy.

BACKGROUND: The optimal procedure for maximizing the diagnostic yield and minimizing the procedural complexity of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is controversial. We conducted a prospective randomized controlled trial to determine the optimal procedure of EBUS-TBNA for mediastinal and hilar lymphadenopathy, with a particular focus on the roles of the inner-stylet and suction. METHODS: Consecutive patients with enlarged mediastinal and hilar lymph nodes (LNs), detected by computed tomography (CT) or positron emission tomography-CT (PET-CT), who underwent EBUS-TBNA were included. Each LN was sampled with three needle passes using suction-stylet, suction-no stylet, and stylet-no suction procedures. The samples were smeared onto glass slides for cytological evaluation. A single, blinded cytopathologist evaluated each set of slides. The primary outcomes were cytological specimen adequacy rate and diagnostic yield of malignant LNs. The secondary outcomes were tissue-core acquisition rate, procedural time, and the amount of bleeding. RESULTS: This study evaluated 97 patients with a total of 255 LNs. The final LN diagnosis was benign in 144, malignant in 104, and inadequate in 7 cases. There were no significant differences among the suction-stylet, suction-no stylet, and stylet-no suction groups in specimen adequacy rate (87.1, 88.2, 85.9%, respectively) or diagnostic yield of malignancy (32.2, 31.8, 31.0%, respectively). However, the use of suction was associated with an increase in tissue-core acquisition rate (P <  0.001). The no-stylet procedure decreased the average procedural time by 14 s (P <  0.001). There was no significant difference in the amount of bleeding among the procedures. CONCLUSIONS: The use of suction or non-use of an inner-stylet does not make a significant difference in cytological specimen adequacy or diagnostic yield when performing EBUS-TBNA. While omitting the stylet can simplify the procedure, applying suction can increase the tissue-core acquisition rate. These findings may assist endoscopic physicians in determining the optimal EBUS-TBNA procedure and warrant clinical verification in a future multicentre study. TRIAL REGISTRATION: Trial registration: ( ChiCTR-IOR-17010616 ). Retrospective registered date: 12th February, 2017.

Intrabronchial display of hilar-mediastinal lymph nodes by virtual bronchoscopic navigation system.

The description of precise intrabronchial positions for the sampling of mediastinal-hilar lymph nodes is critical to successfully perform conventional transbronchial needle aspiration. Previously published maps of mediastinal-hilar lymph nodes were primarily drawn based on experts' experience. We generated a virtual map of the most frequently sampled intrathoracic lymph nodes from an intrabronchial perspective using a virtual bronchoscopic navigation system, to assist with training in conventional transbronchial needle aspiration.

Bronchoscopy with endobronchial ultrasound guided transbronchial needle aspiration vs. transthoracic needle aspiration in lung cancer diagnosis and staging.

BACKGROUND: In evaluating patients with suspected lung cancer, it is important to not only obtain a tissue diagnosis, but also to obtain enough tissue for both histologic and molecular analysis in order to appropriately stage the patient with a safe and efficient strategy. The diagnostic approach may often be dependent on local resources and practice patterns rather than current guidelines. We Describe lung cancer staging at two large academic medical centers to identify the impact different procedural approaches have on patient outcomes. METHODS: We conducted a retrospective cohort study of all patients undergoing a lung cancer diagnostic evaluation at two multidisciplinary centers during a 1-year period. Identifying complication rates and the need for multiple biopsies as our primary outcomes, we developed a multivariate regression model to determine features associated with complications and need for multiple biopsies. RESULTS: Of 830 patients, 285 patients were diagnosed with lung cancers during the study period. Those staged at the institution without an endobronchial ultrasound (EBUS) program were more likely to require multiple biopsies (OR 3.62, 95% CI: 1.71-7.67, P=0.001) and suffer complications associated with the diagnostic procedure (OR 10.2, 95% CI: 3.08-33.58, P<0.001). Initial staging with transthoracic needle aspiration (TTNA) and conventional bronchoscopy were associated with greater need for subsequent biopsies (OR 8.05 and 14.00, 95% CI: 3.43-18.87 and 5.17-37.86, respectively) and higher complication rates (OR 37.75 and 7.20, 95% CI: 10.33-137.96 and 1.36-37.98, respectively). CONCLUSIONS: Lung cancer evaluation at centers with a dedicated EBUS program results in fewer biopsies and complications than at multidisciplinary counterparts without an EBUS program.

International association for the study of lung cancer map, Wang lymph node map and rapid on-site evaluation in transbronchial needle aspiration.

