Cáncer de pulmón diagnosticado mediante ecoendoscopia transesofágica y biopsia por punción con aguja fina / Lung cancer diagnosed by transesophageal ecoendoscopy and fine needle aspiration biopsy

El cáncer de pulmón es la principal causa de muerte por cáncer en todo el mundo. Los nódulos pulmonares ubicados en proximidad al mediastino, retrocardíacos, cercanos a grandes vasos o por delante de la columna vertebral pueden resultar de difícil acceso por vía percutánea o broncoscópica. La punción aspiración/biopsia con aguja fina guiada por ecoendoscopía transesofágica (EUS-FNA/FNB) es un método mini invasivo con baja morbilidad que permitiría acceder a estas localizaciones. Presentamos el caso de un paciente con nódulo pulmonar solitario, en el que se obtuvo el diagnóstico de cáncer de pulmón mediante EUS-FNA/FNB.

Lung cancer is one of the leading causes of death worldwide. Pulmonary nodules located in the vicinity of the mediastinum, retrocardiac, near the aorta or pulmonary vessels, and in front of the spine, may be difficult to access through a percutaneous or bronchoscopic approach. Fine needle aspiration/biopsy guided by transesophageal echoendoscopy (EUS-FNA/FNB) is a minimally invasive method with low morbidity that could allow access to lesions in these places. We present the case of a patient with a solitary pulmonary nodule, in which the diagnosis of lung cancer was obtained by EUS-FNA/FNB.

Is the new procore 20g double forward-bevel needle capable to obtain better histological samples by endoscopic ultrasound for diagnosing solid pancreatic lesions? / A nova agulha procore 20g com bisel frontal duplo é capaz de obter melhores amostras histológicas por ecoendoscopia no diagnóstico de lesões sólidas pancreáticas?

ABSTRACT Background: It is important to obtain representative histological samples of solid biliopancreatic lesions without a clear indication for resection. The role of new needles in such task is yet to be determined. Aim: To compare performance assessment between 20G double fine needle biopsy (FNB) and conventional 22G fine needle aspiration (FNA) needles for endoscopic ultrasound (EUS)-guided biopsy. Methods: This prospective study examined 20 patients who underwent the random puncture of solid pancreatic lesions with both needles and the analysis of tissue samples by a single pathologist. Results: The ProCore 20G FNB needle provided more adequate tissue samples (16 vs. 9, p=0.039) with better cellularity quantitative scores (11 vs. 5, p=0.002) and larger diameter of the histological sample (1.51±1.3 mm vs. 0.94±0.55 mm, p=0.032) than the 22G needle. The technical success, puncture difficulty, and sample bleeding were similar between groups. The sensitivity, specificity, and diagnostic accuracy were 88.9%, 100%, and 90% and 77.8%, 100%, and 78.9% for the 20G and 22G needles, respectively. Conclusions: The samples obtained with the ProCore 20G FNB showed better histological parameters; although there was no difference in the diagnostic performance between the two needles, these findings may improve pathologist performance.

RESUMO Racional: As lesões sólidas pancreáticas não ressecáveis cirurgicamente demandam boa amostragem tecidual para definição histológica e condução oncológica . O papel das novas agulhas de ecopunção no aprimoramento diagnóstico ainda necessita elucidação. Objetivo: Comparar as biópsias guiadas por ecoendoscoopia com a nova agulha 20G de bisel frontal duplo (FNB) com a agulha de aspiração fina 22G convencional. Métodos: Este estudo prospectivo avaliou 20 pacientes submetidos à punção de lesões pancreáticas sólidas com ambas agulhas e envolveu análise de amostras teciduais por um único patologista. Resultados: A agulha FNB 20G forneceu amostras de tecido mais adequadas (16 vs. 9, p=0,039) com melhores escores quantitativos de celularidade (11 vs. 5, p=0,002) e maior diâmetro máximo da amostra histológica (1,51±1,3 mm vs. 0,94±0,55 mm, p=0,032) que a agulha 22G. O sucesso técnico, dificuldade de punção e sangramento da amostra foram semelhantes entre os grupos. A sensibilidade, especificidade e acurácia diagnóstica foram 88,9%, 100% e 90% e 77,8%, 100% e 78,9% para as agulhas 20G e 22G, respectivamente. Conclusão: As amostras obtidas com a FNB 20G apresentaram melhores parâmetros histológicos, embora não tenha havido diferença no desempenho diagnóstico entre as duas agulhas.

The role of endobronchial ultrasound-guided transbronchial needle aspiration in isolated intrathoracic lymphadenopathy in non-neoplastic patients: a common dilemma in clinical practice / O papel da aspiração transbrônquica com agulha guiada por ultrassonografia endobrônquica na linfonodomegalia intratorácica isolada em pacientes não neoplásicos: um dilema comum na prática clínica

