Role of EBUS TBNA in staging of lung cancer: A clinician's perspective

The treatment of non-small cell lung cancer (NSCLC) includes surgical resection with curative intent in early-stage disease and chemoradiation in the advanced stage disease. Therefore, an accurate preoperative mediastinal lymph node staging is required not only to offer the appropriate treatment but also to avoid unnecessary invasive procedures including thoracotomy. The mediastinal lymph nodes can be sampled using several techniques including mediastinoscopy, surgery (open or video-assisted thoracoscopic surgery), endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA), or endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA). Currently, EBUS-TBNA/EUS-FNA is the preferred modality for sampling mediastinal lymph nodes because of its minimally invasive nature and high diagnostic yield. In this review, we discuss the utility of endosonographic procedures in mediastinal lymph node staging of NSCLC

Xpert MTB/RIF Ultra versus Xpert MTB/RIF for diagnosis of tuberculous pleural effusion: A systematic review and comparative meta-analysis.

ObjectiveWe compared diagnostic accuracy of pleural fluid Xpert MTB/RIF (Xpert) and Xpert MTB/RIF Ultra (Ultra) assays for diagnosing tuberculous pleural effusion (TPE), through systematic review and comparative meta-analysis.MethodsWe searched PubMed and Embase databases for publications reporting diagnostic accuracy of Xpert or Ultra for TPE. We used bivariate random-effects modeling to summarize diagnostic accuracy information from individual studies using either mycobacterial culture or composite criteria as reference standard. We performed meta-regression through hierarchical summary receiver operating characteristic (HSROC) modeling to evaluate comparative performance of the two tests from studies reporting diagnostic accuracy of both in the same study population.ResultsWe retrieved 1097 publications, and included 74 for review. Summary estimates for sensitivity and specificity for Xpert were 0.52 (95% CI 0.43-0.60, I2 82.1%) and 0.99 (95% CI 0.97-0.99, I2 85.1%), respectively, using culture-based reference standard; and 0.21 (95% CI 0.17-0.26, I2 81.5%) and 1.00 (95% CI 0.99-1.00, I2 37.6%), respectively, using composite reference standard. Summary estimates for sensitivity and specificity for Ultra were 0.68 (95% CI 0.55-0.79, I2 80.0%) and 0.97 (95% CI 0.97-0.99, I2 92.1%), respectively, using culture-based reference standard; and 0.47 (95% CI 0.40-0.55, I2 64.1%) and 0.98 (95% CI 0.95-0.99, I2 54.8%), respectively, using composite reference standard. HSROC meta-regression yielded relative diagnostic odds ratio of 1.28 (95% CI 0.65-2.50) and 1.80 (95% CI 0.41-7.84) respectively in favor of Ultra, using culture and composite criteria as reference standard.ConclusionUltra provides superior diagnostic accuracy over Xpert for diagnosing TPE, mainly because of its higher sensitivity

Utility of endobronchial ultrasound-guided transbronchial needle aspiration in HIV-infected patients with undiagnosed intrathoracic lymphadenopathy

Background: Intrathoracic lymphadenopathy is a common problem in people living with human immunodeficiency virus (PLHIV). There is, however, limited literature on the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in these patients. Herein, we describe our experience with EBUS-TBNA in PLHIV. Materials and Methods: This is a retrospective study of all PLHIV who underwent EBUS-TBNA for the evaluation of intrathoracic lymphadenopathy. We also perform a systematic review of the English literature for studies reporting the yield of EBUS-TBNA in PLHIV. Results: During the study, 1733 EBUS procedures were performed. Among them, 22 (1.3%) were performed in PLHIV. The median age of the individuals (18.2% women) was 46 years. The median CD4 count was 144 cells/mm3. The common lymph node stations involved were station 7, 4R, and 11 L. On endosonographic examination, heterogeneous appearance and coagulation necrosis sign were observed in 14 (63.6%) and 11 (50%) individuals, respectively. EBUS-TBNA was diagnostic in 17 (77.3%) individuals, with tuberculosis being the most common diagnosis (68.2%). There were no major complications related to the procedure. Our systematic review yielded two studies describing the use of EBUS-TBNA in PLHIV. The mean diagnostic yield of EBUS-TBNA was 71% (95% confidence interval: 56–84). Conclusions: EBUS-TBNA is a safe and useful procedure in the evaluation of intrathoracic lymphadenopathy in PLHIV

Patient characteristics and outcome of end-stage lung diseases referred for lung transplantation in North India