The invaluable role of transbronchial needle aspiration (TBNA) in the diagnosis and staging of mediastinal adenopathy and lung cancer has been well established. Different lymph nodes regional nomenclatures and maps had been described over the years. The international association for the study of lung cancer (IASLC) and Wang's maps complement each other benefiting patients with lung cancer. In this article we briefly reviewed the roles of IALSC, Wang's maps and ROSE in TBNA.

Efficacy and adequacy of conventional transbronchial needle aspiration of IASLC stations 4R, 4L and 7 using endobronchial landmarks provided by the Wang nodal mapping system in the staging of lung cancer.

BACKGROUND: The role of transbronchial needle aspiration (TBNA) in the diagnosis and staging of lung cancer has been well established. Recently, the efficacy of conventional TBNA in the staging of lung cancer has been enhanced by the use of endobronchial ultrasound (EBUS)-TBNA. Our study sought to evaluate the adequacy of TBNA of International Association for the Study of Lung Cancer (IASLC) stations 4R, 4L and 7 using endobronchial landmarks provided by the Wang nodal mapping system in the staging of lung cancer. METHODS: We retrospectively analyzed all bronchoscopic cases with conventional TBNA punctures positive for malignancy at our institution from 1 January to 31 October 2014. The endobronchial puncture site was guided by the Wang nodal mapping system. The Wang stations were correlated with the IASLC lymph node map. No endobronchial ultrasound or rapid on-site evaluation was used. Pathological analysis included cytological and histological examination. RESULTS: Diagnosis by histological analysis was obtained in 115 (55.3%) out of 208 puncture sites. The metastatic lymph nodes were distributed at IASLC stations 4R (W1, 3, 5) 46.6 %, 7 (W2, 8, 10) 19.7%, 4L (W4, 6) 11.5%, 11R (W7, W9) 11.1% 11L (W11) 9.6%, 2R (high station W3) 0.5%, and the proximal portion of station 8 (station W10 beyond the middle lobe orifice) 1%. No complications were observed. CONCLUSION: IASLC station 4R (W1, 3, 5), 7 (W2, 8, 10) and 4L (W4, 6) are adequate for the staging of lung cancer.

Utilization of the International Association for the Study of Lung Cancer and Wang's nodal map for the identification of mediastinum and hilar lymph nodes.

BACKGROUND: Transbronchial needle aspiration (TBNA), serving as a remarkably invaluable and minimally invasive technique, has been widely used for the diagnosis and staging of mediastinal adenopathy and masses. To date, the International Association for the Study of Lung Cancer (IASLC) and Wang's nodal map are two well-documented intrathoracic lymph node guidelines for the TBNA procedure. METHOD: We characterized IASLC's and Wang's map, and interpreted the correlation of the two maps station by station. RESULTS: The pivotal role of IASLC map is to determine N descriptor in the tumor node metastasis (TNM) staging system of lung cancer, whilst Wang's map is employed to facilitate the localization of biopsy sites for bronchoscopists during TBNA performance. Furthermore, stations 1, 3 and 5 in Wang' map are equivalent to 4R station in IASLC' system, while stations 4 and 6 in Wang's account for IASLC station 4L as N2 stations. In addition, Wang's stations 2, 8 and 10 are correlated with station 7 in IASLC's. Wang's stations 7 and 9 are responsible for station 11R in IASLC's map. CONCLUSION: Given their unique benefits and limitations, and the practical links between the two maps, it appears reasonable to highlight the significance of their complementary utilization upon TBNA performance and lung cancer staging.

Evolution of transbronchial needle aspiration technique.

Transbronchial needle aspiration (TBNA) is an established technique to collect cell and tissue specimens from lesions outside the airway wall, generally guided by flexible bronchoscope under the direct visualization of the puncture site. TBNA has been utilized for 30 years, and now there is renewed interest in utilizing it in conjunction with endobronchial ultrasound. Although the basic operational principles have remained the same, conventional TBNA (cTBNA) and endobronchial ultrasound-guided TBNA (EBUS-TBNA) have been greatly improved over the years with the increased application in clinic and the advance of new technology. In this article we briefly discussed the evolution of TBNA technique and its future.

Evaluation of lymph node metastasis in lung cancer: who is the chief justice?

