Biomedical Research

Abstract

Background and Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUSTBNA) is a safe and minimally invasive procedure that yields accurate results in the evaluation of mediastinal lymphadenopathies. The aim of our study was to retrospectively evaluate EBUS-TBNA procedures performed in our clinic and to reveal the value of EBUS-TBNA in terms of mediastinal lymph node diagnoses.

Methods: A total of 52 patients with mediastinal lymph node enlargement (short axis >1 cm) who underwent thoracic computed tomography and EBUS-TBNA were retrospectively included in this study.

Results: The mean age of the patients was 51.3 ± 15.5 (range: 18-74) years and there were 23 (44.2%) females and 29 (55.8%) males. The sizes of the sampled lymph nodes ranged from 10 mm to 30 mm. Of the 52 patients who underwent EBUS-TBNA, 43 (82.7%) had a final diagnosis. Mediastinoscopy was performed in nine (17.3%) patients who reached a negative cytological outcome. As a final diagnosis, sarcoidosis was found in 23 patients, tuberculosis in 3 patients, squamous cell lung cancer in 6 patients, small cell lung cancer in 9 patients, lung adenocarcinoma in 1 patient and a benign diagnosis in 10 cases. No complications were observed in any of the cases.

Conclusion: TBNA is a safe interventional procedure under EBUS guidance that provides a high adequacy and diagnostic rate for mediastinal lymph nodes and reduces the need for invasive surgery.

Keywords

Endobronchial ultrasound-guided transbronchial needle aspiration, Mediastinoscopy

Introduction

Endobronchial ultrasound-guided transbronchial needleaspiration (EBUS-TBNA) is an ultrasound method used todiagnose diseases that involve mediastinal lymph nodes,especially lung cancer. In conventional bronchoscopy, thebronchoscopist can only observe the internal surface and lumenof the airways. However, with endobronchial ultrasound, theycan observe the tracheobronchial wall and surroundingstructures. Peribronchial structures, such as veins and masses,can be assessed through ultrasonic probes developed to fit thebronchoscope processing channel, and the location of thelesion can be clearly identified, and safer and more appropriatesamples can be obtained [1-3]. The purpose of this study wasto assess the importance of TBNA with EBUS guidance in thediagnosis of mediastinal or hilar lymph nodes by sharing ourclinical experiences.

Materials and Methods

In this study, we analysed patient results from the YedikuleChest Diseases and Chest Surgery Training and Research Hospital 4^th Clinic between January 2012-february 2013, andfrom the Sakarya University Education and Research HospitalChest Diseases Clinic from 2016. We retrospectively analysedpatients with a hilar or mediastinal lymph node over 1 cm insize, as determined by computerized tomography (CT), withouta pathologic diagnosis. In all patients, TBNA was indicated fordiagnosis and lymph node sampling with a 22-gauge cytologyneedle in a convex probe (CP)-EBUS. The patient sample wascomprised of 23 (44.2%) females and 29 (55.8%) males.Lymph nodules were classified according to the internationalstaging system reported by Mountain and Dressler [4]. Patientswith a mediastinal lymph node accessible with EBUS-TBNAin the axial thoracic CT and those whose lymph nodes’ shortdiameter was between 10 and 30 mm were included in thestudy. Permission for this study was obtained from the ethicscommittee of Sakarya University Medical Faculty.

EBUS-TBNA was performed under deep sedation withmidazolam and propofol. CP-EBUS was used to examine thelymph nodes and evaluate the ultrasound image. Lymph nodesampling was performed with 22-gauge needles.

Results

Of the 52 patients, 23 (44.2%) were female and 29 (55.8%)were male. The age range of the patients was 18-74 years witha mean age of 51.3 ± 15.5 years (Table 1).

Table 1: Demographic data of patients who underwent EBUS-TBNA.

Areas where lymph node sampling performed in these areas:32 times from the subcarinal lymph node (7), 22 times from theright paratracheal lymph node (4R), 12 times from the righthilar lymph node (10R), 7 times from the left hilar lymph node(10L), 2 times from the right interlobar lymph node, 2 from theleft interlobar lymph node (11L), 2 from the left lowerparatracheal lymph node (4L), 2 from the left upper paratracheal lymph node (2L) and 1 from the right upperparatracheal (2R).