ABSTRACT Objective: To determine the diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in non-neoplastic patients with isolated intrathoracic lymphadenopathy (IL). Methods: This was a retrospective study of patients with isolated IL referred for EBUS-TBNA. We calculated the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of EBUS-TBNA in the diagnosis of granulomatous, reactive, and neoplastic lymphadenopathy. In cases of nonspecific granulomas, reactive lymphadenopathy, or inconclusive results, a definitive diagnosis was established by other diagnostic procedures or during a follow-up period of at least 18 months. Results: Among the 58 patients included in the study, EBUS-TBNA established a diagnosis of granulomatous disease in 22 (38%), reactive lymphadenopathy in 15 (26%), cancer in 8 (14%), and other diseases in 3 (5%). Results were inconclusive in 10 (17%), the diagnosis being established by other bronchoscopic procedures in 2 (20%) and by surgical procedures in 8 (80%). A final diagnosis of reactive lymphadenopathy was established in 12. Of those, 11 (92%) had their diagnosis confirmed during follow-up and 1 (8%) had their diagnosis confirmed by mediastinoscopy. In another 3, a final diagnosis of sarcoidosis or neoplasm was established. For the diagnosis of granulomatous disease, neoplasms, and reactive lymphadenopathy, EBUS-TBNA was found to have a sensitivity of 73%, 68%, and 92%, respectively; a specificity of 100%, 100%, and 93%, respectively; an accuracy of 86%, 93%, and 93%, respectively; a PPV of 100%, 100%, and 80%, respectively; and an NPV of 78%, 92%, and 98%, respectively. Conclusions: In non-neoplastic patients, granulomatous disease and reactive lymphadenopathy appear to be common causes of isolated IL. EBUS-TBNA shows promising results as a first-line minimally invasive diagnostic procedure. The results obtained by EBUS-TBNA can be optimized by examining clinical and radiological findings during follow-up or by comparison with the results obtained with other bronchoscopic methods.

RESUMO Objetivo: Determinar o rendimento diagnóstico da endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA, aspiração transbrônquica com agulha guiada por ultrassonografia endobrônquica) em pacientes não neoplásicos com linfonodomegalia intratorácica (LI) isolada. Métodos: Estudo retrospectivo com pacientes com LI isolada encaminhados para EBUS-TBNA. Foram calculados a sensibilidade, especificidade, precisão, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) da EBUS-TBNA no diagnóstico de linfadenopatia granulomatosa, reacional e neoplásica. Em casos de granulomas inespecíficos, linfadenopatia reacional ou resultados inconclusivos, o diagnóstico definitivo foi estabelecido por meio de outros procedimentos diagnósticos ou ao longo de pelo menos 18 meses de acompanhamento. Resultados: Nos 58 pacientes incluídos, a EBUS-TBNA permitiu que se estabelecesse o diagnóstico de doença granulomatosa em 22 (38%), linfadenopatia reacional em 15 (26%), câncer em 8 (14%) e outras doenças em 3 (5%). Os resultados foram inconclusivos em 10 (17%), nos quais o diagnóstico foi feito por meio de outros procedimentos broncoscópicos, em 2 (20%), ou de procedimentos cirúrgicos, em 8 (80%). O diagnóstico final de linfadenopatia reacional foi feito em 12. Destes, 11 (92%) receberam confirmação diagnóstica durante o acompanhamento e 1 (8%), por meio de mediastinoscopia. Em outros 3, o diagnóstico final foi sarcoidose ou neoplasia. Para o diagnóstico de doença granulomatosa, câncer e linfadenopatia reacional, a EBUS-TBNA apresentou sensibilidade de 73%, 68% e 92%, respectivamente; especificidade de 100%, 100% e 93%, respectivamente; precisão de 86%, 93% e 93%, respectivamente; VPP de 100%, 100% e 80%, respectivamente; VPN de 78%, 92% e 98%, respectivamente. Conclusões: Em pacientes não neoplásicos, doenças granulomatosas e linfadenopatia reacional parecem ser causas comuns de LI isolada. A EBUS-TBNA apresenta resultados promissores como procedimento diagnóstico minimamente invasivo de primeira linha. Os resultados obtidos pela EBUS-TBNA podem ser otimizados pelos achados clínicos e radiológicos durante o acompanhamento ou pela comparação com os resultados de outros métodos broncoscópicos.

EBUS-TBNA versus surgical mediastinoscopy for mediastinal lymph node staging in potentially operable non-small cell lung cancer: a systematic review and meta-analysis / EBUS-TBNA versus mediastinoscopia cirúrgica no estadiamento linfonodal mediastinal do câncer de pulmão de células não pequenas potencialmente operável: revisão sistemática e meta-análise

ABSTRACT Objective: Lung cancer (LC) is one of the leading causes of death worldwide. Accurate mediastinal staging is mandatory in order to assess prognosis and to select patients for surgical treatment. EBUS-TBNA is a minimally invasive procedure that allows sampling of mediastinal lymph nodes (LNs). Some studies have suggested that EBUS-TBNA is preferable to surgical mediastinoscopy for mediastinal staging of LC. The objective of this systematic review and meta-analysis was to compare EBUS-TBNA and mediastinoscopy in terms of their effectiveness for mediastinal LN staging in potentially operable non-small cell lung cancer (NSCLC). Methods: This was a systematic review and meta-analysis, in which we searched various databases. We included studies comparing the accuracy of EBUS-TBNA with that of mediastinoscopy for mediastinal LN staging in patients with NSCLC. In the meta-analysis, we calculated sensitivity, specificity, positive likelihood ratios, and negative likelihood ratios. We also analyzed the risk difference for the reported complications associated with each procedure. Results: The search identified 4,201 articles, 5 of which (with a combined total of 532 patients) were selected for inclusion in the meta-analysis. There were no statistically significant differences between EBUS-TBNA and mediastinoscopy in terms of the sensitivity (81% vs. 75%), specificity (100% for both), positive likelihood ratio (101.03 vs. 95.70), or negative likelihood ratio (0.21 vs. 0.23). The area under the summary ROC curve was 0.9881 and 0.9895 for EBUS-TBNA and mediastinoscopy, respectively. Although the number of complications was higher for mediastinoscopy, the difference was not significant (risk difference: −0.03; 95% CI: −0.07 to 0.01; I2 = 76%). Conclusions: EBUS-TBNA and mediastinoscopy produced similar results for mediastinal staging of NSCLC. EBUS-TBNA can be the procedure of first choice for LN staging in patients with NSCLC.

