Franseen needle in endobronchial ultrasound-guided transbronchial needle aspiration: a phase II prospective study.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been used to diagnose and stage lung cancer. Acquire™ Pulmonary and Expect™ Pulmonary dedicated EBUS-TBNA needles were introduced as the Franseen and Lancet needles, respectively. It is still unclear whether the Franseen or Lancet needles yield a higher quality specimen especially focusing on next-generation sequencing-based molecular testing. METHODS: A single-center, prospective study performed at the Chiba University Hospital randomly assigned patients to two groups: Group A, wherein the first and second EBUS-TBNA were performed using Lancet and Franseen needles, respectively, and Group B, wherein the first and second EBUS-TBNA were performed using Franseen and Lancet needles, respectively. Each specimen was compared and analyzed pathologically. The primary outcome was the histological tissue area except blood clot and the cellularity of each sample. We also examined the success rate of molecular testing. RESULTS: Twelve patients who underwent EBUS-TBNA between November 2022 and February 2023 were enrolled in this study. The tissue area of the specimens obtained by the Franseen and Lancet needles was 13.3 ± 6.4 mm2 and 10.6 ± 6.3 mm2, respectively (P = .355). The tumor cellularity in the specimens obtained using the Franseen and Lancet needles was 54.0 ± 30.3 and 46.2 ± 36.3%, respectively (P = .608). The success rate of molecular testing using the single-pass sample by Franseen needle was 85.7 and 57.1% by Lancet needle. No serious complications were reported. CONCLUSIONS: The Franseen needle tended to show a greater amount of specimen with higher tumor cellularity than the Lancet needle which may contribute higher success rate of molecular testing. Further studies must be conducted to validate the results of this study. KEY FINDINGS: What is known and what is new?  What is the implication, and what should change now?

Impact of rapid on-site evaluation in expediting the fast investigative lung cancer pathway.

OBJECTIVE: EBUS-TBNA is a method of acquiring tissue samples from intrathoracic lymph nodes and central intrathoracic tumours in patients suspected of having lung cancer. Rapid on-site evaluation (ROSE) denotes assessing tissue samples during EBUS (or bronchoscopy), providing instant feedback on sample adequacy and provisional cytomorphological diagnosis. Sector multidisciplinary team (MDT) discussion can then make informed treatment decisions, with confirmatory immunohistochemistry being finalised before provision of final treatment. Currently, impact of ROSE on length of time patients spend on the lung cancer diagnostic pathway remains unclear. METHODS: We retrospectively evaluated the impact of ROSE on the length of time between patients' EBUS/bronchoscopy procedures and discussion at sector MDT, referred to as time to treatment decision (TTD), at our institution. Additionally, we assessed impact of ROSE on number of passes (number of times nodes/masses were sampled) per procedure. RESULTS: The mean TTD was 77.9% shorter (p = 0.001) with ROSE present than when absent. Patients who received ROSE spend 34.3% less time (p = 0.028) on lung cancer diagnostic pathway overall. There was a significant reduction in number of passes in non-malignant nodes with ROSE present (2.23) than when absent (3.14) (p < 0.001). With ROSE present there was a significantly greater number of passes at malignant sites (5.07) than non-malignant sites (2.23) (p < 0.001). CONCLUSIONS: These findings support conclusions made in our institution's previous study, that utilisation of ROSE reduces TTD. ROSE also allows safe advancement through nodes with low suspicion of malignant involvement, focusing time on sampling nodes/masses of greater suspicion.

Endoscopic nodal staging in oligometastatic non-small cell lung cancer (NSCLC) being treated with stereotactic ablative radiotherapy (ENDO-SABR).

