Journal of Cytology
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SYMPOSIUM  
Year : 2019  |  Volume : 36  |  Issue : 1  |  Page : 59-60
EBUS-TBNA for diagnosis of extrapulmonary lesions


Department of Pathology, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication17-Jan-2019
 

   Abstract 


Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has recently emerged as a minimally invasive and safe modality for the evaluation of mediastinal lymphadenopathy, particularly in staging of lung carcinoma patients. In high tuberculosis endemic countries, EBUS-TBNA is useful in obtaining tissue diagnosis of granulomatous inflammation. Role of EBUS-TBNA in workup of extrapulmonary malignancies is not widely described. Herein, a brief overview of importance of EBUS-TBNA in investigation of extrapulmonary lesions/malignancies is presented.

Keywords: Endobronchial ultrasound-guided transbronchial needle aspiration, extrapulmonary malignancies, metastasis

How to cite this article:
Jain D. EBUS-TBNA for diagnosis of extrapulmonary lesions. J Cytol 2019;36:59-60

How to cite this URL:
Jain D. EBUS-TBNA for diagnosis of extrapulmonary lesions. J Cytol [serial online] 2019 [cited 2019 Feb 22];36:59-60. Available from: http://www.jcytol.org/text.asp?2019/36/1/59/250123




Mediastinoscopy is the gold standard technique for mediastinal staging in patients with pulmonary and extrapulmonary malignancy (EPM); however, it is limited by invasiveness of the procedure, requirement of general anesthesia, and increased risk of mortality and morbidity. Mediastinoscopy is also a technically challenging procedure and fraught with considerable postoperative mediastinal fibrosis which complicates reexplorations.[1]

Conventional transbronchial needle aspiration (TBNA), although safer, is a “blind” procedure used for sampling only large subcarinal/right paratracheal lymph nodes.[2]

In contrast, endobronchial ultrasound (EBUS)-guided needle aspiration technique is minimally invasive, safe, and performed under local anesthesia and allows real-time sampling of small mediastinal nodes inaccessible by other modalities.[3]

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been extensively used for the nodal staging of lung cancer with a high yield and superior sensitivity to mediastinoscopy.[4] However, in a small proportion (~10–16%) of cases, EBUS-TBNA is indicated for evaluation of mediastinal masses in patient with known/suspected EPMs.[5] Extrapulmonary lesions diagnosed on EBUS-TBNA are most frequently either metastases from EPM or granulomatous inflammation or other infective pathology.[6]

Mediastinal and hilar lymphadenopathy are common findings on imaging in patients with EPMs. They may indicate distant metastasis in a newly diagnosed patient, disease relapse, second primary malignancy, or granulomatous disease in a previously diagnosed and treated patient, may be the first sign of malignancy in an occult EPM, or may be reactive lymphoid hyperplasia. Patients with EPMs who develop lung metastasis, coexistent mediastinal, or hilar lymphadenopathy are seen in near about a third of these cases.[7] Confirmation of lymph node metastases is important in these patients as it worsens prognosis. Lung metastasectomy is not beneficial in patients with metastatic lymph nodes.[3]

Role of EBUS-TBNA in sampling mediastinal lymph nodes and masses in patients with EPMs has been evaluated in a few clinical studies previously, with variable sensitivities (81–95%) and negative predictive values (NPV) reported. Metastases are found in half of these cases, whereas a quarter of them harbor a second primary malignancy, most commonly in the lung. Most importantly, a significant proportion of patients are found to have granulomatous inflammation such as tuberculosis and sarcoidosis.[5],[8],[9],[10] It is clinically very important as each of these diagnoses requires completely different treatment. It has been observed in prior studies that EBUS-TBNA results alter treatment procedures in over half of cases and obviate invasive surgical procedures in 60–87% of patients with EPM.[5],[11] The positive predictive value of EBUS-TBNA for malignancy is nearly 100% and patients usually do not require further workup, except when EBUS-TBNA material is inadequate for proper characterization or biomarker testing.[3],[12] False-negative EBUS-TBNA results are not uncommon and the NPV for malignancy ranged from 73% to 92%.[7],[13]

