Nueclear Web Banner
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 3  |  Page : 1172-1177

Diagnostic value of core biopsy histology and cytology sampling of mediastinal lymph nodes using 21-gauge EBUS-TBNA needle


1 Institute of Pulmonology, Medical Research and Development, Mumbai; Lung Care and Sleep Centre, Fortis Hiranandani Hospital, Navi Mumbai, Maharashtra, India
2 Institute of Pulmonology, Medical Research and Development, Mumbai, Maharashtra, India

Date of Web Publication4-Jan-2017

Correspondence Address:
Prashant N Chhajed
Institute of Pulmonology, Medical Research and Development, A/405, Sangam, Corner of S. V. Road and Saibaba Road, Santacruz West, Navi Mumbai - 400 054, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.197535

Rights and Permissions
 > Abstract 

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the initial modality of choice in sampling mediastinal lymphadenopathy. It is possible to obtain both cytological and histological samples using both 21-gauge and 22-gauge EBUS-TBNA needles. The current study was undertaken to compare the diagnostic yield of cytology and histology samples obtained by the same EBUS-TBNA 21-gauge needle.
Patients and Methods: One hundred sixty-six consecutive patients who underwent EBUS-TBNA with a 21-gauge EBUS-TBNA needle over a period of 3 years were included in this retrospective analysis. The diagnostic yields of EBUS-TBNA histology (EBUS-TBNA-H) and EBUS-TBNA cytology (EBUS-TBNA-C) specimens were compared using the McNemar test.
Results: The overall sensitivity and specificity of EBUS-TBNA were 89% and 100%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) of EBUS-TBNA were 100% and 53%, respectively. The overall sensitivity and specificity of EBUS-TBNA-H were 85% and 100%, respectively. The PPV and NPV of EBUS-TBNA-H were 100% and 43%, respectively. The overall sensitivity and specificity of EBUS-TBNA-C were 65% and 100%, respectively. The PPV and NPV of EBUS-TBNA-C were 100% and 14%, respectively. The diagnostic yield of EBUS-TBNA-H over EBUS-TBNA-C was statistically significant (P < 0.0001).
Conclusion: EBUS-TBNA-H with 21-gauge needle significantly improves the diagnostic yield of EBUS-TBNA. EBUS-TBNA-H improves the NPV of EBUS-TBNA. The combination of EBUS-TBNA-H and EBUS-TBNA-C improves the overall diagnostic yield of EBUS-TBNA.

Keywords: Biopsy, cytology, ebus tbna, endobronchial ultrasound, histology, lymph node


How to cite this article:
Vaidya PJ, Saha A, Kate AH, Pandey K, Chavhan VB, Leuppi JD, Chhajed PN. Diagnostic value of core biopsy histology and cytology sampling of mediastinal lymph nodes using 21-gauge EBUS-TBNA needle. J Can Res Ther 2016;12:1172-7

How to cite this URL:
Vaidya PJ, Saha A, Kate AH, Pandey K, Chavhan VB, Leuppi JD, Chhajed PN. Diagnostic value of core biopsy histology and cytology sampling of mediastinal lymph nodes using 21-gauge EBUS-TBNA needle. J Can Res Ther [serial online] 2016 [cited 2017 Oct 18];12:1172-7. Available from: http://www.cancerjournal.net/text.asp?2016/12/3/1172/197535


 > Introduction Top


Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) used as an initial diagnostic tool has a significant impact on the diagnosis of mediastinal lymphadenopathy due to both malignant and benign pathologies.[1],[2],[3],[4] EBUS-TBNA was initially performed with a dedicated 22-gauge EBUS-TBNA needle. Subsequently, the 21-gauge EBUS-TBNA needle was introduced with the idea of obtaining better samples, particularly for histology.[5] It is possible to obtain both cytological and histological samples from both 22-gauge and 21-gauge EBUS-TBNA needles.[5] Several studies have compared yields of 21-gauge and 22-gauge EBUS-TBNA needles.[5],[6],[7],[8],[9],[10] Of these, two studies did not report a significant difference in the diagnostic yield. However, the cellular architecture is better preserved with cytology samples obtained by 21-gauge needle albeit with increased blood contamination.[10] The samples obtained from 21-gauge needle improve characterization of benign lesions and subtyping of nonsmall cell lung cancer.[5] Histology specimens can also be obtained with EBUS transbronchial biopsy forceps.[11],[12],[13]