Objective: Most countries worldwide have transplant registries for patients with end-stage lung diseases (ESLD) requiring lung transplantation. There is no such lung transplant registry in India. Herein, we describe the demographic profile and clinical outcomes among patients referred for lung transplantation at a tertiary care center in North India. Materials and Methods: This was a prospective, observational study of consecutive patients with chronic respiratory diseases who were referred for lung transplantation between July 2013 and December 2016. Patients were evaluated using standard criteria for listing for lung transplantation. Results: Of the 176 patients assessed for lung transplantation, 167 were included in the study. The mean (standard deviation [SD]) age of the study population (52.1% females) was 53.2 (14.7) years. Interstitial lung disease (ILD, 46.7%), chronic obstructive pulmonary disease (COPD, 25.7%), and bronchiectasis (10.2%) were the most common diseases in this population. The median (interquartile range, IQR) survival was worst for patients with bronchiolitis (78.5 [9–208] days) and idiopathic pulmonary fibrosis (IPF, 93.5 [19–239] days) and best for patients with idiopathic pulmonary arterial hypertension (757 [340–876] days) and COPD (578 [184–763] days). Only 13% of the patients expressed willingness for lung transplantation. Patients willing for transplantation died earlier than those unwilling (median [IQR], 102 [36-224] days vs. 310 [41-713] days, P < 0.001). Conclusion: ILD was the most common cause of ESLD in patients referred for lung transplantation. The waitlist mortality was highest for patients with bronchiolitis and IPF. Despite having ESLD, very few patients were willing for lung transplantation. Patients willing for lung transplantation died earlier than those who were unwilling

Endobronchial ultrasound-guided transbronchial needle aspiration in the economically disadvantaged: A retrospective analysis of 1582 individuals

Background: Whether the indications and diagnostic yield of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) vary according to the socioeconomic status of the patient, remains unknown. Herein, we evaluate this aspect in participants who underwent EBUS-TBNA. Materials and Methods: This is a retrospective analysis of all participants who underwent EBUS-TBNA for the evaluation of intrathoracic lymphadenopathy. We evaluated the indications and outcome of EBUS-TBNA in participants with and without economic disadvantage (issuance of a below poverty line card by the government). Results: Of the EUBUS procedures performed on 1582 participants (mean [standard deviation] age, 46.1 [15.7] years; 593 [37.5%] women) performed during the study, 61 (3.9%) were done in the economically disadvantaged (ED) group. Individuals in the ED group were younger (median age, 40 vs. 46 years; P = 0.002) and more likely to have tuberculosis (42.6% vs. 26.2%, P = 0.005) or malignancy (39.3% vs. 26.9%, P = 0.032) as a presumptive diagnosis. The overall diagnostic yield of EBUS was 63% and was significantly lower in the ED group (49.2% vs. 63.5%, P = 0.023). Previously used EBUS-TBNA needles were more commonly employed in the ED participants (62.7% vs. 20.1%, P < 0.001). On multivariate logistic regression analysis, younger age, larger size, and number of nodes sampled, and the use of new (versus reused) needles were independent predictors of higher diagnostic yield. There was no difference in the complication rate between the two groups. Conclusion: The diagnostic yield of EBUS was significantly lower in the ED participants, which is due to the differences in the clinical and procedural characteristics

Spectrum of interstitial lung diseases at a tertiary center in a developing country: A study of 803 subjects.

The spectrum of interstitial lung diseases (ILDs) have mainly been reported from the developed countries; data from developing countries is sparse and conflicting. The aim of this study is to describe the distribution of various ILDs from a developing country.This is an analysis of prospectively collected clinical, radiological and histological data of consecutive subjects (age >12 years) with ILDs from a single tertiary care medical center. The diagnosis of the specific subtype of ILD was made according to standard criteria for various ILDs.A total of 803 subjects (mean age, 50.6 years; 50.2% women) were enrolled between March 2015 to February 2017 of which 566 (70.5%) were diagnosed during the study period (incident cases). Sarcoidosis (42.2%), idiopathic pulmonary fibrosis (IPF, 21.2%), connective tissue disease (CTD)-related ILDs (12.7%), hypersensitivity pneumonitis (10.7%), and non-IPF idiopathic interstitial pneumonias (9.2%) were the most common ILDs. The spectrum of ILDs was not significantly different (p = 0.87) between incident and prevalent cases. A histopathological specimen was obtained in 49.9% of the subjects yielding a histologically confirmed diagnosis in 40.6%. A diagnostic procedure was not performed in 402 subjects; the most common reasons were presence of definite usual interstitial pneumonia pattern on high resolution computed tomography and patients' unwillingness to undergo the procedure.Sarcoidosis, IPF and CTD-ILDs were the most common ILDs seen at a tertiary center in northern India similar to the spectrum reported from developed countries. More studies are required from developing countries to ascertain the spectrum of ILDs in different geographic locales