In my institutional experience, with interventional pulmonology department, we have collective data of over 100 patients in which EBUS-TBNA was performed with or without rapid on-site evaluation (ROSE) for workup of hilar or mediastinal lymphadenopathies or mass lesions in patients of EPMs (Under publication). ROSE has been proved to be associated with adequacy of the sample and helpful in preliminary diagnostic evaluation of EBUS-TBNA.[14],[15] EBUS-TBNA confirmed metastases in 45% and granulomatous inflammation in 15%. Most common primary site was breast followed by head and neck region. In patients with suspected EPM with no known primary site, EBUS-TBNA identified malignancy in 75% and characterized type and primary site of malignancy in two-thirds of these cases. In patients of lymphoma, relapse was confirmed by EBUS-TBNA. Tuberculosis and granulomatous inflammation were diagnosed through EBUS-TBNA in a significant proportion of patients with EPM. It is important to note that mediastinal and hilar lymphadenopathy do not always result from metastases in patients with EPM; hence, pathologic confirmation is necessary for definite diagnosis. In conclusion, EBUS-TBNA is a sensitive, specific, minimally invasive, and a safe procedure for the correct diagnosis of mediastinal and hilar lesions or lymphadenopathies in patients with EPM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
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2.
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3.
Nakajima T, Yasufuku K, Iyoda A, Yoshida S, Suzuki M, Sekine Y, et al. The evaluation of lymph node metastasis by endobronchial ultrasound-guided transbronchial needle aspiration: Crucial for selection of surgical candidates with metastatic lung tumors. J Thorac Cardiovasc Surg 2007;134:1485-90.  Back to cited text no. 3
    
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Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: A systematic review and meta-analysis. Eur J Cancer 2009;45:1389-96.  Back to cited text no. 4
    
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6.
Kumari K, Jain D, Kumar R, Mohan A, Kumar R. Metastatic carotid body paraganglioma of lungs and lymphnodes: Unsuspected diagnosis on EBUS-TBNA. Diagn Cytopathol 2017;45:327-32.  Back to cited text no. 6
    
7.
Kondo H, Okumura T, Ohde Y, Nakagawa K. Surgical treatment for metastatic malignancies. Pulmonary metastasis: Indications and outcomes. Int J Clin Oncol 2005;10:81-5.  Back to cited text no. 7
    
8.
Song JU, Park HY, Jeon K, Koh WJ, Suh GY, Chung MP, et al. The role of endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal and hilar lymph node metastases in patients with extrapulmonary malignancy. Intern Med 2011;50:2525-32.  Back to cited text no. 8
    
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Navani N, Nankivell M, Woolhouse I, Harrison RN, Munavvar M, Oltmanns U, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrathoracic lymphadenopathy in patients with extrathoracic malignancy: A multicenter study. J Thorac Oncol 2011;6:1505-9.  Back to cited text no. 9
    
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Parmaksız ET, Caglayan B, Salepci B, Comert SS, Kiral N, Fidan A, et al. The utility of endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal or hilar lymph node evaluation in extrathoracic malignancy: Benign or malignant? Ann Thorac Med 2012;7:210-4.  Back to cited text no. 10
    
11.
Navani N, Lawrence DR, Kolvekar S, Hayward M, McAsey D, Kocjan G, et al.; REMEDY Trial Investigators. Endobronchial ultrasound-guided transbronchial needle aspiration prevents mediastinoscopies in the diagnosis of isolated mediastinal lymphadenopathy: A prospective trial. Am J Respir Crit Care Med 2012;186:255-60.  Back to cited text no. 11
    
12.
Jain D, Roy-Chowdhuri S. Molecular pathology of lung cancer cytology specimens: A concise review. Arch Pathol Lab Med 2018;142:1127-33.  Back to cited text no. 12
    
13.
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. 13
    
14.
Jain D, Allen TC, Aisner DL, Beasley MB, Cagle PT, Capelozzi VL, et al. Rapid on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspirations for the diagnosis of lung cancer: A perspective from members of the pulmonary pathology society. Arch Pathol Lab Med 2018;142:253-62.  Back to cited text no. 14
    
15.
Madan NK, Madan K, Jain D, Walia R, Mohan A, Hadda V, 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;33:22-6.  Back to cited text no. 15
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Correspondence Address:
Deepali Jain
Associate Professor, Department of Pathology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOC.JOC_124_18

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