Radial probe endobronchial ultrasound assisted conventional transbronchial needle aspiration in the diagnosis of solitary peribronchial pulmonary lesion located in the segmental bronchi

Background: The diagnosis of peribronchial pulmonary lesions located in the tertiary bronchi, also known as segmental bronchi, as well as, the 4th order and 5th order segmental bronchi is very difficult. Histopathological specimens cannot be easily obtained by endobronchial biopsies (EBBX) due to the patent but small segmental bronchial lumen. The aim of the present study was to evaluate the diagnostic accuracy and safety of the novel technique with radial probe endobronchial ultrasound (R-EBUS) assisted conventional transbronchial needle aspiration (C-TBNA) in the diagnosis of solitary peribronchial pulmonary lesions located in segmental bronchi from 3th to 5th order. Methods: From December 2014 to December 2015, 16 patients with solitary peribronchial pulmonary lesions in the segmental bronchi from 3th to 5th order confirmed by computed tomography (CT) were enrolled. The lesions were located using radial probe endobronchial ultrasound (R-EBUS) to determine the sites of conventional transbronchial needle aspiration (C-TBNA), then, histopathological specimens were obtained using the technique of C-TBNA. The final pathological diagnosis was made based on the findings from the surgical specimens. Statistical analyses were performed for specimen results and complications. Results: On pathological evaluation, 14 of the 16 specimens were malignant, including 8 adenocarcinomas, 4 squamous cell carcinomas, and 2 small cell carcinomas, while 2 were non-malignant diseases. The diagnostic accuracy rate, sensitivity and missed diagnosis rates were 87.5%, 87.5% and 12.5%, respectively. When Combined the results of cytology with histologic samples obtained from C-TBNA the total diagnostic accuracy rate, sensitivity and missed diagnosis rate were 93.75%, 93.75% and 6.25%, respectively. There were 2 cases of bleeding complications \u3e5 mL after C-TBNA, and both were resolved with endobronchial management. Conclusions: The combination of R-EBUS with C-TBNA was advantageous and safe for the diagnosis of solitary peribronchial pulmonary lesions located in the segmental bronchi. However, possible bleeding complications should be anticipated with needle aspiration. Further verification of this combined application should be investigated in larger clinical trials

Endoscopic Technologies for Peripheral Pulmonary Lesions: From Diagnosis to Therapy

Peripheral pulmonary lesions (PPLs) are frequent incidental findings in subjects when performing chest radiographs or chest computed tomography (CT) scans. When a PPL is identified, it is necessary to proceed with a risk stratification based on the patient profile and the characteristics found on chest CT. In order to proceed with a diagnostic procedure, the first-line examination is often a bronchoscopy with tissue sampling. Many guidance technologies have recently been developed to facilitate PPLs sampling. Through bronchoscopy, it is currently possible to ascertain the PPL’s benign or malignant nature, delaying the therapy’s second phase with radical, supportive, or palliative intent. In this review, we describe all the new tools available: from the innovation of bronchoscopic instrumentation (e.g., ultrathin bronchoscopy and robotic bronchoscopy) to the advances in navigation technology (e.g., radial-probe endobronchial ultrasound, virtual navigation, electromagnetic navigation, shape-sensing navigation, cone-beam computed tomography). In addition, we summarize all the PPLs ablation techniques currently under experimentation. Interventional pulmonology may be a discipline aiming at adopting increasingly innovative and disruptive technologies

Endobronchial Ultrasound-Guided Transbronchial Biopsy Using Novel Thin Bronchoscope for Diagnosis of Peripheral Pulmonary Lesions

Background:The aim of this study was to evaluate the diagnostic utility of endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) using a novel 3.4-mm thin bronchoscope and a 1.4-mm ultrasonic probe for peripheral pulmonary lesions.Methods:A total of 86 patients with suspected peripheral lesions were included in this prospective study. EBUS-TBBs were performed using a prototype 3.4-mm thin bronchoscope and a 1.4-mm radial ultrasonic probe under fluoroscopic guidance.Results:Twelve patients with endobronchial lesions within the segmental bronchi and three patients who did not return to follow-up were excluded from this analysis. Thus, a total of 71 patients with peripheral pulmonary lesions (mean size, 31.2 ± 12.7 mm) were included in the final analysis. The mean bronchus level reached with the thin bronchoscope was 4.6 generations. Diagnostic histologic specimens were obtained in 49 of 71 patients (69%:80% for malignant lesions and 52% for benign lesions). A definitive diagnosis of malignancy for lesions ≥20 mm and lesions <20 mm was made in 82% (31 of 38) and 67% (four of six), respectively. There were no significant complications.Conclusion:The EBUS-TBB using a 3.4-mm thin bronchoscope and a 1.4-mm radial probe is feasible, accurate, and safe for the diagnosis of peripheral pulmonary lesions

Interventional Bronchoscopy:State-of-the-Art Review

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases

Recent advances in diagnostic technologies in lung cancer

The increase in lung cancer incidence of Korea has been dampened since 2000; however, increased human lifespan, interest in health care and the widespread implementation of health examinations have resulted in a considerable rise in detection of small lesions that need to be differentiated from lung cancer. Detection of lung cancer at an early stage rather than at a symptomatic advanced stage is also increasing, suggesting that there are increasing diagnostic demands for small peripheral lung lesions. The development of new molecular diagnostics, including next generation sequencing, companion diagnostics that accompany development of new anti-cancer drugs, and re-biopsy for application of new therapeutic modality accelerate the development of lung cancer diagnostics. In this review, we extensively describe the current available diagnostic tools in lung cancer.ope

Proposed quality indicators and recommended standard reporting items in performance of EBUS bronchoscopy: An official world association for bronchology and interventional pulmonology expert panel consensus statement

