Overview of endobronchial ultrasound guided fine needle ... · Overview of endobronchial ultrasound...

Overview of endobronchial ultrasound guided fine needle aspiration (EBUS FNA): benefits and challenges

Ross A Miller, MD FCAP FASCP Houston Methodist Hospital

PRESENTATION TITLE EBUS FNA: benefits and challenges

PRESENTATION TITLE

Disclosure of Relevant Financial Relationships

USCAP requires that all planners (Education Committee) in a position to influence or control the content of CME disclose any relevant financial

relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to

the content of this educational activity and creates a conflict of interest. Dr. Ross A Miller declares he/she has no conflict(s) of interest

to disclose.

EBUS FNA: benefits and challenges

PRESENTATION TITLE

Disclosure of Relevant Financial Relationships

USCAP requires that all faculty in a position to

influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their

spouse/partner have, or have had, within the past 12 months, which relates to the content of this educational activity and creates a conflict of interest.

Dr. Ross A Miller declares he/she has no conflict(s) of interest to disclose.



•  LeadingcauseofcancerdeathintheUnitedStatesandworldwideformenandwomen•  ~85%arenon-smallcelllungcancers(NSCLC)

•  Adenocarcinoma>Squamouscellcarcinoma

•  UnitedStates:over200,000peoplearediagnosedwithlungcancerperyear•  Canada:nearly30,000peoplediagnosedperyear

So….whenapa,entpresentswithasuspectedlungcancer,howaretheyevaluated?

Lungcancer


Left upper lobe lung nodule

Station 4L lymphadenopathy


Nodal map remain unchanged for the 8th Edition

Image source: R

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ura H, W

atanabe H, et al. The IA

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L lung Cancer staging project: a proposal for a new

international lym

ph node map in the forthcom

ing 7th edition of the TN

M classification for lung cancer. J Thorac O

ncol. 4:468-577.


Image source: R

usch VW

, Asam

ura H, W

atanabe H, et al. The IA

SC

L lung Cancer staging project: a proposal for a new

international lym

ph node map in the forthcom

ing 7th edition of the TN

M classification for lung cancer. J Thorac O

ncol. 4:468-577.

Patient

4R

3p

6

3a

PRESENTATION TITLE

Suspected lung cancer •  Tissue procurement goals

•  Benign vs malignant •  Primary lung cancer versus secondary lung cancer •  Histologic subtype •  Confirm suspected metastatic disease (staging) •  Molecular testing

•  Ideally, achieve the above in the least number of procedures possible

•  So… in the ideal setting, we are obtaining all necessary information while minimizing procedural related risks to the patient


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Biopsy target • Target selection based on multiple factors,

tailored to the patient •  Maximize information, minimize the number of

procedures, and minimize potential harm to the patient

•  Factors taken into consideration •  History and physical exam, laboratory findings

•  What type of procedure can the patient tolerate? •  Chest CT, possible PET or other imaging studies (if done…)

•  Goal: Determine the clinical stage


“Primum non nocere” First, do no harm

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Biopsy target • Suspected distant metastatic disease à stage IV

•  In this setting, the metastatic lesion is often sampled •  Ease of targeting, less patient risk •  Patient is not a surgical candidate

So…EBUS procedures are likely not used much in this setting


7th Ed M1a: Separate tumor nodule(s) in a contralateral lobe tumor with pleural nodules or malignant pleural (or pericardial) effusion M1b: Distant metastasis

7th Ed 8th Ed 7th 8th

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Biopsy target • Suspected stage IA (T1aN0M0 or T1bN0M0), peripheral lesion

•  No suspected nodal/distant metastasis •  These patients are considered surgical candidates •  Surgical resection of the lung lesion with lymph node sampling

•  Nodes: peribronchial/hilar

No nodal involvement à no need for further therapy (Stage 1A)

If there is nodal involvement (stage II, N1 disease) à adjuvant chemotherapy

So…EBUS procedures may potentially be used to look for nodal disease


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Biopsy target •  Suspected Nodal involvement