Accurate determination of the diagnosis and the stage of lung cancer play a critical role to ensure that patients are provided the optimal treatment. However, the process is usually beyond complex. Early studies have suggested lymph nodes (LNs) >1.0 cm in size on computed tomography (CT) are considered as metastatic nodes, while the sensitivity of this criterion is not satisfied. Subsequently, positron emission tomography-computed tomography (PET-CT) was shown to be superior to CT alone on assessment of nodal involvement and was widely used to estimate suitability for resection with curative intent, but the dependability also remains controversial. Furthermore, transbronchial needle aspiration (TBNA) with and without endobronchial ultrasound (EBUS), as a well-accepted minimally invasive approach for LN biopsy, has been documented as an efficient tool in evaluation of CT and PET-CT negative LNs. Additionally, radiographic features including ground-glass/solid nodules ratio, referring as imaging biomarker, were indicated to be correlated with metastasis. Hence, we highlight the importance of comprehensive estimation of mediastinal and hilar LNs, and we suggested the judgment of LNs by radiographic tools alone might not be reliable and TBNA is indispensable in certain circumstances.

Insight into the differences in classification of mediastinal and hilar lymph nodes between Wang's lymph node map and the International Association for the Study of Lung Cancer lymph node map.

Lung cancer is the leading cause of malignant-tumor-related morbidity and mortality worldwide. Transbronchial needle aspiration (TBNA) has for the past 30 years been an effective technique for the diagnosis and staging of lung cancer. Understanding the anatomy of mediastinal and hilar lymph nodes is essential to improve the yield of TBNA. Wang's lymph node map is based on the lymph node map of the American Thoracic Society (ATS), and on the TBNA technique; it was published in 1994, and has promoted the development of both conventional TBNA (cTBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In 2009, the International Association for the Study of Lung Cancer (IASLC) developed a new chest lymph node map to reconcile the differences between the Naruke and The Mountain-Dresler (MD)-ATS lymph node maps. The IASLC lymph node map was incorporated into the seventh edition of the tumor, node, metastasis (TNM) staging system for lung cancer, which directly affected the treatment and prognosis of lung cancer. There are significant differences between Wang's lymph node map and the IASLC lymph node map in TNM staging, and it is imperative to understand these differences and correlate these maps for the prognosis and staging of lung cancer using cTBNA or EBUS-TBNA.

Standardized transbronchial needle aspiration procedure for intrathoracic lymph node staging of non-small cell lung cancer.

BACKGROUND: Thoracic lymph node (LN) metastasis is the determining factor for NSCLC staging. However, enlargement in thoracic LNs, which can be detected by chest computed tomography (CT), may not be adequate for NSCLC staging. This study aimed to investigate the effectiveness of a new transbronchial needle aspiration (TBNA) procedure to improve the sensitivity and accuracy of lung cancer diagnosis and staging. METHODS: A standardized TBNA procedure was performed on enlarged and non-enlarged LNs in the order of N3 to N1 station according to Wang's LN map. The status of LN metastasis determined by the standardized TBNA procedure was compared with the results from CT scan. RESULTS: The TBNA biopsy revealed that 21.43% of non-enlarged LNs were malignant. Compared with chest CT, the standardized TBNA procedure improved the accuracy of LN metastasis staging and discovered skip LN metastasis. CONCLUSIONS: The standardized TBNA procedure of this study may be recommended to be used as a routine TBNA procedure, in which LNs should be biopsied in the order of N3 to N1 station and both enlarged and non-enlarged LNs should be included to improve the accuracy of lung cancer staging.

Transbronchial needle aspiration: development history, current status and future perspective.

BACKGROUND: Transbronchial needle aspiration (TBNA) technology was underutilized by clinicians because it is "blind". Recent development of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) renewed the interest and confident of TBNA. TBNA without EBUS is referred as conventional transbronchial needle aspiration (C-TBNA). METHODS: This paper focuses on C-TBNA technology development history, present situation and future development to do a detailed introduction. RESULTS: TBNA is a simple, cost effective and minimally invasive technique for diagnosing disease of the mediastinum and lung in adult as well as children patients. CONCLUSIONS: More improvements of TBNA technology should be made, including employing technological advances to perfect the instruments and techniques, focusing on patient comfort, optimizing yield, simplifying instruments, maximizing ease of use and minimizing training requirements for the pulmonologist. The ideal TBNA scope deserves further evaluation and study.

Endobronchial ultrasound transbronchial needle aspiration: a hybrid method.