BACKGROUND: Research in treatment of non-small cell lung cancer (NSCLC) has shown promising results with stereotactic ablative radiotherapy (SABR) of oligometastatic disease, wherein distant disease may be limited to one or a few distant organs by host factors. Traditionally, PET/CT has been used in detecting metastatic disease and avoiding futile surgical intervention, however, sensitivity and specificity is limited to only 81 and 79%, respectively. Mediastinal staging still identifies occult nodal disease in up to 20% of NSCLC patients initially thought to be operative candidates. Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive tool for the staging and diagnosis of thoracic malignancy. When EBUS is combined with endoscopic ultrasound using the same bronchoscope (EUS-B), the diagnostic sensitivity and negative predictive value increase to 84 and 97%, respectively. Endoscopic staging in patients with advanced disease has never been studied, but may inform treatment if a curative SABR approach is being taken. METHODS: This is a multi-centre, prospective, cohort study with two-stage design. In the first stage, 10 patients with oligometastatic NSCLC (lung tumour ± hilar/mediastinal lymphadenopathy) with up to 5 synchronous metastases will be enrolled An additional 19 patients will be enrolled in the second stage if rate of treatment change is greater than 10% in the first stage. Patients will be subject to EBUS or combined modality EBUS/EUS-B to assess bilateral lymph node stations using a N3 to N2 to N1 progression. Primary endpoint is defined as the rate of change to treatment plan including change from SABR to conventional dose radiation, change in mediastinal radiation field, and change from curative to palliative intent treatment. DISCUSSION: If a curative approach with SABR for oligometastatic disease is being explored, invasive mediastinal staging may guide treatment and prognosis. This study will provide insight into the use of endoscopic mediastinal staging in determining changes in treatment plan of NSCLC. Results will inform the design of future phase II trials. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT04852588. Date of registration: April 19, 2021. PROTOCOL VERSION: 1.1 on December 9, 2021.

Diagnostic value of endobronchial ultrasound elastography combined with rapid onsite cytological evaluation in endobronchial ultrasound-guided transbronchial needle aspiration.

BACKGROUND: Endobronchial ultrasound (EBUS) elastography has been used in EBUS-guided transbronchial needle aspiration (EBUS-TBNA) to identify malignant lymph nodes based on tissue stiffness. Rapid onsite cytological evaluation (ROSE) has been widely utilized for onsite evaluation of sample adequacy and for guiding sampling during EBUS-TBNA. The aim of this study was to investigate the diagnostic value of combined EBUS elastography and ROSE in evaluating mediastinal and hilar lymph node status. METHODS: Retrospective chart review was performed from December 2018 to September 2020. Patient demographics, EBUS elastography scores, and ROSE, pathologic, and clinical outcome data were collected. The EBUS elastography scores were classified as follows: Type 1, predominantly nonblue; Type 2, partially blue and partially nonblue; and Type 3, predominantly blue. A receiver operating characteristic curve was used to compare the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for evaluation of malignant lymph nodes among the EBUS elastography, ROSE, and EBUS combined with ROSE groups. RESULTS: A total of 245 patients (345 lymph nodes) were included. The sensitivity and specificity of the EBUS elastography group for the diagnosis of malignant lymph nodes were 90.51% and 57.26%, respectively. The sensitivity and specificity in the ROSE group were 96.32% and 79.05%, respectively. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of EBUS elastography combined with ROSE were 86.61%, 92.65%, 11.78, and 0.14, respectively, and the area under the curve was 0.942. CONCLUSIONS: Combining EBUS elastography and ROSE significantly increased the diagnostic value of EBUS-TBNA in evaluating mediastinal and hilar lymph node status compared to each method alone.

Diagnostic Yield of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Cytological Smears and Cell Blocks: A Single-Institution Experience.