RESUMO Objetivo: O câncer de pulmão (CP) é uma das principais causas de morte no mundo. Um estadiamento mediastinal preciso é obrigatório para avaliação do prognóstico e seleção de pacientes para tratamento cirúrgico. EBUS-TBNA é um procedimento minimamente invasivo que permite a amostragem de linfonodos mediastinais. Alguns estudos sugerem que a EBUS-TBNA é preferível que a mediastinoscopia cirúrgica no estadiamento mediastinal do CP. O objetivo desta revisão sistemática e meta-análise foi comparar a eficácia da EBUS-TBNA e da mediastinoscopia no estadiamento linfonodal mediastinal do câncer de pulmão de células não pequenas (CPCNP) potencialmente operável. Métodos: Foram pesquisados diversos bancos de dados. Estudos comparando a precisão da EBUS-TBNA e da mediastinoscopia no estadiamento linfonodal mediastinal em pacientes com CPCNP foram incluídos. Na meta-análise, foram calculadas sensibilidade e especificidade, bem como razões de verossimilhança positiva e negativa. A diferença de risco de complicações relatadas para cada procedimento também foi analisada. Resultados: A pesquisa identificou 4.201 artigos, dos quais 5 foram selecionados para a meta-análise (total combinado de 532 pacientes). Não houve diferenças estatisticamente significativas entre EBUS-TBNA e mediastinoscopia: sensibilidade (81% vs. 75%), especificidade (100% para ambas), razão de verossimilhança positiva (101,03 vs. 95,70) e razão de verossimilhança negativa (0,21 vs. 0,23). A área sob a curva summary ROC para EBUS-TBNA e para mediastinoscopia foi de 0,9881 e 0,9895, respectivamente. Embora o número de complicações tenha sido maior para mediastinoscopia, não foi encontrada diferença significativa (diferença de risco: −0,03; IC95%: −0,07 to 0,01; I2 = 76%). Conclusões: EBUS-TBNA e mediastinoscopia apresentaram resultados semelhantes no estadiamento mediastinal do CPCNP. EBUS-TBNA pode ser o procedimento de primeira escolha no estadiamento linfonodal em pacientes com CPCNP.

Citología aspirativa con aguja fina transbroncoscópica guiada por ultrasonido endobronquial / Endobronchial ultrasound-guided transbronchoscopic fine needle aspiration cytology

Introducción: El enfrentamiento diagnóstico de las lesiones sospechosas de cáncer pulmonar ha cambiado en los últimos años. Objetivo: Describir el primer caso diagnosticado en Cuba de carcinoma de pulmón por aspiración transbronquial por aguja fina guiada por ultrasonografía endobronquial. Presentación del caso: Se presenta un caso de carcinoma indiferenciado de células pequeñas. El diagnóstico se obtiene mediante la realización de una citología aspirativa con aguja fina de ganglios mediastinales, transbroncoscópica y guiada por ultrasonido endobronquial. Conclusiones: El uso de EBUS-TBNA es una herramienta con un alto rendimiento diagnóstico, con escasas complicaciones descritas y debe considerarse como una posibilidad en el estudio de lesiones adyacentes a la vía aérea central(AU)

Introduction: The diagnostic confrontation of lesions suspected of lung cancer has changed in recent years. Objective: To describe the first case of lung carcinoma, diagnosed in Cuba by endobronchial ultrasound-guided transbronchoscopic fine needle aspiration cytology. Case report: A case of undifferentiated small cell carcinoma is reported. Diagnosis is obtained by performing a fine needle aspiration cytology of the mediastinal lymph nodes, transbronchoscopic and guided by endobronchial ultrasound. Conclusions: The use of EBUS-TBNA is a tool with high diagnostic yield, with few described complications and should be considered as a possibility in the study of lesions adjacent to the central airway(AU)

Endobronchial ultrasound: a minimally invasive technology to assist diagnosis of thoracic diseases / Ultrassonografia endobrônquica: tecnologia minimamente invasiva para auxiliar no diagnóstico de doenças torácicas

ABSTRACT The endobronchial ultrasound is a minimally invasive technique that simultaneously associates ultrasound and bronchoscopy, to visualize lung nodule or masses, airway wall, and structures adjacent to the tracheobronchial tree. Endobronchial ultrasound has been incorporated into clinical practice all over the world because of its low risk and high diagnostic yield in neoplastic and non-neoplastic disease.