•  Specifically, suspected stage IIIA/B: N2 and N3 disease •  N2: ipsilateral, mediastinal node or subcarinal node •  N3: contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene,

supraclavicular •  Biopsy target: often the lymph node

•  Confirms presence of disease •  The distinction between Stage IIIA (N2 disease) and IIIB (N3) disease is

important •  IIIA: may be eligible for chemo followed by surgery •  IIIB: Not surgical candidates

•  As such, may want to target more than one node if clinically suspicious

EBUS procedures are often requested


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Fast stats, National cancer institute, Surveillance, epidemiology, and end

results program.

http://seer.cancer.gov/faststats/selections.php?#Output. Accessed February 6, 2017 Compare statistics by cancer site, stage distribution


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Historical Overview

• 1949: Transbronchial needle aspiration described - rigid bronchoscope (Schieppati)

• 1983: TBNA used through a flexible bronchoscope (Wang and colleagues)

•  Used to stage lung cancer • 1992: ultrasound applied to bronchoscopy

• 1999: EBUS bronchoscope became commercially available

•  Improvements and advances made since


PRESENTATION TITLE

Endobronchial ultrasound (EBUS) fine needle aspiration (FNA) and biopsy • Combines bronchoscopy with ultrasound, FNA or biopsy can be

obtained •  Indications

•  Staging or re-staging non-small cell lung carcinoma •  Sampling lymph node/s

•  Obtaining tissue for diagnosis on large central lung tumors •  Workup of lymphadenopathy

•  Diagnosis or “ruling out” sarcoidosis, lymphoma, or metastatic disease (non-lung)

•  Sampling mediastinal masses •  Usually superior and anterior mediastinal tumors

•  Before EBUS: cervical mediastinoscopy used to stage


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Cervical Mediastinoscopy


Photo from: http://www.webmd.com/, accessed January 19, 2017

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EBUS FNA: Advantages • Ability to sample lung and mediastinal lesions

•  Less invasive than mediastinoscopy/surgery •  More cost effective than surgical mediastinoscopy

• Generally safe, complications are relatively uncommon •  Agitation, cough, blood •  Some probes used for peripheral nodules, bleeding/pneumothorax •  Infection/fistula formation is rare

• Good Sensitivity and Specificity!


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EUS and EBUS “medical mediastinoscopy”

EBUS

Potential to sample 2R and 2L 4R and 4L 7 10 11 Sometimes 12

EUS Potential to sample

8 9 Left adrenal


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EBUS FNA: Challenges

•  Limited or no diagnostic material obtained • May require a second staging procedure (mediastinoscopy)

• Requires an endoscopist with expertise •  Proper training programs are a necessity! • No current method in place to assess competency/technical skills

• Some targets cannot be assessed due to anatomic location • Combined EUS and EBUS are sometimes used, “medical

mediastinoscopy” •  Complementary procedures with better sensitivity


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EBUS FNA and rapid on-site evaluation (ROSE) Advantages •  “Real time” evaluation of procured material

•  Evaluates if lesion tissue is being sampled and allows the physician performing the FNA to make additional passes if needed

•  Improves accuracy of staging •  Fewer passes, superior adequacy rates

•  Improved patient care, less repeat procedures •  The performance of FNA is dependent on specimen adequacy and sampling

•  Up to one-third are nondiagnostic when ROSE is not utilized

•  This is dependent on the experience level of the endoscopist •  Some studies suggest ROSE does not make a difference in diagnostic yield

•  Task force guidelines have suggested •  ROSE is only effective in reducing additional procedures •  No statistically significant differences in # of aspirations, diagnostic yield, time, or

complications •  One expert panel recommended tissue sampling with or without ROSE in patients

undergoing EBUS-TBNA for diagnostic evaluation of lung cancer (Grade 1C)


