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EDITORIAL
Year : 2013  |  Volume : 9  |  Issue : 4  |  Page : 549-551

Endobronchial ultrasound-guided transbronchial needle aspiration: The standard of care for evaluation of mediastinal and hilar lymphadenopathy


1 Institute of Pulmonology, Medical Research and Development; Department of Lung Care and Sleep Center, Fortis Hiranandani Hospital, Vashi, India
2 Institute of Pulmonology, Medical Research and Development; Department of Lung Care and Sleep Center, Fortis Hiranandani Hospital, Vashi; Department of Respiratory Medicine, Dr. Balabhai Nanavati Hospital and Lilavati Hospital, Mumbai, Maharashtra, India

Date of Web Publication11-Feb-2014

Correspondence Address:
Prashant N Chhajed
Institute of Pulmonology, Medical Research and Development, B/24, Datta Apartments, Ramkrishna Mission Marg, 15th Road, Khar West, Mumbai - 400 052, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.126430

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How to cite this article:
Vaidya PJ, Kate AH, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: The standard of care for evaluation of mediastinal and hilar lymphadenopathy. J Can Res Ther 2013;9:549-51

How to cite this URL:
Vaidya PJ, Kate AH, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: The standard of care for evaluation of mediastinal and hilar lymphadenopathy. J Can Res Ther [serial online] 2013 [cited 2020 Jun 1];9:549-51. Available from: http://www.cancerjournal.net/text.asp?2013/9/4/549/126430

Mediastinal lymphadenopathy is a common clinical problem. The common causes of mediastinal and hilar lymphadenopathy include infection, neoplasia, granulomatous disease, and reactive hyperplasia. Sometimes, it can be difficult to treat, particularly in tuberculosis (TB)-endemic countries, where a coexistence of TB and malignancy is known to exist. In a TB-endemic country, both thoracic and extra-thoracic malignancies with mediastinal lymphadenopathy can be metastatic, tuberculous or rarely a sarcoid reaction to the malignancy. Although various techniques are available for obtaining pathology specimens from the mediastinal lymph nodes, including conventional bronchoscopic transbronchial needle aspiration (TBNA), transesophageal ultrasonography-guided needle aspiration, computed tomography (CT)-guided transthoracic needle aspiration, and mediastinoscopy, there are limitations to these techniques, which include low yield, poor access, need for general anesthesia or complications. However, with the invention of real-time endobronchial ultrasound-guided mediastinal lymph node TBNA, it is possible to overcome these limitations. The endobronchial ultrasound (EBUS) is a technique that uses an ultrasound along with a bronchoscope to visualize the airway wall and the structures adjacent to it. Real-time EBUS-guided TBNA of the mediastinal and hilar lymph nodes is now becoming a standard of care that is safe and has a good diagnostic yield. [1] The sensitivity, specificity, and accuracy of the convex probe EBUS-guided TBNA in the diagnosis of mediastinal and hilar adenopathy is 95.7, 100, and 97.1%, respectively. [1] The procedure is safe, with a low-risk of complications. EBUS TBNA has also been shown to have a good diagnostic yield in hilar lymphadenopathy and in conventional TBNA-negative mediastinal lymphadenopathy. [2] A recent study in the Journal reported that EBUS-TBNA is a sensitive, specific, minimally invasive, and safe procedure for the diagnosis of mediastinal and hilar metastases from extrapulmonary malignancy in a TB-endemic country. [3] In 40 patients with proven or suspected metastasis of unknown origin, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of EBUS-TBNA, based on the number of patients, were 90.0, 100, 100, 90.9, and 95.0%, respectively. [3] The association between a larger lymph node size on EBUS and malignancy of the lymph node sample on pathological examination was statistically significant (P = 0.018). [3] In addition, the authors report that fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) had a low PPV (66.6%) in patients with metastasis from an extrathoracic malignancy. [3]