In a tuberculosis-endemic country like India, EBUS-TBNA is an important diagnostic tool for diagnosing granulomatous lymphadenitis.[14] EBUS-TBNA is not inferior to mediastinoscopy in sampling mediastinal lymphadenopathy and has even been reported to be superior in that more lymph node stations can be sampled.[15],[16],[17] Cytology material obtained by EBUS-TBNA have been adequate to cell type both small-cell and nonsmall cell lung cancer.[18] However, with the advent of targeted therapies, it is important to obtain additional material for molecular subtyping of lung cancer. In addition, in benign lesions, substantial sample needs to be collected for molecular and microbiological studies. EBUS-TBNA yields core biopsies for histological analysis [Figure 1].[10],[19] To the best of our knowledge, the added value of obtaining a histology specimen in addition to a cytology specimen in the same setting with the same EBUS-TBNA 21-gauge needle is not reported. The current study was undertaken to compare the diagnostic yield of cytology and histology samples obtained by the same EBUS-TBNA 21-gauge needle.
Figure 1: Core biopsy obtained by 21-gauge endobronchial ultrasound-guided transbronchial needle aspiration needle

Click here to view



 > Patients and Methods Top


One hundred sixty-six consecutive patients who underwent EBUS-TBNA (Olympus, Japan) with a 21-gauge EBUS-TBNA needle over a period of 3 years were included in this retrospective analysis. EBUS-TBNA was performed with 21-gauge needle under anesthetist guided sedation and local anesthesia by a single experienced operator. EBUS-TBNA sample during the first pass was obtained without applying suction on EBUS-TBNA needle. Suction with provided syringe was applied only when adequate histology sample was not obtained. Procedure was stopped when adequate core biopsy specimens were obtained or after five passes per lymph node. Smears were prepared from the aspirate material and the histological core biopsies were separated and transferred to a formalin container. Aspirated samples were also collected in a sterile container and sent for microbiological analyses. The rapid onsite evaluation was not available. Approval for the study was obtained from the Institutional Ethics Committee.

Statistical analysis

The diagnostic yields of EBUS-TBNA histology (EBUS-TBNA-H) and EBUS-TBNA cytology (EBUS-TBNA-C) specimens were compared using the McNemar test and calculations were done using GraphPad Quickcalcs (GraphPad Software Inc., USA). P values were calculated using McNemar's test with continuity correction, and P < 0.05 was considered statistically significant. False positive and false negatives were confirmed during follow-up of the patients.


 > Results Top


One hundred and sixty-six consecutive patients (101 males and 65 females) underwent EBUS-TBNA with 21-gauge needle. The mean age was 47.5 years (standard deviation ± 15; 12–79 years). The overall EBUS-TBNA was diagnostic in 145 of 166 patients. The overall sensitivity and specificity of EBUS-TBNA were 89% (95% confidence interval [CI]: 83%–93%) and 100% (95% CI: 81%–100%), respectively. The positive predictive value (PPV) and negative predictive value (NPV) of EBUS-TBNA were 100% (95% CI: 97%–100%) and 53% (95% CI: 36%–70%), respectively. A definitive diagnosis could not be obtained in 21 patients despite acquiring adequate cellular material in the histology or cytology of aspirate. Diagnoses of the 145 patients at EBUS-TBNA were granulomatous adenopathy 93 (63%), malignancy 23 (16%), anthracosis 12 (8%), and reactive or inflammatory or others 17 (13%) [Table 1]. The final diagnoses in 18 patients with inconclusive EBUS-TBNA were arrived at during follow-up and were sarcoidosis 4, tuberculosis 8, malignancy 1, benign lymphadenopathy 4, and fibrosing mediastinitis 1. Three patients were lost to follow-up.
Table 1: Final diagnosis in 166 patients

Click here to view


EBUS-TBNA-H specimens were available in 148 of 166 (90%) patients and were diagnostic in 128 (86%) of these. Of the remaining 18 (10%) patients, ten patients had pus aspiration and hence biopsy material was not obtained while a biopsy sample was not obtained even after five passes in eight patients. The overall sensitivity and specificity of EBUS-TBNA-H were 85% (95% CI: 78%–90%) and 100% (95% CI: 78%–100%), respectively. The PPV and NPV of EBUS-TBNA-H were 100% (95% CI: 97%–100%) and 43% (95% CI: 26%–61%), respectively.