PRESENTATION TITLE

EBUS FNA and rapid on-site evaluation (ROSE) Advantages

•  Allows preliminary information to be relayed

•  Specimen triage for ancillary studies

•  Flow cytometry, Microbiology studies, Molecular testing, Cell block preparations

•  Potential to give guidance on how to improve yield/technique •  More on this…

•  Sampling can be stopped when diagnostic material is obtained •  Opposed to doing a set number of passes

•  Builds relationship between pathologist and endoscopist: better patient care


Pulmonary pathology consensus paper (soon to be submitted) Rapid on-site evaluation of endobronchial ultrasound guided transbronchial needle aspirations (EBUS-TBNA) for the diagnosis of lung cancer Lead author: Jain Deepali


PRESENTATION TITLE

Left upper lobe lung nodule


Station 4L lymphadenopathy


Clinically suspect stage IIIA disease 4L lymphadenopathy

N2: ipsilateral mediastinal node So.. we want to obtain tissue •  least number of procedures possible •  obtain sufficient material for histologic

subtyping and molecular studies EBUS FNA, Station 4L, lymph node

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Initial Pass


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Subsequent passes


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Papanicolaou stain


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Cell block

TTF-1

p40


EBUS FNA, Station 4L, lymph node

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Another example 60 M with mediastinal lymphadenopathy



Pass #1

Recommendations?

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Papanicolaou stain



Cell block

GMS AFB

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ROSE: Potential to give guidance on how to improve yield/technique

•  The performing physician has to be receptive… •  FNA technique

•  “aspiration” biopsy is a misnomer! •  Needle into lesion

•  Visualized via ultrasound (convex probe) •  Distal end grooved: more hyperechoic on US

•  Stylet moved “in and out to dislodge bronchial wall contaminant •  Stylet removed •  Generate vacuum (pull back on syringe) •  Make excursions! •  2-3 per second, long amplitude

•  Negative pressure without proper needle movement is insufficient for tissue collection, needle movement “cuts the tissue”, negative pressure assists tissue into needle

•  Limit dwell time 5-10 seconds maximum, shorter (2-5 seconds) for nodes/vascular lesions •  Release vacuum •  Now pull needle out of lesion


Additional sources for slide: 1)  Demay RM. Introduction to Fna Biopsy. In: Demay RM. The Art and Science of Cytopathology, 2nd ed. Chicago, IL: ASCP Press; 2012: 535-560. 2)  Ly A. Fine-needle aspiration biopsy technique and specimen handling. In: Cibas ES and Ducatman BS. Cytology, Diagnostic principles and clinical correlates, 4th ed.

Philadelphia, PA: Elsevier-Saunders; 2014: 221-231. 3)  Murgu S, Davoudi M, Dolt H. EBUS Step by Step video available on YouTube 4)  Personal experience and training

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Dwell time too long


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“ the needle is in the lesion….” but that does not mean the lesion is inside the needle

• Technique issues • Bronchial wall material pushed into

the target and then taken up by the needle when excursions are made

•  Repeat FNA •  Move stylet “back and forth”


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Challenges of ROSE • Need a pathologist experienced with ROSE • Time consuming • Average amount of time per site sampled: 12-22 minutes

•  Often more than one site sampled •  We found the average pathologist adequacy assessment time was ~38 min

•  Range 2-142 min

• Current Medicare compensation rates are insufficient to cover Pathology costs (adequacy assessment CPT code 88172)


PRESENTATION TITLE

Challenges of ROSE

• One study suggests training interventional pulmonologists or using cytotechnologists for ROSE

•  Over 90% concordance with cytopathologist

• Caution: this would really be an adequacy assessment only •  Limited literature on this

• Telecytology can be used


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Challenges of ROSE

• Although pathology costs exceed reimbursement, the overall cost of EBUS is far less than mediastinoscopy

• However (and more important than cost) ROSE has value

•  Improves procedural outcomes •  Reduces the need for repeat procedures


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Take home messages about ROSE