Background and Objective: Endobronchial ultrasound (EBUS) is a minimally invasive endobronchial technique, which uses ultrasound along with a bronchoscope to visualize the airway wall and structures that are adjacent to it. Indications for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are samplings of mediastinal, hilar lymph nodes, and tumors adjacent to airway walls. EBUS-TBNA has been used in our clinic since 2009. The aim of the study is to evaluate the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of cytological and histological specimens, and the safety of EBUS-TBNA in an unselected patient population that has been referred to our hospital. Materials and Methods: We have retrospectively analyzed the medical documentation of 215 patients who had EBUS-TBNA performed in our clinic from April 2009 to February 2014. Results: There were 215 patients who underwent EBUS-TBNA. A total of 296 lymph nodes were sampled. EBUS-TBNA was diagnostic in 176 (81.9%) cases of cytological, 147 (68.4%) cases of histological, and 191 (88.9%) cases of the combined evaluation. In the lung cancer patients, EBUS-TBNA cytology had a sensitivity of 72.9% and histology of 72.9%, and in the sarcoidosis group, it had a cytology of 55.8% and histology of 64.5%. As all positive cytology and histology specimens were assumed to be true positive, specificity and positive predictive value (PPV) were 100%. The sensitivity and diagnostic accuracy was significantly higher when cytology and histology specimens were combined, compared with cytology or histology results evaluated separately (p < 0.05) (for lung cancer 84.1% and for sarcoidosis 78.8%). The sensitivity and diagnostic accuracy of EBUS-TBNA procedures increased significantly over time, with increased experience. There were no complications with EBUS-TBNA in our clinical practice. Conclusions: EBUS-TBNA had a high diagnostic yield and was safe in the diagnosis of lung cancer and sarcoidosis. It was most informative when cytology and histology were combined. The informative value of EBUS-TBNA histology increased with our experience.

Endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy: a narrative review.

Background and Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe, and well-established method for diagnosing and staging lung cancer and other conditions associated with mediastinal lymphadenopathy. Efforts have been made to enhance the material adequacy of EBUS-TBNA, including the recent introduction of EBUS-guided transbronchial mediastinal cryobiopsy (EBUS-TMC). This advancement facilitates the acquisition of larger and better-preserved tissue samples from the mediastinum. We evaluated the diagnostic accuracy and safety of EBUS-TMC in the diagnosis of malignant lesions and its effectiveness in relation to benign conditions, such as tuberculosis and sarcoidosis. Methods: We searched the PubMed® database for relevant English articles published up to July 1, 2023. Subsequently, we conducted a comprehensive bibliographic analysis with a particular emphasis on diagnostic yield, safety profile, and procedural technicalities. Key Content and Findings: Our narrative review, comprising seven publications, emphasizes the significance of EBUS-TMC as an effective technique for obtaining diagnostic tissue in malignant and benign conditions while maintaining an excellent safety profile. Furthermore, its capability for obtaining larger tissue samples facilitates molecular and immunological analysis in non-small cell lung cancer. Conclusions: EBUS-TMC exhibits significant efficacy with regard to obtaining diagnostic tissue in malignant and benign conditions. However, further studies are needed to evaluate uncertainties regarding the selection of suitable cases and technical intricacies.

Role of Bronchoscopy in Diagnosis of Sarcoidosis.

Sarcoidosis is a multisystem inflammatory disorder with unclear etiology and can often pose a diagnostic challenge. A tissue diagnosis is often necessary to illustrate the non-caseating granulomas on histopathology. This review aims to synthesize current evidence related to tissue diagnosis of sarcoidosis using various bronchoscopic techniques. We start by discussing standard bronchoscopic techniques which have remained the cornerstone of diagnostic workup such as bronchoalveolar lavage (BAL), endobronchial biopsy (EBB), conventional transbronchial needle aspiration (cTBNA) and transbronchial lung biopsy (TBLB) followed by newer modalities that incorporate real-time image guidance using endobronchial and endoscopic ultrasound. Although BAL, EBB, and TBLB have been employed as a diagnostic tool for several decades, their sensitivity and diagnostic yield is inferior to ultrasound-based endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). More recently, convincing evidence has also emerged to support the diagnostic accuracy and tissue yield of transbronchial lung cryobiopsy which will also be discussed in this review. These advances in bronchoscopic equipment and techniques over the last 2 decades have made it possible to obtain tissue samples using minimally invasive techniques thus avoiding invasive open lung biopsy and the risks that inherently follow. Up-to-date knowledge of these modalities is imperative for ensuring evidence-based medicine and improving patient-centric outcomes.