BACKGROUND: Conventional transbronchial needle aspiration (cTBNA) was first performed approximately 30 years ago; however TBNA was not widely adopted until the development of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA). Current EBUS-TBNA needle sizes are limited to 21- and 22-gauge. In order to determine whether a 19-gauge (19G) needle in EBUS-TBNA can further improve the diagnostic yield and simplify the methodology of EBUS-TBNA we developed a hybrid method. Here we report our initial experience in assessing the feasibility of performing EBUS-TBNA using a conventional 19G TBNA needle. METHODS: Ten patients with diagnosed or suspected lung cancer with or without lymphadenopathy (LAD) were sampled for diagnostic and/or staging purposes. Patients with suspected benign processes were sampled only for diagnosis. A 19G cTBNA needle was deployed through the working channel of the EBUS bronchoscope. Samples obtained were evaluated for cyto- and histopathologic adequacy. RESULTS: All 10 patients successfully underwent hybrid 19G EBUS-TBNA. All samples were considered adequate for cyto- and histopathologic evaluation. CONCLUSIONS: Hybrid EBUS-TBNA utilizing a 19G cTBNA needle through an EBUS scope is feasible and may be able to reliably acquire histologic specimens.

Transbronchial needle aspirations vs. percutaneous needle aspirations.

Over the last decade, the increasing diffusion of innovative and more powerful imaging guided techniques has further broadened the bronchoscopist's horizons in the diagnostic work-up of peripheral pulmonary nodules/masses (PPN/M). However, in most of institutions worldwide, due to the lack of resources and specific skills, the routinely diagnostic approach to PPN/M is still represented by imaging-guided transbronchial needle aspirations (TBNA) and percutaneous needle aspirations (PCNA). So far, no randomized clinical trials directly comparing the accuracy of the two procedures are available, and a standardized strategy that defines the proper role of each technique has yet to be established. In fact, the choice between these procedures is mostly influenced by "environmental" factors, such as operator's experience and local resources, rather than by an established algorithm, based on selected clinical scenarios. Data from literature indirectly suggest a higher sensitivity of PCNA compared to transbronchial approach, especially when lesions are peripheral and less than 2 cm. On the other hand, the transbronchial approach has been shown to have a better safety profile. Moreover, it offers the advantages to provide, during a single examination, a pathological diagnosis of nodules, information on mediastinal staging and airways involvement, and to identify potential synchronous lesions. In this context, it would be reasonable to firstly perform flexible bronchoscopy with TBNA, and, in case of inconclusive results, PCNA. In conclusions, both the techniques have been shown to be useful in the diagnostic pre-operative work-up of PPN/M. In order to optimize the diagnostic yield and to minimize the risk of patients they should not to be considered as two alternative options, but, rather, as two complementary techniques integrated in a standardized algorithm.

Past, present, and future of endobronchial laser photoresection.

Laser photoresection of central airway obstruction is a useful tool for an Interventional Pulmonologist (IP). Endobronchial therapy of the malignant airway obstruction is considered as a palliative measure or a bridge therapy to the definite treatment of cancer. Several ablative therapies such as electrocautery, argon plasma coagulation (APC), cryotherapy and laser photoresection exist in the armamentarium of IP to tackle such presentations. Besides Neodymium-Yttrium, Aluminum, Garnet (Nd:YAG) laser, there are several different types of laser that have been used by the pulmonologist with different coagulative and cutting properties. This chapter focuses on the historical perspective, current status, and potentials of lasers in the management of central airway lesions.

Improved diagnostic yield of bronchoscopy in peripheral pulmonary lesions: combination of radial probe endobronchial ultrasound and rapid on-site evaluation.

BACKGROUND: Rapid on-site evaluation (ROSE) of cytologic specimens is a useful ancillary technique in needle aspiration procedures of pulmonary/mediastinal lesions, but few reports had been carried out to confirm the utility in the diagnosis of peripheral pulmonary lesions (PPLs) by radial probe endobronchial ultrasound (R-EBUS). METHODS: To evaluate the impact of ROSE on the diagnostic yield of R-EBUS for PPLs, we retrospectively analyzed the diagnostic yields of transbronchial biopsy (TBB) or brushing using R-EBUS for patients with PPLs in a tertiary university hospital from December 2012 to December 2014. RESULTS: A total of 815 patients with PPLs were included. A definite diagnosis was made by R-EBUS-guided TBB or brushing for 627 patients (76.9%). A total of 279 patients (34.2%) were examined by a ROSE technique. The combination of R-EBUS guided TBB or brushing with ROSE raised the diagnostic yield in the diagnosis of PPLs, especially difficult cases: right apical and left apical-posterior segment locations, small PPLs <3 cm without bronchus signs on computed tomography (CT) scan, PPLs with pleural effusions, and the position of probe is not within. CONCLUSIONS: ROSE can improve the PPLs diagnostic yield when using R-EBUS guided TBB or brushing.