Bankstown Hospital - Grand Rounds - Further Reading

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Dhamija, A., et al. (2019). "Endobronchial ultrasound for tubercular mediastinal adenopathy and its comparison with traditional tools." The International Journal of Tuberculosis and Lung Disease 23(8): 907-912 

https://www.ingentaconnect.com/content/iuatld/ijtld/2019/00000023/00000008/art00006

                SETTING: Endobronchial ultrasound (EBUS) is now the preferred tool to sample malignant mediastinal lesions. Data on its role in tubercular mediastinal adenopathy are limited. OBJECTIVE: To evaluate the efficacy of EBUS in diagnosing tubercular mediastinal lymphadenopathy and correlate the cytological and microbiological results obtained on aspirate with standard methods (radiology and the tuberculin skin test) suggesting tuberculosis (TB). DESIGN: A prospective study of 125 patients with suspected tubercular mediastinal lymphadenopathy who underwent EBUS-transbronchial needle aspiration. Only patients with a microbiologically confirmed diagnosis or unequivocal clinico-radiological response to anti-TB treatment during follow-up were included. RESULTS: A total of 122 patients showed findings suggesting TB on cytopathology (sensitivity 97.6%), 105 (84%) of whom had microbiological evidence of TB (positive smear/culture or both). Performing staining for acid-fast bacilli on slides prepared during the procedure vs. only on samples submitted in saline significantly improved the yield. Only 92 patients (73.6%) were Mantoux-positive. Cytology was more sensitive than computed tomography in picking up necrosis. Granulomas, with or without necrosis, were equally likely to be microbiologically positive. However, presence of only necrosis in a TB-endemic region invariably points towards TB diagnosis. CONCLUSIONS: EBUS was highly sensitive and specific for diagnosis of mediastinal TB and may be considered the investigation of choice for tubercular mediastinal adenopathy.

Shanthikumar, S., et al. (2019). "Utility of Endobronchial Ultrasound in Assessment of Intrathoracic Lesions in Paediatric Patients." Respiration 98(4): 340-346  https://doi.org/10.1159/000501466

                Introduction: In adults, linear endobronchial ultrasound (EBUS) is the preferred modality to sample intrathoracic adenopathy and radial EBUS is a useful tool to biopsy peripheral pulmonary nodules. Utility in children is less well known. Objectives: The objective of this study was to review the EBUS experience of two specialist centres to better define the current role of EBUS in paediatric practice. Methods: A retrospective record review of EBUS procedures undertaken in patients aged 0–17 years at the Royal Children’s Hospital (Melbourne, Australia) and Thoraxklinik (Heidelberg, Germany) was performed. Data extracted included patient demographics, clinical presentation, bronchoscope (size and model), EBUS technique used, pathologic results, need for further invasive investigation, and complications. Results: Between 2008 and 2017, ten EBUS procedures were performed (6 linear EBUS and 4 radial EBUS). No complications were reported. Linear EBUS was performed on subjects who were between 4 and 15 years old, with a 100% diagnostic yield. Radial EBUS was non-diagnostic in three cases of non-malignant disease. In one case, it was used successfully for imaging alone. Conclusion: Both linear and radial EBUS are safe and feasible in children. Diagnostic yield of linear EBUS was 100%. Radial EBUS did not demonstrate utility, likely reflecting the pathologies of underlying parenchymal masses in paediatric populations.

Trisolini, R., et al. (2019). "Endobronchial ultrasound-guided transbronchial needle aspiration in sarcoidosis: Beyond the diagnostic yield." Respirology 24(6): 531-542

https://onlinelibrary.wiley.com/doi/abs/10.1111/resp.13537

                ABSTRACT Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the commonly used technique for pathological confirmation of clinically suspected sarcoidosis, mostly owing to its consistently high success rate in the detection of granulomas. However, other possible advantages, which are less appreciated and often poorly studied, may also contribute to the wider use of EBUS-TBNA in the future. These advantages include refinement of differential diagnoses through the study of lymph node characteristics during B-mode examination; reduction of complications associated with bronchoscopy, as well as improved triage of the specimen for ancillary studies with the use of rapid on-site evaluation; optimization of the quality of the sample through the selection of a target area for biopsy with minimal vascularity and absence of calcifications by using the colour Doppler and the B-mode; and prediction of the presence of extensive lymph node fibrosis by using the strain elastography module. Yet, limitations and possible clinical drawbacks should also be acknowledged. Indeed, due to the lack of specificity of the pathology findings in EBUS-derived samples, the diagnosis of sarcoidosis is one of the exclusion and should remain essentially clinical. The external validity of EBUS-TBNA results in sarcoidosis is questionable, as they mainly derive from studies in populations with a high disease prevalence. Finally, the risk exists that the low morbidity and high diagnostic yield of EBUS-TBNA may lead to its overuse in patients with clinical/radiological findings specific enough to secure a clinical diagnosis of sarcoidosis.

Therapeutic Guidelines -  Respiratory.

Available via CIAP (login required for home use).

BMJ Best Practice. Available via CIAP (login required for home use).