Endobronchial ultrasound (EBUS)-guided transbronchial miniforceps biopsy an urban center experience.

Background: The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in staging mediastinal and hilar lymph nodes in non-small cell lung cancer (NSCLC) is well established. However, evidence of its diagnostic utility in other pathologies-such as lymphoma-remains inadequate. This retrospective observational study aims to determine the diagnostic yield of EBUS-guided miniforceps biopsy (EBUS-MFB) compared to EBUS-TBNA in both malignant and nonmalignant conditions. Methods: We conducted a retrospective cross-sectional chart review of all adult patients referred for EBUS at our institution between January 2019 and December 2022. All patients who underwent both EBUS-TBNA and EBUS-MFB were included, with some patients also undergoing transbronchial cryobiopsy. Patients without pathology reports available were excluded. Results: The combination of EBUS-MFB and EBUS-TBNA had the highest percentage of diagnostic results both in the overall cohort (34.4%) and in patients who did not undergo transbronchial cryobiopsy (46.2%). EBUS-MFB alone yielded more diagnostic results compared to EBUS-TBNA. Transbronchial cryobiopsy was the sampling method with the highest percentage of diagnostic results in the cryobiopsy group (64.5%). Statistical analysis revealed a significant difference in diagnostic yield between EBUS-MFB and EBUS-TBNA (P<0.001), with EBUS-MFB showing a higher diagnostic yield overall. EBUS-MFB had a significantly higher diagnostic yield than EBUS-TBNA in benign cases, in patients diagnosed with sarcoidosis, but not in malignant disease. Conclusions: Our study suggests that combining EBUS-MFB with EBUS-TBNA can improve the diagnostic yield, particularly in benign cases and sarcoidosis. These findings support the potential superiority of adding EBUS-MFB over EBUS-TBNA alone and highlight the need for further randomized control trials to validate these results. The retrospective nature of this study and certain limitations, such as the lack of adequate longer-term follow-up, selection and operator biases, and the absence of rapid on-site evaluation (ROSE) in some cases, should be considered when interpreting the results. Nonetheless, this study contributes to the growing evidence for the utility of EBUS-MFB in improving the diagnostic yield of EBUS procedures in specific clinical scenarios.

Endobronchial ultrasound-guided cautery-assisted transbronchial mediastinal cryobiopsy in the diagnosis of fibrosing mediastinitis secondary to atypical sarcoidosis: a case report.

Background: Fibrosing mediastinitis (FM) secondary to atypical sarcoidosis (atypical presentation of sarcoidosis) is rarely reported at home and abroad. Its clinical manifestations represent a lack of specificity, and the initial diagnosis is frequently difficult. In particular, this case has multiple pulmonary nodules with mediastinal lymph node enlargement and bilateral pleural effusion, and pulmonary fibrosis still exists after treatment, which is inconsistent with any clinical stage of pulmonary sarcoidosis, further increasing the diagnostic difficulty. We retrospectively analyzed the clinical data of a case of FM secondary to atypical sarcoidosis diagnosed by endobronchial ultrasound-guided cautery-assisted transbronchial mediastinal cryobiopsy (EBUS-CA-TBMCB) in Chongqing University Fuling Hospital, to improve clinicians' attention to FM and understand that EBUS-CA-TBMCB remains an effective way of etiological diagnosis. Case Description: A 70-year-old man was hospitalized with cough and dyspnea for two months. After admission, through chest computed tomography (CT), ultrasound guided bilateral lung biopsy, left parietal pleural biopsy, and EBUS-CA-TBMCB, the final diagnosis was atypical sarcoidosis secondary FM. After taking glucocorticoid orally, the patient's condition improved significantly, and was discharged from the hospital. We continued following up outside the hospital, and the patient's condition was further improved. Conclusions: The diagnosis of FM is mainly based on typical imaging manifestations. When the contrast-enhanced chest CT finds localized or diffuse soft tissue density shadows around the mediastinum and pulmonary hilum with an irregular shape, with or without calcification, particular attention should be paid to exclude FM. EBUS-CA-TBMCB, as an improved minimally invasive method, can obtain enough tissue samples for pathological diagnosis, which may be the effective biopsy method for the etiology of FM to avoid missed diagnosis and misdiagnosis in the future.