EBUS-TBNA-C was available in 162 patients and was diagnostic in 108 (67%). The overall sensitivity and specificity of EBUS-TBNA-C were 65% (95% CI: 57%–72%) and 100% (95% CI: 66%–100%), respectively. The PPV and NPV of EBUS-TBNA-C were 100% (95% CI: 96%–100%) and 14% (95% CI: 7%–25%), respectively.

Patients with both endobronchial ultrasound-guided transbronchial needle aspiration histology and endobronchial ultrasound-guided transbronchial needle aspiration cytology specimens (n = 144)

Both EBUS-TBNA-H and EBUS-TBNA-C specimens could be obtained in 144 patients. EBUS-TBNA-H and/or EBUS-TBNA-C were diagnostic in 130 patients [Table 2]. Both EBUS-TBNA-H and EBUS-TBNA-C were diagnostic in 91 of 144 (63%) patients. Of the total 144 patients, EBUS-TBNA-H specimens were diagnostic in 125 patients. In these 125 patients, EBUS-TBNA-C was diagnostic in 91 patients. Therefore, the additional yield of histology samples over cytology samples was 34 of a total of 144 (24%). EBUS-TBNA-C was diagnostic in 96 of 144 patients, and of these, EBUS-TBNA-H was diagnostic in 91. Therefore, the additional yield of EBUS-TBNA-C over EBUS-TBNA-H was 5 of a total of 144 (3%). Both cytology and histology were nondiagnostic in 14 of 144 (10%) patients. The diagnostic yield of EBUS-TBNA-H over EBUS-TBNA-C was statistically significant (P < 0.0001). EBUS-TBNA-C was diagnostic in 12 (67%) of the 18 patients in whom an EBUS-TBNA-H core specimen could not be obtained. EBUS-TBNA-H samples were diagnostic in three (75%) of four patients in whom a cytology smear could not be obtained.
Table 2: Comparison of diagnostic yields from endobronchial ultrasound-guided transbronchial needle aspiration-cytology and endobronchial ultrasound-guided transbronchial needle aspiration-histology samples obtained in same patients (n=144)

Click here to view


Granulomatous lymphadenitis (n = 93)

Among the 93 patients with granulomatous lymphadenitis diagnosed on EBUS-TBNA, an EBUS-TBNA-C sample was obtained in 88 (97%) patients, and EBUS-TBNA-H sample obtained in 82 (90%) patients [Table 2] and [Table 3]. Both EBUS-TBNA-C and EBUS-TBNA-H samples were obtained in 81 (89%) patients. EBUS-TBNA-H specimens were diagnostic in 76 patients. In these patients, EBUS-TBNA-C was diagnostic in 63. Therefore, the additional yield of histology samples over cytology samples was 13 of 81 (16%). EBUS-TBNA-C was diagnostic in 68 patients. In these patients, EBUS-TBNA-H was diagnostic in 63 patients. Therefore, the additional yield of EBUS-TBNA-C over EBUS-TBNA-H was 5 of 81 (6%).
Table 3: Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration histology and cytology samples in granulomatous lymphadenitis and malignancy

Click here to view


Malignancy (n = 23)

There were 23 patients diagnosed with malignancy on EBUS-TBNA [Table 2] and [Table 3]. Cytology samples were obtained in all. A diagnosis at cytology was obtained in 18 of 23 (78%) patients. EBUS-TBNA-H was obtained in 22 of 23 (96%) patients. EBUS-TBNA-H was diagnostic in all 22 (100%) patients. Both EBUS-TBNA-C and histology samples were obtained in 22 of 23 (96%). Among the 22 patients in whom EBUS-TBNA-H was diagnostic, EBUS-TBNA-C was also diagnostic in 17. Therefore, the additional yield of histology samples over cytology samples was 5 of 22 (24%). EBUS-TBNA-C was diagnostic in 17 patients. EBUS-TBNA-H was also diagnostic in all these 17 patients. However, in one patient in whom a histology sample could not be obtained, cytology was diagnostic for malignancy.