When feasible, ROSE should be provided – plenty of literature supporting the use of ROSE Better overall EBUS-FNA performance


Advantages: •  Adequacy assessment •  Specimen Triage •  Reduces need for additional procedures •  Improves diagnostic yield •  Builds relationship between pathologist

and endoscopist •  Overall: improved patient care

Disadvantages: •  Requires experienced pathologist •  Time and cost

PRESENTATION TITLE

References 1)  U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2016. Available at: http://www.cdc.gov/uscs. 2)  Canadian Cancer Society's Advisory Committee on Cancer Statistics. (2016). Canadian Cancer Statistics 2016. Toronto, ON: Canadian Cancer Society. 3)  Torre LA, Bray F, Siegal RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer staristicis, 2012. CA Cancer J Clin. 2015;65(2):87. 4)  Groth SS, Andrade RS. Endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal lymph node staging in non-small cell lung cancer. Semin Thrac Cardiovasc Surg. 2008;20(4):274-278. 5)  Siegal RL, Miller KD, Jermal A. Cancer Statistics, 2015. CA Cancer J Clin. 2015;65:5-29. 6)  Selection of modality for diagnosis and staging of patients with suspected non-small cell lung cancer. UpTo Date Website. http://www.uptodate.com/contents/selection-of-modality-for-diagnosis-and-staging-of-patients-with-suspected-non-small-cell-lung-cancer?source=see_link. Updated Jul 14, 2016. Accessed July 19, 2016. 7)  Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143 (5 Suppl):e142S-65S. 8)  Kinsey CM, Arenberg DA. Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging. Am J Respir Crit Care Med. 2014 Mar 15;189(6):640-9. 9)  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 Jun;3(6):577-82. 10)  Groth SS, Andrade RS. Endobronchial ultrasound- guided transbronchial needle aspiration for mediastinal lymph node staging in non-small cell lung cancer. Semin Thorac Cardiovasc Surg. 2008 Winter;20(4):274-8. 11)  Herth FJ, Annema JT, Eberhardt R, et al. Endobronchial ultrasound with transbronchial needle aspiration for restaging the mediastinum in lung cancer. J Clin Oncol. 2008 Jul 10;26(20):3346-50. 12)  Nakajima T, Yasufuku K, Saegusa F, et al. Rapid on-site cytologic evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for nodal staging in patients with lung cancer. Ann Thorac Surg. 2013 May;95(5):1695-9. 13)  Guo H, Liu S, Guo J, et al. Rapid on-site evaluation during endobronchial ultrasound-guided trans bronchial needle aspiration for the diagnosis of hilar and mediastinal lymphadenopathy inpatients with lung cancer. Cancer Lett. 2016 Feb 28;371(2):182-6. 14)  Madan NK, Madan K, Jain D, et al. Utility of conventional transbronchial needle aspiration with rapid on-site evaluation (c-TBNA ROSE) at a tertiary care center with endobronchial ultrasound (EBUS) facility. J Cytol. 2016 Jan-Mar;33(1):22-6. 15)  Mfokazi A, Wright CA, Louw M, et al. Direct comparison of liquid-based and smear-based cytology with and without rapid on site evaluation for fine needle aspirates of thoracic tumors. Diagn Cytopathol. 2016 May;44(5):363-8. 16)  Thiryayi SA, Rana DN, Narine N, Najib M, Bailey S. Establishment of an endobronchial ultrasound-guided transbronchial fine needle aspiration service with rapid on-site evaluation: 2 years experience of a single UK centre. Cytopathology. 2016 Oct;27(5):335-43. 17)  Jeffus SK, Joiner AK, Siegel ER, et al. Rapid on-site evaluation of EBUS-TBNA specimens of lymph nodes: comparative analysis and recommendations for standardization. Cancer Cytopathol. 2015 Jun;123(6):362-72. 18)  Walia R, Madan K, Mohan A, et al. Diagnostic utility of conventional transbronchial needle aspiration without rapid on-site evaluation inpatients with lung cancer. Lung India. 2015 Mar-Apr;32(2):198-9. 19)  Cancer Staging Handbook, From the AJCC Cancer staging Manual, 7th Ed. New York, NY: Springer, 2010. 20)  Schieppati E. Mediastinal puncture thru the tracheal carina. Rev Assoc Med Argent. 1949;63:497-499. 21)  Wang KP, Brower R, Haponik EF, Siegelman S. Flexible transbronchial needle aspiration for staging of bronchogenic carcinoma. Chest. 1983;84:571-576. 22)  Hurter T, Hanrath P. Endobronchial sonography: feasibility and preliminary results. Thorax. 1992;47:565-567. 23)  VanderLaan, P. A., Wang, H. H., Majid, A. and Folch, E. (2014), Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): An overview and update for the cytopathologist. Cancer Cytopathology, 122: 561–576 24)  Medford AR, Bennett JA, Free CM, Agrawal S. Mediastinal stagning procedures in lung cancer: EBUS, TBNA and mediastinoscopy. Curr Opin Pulm Med. 2009;15(4):334-342. 25)  Cameron SE, Andrade RS, Pambuccoan SE. Endobronchial ultrasound-guided transbronchial needle aspiration cytology: a state of the art review. Cytopathology. 2010;21(1):6-26. 