Proposal for a standardized methodology for performing endobronchial ultrasound-guided mediastinal cryobiopsy: a four-step approach.

Endobronchial ultrasound (EBUS)-guided mediastinal cryobiopsy is a novel technique that increases the accuracy of diagnosing most pathologies that affect the mediastinum. Although EBUS-guided transbronchial needle aspiration (EBUS-TBNA) is the first choice in the diagnosis of mediastinal pathology, mediastinal cryobiopsy offers a larger and higher quality biopsy with minimal artifacts and no crushing when compared to conventional cytological samples obtained through EBUS-TBNA. It is particularly valuable in pathologies where EBUS-TBNA has diagnostic limitations, such as lymphoproliferative diseases, benign granulomatous conditions like sarcoidosis and silicosis, some rare infectious processes, metastases from rare non-pulmonary tumors, and in advanced stages of non-small cell lung cancer (NSCLC) where immunohistochemistry and molecular analysis are essential for personalized treatment. Therefore, mediastinal cryobiopsy seems to play a crucial role in these challenging scenarios. However, there is ongoing debate in the field of interventional pulmonology regarding the best approach for obtaining a mediastinal cryobiopsy. Some interventional pulmonologists use a high-frequency needle knife to create an incision in the tracheobronchial wall adjacent to the mediastinal lesion before inserting the cryoprobe, while others use a needle to create a pathway to the target area. There are also variations in the use of endoscopic or ultrasound imaging for guidance. In this article, we aim to review the current literature on different methods of performing mediastinal cryobiopsy and share our own clinical experience and methodology in a systematic way for its implementation in a safe, fast, and effective way.

Bronchoscopic deployment and implantation of Diffusing alpha-emitters Radiation Therapy into the lung and mediastinum for treatment of lung cancer: a pre-clinical safety and feasibility study.

Background: Radiotherapy is a standard treatment modality in cancer therapy, particularly for lung cancer. Diffusing alpha-emitters Radiation Therapy sources (hereafter, "Alpha DaRTs") are fixed with Ra-244 (half-life =3.6 days) that releases alpha-emitting atoms into the tumor tissue to an effective range of a few millimeters. Methods: The feasibility, usability, and safety of Alpha DaRTs deployment and implantation via bronchoscopy into the lung parenchyma and mediastinum in a big animal model of healthy swine was studied in two phases: (I) inert and (II) active Alpha DaRTs deployment. The Alpha DaRTs were inserted in both individual and cluster patterns based on a predefined plan. Swine health was monitored throughout the study. The usability of bronchoscopic deployment and implantation was evaluated using a user questionnaire. The movement and migration of the Alpha DaRTs were assessed. Necropsy was performed, and lungs were evaluated via gross pathology and histopathology. Results: A total of 158 Alpha DaRTs were inserted successfully in the lung parenchyma and mediastinum of five swine in two phases. It was possible to deliver and place the Alpha DaRTs in clusters of no more than 4 mm distance between the Alpha DaRTs. No adverse event or change in the health and general condition of animals was observed. Hematologic evaluation did not show any clinically significant abnormality related to the Alpha DaRTs. Histopathology demonstrated local mild inflammatory changes, minimal fibrosis, and dystrophic mineralization with giant cells. Minimal movement and no migration of Alpha DaRTs were observed. Conclusions: Bronchoscopic deployment of Alpha DaRTs in the lung parenchyma and mediastinum of the porcine animal is feasible, precise, and safe.