 > Discussion Top


EBUS-TBNA has caused a paradigm shift in the sampling of mediastinal lymphadenopathy. EBUS-TBNA has a good diagnostic yield for both benign and malignant lesions. A high diagnostic accuracy of EBUS-TBNA may render mediastinoscopy unnecessary.[5],[15],[16],[17] EBUS-TBNA in a tuberculosis-endemic country like India is utilized as a diagnostic tool in evaluation of mediastinal lymphadenopathy. Its role in staging of lung cancer is utilized.[14],[20] The evolution in molecular subtyping of nonsmall cell lung cancer and administration of tailored chemotherapy has compelled clinicians to acquire adequate tissue samples at the outset to prevent delay in the management and improve patient outcomes

EBUS-TBNA with 21-gauge needle yields histological lymph node core biopsies.[5] Jeyabalan et al. reported the superiority of histological samples obtained during EBUS-TBNA with 21-gauge needle over the 22-gauge needle in characterization of both benign and malignant diseases.[5] A large AQuIRE study reported no significant differences in the diagnostic yield and sample adequacy between the two needles but fewer passes were required with 21-gauge needle when rapid onsite cytology was available.[7]

The majority of diagnoses in the current study were benign. In the current study, the diagnostic yield of EBUS-TBNA-C is in concurrence with literature.[1],[21],[22] However, the combined diagnostic yield of EBUS-TBNA-C and histology was higher than that reported in literature.[14],[22] The overall NPV was higher than the reported NPV.[1],[14] Thus, acquisition of histology samples may reduce the need for further intervention. The most common diagnosis in the current study was granulomatous lymphadenitis followed by malignancy. This is in concurrence with the other reports on EBUS-TBNA in tuberculosis-endemic regions.[1],[14],[23]

Histology samples may not be obtained in 10% patients undergoing EBUS-TBNA with a 21-gauge needle. Pus aspiration in sampling of mediastinal lymphadenopathy may be obtained. It suggests a plausible infective diagnosis and obtaining a core biopsy may not be feasible in such situations. Microbiology studies of purulent EBUS-TBNA aspirate may further enhance the diagnostic yield in infections. Diagnostic yield of individually obtained histology samples was higher compared to individually obtained cytology samples.

Value of combined endobronchial ultrasound-guided transbronchial needle aspiration cytology and histology

The current study highlights the benefit of having EBUS-TBNA-H samples over EBUS-TBNA-C samples obtained with the 21-gauge needle in the same setting. The diagnostic yield was significantly better with EBUS-TBNA-H when compared with EBUS-TBNA-C in patients where both the samples were obtained. This significance was maintained when tested in both benign and malignant lesions. In combination, EBUS-TBNA-H and EBUS-TBNA-C improve the diagnostic yield of EBUS-TBNA. These data highlight the importance of obtaining both EBUS-TBNA-H and EBUS-TBNA-C specimens using the same EBUS-TBNA needle.

Both cytology and histology samples can be obtained with 22-gauge and 21-gauge EBUS-TBNA needles. EBUS transbronchial forceps biopsies with varied techniques have been reported to improve the diagnostic yield of EBUS-TBNA.[11],[12],[13],[24],[25] The diagnostic yield reported in the current study is in concurrence with the reported diagnostic yield of EBUS forceps biopsies.[11],[13],[24],[25] The technical disadvantage of EBUS forceps biopsy procedure is the need of separate equipment (cautery, mini forceps, and needle forceps) other than the EBUS-TBNA needle.[11],[13],[24],[25] This may add to the cost, learning curve, and technical expertise compared to using the conventional EBUS-TBNA needle. However, larger studies are required to establish the practicality and superiority of the EBUS forceps biopsy samples over EBUS-TBNA samples.

In the current study, cytology samples were obtained in more patients compared to histology. Cell block method of processing the cytology samples obtained from EBUS-TBNA has been reported.[26],[27],[28] The cell block method has been reported to increase the cytology yield by around 7% in adenocarcinoma.[27] The cell block method of processing cytological samples improves diagnostic yield in sarcoidosis.[26],[28],[29] There is paucity of data about significance of cell block method in achieving a benign diagnosis other than sarcoidosis with EBUS-TBNA. Processing EBUS-TBNA aspirates by cell block method has been reported to increase the diagnostic yield of EBUS-TBNA. This may help in achieving a diagnosis on cytology when histology samples are not obtained.[26],[27],[28],[29]

The weaknesses of the current study are its retrospective nature and the lack of mediastinoscopy. However, several trials have shown EBUS-TBNA to be noninferior and sometimes superior to mediastinoscopy.[15],[16],[17] Despite this, mediastinoscopy may still have a role in patients where EBUS-TBNA is inconclusive.