26)  Krasnik M, Vilmann P, Larsen SS, Jacobsen GK. Preliminary experience with a new method of endoscopic transbronchial real time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions. Thorax. 2003;58(12):1083. 27)  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(1):122. 28)  Rintoul RC, Glover MJ, Jackson C,, et al. Cost effectivness of endosonography versus surgical staging in potentially resectable lung cancer: a health economics analysis of the ASTER trial from a European perspective. Throax 2014;69:679-681. 29)  Kang HJ, Hwangbo B, Lee GK, Nam BH, et al. EBUS-centred versus EUS-centred mediastinal staging in lung cancer: a randomised trial. Throax 2014;69:261-268. 30)  Kurimoto N, Miyazawa T, Okimasa S, Maeda A, Oiwa H, Miyazu Y, Murayama M. Endobronchial ultrasonography using a guide sheath increases the ability to diagnose peripheral pulmonary lesions endoscopically. Chest. 2004;126(3):959. 31)  Chen A, Chenna P, Loiselle A, Massoni J, Mayse M, Misselhorn D. Radial probe endobronchial ultrasound for peripheral pulmonary lesions. A 5-year institutional experience. Ann Am Thorac Soc. 2014 May;11(4):578-82. 32)  Sánchez-Font A,Álvarez L, Ledesma G, Curull V. Localized Subcarinal Adenitis following Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration. Respiration. 2015 Oct;90(4):329-31. 33)  Asano F, Aoe M, Ohsaki Y, Okada Y, Sasada S, Sato S, Suzuki E, Semba H, Fukuoka K, Fujino S, Ohmori K. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res. 2013;14:50. 34)  Varela-Lema L, Fernández-Villar A, Ruano-Ravina A. Effectiveness and safety of endobronchial ultrasound-transbronchial needle aspiration: a systematic review. Eur Respir J. 2009;33(5):1156. 35)  Haas AR. Infectious complications from full extension endobronchial ultrasound transbronchial needle aspiration. Eur Respir J. 2009 Apr;33(4):935-8. 36)  Parker KL, Bizekis CS, Zervos MD. Severe mediastinal infection with abscess formation after endobronchial ultrasound-guided transbrochial needle aspiration. Ann Thorac Surg. 2010 Apr;89(4):1271-2. 37)  Unroe MA, Shofer SL, Wahidi MM. Training for endobronchial ultrasound: methods for proper training in new bronchoscopic techniques. Curr Opin Pulm Med. Jul 2010. 16(4):295-300. 38)  Vilmann P, Clementsen PF. Combined EUS and EBUS are complementary methods in lung cancer staging: Do not forget the esophagus. Endoscopy International Open. 2015;3(4):E300-E301. 39)  Zhang R, Ying K, Shi L, Zhang L, Zhou L. Combined endobronchial and endoscopic ultrasound-guided fine needle aspiration for mediastinal lymph node staging of lung cancer: a meta-analysis. Eur J Cancer. 2013;49(8):1860-1867. 40)  Yasufuku K, Chiyo M, Sekine Y, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest. 2004;126:122-8 41)  Herth FJ, Becker HD, Ernst A. Ultrasound-guided transbronchial needle aspiration: an experience in 242 patients. Chest. 2003;123:604-7 42)  Herth FJ, Eberhardt R, Vilmann P, Krasnik M, Ernst A. Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes. Thorax. 2006;31()9):795-798. 43)  Schmidt RL, Witt BL, Lopez-Calderon LE, et al. The influence of rapid onsite evaluation on the adequacy rate of fine-needle aspiration cytology. Am J Clin Pathol. 2013;139: 300–308. 44)  Shield PW, Cosier J, Ellerby G, et al. Rapid on-site evaluation of fine needle aspiration specimens by cytology scientists: a review of 3032 specimens. Cytopathology. 2014; 25(5): 322-329. 45)  Collins BT, Chen AC, Wang JF, et al. Improved laboratory resource utilization and patient care with the use of rapid on-site evaluation for endobronchial ultrasound fine-needle aspiration biopsy. Cancer Cytopathol 2013; 121(10):544-51. 46)  Baram D, Garcia RB, Richman PS. Impact of rapid on-site cytologic evaluation during transbronchial needle aspiration. Chest 2005; 128: 869–875. 47)  Gasparini S. It is time for this ‘ROSE’ to flower. Respiration 2005; 72: 129–131. 48)  Austin JH, Cohen MB. Value of having a cytopathologist present during percutaneous fine-needle aspiration biopsy of lung: report of 55 cancer patients and metaanalysis of the literature.AJR Am J Roentgenol. 1993;160: 175–177. 49)  Azabdaftari G, Goldberg SN, Wang, HH. Efficacy of on-site specimen adequacy evaluation of image-guided fine and core needle biopsies. Acta Cytol. 2010;54: 132–137. 50)  Griffin AC, Schwartz LE, Baloch ZW. Utility of on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspiration specimens. Cytojournal. 2011;8:20 51)  van der Heijden EH, Casal RF, Trisolini R, et al; World Association for Bronchology and Interventional Pulmonology, Task Force on Specimen Guidelines. Guideline for the acquisition and preparation of conventional and endobronchial ultrasound-guided transbronchial needle aspiration specimens for the diagnosis and molecular testing of patients with known or suspected lung cancer. Respiration.