The most frequently sampled sites were the subcarinal (7)lymph nodes (61.5%) and right paratracheal (4R) lymph nodes(42.3%) (Table 2).

Table 2: Lymph node sizes and number of samples by location.

A total of 43 cases (82.7%) were diagnosed and 9 (17.3%)cases were diagnosed by mediastinoscopy. The diagnosticdistribution in 43 cases diagnosed with EBUS-TBNA included:sarcoidosis in 20 cases, tuberculosis in 3 cases, squamous celllung cancer in 5 cases, small cell lung cancer in 7 cases, lungadenocarcınoma in 1 case and benign masses in 7 cases.

Mediastinoscopy was performed in nine (17.3%) patients whohad a negative cytologic outcome. The final diagnosis in 52patients was sarcoidosis in 20 cases, tuberculosis in 3 cases,squamous cell lung cancer in 6 cases, small cell lung cancer in9 cases, lung adenocarcinoma in 1 case and benign masses in10 cases (Table 3).

Table 3: Diagnostic evaluation of patients diagnosed with EBUS-TBNA, and those diagnosed by mediastinoscopy without being diagnosed with EBUS-TBNA.

The sarcoidosis diagnosis was made according to the criteria ofthe absence of significant necrosis in 23 cases of cytologydetected with chronic granulomatous inflammation, absence ofcontact with tuberculosis, clinic compatibility and bilateralhilar involvement radiologically. Tuberculosis was diagnosedwith the presence of a contact history in three cases, thepresence of unilateral hilar or mediastinal involvement, thepresence of marked necrosis in the cytology and the presenceof antituberculosis treatment response. No complicationsdeveloped in any of the cases.

Discussion

EBUS-TBNA is an ultrasound method developed to visualizestructures of unknown hilar origin, mediastinallymphadenopathies and masses that can be used to samplemasses. There are two EBUS devices, radial and CP. The mostimportant advantage of the CP-EBUS is the simultaneousimaging [1-3]. It can be used as a guide in the evaluation ofinvasion of mediastinal structures, in the diagnosis ofmediastinal and hilar lymph nodes, in the diagnosis of lungcancer, and in the staging and endobronchial treatment of lungcancer [5,6]. CP-EBUS can also be used in the evaluation ofbenign central airway stenosis to make treatment decisions,such as laser ablation or stent placement [7].

Although the assessment of mediastinal and hilar lymph nodeinvolvement performed with TBNA in 1983 by Wang et al.became a main topic of conversation, however, more recently,less attention has been given to this process [8-10]. The studiesthat showed EBUS-guided TBNA increased the lymph nodesdetected in pathologically-sized CT compared to conventionalTBNA, by Herth et al. were the first studies showing thesignificance of EBUS guidance in TBNA [11]. Several studieshave shown the sensitivity and specificity of TBNA in thepresence of EBUS in the diagnosis of lymph nodes. Wong et al.diagnosed 61 of 65 sarcoıdosis patients with EBUS-TBNA[12].

Çetinkaya et al. diagnosed 10 sarcoidosis (stage I and stage II)in their study performed with fiberoptic bronchoscopy. Eightpatients (87.5%) were diagnosed with TBNA using 19-gaugeneedles [13]. The diagnostic value of EBUS-TBNA insarcoidosis was reported as 79.5% in a study performed byÇağlayan et al. [14].

In our study, 20 of 23 patients were diagnosed with EBUS-TBNA.The diagnostic value of EBUS-TBNA for sarcoidosiswas 86.9%.