[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.

Metastatic Melanoma Causing Superior Vena Cava (SVC) Syndrome: A Case Report of a 65-Year-Old Male With a History of Multiple Myeloma and Melanoma.

A 65-year-old male with a history of multiple myeloma and melanoma presented to the hospital with shortness of breath and lightheadedness. He was subsequently diagnosed with mild superior vena cava (SVC) syndrome due to a metastatic melanoma mediastinal mass. While melanoma frequently metastasizes to the lungs, the occurrence of SVC syndrome resulting from metastatic melanoma is exceedingly rare compared to other malignancies like lung cancer. Consequently, data on the incidence or prevalence of SVC syndrome caused by metastatic melanoma are sparse and variable. This case particularly underscores the rarity of melanoma causing SVC syndrome, as evidenced by the oncology team's request to perform a second biopsy to confirm the diagnosis. This case also highlights the need for a tailored diagnostic and management approach, providing valuable insights into the diverse presentations of melanoma and enriching the medical literature on this subject.

Pulmonary endoscopy - central to an interventional pulmonology program.

INTRODUCTION: Pulmonary endoscopy occupies a central role in Interventional Pulmonology and is frequently the mainstay of diagnosis of respiratory disease, in particular lung malignancy. Older techniques such as rigid bronchoscopy maintain an important role in central airway obstruction. Renewed interest in the peripheral pulmonary nodule is driving major advances in technologies to increase the diagnostic accuracy and advance new potential endoscopic therapeutic options. AREAS COVERED: This paper describes the role of pulmonary endoscopy, in particular ultrasound in the diagnosis and staging of lung malignancy. We will explore the recent expansion of ultrasound to include endoscopic ultrasound - bronchoscopy (EUS-B) and combined ultrasound (CUS) techniques. We will discuss in detail the advances in the workup of the peripheral pulmonary nodule.We performed a non-systematic, narrative review of the literature to summarize the evidence regarding the indications, diagnostic yield, and safety of current bronchoscopic sampling techniques. EXPERT OPINION: EBUS/EUS-B has revolutionized the diagnosis and staging of thoracic malignancy resulting in more accurate assessment of the mediastinum compared to mediastinoscopy alone, thus reducing the rate of futile thoracotomies. Although major advances in the assessment of the peripheral pulmonary nodule have been made, the role of endoscopy in this area requires further clarification and investigation.

Safety and feasibility of oesophageal ultrasound for the work-up of thoracic malignancy in patients with respiratory impairment.

Biopsying lung tumours with endobronchial access in patients with respiratory impairment is challenging. However, fine needle aspiration with the endobronchial ultrasound-endoscope via the oesophagus (EUS-B-FNA) makes it possible to obtain tissue samples without entering the airways. Safety of EUS-B-FNA in these patients has not earlier been investigated prospectively. Therefore, this study aimed at assessing feasibility and safety of EUS-B-FNA from centrally located tumours suspected of thoracic malignancy in patients with respiratory insufficiency. The study is a prospective observational study. Patients with indication of EUS-B-FNA of centrally located tumours and respiratory impairment defined as modified Medical Research Council (mMRC) dyspnoea scale score of ≥3, saturation ≤90% or need of continuous oxygen supply were included prospectively in three centres. Any adverse events (AEs) were recorded during procedure and 1-hour recovery. AEs were defined as hypoxemia (saturation <90% or need for increased oxygen supply) or any kind of events needing intervention. Late procedure-related events were recorded during 30-day follow-up. Between April 1, 2020 and January 30, 2021, 16 patients were included. No severe AEs (SAEs) occurred, but AEs were seen in 50% (n=8) and 13% (n=2) of the patients during procedure and recovery respectively. AEs included hypoxemia corrected with increased oxygen supply and in two cases reversal of sedation. Late procedure-related events were seen in 13% (n=2) and included prolonged need of oxygen and one infection treated with oral antibiotics. In this cohort, EUS-B-FNA of centrally located tumours was safe and feasible in patients with respiratory impairment, when examined in the bronchoscopy suite. A variety of mostly mild and manageable complications may occur, a few even up to 30 days post-procedure.

Transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) for left adrenal gland (LAG) sampling: A report of three cases with a review of the literature.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard-of-care modality for evaluating mediastinal lymph nodes and masses. The EBUS bronchoscope may also be introduced through the oesophageal route to perform sampling of accessible lesions, a technique described as transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA). Because of the central oesophageal approach, EUS-B-FNA provides easy access to the left para-tracheal, subcarinal and para-oesophageal lymph nodes. In addition, the left adrenal gland (LAG) can also be imaged and sampled during the EUS-B-FNA procedure. In patients with suspected lung cancer, accurate staging is essential. Adrenal metastasis is relatively common and may often be a solitary metastatic site. We describe three cases where EUS-B-FNA was performed to safely sample the enlarged LAG in suspected lung cancer. We also review the literature on the performance characteristics of EUS-B-FNA for LAG aspiration.

First Asia-Pacific experience of trans-bronchial core biopsy with a Franseen needle.

Background: Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is the standard for evaluating mediastinal and hilar lesions. EBUS-TBNA is limited by small volume of material obtained for immunohistochemistry (IHC) and ancillary studies important for oncological therapies. The Franseen AcquireTM needle is designed for EBUS-transbronchial needle core biopsy (TBNB) allowing larger core sizes with evidence in gastroenterology literature but little in pulmonology. This study reports the first Asia-Pacific experience of EBUS-TBNB and adequacy of samples for diagnosis and ancillary studies. Methods: A retrospective cohort study of EBUS-TBNB at the Royal Adelaide Hospital was conducted between December 2019 and May 2021. Diagnostic rate, adequacy for ancillary studies and complications were evaluated. Samples were flushed into formalin for histological processing with no rapid on-site cytological evaluation (ROSE). For suspected lymphoma, samples were flushed into HANKS for flow cytometry. Cases performed with the Olympus VizishotTM during the same 18-month were similarly analysed. Results: One hundred and eighty-nine patients were sampled with the AcquireTM needle. Diagnostic rate was 174/189 (92.1%). Where reported [146/189 (77.2%)], average core aggregate sample size was 13.4 mm × 10.7 mm × 1.7 mm. For non-small cell lung cancer (NSCLC) cases, 45/49 (91.8%) had adequate tissue for programmed cell death-ligand 1 (PD-L1). 32/35 (91.4%) adenocarcinoma cases had sufficient tissue for ancillary studies. There was one false negative malignant lymph node at the first AcquireTM procedure. There were no major complications. One hundred and one patients were sampled with the VizishotTM needle. Diagnostic rate was 86/101 (85.1%) with only 25/101 (24.8%) having reported tissue cores (P<0.0001 of VizishotTM) with the remaining samples processed via cell block. Conclusions: AcquireTM EBUS-TBNB diagnostic rate is comparable to historical data with >90% of cases having sufficient core material for ancillary studies. There appears to be a role for the AcquireTM alongside the standard of care for the work up of lymphadenopathy and particularly for lung cancer.

Diagnostic value of endobronchial ultrasound elastography in differentiating between benign and malignant hilar and mediastinal lymph nodes: a retrospective study.