 > Conclusion Top


EBUS-TBNA-H samples with 21-gauge needle significantly improve the diagnostic yield of EBUS-TBNA. EBUS-TBNA-H improves the NPV of EBUS-TBNA. The combination of EBUS-TBNA-H and EBUS-TBNA-C improves the overall diagnostic yield of EBUS-TBNA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Choi YR, An JY, Kim MK, Han HS, Lee KH, Kim SW, et al. The diagnostic efficacy and safety of endobronchial ultrasound-guided transbronchial needle aspiration as an initial diagnostic tool. Korean J Intern Med 2013;28:660-7.  Back to cited text no. 1
    
2.
Vaidya PJ, Kate AH, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: The standard of care for evaluation of mediastinal and hilar lymphadenopathy. J Cancer Res Ther 2013;9:549-51.  Back to cited text no. 2
    
3.
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. 3
    
4.
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. 4
    
5.
Jeyabalan A, Shelley-Fraser G, Medford AR. Impact of needle gauge on characterization of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) histology samples. Respirology 2014;19:735-9.  Back to cited text no. 5
    
6.
Giri S, Pathak R, Yarlagadda V, Karmacharya P, Aryal MR, Martin MG. Meta-analysis of 21– Versus 22-G aspiration needle during endobronchial ultrasound-guided transbronchial needle aspiration. J Bronchology Interv Pulmonol 2015;22:107-13.  Back to cited text no. 6
    
7.
Yarmus LB, Akulian J, Lechtzin N, Yasin F, Kamdar B, Ernst A, et al. Comparison of 21-gauge and 22-gauge aspiration needle in endobronchial ultrasound-guided transbronchial needle aspiration: Results of the American College of Chest Physicians Quality Improvement Registry, education, and evaluation registry. Chest 2013;143:1036-43.  Back to cited text no. 7
    
8.
Oki M, Saka H, Kitagawa C, Kogure Y, Murata N, Ichihara S, et al. Randomized study of 21-gauge versus 22-gauge endobronchial ultrasound-guided transbronchial needle aspiration needles for sampling histology specimens. J Bronchology Interv Pulmonol 2011;18:306-10.  Back to cited text no. 8
    
9.
Saji J, Kurimoto N, Morita K, Nakamura M, Inoue T, Nakamura H, et al. Comparison of 21-gauge and 22-gauge needles for endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. J Bronchology Interv Pulmonol 2011;18:239-46.  Back to cited text no. 9
    
10.
Nakajima T, Yasufuku K, Takahashi R, Shingyoji M, Hirata T, Itami M, et al. Comparison of 21-gauge and 22-gauge aspiration needle during endobronchial ultrasound-guided transbronchial needle aspiration. Respirology 2011;16:90-4.  Back to cited text no. 10
    
11.
Herth FJ, Schuler H, Gompelmann D, Kahn N, Gasparini S, Ernst A, et al. Endobronchial ultrasound-guided lymph node biopsy with transbronchial needle forceps: A pilot study. Eur Respir J 2012;39:373-7.  Back to cited text no. 11
    
12.
Franke KJ, Bruckner C, Szyrach M, Ruhle KH, Nilius G, Theegarten D. The contribution of endobronchial ultrasound-guided forceps biopsy in the diagnostic workup of unexplained mediastinal and hilar lymphadenopathy. Lung 2012;190:227-32.  Back to cited text no. 12
    
13.
Bramley K, Pisani MA, Murphy TE, Araujo KL, Homer RJ, Puchalski JT. Endobronchial ultrasound-guided cautery-assisted transbronchial forceps biopsies: Safety and sensitivity relative to transbronchial needle aspiration. Ann Thorac Surg 2016;101:1870-6.  Back to cited text no. 13
    
14.
Madan K, Mohan A, Ayub II, Jain D, Hadda V, Khilnani GC, et al. Initial experience with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) from a tuberculosis endemic population. J Bronchology Interv Pulmonol 2014;21:208-14.  Back to cited text no. 14
    