Impact of endobronchial ultrasound on lung cancer and extrapulmonary malignancy

Lung cancer is the most common cause of cancer deaths in males in the world, and is now emerging as number one in females, in the world, surpassing breast cancer. Conventional TBNA as well as EBUS-TBNA play a role in safely diagnosing and staging lung cancer. [4] Accurate staging of the mediastinum in lung cancer is essential for optimizing the treatment strategies. In the diagnosis of patients with a lung mass and hilar or mediastinal lymph nodes (N1or N2), it is possible that patients are unnecessarily having biopsies of the primary lung cancer, when sampling of the nodes will give both the tissue diagnosis and staging. [5] With expanding the use of EBUS TBNA, a new guideline for its initial application in such patients can reduce the overall number of procedures. [5] Compared to CT and PET, EBUS-TBNA has a high sensitivity as well as specificity for mediastinal and hilar lymph node staging in patients with lung cancer. [6] Endobronchial ultrasound-guided transbronchial needle aspiration can accurately sample even small mediastinal nodes, thus avoiding unnecessary surgical exploration in one out of six patients who have no computed tomography evidence of mediastinal disease. [6] Potentially operable patients with no signs of mediastinal involvement on computed tomography may benefit from presurgical endobronchial ultrasound-guided transbronchial needle aspiration and staging. [7] EBUS-TBNA enables the sampling of histological cores, which can be used for genetic analysis. [8] In a study by Nakajima et al., DNA was extracted from the paraffin-embedded samples, and the epidermal growth factor receptor (EGFR) mutation was analyzed from the same, by direct sequencing. [8] When EBUS-TBNA is performed, it can be expected to yield sufficient tissue for sequential molecular analysis like EGFR, Kirsten rat sarcoma (Kras) mutation, and anaplastic lymphoma kinase (ALK) gene rearrangement in a majority of patients. [9] In an era of targeted therapy for lung adenocarcinoma, EBUS-TBNA is effective in clinical practice for complete diagnosis, staging, and treatment planning. [9] A multimodality evaluation by EBUS-TBNA can be successful in the diagnosis of de novo mediastinal lymphomas and is ideally suited in distinguishing lymphoma relapse from alternative pathologies. [10]

Impact of endobronchial ultrasound-guided transbronchial needle aspiration on sarcoidosis

is a systemic granulomatous disease of unknown etiology. The diagnosis of sarcoidosis is established when there is a compatible clinical/radiological picture, together with pathological evidence of noncaseating epithelioid cell granulomas. Sarcoidosis occurs throughout the world, in all races, with an average incidence of 16.5 per 100,000 in men and 19 per 100,000 in women. Sarcoidosis is less commonly reported in South America, Spain, India, Canada, and the Philippines. The differing incidence across the world may be at least partially attributable to the lack of screening/diagnostic programs in certain regions of the world, and the overshadowing presence of other granulomatous diseases, such as TB, which may interfere with the diagnosis of sarcoidosis, where they are prevalent.

Endobronchial ultrasound-guided transbronchial needle aspiration has been reported to be an accurate and safe method to confirm a pathological diagnosis of sarcoidosis. In a study by Hong et al., EBUS-TBNA was reported as the most sensitive method for diagnosing stage I and stage II sarcoidosis compared to the other conventional bronchoscopic procedures. [11] EBUS-TBNA has been recommended to be considered first for the histopathological diagnosis of stage I and stage II sarcoidosis. [11] In a study by Oki et al., the diagnostic yield of EBUS-TBNA for stage I and stage II sarcoidosis was found to be higher than that for transbronchial lung biopsy. [12] Endobronchial ultrasound-guided transbronchial needle aspiration has a high diagnostic value in sarcoidosis if the obtained histological specimen is indicative of a noncaseating epithelioid-cell granuloma. The cytological evaluation of the EBUS-TBNA specimens has a higher sensitivity than histological evaluation alone, for intrathoracic lymphadenopathy due to sarcoidosis. [13] In several studies, the sensitivity of EBUS-TBNA alone has been reported to be consistently near 90%. [11],[12],[13],[14],[15],[16],[17]

Impact of endobronchial ultrasound-guided transbronchial needle aspiration on the diagnosis of tuberculosis