RESUMO A ultrassonografia endobrônquica é uma técnica minimamente invasiva que associa simultaneamente broncoscopia à ultrassonografia, com a finalidade de visualizar nódulos ou massas pulmonares, paredes das vias aéreas, e estruturas ao redor de toda a árvore traqueobrônquica. A ultrassonografia endobrônquica foi incorporada à prática clínica em todo o mundo devido a seu baixo risco e elevado rendimento diagnóstico em doenças neoplásicas e não neoplásicas.

Adequate rectal preparation reduces hospital admission for urosepsis after transrectal ultrasound - guided prostate biopsy

ABSTRACT Objectives: Previous studies have compared infectious outcomes on the basis of whether rectal preparation was performed; however, they failed to evaluate the quality of each rectal preparation, which may have led to confounding results. This study aimed to compare hospitalizations for urosepsis within 1 month after transrectal ultrasound-guided prostate biopsy between patients with adequate and traditional rectal preparations. Materials and Methods: Between January 2011 and December 2016, a total of 510 patients who underwent transrectal ultrasound - guided prostate biopsy at our institutions and were orally administered prophylactic antibiotics (levofloxacin) were included. Two rectal preparations were performed: (1) adequate rectal preparation confirmed by digital rectal examination and transrectal ultrasound (Group A, n = 310) and (2) traditional rectal preparation (Group B, n = 200). All patient characteristics were recorded. A logistic regression model was used to assess the effects of the two different rectal preparations on urosepsis, adjusted by patient characteristics. Results: There were a total of three and nine hospitalizations for urosepsis in Groups A and B, respectively. Differences in the demographic data between the two groups were insignificant. Logistic regression showed that adequate rectal preparation before biopsy significantly decreased the risk for urosepsis after biopsy (adjusted odds ratio: 0.2; 95% confidence interval: 0.05 - 0.78; P = 0.021). Conclusions: Adequate rectal preparation could significantly reduce hospitalizations for urosepsis within 1 month after transrectal ultrasound-guided prostate biopsy. The quality of rectal preparation should be evaluated before biopsy. If adequate rectal preparation is not achieved, postponing the biopsy and adjusting the rectal preparation regimen are suggested.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in diagnosis of mediastinal lesions / Punção aspirativa por agulha guiada por ultrassom endobrônquico (EBUS-TBNA) no diagnóstico de lesões do mediastino

ABSTRACT Objective To describe the results of endobronchial ultrasound-guided transbronchial needle aspiration in making diagnosis of mediastinal injuries associated to different causes. Methods A retrospective cross-sectional study of patients submitted to Endobronchial ultrasound-guided transbronchial needle aspiration at a private organization, between June 2013 and October 2016. All cases referred for collection of lymph nodes or peritracheal/peribronchial masses by endobronchial ultrasound-guided transbronchial needle aspiration, and evaluated through tomography or PET-CT were included. Interventional pulmonologists and thoracic surgeons with experience in the method did the procedures. Rapid on-site evaluation of fine needle aspiration was performed by an experienced pathologist. Material analysis included cytological smear and cytopathological analysis of paraffin-embedded cell blocks. Other specific analyses (immunocytochemistry, tests and cultures of infectious agents) were performed whenever necessary. Results We included 72 patients; 6 were excluded for presenting endobronchial lesions in which bronchoscopic biopsy could be performed, or intrathoracic lesions that were not accessible by endobronchial ultrasound-guided transbronchial needle aspiration. The mean age of 66 patients included for analysis was 61.17 years (±14.67 years), with a predominance of males (64%). Endobronchial ultrasound-guided transbronchial needle aspiration was definitive for diagnosis in 60 cases (91%). Three cases (4.5%) had inconclusive test results. There were no major complications related to the procedure. Conclusion Endobronchial ultrasound-guided transbronchial needle aspiration had a high diagnosis yield, with minimal morbidity, being an excellent option for diagnostic approach of patients with lymphadenopathy or intrathoracic lesions, and for neoplasm staging.

RESUMO Objetivo Descrever os resultados da utilização de punção aspirativa por agulha guiada por ultrassom endobrônquico na definição do diagnóstico em casos de lesões mediastinais por diferentes causas. Métodos Estudo transversal retrospectivo de pacientes submetidos à punção aspirativa por agulha guiada por ultrassom endobrônquico em instituição privada, entre junho de 2013 e outubro de 2016. Foram incluídos todos os casos referenciados para coleta de materiais de linfonodos ou massas peritraqueais/peribrônquicas por punção aspirativa por agulha guiada por ultrassom endobrônquico, estudados com tomografia ou PET-CT. Os procedimentos foram realizados por pneumologistas intervencionistas e cirurgiões torácicos com experiência no método. Rapid on-site evaluation da punção aspirativa por agulha fina foi realizada por patologista experiente. A análise do material incluiu citologia dos esfregaços em lâminas e análise citopatológica do emblocado celular. Outras análises específicas (imunocitoquímica, pesquisas e culturas de agentes infecciosos) foram realizadas se necessárias. Resultados Foram incluídos 72 pacientes; destes, 6 foram excluídos por apresentarem lesões endobrônquicas passíveis de biópsia broncoscópica convencional ou lesões intratorácicas não acessíveis a punção aspirativa por agulha guiada por ultrassom endobrônquico. Assim, a média de idade dos 66 pacientes incluídos para análise foi 61,17 anos (±14,67 anos), com predomínio do sexo masculino (64%). A punção aspirativa por agulha guiada por ultrassom endobrônquico foi definitivo para o diagnóstico em 60 casos (91%). Três casos (4,5%) foram inconclusivos. Não houve complicações maiores relacionadas ao procedimento. Conclusão A punção aspirativa por agulha guiada por ultrassom endobrônquico teve elevado rendimento diagnóstico, com mínima morbidade, constituindo excelente opção na abordagem diagnóstica de pacientes com linfadenopatia ou lesões intratorácicas e no estadiamento de neoplasias.