15.
Clementsen PF, Skov BG, Vilmann P, Krasnik M. Endobronchial ultrasound-guided biopsy performed under optimal conditions in patients with known or suspected lung cancer may render mediastinoscopy unnecessary. J Bronchology Interv Pulmonol 2014;21:21-5.  Back to cited text no. 15
    
16.
Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011;142:1393-400.e1.  Back to cited text no. 16
    
17.
Ernst A, Anantham D, Eberhardt R, Krasnik M, Herth FJ. Diagnosis of mediastinal adenopathy-real-time endobronchial ultrasound guided needle aspiration versus mediastinoscopy. J Thorac Oncol 2008;3:577-82.  Back to cited text no. 17
    
18.
Vaidya PJ, Kate AH, Yasufuku K, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer diagnosis and staging. Expert Rev Respir Med 2015;9:45-53.  Back to cited text no. 18
    
19.
Chhajed PN, Sandeepa HS, Chaudhari P, Gandhi S, Tikare R, Leuppi JD, et al. Lymph Node Core Retrieval Comparison Between 22 and 21 Gauge EBUS-TBNA Needle: Abstract. European Respiratory Congress, Vienna, Austria; 2012.  Back to cited text no. 19
    
20.
Agarwal R, Gupta D. Endobronchial ultrasound-guided transbronchial needle aspiration: Indian perspective. J Bronchology Interv Pulmonol 2014;21:284-7.  Back to cited text no. 20
    
21.
Low SY, Koh MS, Ong TH, Phua GC, Anantham D. Use of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of granulomatous mediastinal lymphadenopathy. Ann Acad Med Singapore 2014;43:250-4.  Back to cited text no. 21
    
22.
Ost DE, Ernst A, Lei X, Feller-Kopman D, Eapen GA, Kovitz KL, et al. Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: Results of the AQuIRE bronchoscopy registry. Chest 2011;140:1557-66.  Back to cited text no. 22
    
23.
Ortakoylu MG, Iliaz S, Bahadir A, Aslan A, Iliaz R, Ozgul MA, et al. Portuguese diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in various lung diseases. J Bras Pneumol 2015;41:410-4.  Back to cited text no. 23
    
24.
Chrissian A, Misselhorn D, Chen A. Endobronchial-ultrasound guided miniforceps biopsy of mediastinal and hilar lesions. Ann Thorac Surg 2011;92:284-8.  Back to cited text no. 24
    
25.
Darwiche K, Freitag L, Nair A, Neumann C, Karpf-Wissel R, Welter S, et al. Evaluation of a novel endobronchial ultrasound-guided lymph node forceps in enlarged mediastinal lymph nodes. Respiration 2013;86:229-36.  Back to cited text no. 25
    
26.
Erer OF, Erol S, Anar C, Aydogdu Z, Ozkan SA. Contribution of cell block obtained by endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of malignant diseases and sarcoidosis. Endosc Ultrasound 2016. [Epub ahead of print]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=180763. [Last cited on 2016 Oct 08].  Back to cited text no. 26
    
27.
Sanz-Santos J, Serra P, Andreo F, Llatjós M, Castellà E, Monsó E. Contribution of cell blocks obtained through endobronchial ultrasound-guided transbronchial needle aspiration to the diagnosis of lung cancer. BMC Cancer 2012;12:34.  Back to cited text no. 27
    
28.
Chee A, Khalil M, Stather DR, MacEachern P, Field SK, Tremblay A. Cytologic assessment of endobronchial ultrasound-guided transbronchial needle aspirates in sarcoidosis. J Bronchology Interv Pulmonol 2012;19:24-8.  Back to cited text no. 28
    
29.
Lourido-Cebreiro T, Leiro-Fernández V, Tardio-Baiges A, Botana-Rial M, Núñez-Delgado M, Álvarez-Martín MJ, et al. The contribution of cell blocks in the diagnosis of mediastinal masses and hilar adenopathy samples from echobronchoscopy. Arch Bronconeumol 2014;50:267-71.  Back to cited text no. 29
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Abstract>Introduction>Patients and Methods>Results>Discussion>Conclusion>Article Figures>Article Tables
  In this article
>References

 Article Access Statistics
    Viewed691    
    Printed29    
    Emailed0    
    PDF Downloaded62    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]