Elsevier

Lung Cancer

Volume 63, Issue 1, January 2009, Pages 45-49
Lung Cancer

EBUS-TBNA for the diagnosis of central parenchymal lung lesions not visible at routine bronchoscopy

https://doi.org/10.1016/j.lungcan.2008.04.004Get rights and content

Summary

Background

Obtaining a tissue diagnosis of malignancy is challenging in patients with suspected lung cancer presenting with centrally located intrapulmonary masses.

Objective

(1) To evaluate the yield of endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) for diagnosing centrally located lesions after a non-diagnostic conventional bronchoscopy. (2) To assess the impact of EBUS-TBNA on patient management for this indication.

Study design and patients

A retrospective analysis of a series of patients with a central parenchymal lung lesion suspected to be lung cancer who had been referred to three university hospitals for EBUS-TBNA to obtain a tissue diagnosis was undertaken. If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy, patients were subsequently referred for a transthoracic needle aspiration biopsy or a surgical diagnostic procedure.

Results

Sixty patients were investigated with EBUS-TBNA. The majority (82%) had a prior (non-diagnostic) flexible bronchoscopy. EBUS-TBNA was performed in an out-patient setting in 97%. With ultrasound, the primary lung lesion was observed in all cases. EBUS-TBNA confirmed lung cancer in 46 (77%). A final reference pathology diagnosis was available in 59 (98%) cases. The sensitivity of EBUS-TBNA for diagnosing lung cancer was 82% (95% confidence intervals (CI) 69–91%) with a negative predictive value of 23% (95%CI 5–53%). Based on the EBUS-TBNA findings, transthoracic needle aspiration biopsy or a surgical diagnostic procedure was cancelled in 47% and 30% of patients, respectively. No serious procedure-related complications were reported.

Conclusion

EBUS-TBNA is a sensitive tool for the diagnosis of centrally located primary lung cancer not visible at conventional bronchoscopy. Therefore, EBUS-TBNA can impact on patient management in this setting. However, the low negative predictive value indicates that a negative EBUS-TBNA result should be confirmed by other methods.

Implication

EBUS-TBNA can be considered as a diagnostic test in patients with a centrally located lung lesion after a previous non-diagnostic conventional bronchoscopy.

Introduction

Lung cancer is the leading cause of cancer death with a 5-year survival rate of only 16% [1]. Lung cancer may be suspected in patients presenting with either an abnormal chest radiograph or with symptoms resulting from local or systemic tumour effects. If lung cancer is suspected, a histological diagnosis, in conjunction with accurate staging, should be obtained whenever possible in order to guide therapy and prognosis [2], [3].

Flexible fibreoptic or video-bronchoscopy with its associated procedures (endobronchial biopsy, brushing and washing) is valuable in patients with suspected lung cancer, especially if there is endobronchial tumour visible. However, many central tumours are not visible at bronchoscopy due to their submucosal or parabronchial position and in these situations diagnostic yield by standard bronchoscopic techniques is much lower [4], [5], [6]. The addition of transbronchial needle aspiration (TBNA) may increase diagnostic rates [7] but this technique is not widely practiced and the yield is heavily operator-dependent. Although CT-guided transthoracic needle aspirations for centrally located parabronchial lesions can be undertaken, there is a high risk of pneumothorax and hemoptysis [8]. In addition, the diagnostic yield is lower than for peripheral lesions [8].

Convex curvi-linear endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) is a useful technique for mediastinal lymph node staging of non-small cell lung cancer [9], [10], [11], [12]. In this paper, we have evaluated the yield and the clinical impact of using EBUS-TBNA for diagnosing centrally located parenchymal lung lesions which are not visible by conventional bronchoscopy and which are hardly amenable to CT-guided needle biopsy.

Section snippets

Study design and patients

We retrospectively reviewed the diagnostic performance of EBUS-TBNA in patients with a high clinical suspicion of a centrally located primary lung cancer. These patients were referred to three expert institutions to obtain a tissue diagnosis of the primary lung lesion by EBUS-TBNA. The centrally located lung lesions were defined as an intrapulmonary mass with the medial margin located within the inner third of the hemithorax based on chest CT-scan imaging. Patients with primary mediastinal

Results

In this international retrospective series, 60 patients (36 male) were referred between April 2006 and October 2007 to Ghent University Hospital, Belgium (n = 25), Papworth Hospital, Cambridge, UK (n = 10) or Leiden University Medical Center, The Netherlands (n = 25) for EBUS-TBNA to obtain a tissue diagnosis of lung lesion suspected to be malignant and with its medial margin within one-third of the hemithorax (Fig. 1).

Table 1 details patient characteristics. Forty-nine (82%) patients had a previous

Discussion

In this study, EBUS-TBNA provided a diagnosis of malignancy in 77% of patients with a centrally sited lung lesion that was not visible at routine bronchoscopy. The sensitivity to diagnose lung cancer was 82%. In addition, in this setting EBUS-TBNA was shown to be both safe and have a high impact on patient management.

Flexible bronchoscopy and CT/ultrasound guided transthoracic needle aspiration are the most commonly used techniques to obtain a tissue diagnosis when lung cancer is suspected.

Conflict of interest

None declared.

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