Utilidad del ultrasonido endobronquial para el diagnóstico y etapificación del cáncer pulmonar / Endobronchial ultrasound-guided transbronchial needle aspiration

In the last years, several techniques have been developed to obtain a prompt diagnosis or rule out lung cancer. Endobronchial ultrasound- guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for mediastinal and central pulmonary lesions. This procedure is especially useful for lung cancer diagnosis and mediastinal staging. Two different types of EBUS are currently available: Radial EBUS and lineal EBUS. Each one has technical differences together with a range of clinical indications. The aim of this review is to discuss about EBUS-TBNA and its current clinical indications, evidence about the accuracy of the procedure for lung cancer diagnosis and staging, and evaluation of the pathological and molecular studies (EGFR, ALK, and ROS1) obtained through EBUS-TBNA and rapid on-site evaluation (ROSE).

Is endobronchial ultrasound-guided transbronchial needle aspiration with a stylet necessary for lymph node screening in lung cancer patients?

During endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), a needle is commonly used with a stylet, although recently the stylet has been omitted. This prospective study aimed to compare the quality of specimens obtained by EBUS-TBNA performed with and without a stylet. Between November 2013 and November 2014, 131 patients with lung cancer underwent EBUS-TBNA, with a total of 148 mediastinal or hilar lymph nodes sampled both with and without an inner-stylet, yielding 296 cytological specimens. Specimens were scored cytologically using five parameters: background blood or clot, amount of cellular material, degree of cellular degeneration, degree of cellular trauma, and retention of appropriate architecture. The procedure with a stylet required significantly longer operation time than without a stylet (14.5±0.8 vs 12.7±1.1 min, P<0.001). Excellent specimens were obtained in 261/296 and 260/296 samples in the procedures with and without a stylet, respectively (P=0.9), while the remaining 35 and 36 samples, respectively, were adequate. The diagnosing and staging of lung cancer using EBUS-TBNA did not differ significantly between the groups. In conclusion, specimen collection by EBUS-TBNA without a stylet is easier and faster than the procedure using a stylet and absence of a stylet did not alter specimen quality or diagnostic accuracy.

Evaluación rápida "in situ" de punción con aguja fina guiada por endosonografía mejora rendimiento diagnóstico de lesiones pancreáticas sólidas / Rapid on-site evaluation with endoscopic ultra sound-guided fine needle improves diagnostic yield of solid pancreatic masses

BACKGROUND: The use of endoscopic ultrasound with fine needle aspiration (EUS-FNA) has improved the characterization and staging of pancreatic solid masses. The primary strategy for improving the ability to diagnose malignant masses is the use of rapid on site evaluation (ROSE) by a cytopathologist. OBJECTIVE: To evaluate the diagnostic yield of EUS-FNA after the implementation of ROSE in an academic center. MATERIAL AND METHODS: Prospective enrollment and follow-up of EUS-FNA with ROSE during 2015 and 2016, was compared to EUS-FNA without ROSE in previous years (2011-2014) in Hospital Clínico UCChristus. Clinical and endosonographic features, cytopathological and histological diagnosis and number of passes per procedure were evaluated. All EUS-FNA included cytology and cellular block for definitive diagnosis. RESULTS: 59 pancreatic solid masses were included in the analysis. 44 EUS-FNA were performed with ROSE, compared with 15 EUS-FNA without ROSE. The mean age of patients included was 62.8 years, 54.2% male gender, and most masses studied were in the head of pancreas (77.6%). In EUS 86.5% were hypoechoic and 56.9% had poor defined margins. No differences in baseline characteristics were observed between groups. EUS-FNA led to diagnosis in 86.2% of the overall sample. The diagnostic rate was superior in the group of EUS-FNA with ROSE, compared to EUS-FNA without ROSE (97.7% vs 50%, p < 0.0001). The mean number of passes was inferior in EUS-FNA ROSE (+) (2.71 vs 5.78, p < 0.0001). No differences in rate of complications were observed between groups. CONCLUSION: The use of ROSE associated to EUS-FNA improves the diagnostic yield in the evaluation of pancreatic solid masses. Our findings are consistent with those described in the literature, recommending the use of ROSE in EUS-FNA in centers where the diagnostic yield is less than 90% without the use of ROSE