Mediastinal and hilar lymphadenopathy are known phenomena in the pathogenesis of TB. In the present era where the incidence of drug resistance TB is on the rise, it becomes more important to obtain pathological as well as microbiological evidence to improve the management of TB. Endobronchial ultrasound-guided transbronchial needle aspiration has a high diagnostic yield in the investigation of suspected intrathoracic TB by means of aspiration of the intrathoracic lymph nodes and tracheobronchial wall-adjacent lung lesions. In a study by Sun et al., the sensitivity was 85%, specificity was 100%, positive and negative predictive values were 100 and 75%, respectively, and accuracy was 90% by EBUS-TBNA for TB, in the intrathoracic lymph node. [18] Additionally, the pathology showing necrosis was an independent risk factor associated with a positive culture. [18] In a multicenter study of 156 patients, by Navani et al., EBUS-TBNA was diagnostic of TB in 146 patients (94%; 95% CI 88% to 97%). The pathological findings were consistent with TB in 134 patients (86%). [19] Microbiological investigations yielded a positive culture of TB in 74 patients (47%), with a median time to positive culture of 16 days (range 3-84), and identified eight drug-resistant cases (5%). The authors concluded that EBUS-TBNA was a safe and effective first-line investigation in patients with tuberculous intrathoracic lymphadenopathy. [19] There are case reports suggesting the use of EBUS-TBNA in diagnosing multi-drug resistant (MDR) TB transmission in a contact as well as diagnosing TB in patients with mediastinal adenopathy and focus of TB elsewhere. [20]

Real-time convex probe TBNA has had a tremendous impact on the diagnosis of mediastinal and hilar lymph nodes. It is routinely performed on a day-care basis and provides adequate samples for cytology, histology, molecular, and microbiological diagnostics in patients with malignant as well as non-malignant diseases. In recent years, there has been a flurry of EBUS-TBNA literature on the diagnosis, staging, and re-staging of lung cancer, and has replaced mediastinoscopy as the first-line investigation. It has proved its merit also in the diagnosis of sarcoidosis. All that glitters is not gold, similarly every patient having mediastinal lymph node enlargement in a TB-endemic area does not always have TB. Even if the clinical and radiological picture supports TB, in the present era of drug-resistance TB, it is important to aim for microbiological sampling whenever possible so that diagnosis, molecular testing, and anti- tuberculous drug susceptibility testing can also be done. In a tuberculous-endemic country like India, this technique has the potential to contribute in the rapid diagnosis of TB in patients who have mediastinal lymph node disease, by processing EBUS-TBNA samples for Genexpert studies, in addition to the conventional rapid culture methods. In the era of improved and emerging diagnostics, sampling mediastinal lymph nodes is like opening Pandora's Box, where the gift of precise diagnosis is given by EBUS-TBNA. Thus, EBUS-TBNA has earned its place as a standard of care in the evaluation of mediastinal and hilar lymphadenopathy.

 
 > References Top

1.Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004;126:122-8.  Back to cited text no. 1
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2.Chhajed PN, Odermatt R, von Garnier C, Chaudhari P, Leuppi JD, Stolz D, et al. Endobronchial ultrasound in hilar and conventional TBNA-negative/inconclusive mediastinal lymphadenopathy. J Cancer Res Ther 2011;7:148-51.  Back to cited text no. 2
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3.Ozgül MA, Cetinkaya E, Tutar N, Ozgül G, Onaran H, Bilaceroglu S. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrathoracic lymphadenopathy in patients with extrathoracic malignancy: A study in a tuberculosis-endemic country. J Cancer Res Ther 2013;9:416-21.  Back to cited text no. 3
    
4.Punamiya V, Mehta A, Chhajed PN. Bronchoscopic needle aspiration in the diagnosis of mediastinal lymphadenopathy and staging of lung cancer. J Cancer Res Ther 2010;6:134-41.  Back to cited text no. 4
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5.Fielding D, Windsor M. Endobronchial ultrasound convex-probe transbronchial needle aspiration as the first diagnostic test in patients with pulmonary masses and associated hilar or mediastinal nodes. Intern Med J 2009;39:435-40.  Back to cited text no. 5
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6.Yasufuku K, Nakajima T, Motoori K, Sekine Y, Shibuya K, Hiroshima K, et al. Comparison of endobronchial ultrasound, positron emission tomography, and CT for lymph node staging of lung cancer. Chest 2006;130:710-8.  Back to cited text no. 6
    
