CHEST issues guidelines on EBUS-TBNA
FROM CHEST
Sample adequacy was 90.1% after the first pass, 98.1% after two passes, and reached 100% after three passes. The sensitivity for differentiating malignant from benign lymph node stations was 69.8%, 83.7%, 95.3%, and 95.3% for one, two, three, and four passes, respectively.
No data exist regarding the number of needle passes required to obtain a sufficient diagnostic yield for lymphoma or nonmalignant diseases of the mediastinum.
In a Grade 1C recommendation, the authors said that tissue sampling can be performed with or without rapid on-site evaluation. ROSE does not affect the diagnostic yield in EBUS-TBNA procedures, but it may decrease the number of punctures and reduce the need for additional staging and diagnostic procedures. ROSE may be beneficial in judging the quantity of available malignant cells when testing for molecular markers is planned in patients with advanced adenocarcinoma of the lung.
In another Grade 1C recommendation, the authors said that patients undergoing EBUS-TBNA for the diagnosis or staging of suspected or known non–small cell lung cancer should have additional samples obtained for molecular analysis.
Molecular marker testing is necessary for tailoring chemotherapy to the cancer characteristics of each individual patient. The current data are insufficient to identify the number of passes needed to obtain adequate tissue for molecular marker testing, but it is strongly suggested that additional samples, over the proposed diagnostic threshold of three passes are recommended.
The guideline authors found insufficient quality of evidence to support any route of bronchoscope insertion for EBUS-TBNA over another. Translating the experience and literature from conventional flexible bronchoscopy given the size and rigidity of the EBUS bronchoscope distal tip, as well as the limited bronchoscopic view, is difficult, according to the guideline writers.
They noted that no studies were found that addressed the use of saline-filled balloons to overcome poor contact between the ultrasound probe and the bronchial wall. Although the saline-filled balloon can enhance image acquisition, it is unclear whether that translates into a better diagnostic yield, thus, no recommendations or suggestions can be made.
In a Grade 2C recommendation, they advised that low-fidelity inanimate mechanical airway models and high-fidelity computer-based electronic simulation be incorporated into training. In the three studies that compared conventional EBUS-TBNA training and simulation-based training incorporating either a low- or high-fidelity simulation tool, the same level of training could be acquired via conventional or simulation-based training; however, simulation-based training minimizes novice operators’ practice on patients.
In an Ungraded Consensus-Based Statement, the guideline authors advised that validated EBUS skills assessment tests be used to objectively assess skill level, but added that “none of the included simulation studies examined whether the skills demonstrated on a simulation assessment are transferred to an improvement in clinical skills as performed in patients.”
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