2014;88(6):500-17. 52)  Wahidi MM, Herth F, Yasufuku K, et al. Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report. Chest. 2016 Mar;149(3):816-35. 53)  Diacon AH, Schuurmans MM, Theron J, et al. Utility of rapid on-site evaluation of transbronchial needle aspirates. Respiration 2005; 72: 182–188. 54)  Martin HE, Ellis EB. Aspiration biopsy. Surg Gynecol Obstet 1934;59:578-589. 55)  Cameron SEH, Andrade RS, Pambuccian SE. Endobronchial ultrasound-guided transbronchial needle aspiration cytology: A state of the art review. Cytopathology 2010;21:6-26. 56)  Miller RA, Wright AM, Satrum LS, Mody DR, Schwartz MR, Thrall MJ. Utilization review and reimbursement of cytology services in endobronchial ultrasound-guided procedures: challenge and opportunity. JASC 2016;5, 139-144. 57)  Layfield LJ, Bentz JS, Gopez EV. Immediate on-site interpretation of fine-needle aspiration smears: A cost and compensation analysis. Cancer 2001;93:319-322. 58)  Bonifazi M, Sediari M, Ferretti M, et al: The role of the pulmonologist in rapid on-site cytologic evaluation of transbronchial needle aspiration: a prospective study. Chest. 2014 Jan;145(1):60-5. 59)  Bott MJ, James B, Collins BT, Murray BA, Puri V, Kreisel D, Krupnick AS, Patterson GA, Broderick S, Meyers BF, Crabtree TD. A Prospective Clinical Trial of Telecytopathology for Rapid Interpretation of Specimens Obtained During Endobronchial Ultrasound-Fine Needle Aspiration. Ann Thorac Surg. 2015 Jul;100(1):201-5; discussion 205-6. 60)  Oki M, Saka H, Kitagawa C, Koqure Y, Murata N, Adachi T, Ando M. Rapid on-site cytologic evaluation during endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing lung cancer: a randomized study. Respiration. 2013;85(6):486-92. 61)  Griffin AC, Schwartz LE, Baloch, ZW. Utility of on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspiration specimens. Cytojournal. 2011;8:20.