7.Herth FJ, Ernst A, Eberhardt R, Vilmann P, Dienemann H, Krasnik M. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum. Eur Respir J 2006;28:910-4.  Back to cited text no. 7
    
8.Nakajima T, Yasufuku K, Suzuki M, Hiroshima K, Kubo R, Mohammed S, et al. Assessment of epidermal growth factor receptor mutation by endobronchial ultrasound-guided transbronchial needle aspiration. Chest 2007;132:597-602.  Back to cited text no. 8
    
9.Jurado J, Saqi A, Maxfield R, Newmark A, Lavelle M, Bacchetta M, et al. The efficacy of EBUS-guided transbronchial needle aspiration for molecular testing in lung adenocarcinoma. Ann Thorac Surg 2013;96:1196-202.  Back to cited text no. 9
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10.Moonim MT, Breen R, Fields PA, Santis G. Diagnosis and subtyping of de novo and relapsed mediastinal lymphomas by endobronchial ultrasound needle aspiration. Am J Respir Crit Care Med 2013;188:1216-23.  Back to cited text no. 10
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11.Hong G, Lee KJ, Jeon K, Koh WJ, Suh GY, Chung MP, et al. Usefulness of endobronchial ultrasound-guided transbronchial needle aspiration for diagnosis of sarcoidosis. Yonsei Med J 2013;54:1416-21.  Back to cited text no. 11
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12.Oki M, Saka H, Kitagawa C, Kogure Y, Murata N, Ichihara S, et al. Prospective study of endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes versus transbronchial lung biopsy of lung tissue for diagnosis of sarcoidosis. J Thorac Cardiovasc Surg 2012;143:1324-9.  Back to cited text no. 12
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13.Kitamura A, Takiguchi Y, Kurosu K, Takigawa N, Saegusa F, Hiroshima K, et al. Feasibility of cytological diagnosis of sarcoidosis with endobronchial US-guided transbronchial aspiration. Sarcoidosis Vasc Diffuse Lung Dis 2012;29:82-9.  Back to cited text no. 13
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14.Oki M, Saka H, Kitagawa C, Tanaka S, Shimokata T, Kawata Y, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration is useful for diagnosing sarcoidosis. Respirology 2007;12:863-8.  Back to cited text no. 14
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15.Garwood S, Judson MA, Silvestri G, Hoda R, Fraig M, Doelken P. Endobronchial ultrasound for the diagnosis of pulmonary sarcoidosis. Chest 2007;132:1298-304.  Back to cited text no. 15
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16.Navani N, Booth HL, Kocjan G, Falzon M, Capitanio A, Brown JM, et al. Combination of endobronchial ultrasound-guided transbronchial needle aspiration with standard bronchoscopic techniques for the diagnosis of stage I and stage II pulmonary sarcoidosis. Respirology 2011;16:467-72.  Back to cited text no. 16
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17.Wong M, Yasufuku K, Nakajima T, Herth FJ, Sekine Y, Shibuya K, et al. Endobronchial ultrasound: New insight for the diagnosis of sarcoidosis. Eur Respir J 2007;29:1182-6.  Back to cited text no. 17
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18.Sun J, Teng J, Yang H, Li Z, Zhang J, Zhao H, et al. Endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing intrathoracic tuberculosis. Ann Thorac Surg 2013;96:2021-7.  Back to cited text no. 18
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19.Navani N, Molyneaux PL, Breen RA, Connell DW, Jepson A, Nankivell M, et al. Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: A multicentre study. Thora×2011;66:889-93.  Back to cited text no. 19
    
20.Mehta MR, Connell DW, Wickremasinghe MI, Kon OM. The use of thoracic computed tomography scanning and EBUS-TBNA to diagnose tuberculosis of the central nervous system: Two case reports. Eur Respir Rev 2010;19:345-7.  Back to cited text no. 20
    




 

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