INTRODUCCIÓN: La adquisición de tejido mediante el uso de endosonografía, con punción con aguja fina, (EUS-FNA) ha mejorado el diagnóstico de lesiones pancreáticas sólidas. La principal medida para aumentar el rendimiento diagnóstico de la EUS-FNA es la evaluación por citopatólogo próximo al lugar de punción (in situ) (técnica conocida en inglés como ROSE "rapid on-site evaluation"). OBJETIVO: Evaluar el rendimiento diagnóstico de EUS-FNA en lesiones pancreáticas sólidas posterior a la implementación de ROSE en un centro universitario. MATERIAL Y MÉTODOS: Registro prospectivo de EUS-FNA realizadas con ROSE durante el período 2015-2016, comparado con EUS-FNA con evaluación histopatológica diferida realizada entre los años 2011-2014, en Hospital Clínico UC-Christus. Se evaluaron características clínicas, endosonográficas, diagnóstico histopatológico y número de pases por procedimiento. Todas las EUS-FNA incluyeron citología y block celular para diagnóstico definitivo. RESULTADOS: Se incluyeron en el análisis 59 lesiones pancreáticas sólidas evaluadas con EUS-FNA. Seguimiento prospectivo de 44 EUS-FNA con ROSE, que fueron comparadas con 15 EUS-FNA sin evaluación in situ (retrospectivo). La muestra total incluyó individuos con un promedio de 62,8 años de edad, 54,2% hombres, donde 77,6% de las lesiones se ubicaba en la cabeza pancreática. Endosonográficamente 86,5% de las lesiones eran hipoecoicas y 56,9% tenían márgenes poco definidos. La EUS-FNA fue diagnóstica en 86,2% del total de la muestra. Las EUS-FNA realizadas con ROSE presentaron un mayor rendimiento diagnóstico respecto a las efectuadas sin evaluación in situ (97,7% vs 50%, p < 0,0001). El número de pases por procedimiento fue menor (2,7% vs 5,8%, p < 0,0001) en el grupo con ROSE. No hubo diferencias en complicaciones en ambos grupos. CONCLUSIÓN: La evaluación por citopatólogo in situ de la muestra obtenida por EUS-FNA mejora el rendimiento diagnóstico de las lesiones pancreáticas sólidas. Nuestros hallazgos apoyan el uso de ROSE asociado a EUS-FNA, siendo concordantes con las recomendaciones actuales de utilizar evaluación histopatológica in situ en EUS-FNA, especialmente en centros donde el rendimiento diagnóstico sin uso de ROSE es menor a 90%.

Radial-probe EBUS for the diagnosis of peripheral pulmonary lesions / Ecobroncoscopia radial para o diagnóstico de lesões pulmonares periféricas

ABSTRACT Objective: Conventional bronchoscopy has a low diagnostic yield for peripheral pulmonary lesions. Radial-probe EBUS employs a rotating ultrasound transducer at the end of a probe that is passed through the working channel of the bronchoscope. Radial-probe EBUS facilitates the localization of peripheral pulmonary nodules, thus increasing the diagnostic yield. The objective of this study was to present our initial experience using radial-probe EBUS in the diagnosis of peripheral pulmonary lesions at a tertiary hospital. Methods: We conducted a retrospective analysis of 54 patients who underwent radial-probe EBUS-guided bronchoscopy for the investigation of pulmonary nodules or masses between February of 2012 and September of 2013. Radial-probe EBUS was performed with a flexible 20-MHz probe, which was passed through the working channel of the bronchoscope and advanced through the bronchus to the target lesion. For localization of the lesion and for collection procedures (bronchial brushing, transbronchial needle aspiration, and transbronchial biopsy), we used fluoroscopy. Results: Radial-probe EBUS identified 39 nodules (mean diameter, 1.9 ± 0.7 cm) and 19 masses (mean diameter, 4.1 ± 0.9 cm). The overall sensitivity of the method was 66.7% (79.5% and 25.0%, respectively, for lesions that were visible and not visible by radial-probe EBUS). Among the lesions that were visible by radial-probe EBUS, the sensitivity was 91.7% for masses and 74.1% for nodules. The complications were pneumothorax (in 3.7%) and bronchial bleeding, which was controlled bronchoscopically (in 9.3%). Conclusions: Radial-probe EBUS shows a good safety profile, a low complication rate, and high sensitivity for the diagnosis of peripheral pulmonary lesions.

RESUMO Objetivo: A broncoscopia convencional possui baixo rendimento diagnóstico para lesões pulmonares periféricas. A ecobroncoscopia radial (EBUS radial) emprega um transdutor ultrassonográfico rotatório na extremidade de uma sonda que é inserida no canal de trabalho do broncoscópio. O EBUS radial facilita a localização de nódulos pulmonares periféricos, aumentando assim o rendimento diagnóstico. O objetivo deste estudo foi apresentar nossa experiência inicial com o uso de EBUS radial para o diagnóstico de lesões pulmonares periféricas em um hospital terciário. Métodos: Foi realizada uma análise retrospectiva de 54 pacientes submetidos à broncoscopia guiada por EBUS radial para a investigação de nódulos ou massas pulmonares entre fevereiro de 2012 e setembro de 2013. O EBUS radial foi realizado com uma sonda flexível de 20 MHz, que foi inserida no canal de trabalho do broncoscópio até chegar à lesão-alvo. A fluoroscopia foi usada para localizar a lesão e realizar procedimentos de coleta (escovado brônquico, aspiração transbrônquica com agulha e biópsia transbrônquica). Resultados: O EBUS radial identificou 39 nódulos (média de diâmetro: 1,9 ± 0,7 cm) e 19 massas (média de diâmetro: 4,1 ± 0,9 cm). A sensibilidade global do EBUS radial foi de 66,7% (79,5% para as lesões visíveis pelo método e 25% para as lesões não visíveis pelo método). Nas lesões visíveis pelo método, a sensibilidade foi de 91,7% para massas e de 74,1% para nódulos. As complicações foram pneumotórax (3,7%) e sangramento brônquico controlado broncoscopicamente (9,3%). Conclusões: O EBUS radial apresenta bom perfil de segurança, baixo índice de complicações e alta sensibilidade para o diagnóstico de lesões pulmonares periféricas.