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a first-line approach for diagnosing hilar and mediastinal lymph node metastasis. Endobronchial ultrasound (EBUS) elastography is an imaging technique for describing the elasticity of intrathoracic lesions. However, the reported accuracy of EBUS elastography needs to be improved. In this study, we aimed to explore the diagnostic value of EBUS elastography for differentiating between benign and malignant hilar and mediastinal lymph nodes. Methods: We conducted a single-center, retrospective study enrolling consecutive patients who received EBUS elastography followed by EBUS-TBNA at the Chinese PLA General Hospital from October 2015 to October 2022. The pathological results of EBUS-TBNA confirmed by 6-month follow-up were used as the gold standard. The ultrasound elastography parameters of lymph nodes included strain rate, stiff area ratio, and elasticity score, along with the conventional ultrasound characteristics such as short axis diameter, shape, margin, echogenicity distribution and intensity, and blood flow. The diagnostic performance of these parameters was compared, and conjointly analyzed using multivariate logistic regression. Bootstrapping resampling was applied for internal validation of the regression model. Results: A total of 83 patients were enrolled with an average age of 57 years, and 66.3% of patients were male. In total, 131 lymph nodes were punctured, among which 79 (60.3%) were malignant. All the conventional ultrasound characteristics were significantly different between benign and malignant lymph nodes. All the ultrasound elastography parameters of malignant lymph nodes were markedly higher than those of benign lymph nodes. Multivariate logistic regression analysis showed that the margin, echogenicity intensity, blood flow, short axis diameter, and stiff area ratio were the main factors affecting the lymph node property. The diagnostic accuracy, sensitivity, and specificity were 91.8% [95% confidence interval (CI): 85.4-96.0%], 94.4% (95% CI: 86.4-98.5%), and 88.0% (95% CI: 75.7-95.5%), respectively. Bootstrap resampling validation showed a concordance index (C-index) of 0.949. The calibration plot indicated good agreement between the predicted and observed results. Conclusions: EBUS elastography is a promising approach for differentiating between benign and malignant lymph nodes. The combination of conventional EBUS and elastography can improve diagnostic efficacy, provide reliable complementary information, and guide the implementation of EBUS-TBNA more accurately.

A Case of Vanishing Bronchus Syndrome in a Non-lung Transplant Patient.

Vanishing bronchus syndrome (VBS) is the most severe form of bronchial stenosis. It has been described as a complication following a lung transplant (LT). We present a case of VBS in a patient with non-Hodgkin lymphoma in remission status post chemotherapy and radiation therapy and no history of a lung transplant.

Cone-beam computed tomography-guided endobronchial ultrasound using an ultrathin bronchoscope for diagnosis of peripheral pulmonary lesions: a prospective pilot study.

Background: Multimodal transbronchial biopsy (TBB) may have improved diagnostic yield for peripheral pulmonary lesions suspected as lung cancer. Radial endobronchial ultrasound (R-EBUS) provides real-time imaging and confirmation of the location of the lesions. Cone-beam computed tomography (CBCT) can confirm that the forceps tip has reached the lesion before biopsy. Methods: Patients with peripheral pulmonary lesions and a positive computed tomography (CT) bronchus sign (based on slice thickness of 1 mm) were prospectively enrolled. An ultrathin bronchoscope (UTB) and R-EBUS probe were advanced to the target bronchus. Thereafter, forceps were advanced, and CBCT was performed. R-EBUS was performed for re-navigation, if possible. The obtained EBUS and CBCT images were classified into "within" (type 1), "adjacent to" (type 2), or "far from" (type 3), based on the probe or forceps tip. Results: For 20 lesions, the diagnostic yield was 85%. The primary EBUS images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. The primary CBCT images were of types 1, 2, and 3 in 12, 6, and 2 cases, respectively. Primary EBUS and CBCT image types were equivalent in 14 cases. Of the 12 cases with type 1 primary EBUS image, 9 cases had a type 1 primary CBCT image, while 3 cases exhibited positional misalignment of the forceps tip. Re-navigation was required in 8 cases with types 2 and 3 primary CBCT images. Conclusions: CBCT-guided TBB using an UTB and EBUS may enable real-time positioning guidance and better re-navigation in the diagnosis of peripheral pulmonary lesions.