Background: Since their introduction, both linear and radial endobronchial ultrasound (EBUS) have become an integral component of the practice of Pulmonology and Thoracic Oncology. The quality of health care can be measured by comparing the performance of an individual or a health service with an ideal threshold or benchmark. The taskforce sought to evaluate quality indicators in EBUS bronchoscopy based on clinical relevance/importance and on the basis that observed significant variation in outcomes indicates potential for improvement in health care outcomes. Methods: A comprehensive literature review informed the composition of a comprehensive list of candidate quality indicators in EBUS. A multiple-round modified Delphi consensus process was subsequently performed with the aim of reaching consensus over a final list of quality indicators and performance targets for these indicators. Standard reporting items were developed, with a strong preference for items where evidence demonstrates a relationship with quality indicator outcomes. Results: Twelve quality Indicators are proposed, with performance targets supported by evidence from the literature. Standardized reporting items for both radial and linear EBUS are recommended, with evidence supporting their utility in assessing procedural outcomes presented. Conclusion: This statement is intended to provide a framework for individual proceduralists to assess the quality of EBUS they provide their patients through the identification of clinically relevant, feasible quality measures. Emphasis is placed on outcome measures, with a preference for consistent terminology to allow communication and benchmarking between centres

The peripheral pulmonary lesion - bronchoscopic techniques to improve diagnosis

Lung cancer is a leading cause of cancer-related deaths worldwide. This is no different in Australia where it is the main cause of cancer-related mortality, and the fifth most commonly cancer diagnosed in Australians. The recent National Lung Screening Trial demonstrated an improvement in mortality when patients deemed high risk for lung cancer underwent annual screening with low dose computed tomography imaging. Nearly 25% of participants were shown to have imaging suspicious for lung cancer. In light of these results, and with the possibility of increased uptake of screening, it is very likely that the incidence of identified peripheral pulmonary lesions (PPL) will only continue to rise. In evaluating PPLs, standard bronchoscopic investigation involves obtaining transbronchial forceps biopsies (TB-FB). However TBFB has variable diagnostic sensitivity, influenced by factors such as lesion size and position. The introduction of radial endobronchial ultrasound (RP-EBUS) has helped improve diagnostic yields further. Ultrasound images obtained by the miniprobe reflect the underlying structure of the peripheral lesion being examined and RPEBUS is now a well-established technique in the evaluation of PPLs. The overall aim of this thesis was to examine innovative bronchoscopic techniques which could further aid diagnostic yield in investigating PPLs. Methods (i) Radial Endobronchial Ultrasound Greyscale Texture Analysis Using Whole-Lesion Analysis Can Characterise Benign and Malignant Lesions without Region-of-Interest Selection Bias Custom software was developed to analyse RP-EBUS images based on first and second order greyscale texture features. Unconstrained ROIs were mapped onto lesions. Features from expert and nonexpert defined ROIs were compared, as were results of image analysis to tissue histology. (ii) Radial Endobronchial Ultrasound with Transbronchial Cryobiopsy versus Radial EBUS alone for the Diagnosis of Peripheral Pulmonary Lesions Prospective, single-centre randomised controlled trials of patients with PPLs. Patients were randomised to receive either one transbronchial cryobiopsy (TB-CB) sample, or 5 TB-FB samples. Results (i) Greyscale texture analysis of RP-EBUS images using unconstrained regions of interest (ROIs) demonstrated 5 features which were significantly different between benign and malignant lesions. Highest positive predictive values were associated with maximal and range of pixel intensities. No significant differences were seen between expert and non-expert-defined ROIs. (ii) 28 lesions were evaluated with overall diagnostic yield 76.7%. Diagnostic yields of TB-CB and TB-FB were 91.7% and 68.8% respectively (p=0.14). Median size of TB-CB was 7.0mm compared to 2.55mm (p<0.0001). There were no major complications with either technique. Conclusion Timely diagnosis of PPLs is critical to enable disease staging and to guide initiation of appropriate definitive treatment. Greyscale image analysis and texture analysis using the whole RP-EBUS image as a ROI can assist in distinguishing between malignant and benign lesions. This is a potentially valuable additional clinical tool in the diagnosis of peripheral lesions. However further validation is required. Cryotherapy has provided an alternative method of obtaining transbronchial biopsies (TBBs). Not only does it provide significantly larger biopsy sample, which is advantageous for further immunohistochemical and molecular analysis, but it also could be superior in diagnosing lesions which are not easily accessible by TB-FB.Thesis (MPhil) -- University of Adelaide, Adelaide Medical School, 202

Advancements in Endobronchial Ultrasound

Endobronchial ultrasound (EBUS) is a diagnostic procedure that allows for the diagnosis and staging of lung cancer and other lung-related diseases such as tuberculosis, sarcoidosis, and sarcoma. The radial probe for the EBUS device was first introduced to visualize the inside of the lungs and airway structures, and identify the extent of tumor invasion in the airway and surrounding lymph nodes. The EBUS transbronchial needle aspiration (TBNA) is an acceptable first test in the pretreatment staging of lung cancer to appropriately understand the prognosis for curative therapies. In the future, EBUS is likely to become widely available and accessible to patients, given its low cost and minimal risk of complications compared to other diagnostic and therapeutic procedures. The development of more advanced EBUS technologies, such as radial EBUS, virtual bronchoscopy, fluorescence-guided bronchoscopy, and artificial intelligence will allow for improved visualization of the lungs and adequate lymph node yield, leading to more accurate diagnoses and better treatment outcomes. In conclusion, the future of EBUS modalities combined with the additions of bronchoscopic advances is expected to further improve the accuracy and precision of the procedure while limiting morbidity, and complications, and improving clinical workflow availability in the outpatient setting