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Important Information Regarding CME/SAMs

The Online CME/Evaluations/SAMs claim process will only be

available on the USCAP website until September 30, 2017.

No claims can be processed after that date!

After September 30, 2017 you will NOT be able to obtain any CME or SAMs credits for attending this meeting.

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Supplemental slides


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Suspected stage IA (T1aN0M0 or T1bN0M0) 7th ed: T1a : less than or equal to 2 cm

T1b: >2-3 cm

Proposed T

Proposed Overall stage

8th ed



7th Ed M1a: Separate tumor nodule(s) in a contralateral lobe tumor with pleural nodules or malignant pleural (or pericardial) effusion M1b: Distant metastasis

7th Ed 8th Ed 7th 8th

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Needle types •  21, 22, 25 gauge •  Stainless steel and nitionol •  ProCore needle

•  Pilot study did not show ProCore needle to add value

• Medical literature: •  recommends use of either a 21 or 22 gauge needle •  needle size is usually determined by the operator based on the location

(station) of the LN, vascularity of the node, and the type of specimen processing (cytology versus histology)


Wahidi MM, Herth F, Yasufuku K, et al. Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report. Chest. 2016 Mar;149(3):816-35. Xing J, Manos S, Monaco SE, Wilson DO, Pantanowitz L. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Pilot Study to Evaluate the Utility of the ProCore Biopsy Needle for Lymph Node Sampling. Acta Cytol. 2016;60(3):254-9.

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Radial probe vs Convex probe

• Radial probe (RP-EBUS) image •  Gives a 360 degree image of the airway and surrounding structures

• Convex probe •  Image parallel to shaft of bronchoscope •  Used when performing TBNA


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Molecular testing •  ~80% of lung cancers diagnosed at advanced stage, a portion

diagnosed by cytology or small biopsy •  Material obtained from EBUS procedures may be (and often is) the only material

available for molecular testing • Molecular testing dependent on multiple factors

•  Overall cellularity and tumor fraction •  Analytic sensitivity of the molecular testing platform

• Material suitable for molecular testing in >90% of samples

Schmid-Bindert G, Wang Y, Jiang H, et al. EBUS-TBNA provides highest RNA yield for multiple biomarker testing from routinely obtained small biopsies in non-small cell lung cancer patients – a comparative study of three different minimal invasive sampling methods. PLoS One. 2013 Oct 29;8(10):e77948. Esterbrook G, Anathhanam S, Plant PK. Adequacy of endobronchial ultrasound transbronchial needle aspiration samples in the subtyping of non-small cell lung cancer. Lung Cancer. 2013 Apr;80(1):30-4.


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Molecular testing Study by Yarmus et al:

•  EGFR and KRAS sequencing •  ALK FISH

• 95% of specimens were satisfactory

Yarmus L, Akulian J, Gilbert C, et al. Optimizing endobronchial ultrasound for molecular analysis. How many passes areneeded? Ann Am Thorac Soc. 2013 Dec;10(6):636-43.


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