Yasufuku et al. found the sensitivity of EBUS-TBNA as95.7%, the specificity as 100% and the accuracy of benign and malignant lymph node differentiation as 97.1% [6]. Based onthese studies, EBUS-TBNA has been accepted as a reliablemethod for the diagnosis and staging of lung cancer [15]. Inour study, 12 of 15 malignant patients were diagnosed and thediagnostic value was 86.6%. Diagnosis was made specificallyin 43 patients (82.7%) out of 52 who underwent EBUS-TBNA.Nine (17.3%) cases with a negative cytologic diagnosis werediagnosed by mediastinoscopy. Our findings are consistentwith the results of previous studies. As a result, EBUS-TBNAseems to be a safe diagnostic method. Diseases, such as lungcancer, sarcoidosis and tuberculosis, can be diagnosed byEBUS without the need for more invasive procedures, such asmediastinoscopy, and it is recommended it be performedbefore mediastinoscopy in mediastinal staging of lung cancer.The advantages of this procedure are being minimally invasive,no hospitalization, only local anaesthesia and sedation are usedand it has a high diagnostic yield. However, the disadvantagesare that the subaortic and paraesophageal lymph nodes cannotbe sampled, and the micrometastases can be overlookedbecause only small needles are used in the procedure [16,17].EBUS-TBNA is an interventional procedure that reduces thesurgical need in patients and all pulmonary medicinespecialists should be aware of its advantages.

References

1. Hürter, T, Hanrath, P. Endobronchial sonography: feasibility and preliminary results. Thorax 1992; 47: 565.
2. Kurimoto N, Murayama M, Yoshioka S. Assessment of usefulness of endobronchial ultrasonography in determination of depth of tracheobronchial tumor invasion. Chest 1999; 115: 1500.
3. Baba M, Sekine Y, Suzuki M. Correlation between endobronchial ultrasonography (EBUS) images and histologic findings in normal and tumor-invaded bronchial wall. Lung Canc 2002; 35: 65.
4. Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest 1997; 111: 1718-23.
5. Herth FJ, Ernst A, Schulz M, Becker HD. Endobronchial ultrasound reliably differentiates between airway infiltration and compression by tumor. Chest 2003; 123: 458-462.
6. Yasufuku K, Chiyo M, Sekine Y, Chhajed PN, Shibuya K, Iizasa T, Fujisawa T. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004; 126: 122- 128.
7. Herth F, Becker HD, LoCicero J 3rd, Ernst A. Endobronchial ultrasound in therapeutic bronchoscopy. Eur Respir J 2002; 20: 118-121.
8. Wang KP, Terry PB. Transbronchial needle aspiration in the diagnosis and staging of bronchogenic carcinoma. Am Rev Respir Dis 1983; 127: 344-347.
9. Wang KP. Flexible transbronchial needle aspiration for histology specimen. Chest 1985; 88: 860-863
10. Wang KP. Staging of bronchogenic carcinoma by bronchoscopy. Chest 1995; 106: 588-593.
11. Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration:a randomized trial. Chest 2004; 125:  322-325.
12. Wong M, Yasufuku K, Nakajima T, Herth FJ, Sekine Y, Shibuya K. Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis. Eur Respir J 2007; 29: 1182-1186.
13. Cetinkaya E, Yildiz P, Altin S, Yilmaz V. Diagnostic value of transbronchial needle aspiration byWang 22-Gauge cytology needle in intrathoracic lymphadenopathy. Chest 2004; 125: 527-531.
14. Çağlayan B, Salepçi B, Fidan A, Kiral N, Cömert SS, Yavuzer D. Sensitivity of convex probe endobronchial sonographically guided transbronchial needle aspiration in the diagnosis of granulomatous mediastinal lymphadenitis. J Ultrasound Med 2011; 30: 1683-1689.
15. Arias S, Liu QH, Frimpong B, Lee H. Role of the Endobronchial Landmarks Guiding TBNA and EBUS-TBNA in Lung Cancer Staging. Canad Respirat J 2016.
16. Kikuchi E, Yamazaki K, Sukoh N, Kikuchi J, Asahina H, Imura M, Onodera Y, Kurimoto N, Kinoshita I, Nishimura M. Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions. Eur Respir J 2004; 24: 533.
17. Herth FJ, Eberhardt R, Becker HD, Ernst A. Endobronchial ultrasound-guided transbronchial lung biopsy in fluoroscopically invisible solitary pulmonary nodules: a prospective trial. Chest 2006; 129: 147.