Increasing diagnostic effectiveness of thyroid nodule evaluation by implementation of cell block preparation in routine US-FNA analysis

ABSTRACT Objective Ultrasound-guided fine-needle aspiration (US-FNA) biopsy has proven to be an accurate and efficient tool in thyroid nodule evaluation. We evaluated whether cell block adds to the diagnostic accuracy of US-FNA. Subjects and methods Three hundred twenty-eight consecutive patients underwent US-FNA, cytology and cell block evaluation. Six slides were prepared for each patient and stained by Papanicolaou and Giemsa techniques. The residual hemorrhagic aspirate in the syringe and needle was fixed in 10% formalin and paraffin-embedded (cell block). The histological sections were examined as a complementary diagnostic tool to US-FNA. Results The study population comprised 89% females and the mean age was 57.4 ± 13.7 years. The mean nodule size was 2.3 ± 1.2 cm. US-FNA cytological results were as follows: Bethesda I, 17.1% (n = 56); Bethesda II, 61.6% (n = 202); Bethesda III, 9.5% (n = 31); Bethesda IV, 5.8% (n = 19); Bethesda V, 2.4% (n = 8), and Bethesda VI, 3.6% (n = 12). Cell blocks were obtained in 100% of cases and were considered diagnostic in 89.6%. Combined cytological and cell block (cyto-cell block) results were as follows: unsatisfactory, 4.3% (n = 14); benign, 72.6% (n = 238); indeterminate, 11.3% (n = 37); follicular lesion, 5.8% (n = 19); suspicious for malignancy, 2.4% (n = 8), and malignant, 3.6% (n = 12). The sensitivity and specificity for cyto-cell block was 100% and 90%, respectively, and the accuracy was 94%. Cyto-cell block analysis reduced the rate of unsatisfactory samples (p < 0.001). Conclusions The cyto-cell block interpretation improved the efficiency of US-FNA. This simple, fast and low-cost technique should be used as an adjunctive test in thyroid nodule evaluation. Arch Endocrinol Metab. 2016;60(4):367-73.

Ultrasonografía bronquial con aspiración por aguja fina en el estudio lesiones adyacentes a la vía aérea central / Endobronchial ultrasound and fine needle aspiration for central airway lesions

Background: Endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for lesions adjacent to the central airway. Aim: To describe the diagnostic yield of EBUS-TBNA for lesions suspicious of Non-Small Cell Lung Cancer (NSCLC). Material and Methods: Prospective study of 128 patients aged 25 to 87 years (56% males) undergoing EBUS-TBNA. Radiological features of the lesions were recorded by chest CT scan such as morphology, margins of the lesion, lesion size and location based on the International Association for the Study of Lung Cancer (IASLC) map. Definitive pathological results were evaluated. Results: The average size of lesions was 18.5 millimeter and; 68 cases were of less than 20 millimeters. Sensitivity was 96.7%, specificity 100%, and negative predictive value 93.3%. The most common histological diagnosis was adenocarcinoma. Conclusions: EBUS-TBNA is a useful diagnostic tool for NSCLC suspicious lesions adjacent to the central airway.

Visually Estimated MRI Targeted Prostate Biopsy Could Improve the Detection of Significant Prostate Cancer in Patients with a PSA Level <10 ng/mL

PURPOSE: To compare prostate cancer detection rates between 12 cores transrectal ultrasound-guided prostate biopsy (TRUS-Bx) and visually estimated multiparametric magnetic resonance imaging (mp-MRI)-targeted prostate biopsy (MRI-visual-Bx) for patients with prostate specific antigen (PSA) level less than 10 ng/mL. MATERIALS AND METHODS: In total, 76 patients with PSA levels below 10 ng/mL underwent 3.0 Tesla mp-MRI and TRUS-Bx prospectively in 2014. In patients with abnormal lesions on mp-MRI, we performed additional MRI-visual-Bx. We compared pathologic results, including the rate of clinically significant prostate cancer cores (cancer length greater than 5 mm and/or any Gleason grade greater than 3 in the biopsy core). RESULTS: The mean PSA was 6.43 ng/mL. In total, 48 of 76 (63.2%) patients had abnormal lesions on mp-MRI, and 116 targeted biopsy cores, an average of 2.42 per patient, were taken. The overall detection rates of prostate cancer using TRUS-Bx and MRI-visual-Bx were 26/76 (34.2%) and 23/48 (47.9%), respectively. In comparing the pathologic results of TRUS-Bx and MRI-visual-Bx cores, the positive rates were 8.4% (77 of 912 cores) and 46.6% (54 of 116 cores), respectively (p<0.001). Mean cancer core lengths and mean cancer core percentages were 3.2 mm and 24.5%, respectively, in TRUS-Bx and 6.3 mm and 45.4% in MRI-visual-Bx (p<0.001). In addition, Gleason score ≥7 was noted more frequently using MRI-visual-Bx (p=0.028). The detection rate of clinically significant prostate cancer was 27/77 (35.1%) and 40/54 (74.1%) for TRUS-Bx and MRI-visual-Bx, respectively (p<0.001). CONCLUSION: MRI-visual-Bx showed better performance in the detection of clinically significant prostate cancer, compared to TRUS-Bx among patients with a PSA level less than 10 ng/mL.

Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in various lung diseases / Valor diagnóstico da punção aspirativa por agulha guiada por ultrassom endobrônquico em diferentes doenças pulmonares

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of lung disease, and its use is increasing worldwide. It has been used as a means of diagnosing lung cancer in its initial stages, and there are data supporting its use for the diagnosis of benign lung disease. The aim of this study was to share our experience with EBUS-TBNA and discuss its diagnostic value.Methods: We retrospectively analyzed the results related to 159 patients who underwent EBUS-TBNA at our pulmonary medicine clinic between 2010 and 2013. We recorded the location and size of lymph nodes seen during EBUS. Lymph nodes that appeared to be affected on EBUS were sampled at least twice. We recorded the diagnostic results of EBUS-TBNA and (for cases in which EBUS-TBNA yielded an inconclusive diagnosis) the final diagnoses after further investigation and follow-up.Results: We evaluated 159 patients, of whom 89 (56%) were male and 70 (44%) were female. The mean age was 54.6 ± 14.2 years among the male patients and 51.9 ± 11.3 years among the female patients. Of the 159 patients evaluated, 115 (84%) were correctly diagnosed by EBUS. The diagnostic accuracy of EBUS-TBNA was 83% for benign granulomatous diseases and 77% for malignant diseases.Conclusions: The diagnostic value of EBUS-TBNA is also high for benign pathologies, such as sarcoidosis and tuberculosis. In patients with mediastinal disorders, the use of EBUS-TBNA should be encouraged, primarily because it markedly reduces the need for mediastinoscopy.

Objetivo: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA, punção aspirativa por agulha guiada por ultrassom endobrônquico) é um novo método para o diagnóstico e estadiamento das doenças pulmonares e seu uso está aumentando em todo o mundo. Ela tem sido utilizada como um método diagnóstico de câncer de pulmão em estágios iniciais, e há dados que apoiam sua utilização para o diagnóstico de doenças pulmonares benignas. O objetivo deste estudo foi compartilhar a nossa experiência com EBUS-TBNA e discutir seu valor diagnóstico.Métodos: Analisamos, retrospectivamente, os resultados relacionados a 159 pacientes submetidos a EBUS-TBNA em nossa clínica de medicina pulmonar entre 2010 e 2013. Registramos a localização e o tamanho dos linfonodos visualizados durante EBUS. Os linfonodos suspeitos durante o procedimento foram puncionados ao menos duas vezes. Foram registrados os resultados diagnósticos por EBUS-TBNA e, para os casos com diagnóstico indefinido após EBUS-TBNA, os diagnósticos finais após investigação aprofundada e acompanhamento.Resultados: Avaliamos 159 pacientes, dos quais 89 (56%) eram homens e 70 (44%) eram mulheres. As médias de idade foram de 54,6 ± 14,2 anos nos homens e de 51,9 ± 11,3 anos nas mulheres. Dos 159 pacientes avaliados, 115 (84%) foram diagnosticados corretamente por EBUS. A acurácia diagnóstica de EBUS-TBNA foi de 83% para doenças granulomatosas benignas e de 77% para doenças malignas.Conclusões: O valor diagnóstico de EBUS-TBNA também é alto para patologias benignas, como sarcoidose e tuberculose. Em pacientes com alterações no mediastino, o uso de EBUS-TBNA deve ser incentivado, principalmente devido à redução significativa da necessidade de mediastinoscopia.

Rapid on-site cytopathological examination (ROSE) performed by endosonagraphers and its improvement in the diagnosis of pancreatic solid lesions

PURPOSE: To evaluate the diagnosis improvement of EUS-FNA when using ROSE performed by the endosonographer. METHODS: A retrospective study was conducted. A total of 48 pancreatic solid masses EUS-FNA were divided into two groups according to the availability of on-site cytology (ROSE) - the first 24 patients (group A-without ROSE) and the latter 24 cases (group B-with ROSE). Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, complications and inadequacy rate of EUS-FNA were determined and compared. RESULTS: Among the 48 EUS-FNA, the overall performance was: sensitivity 82%; specificity 100%; positive predictive value (PPV) 100%; negative predictive value (NPV) 70% and accuracy 87%. The sensitivity of the Group A was 71%, versus 94% in-group B (p=0.61). Moreover, the negative predictive value was 58% versus 87% (p=0.72). The accuracy rate increased from 79% to 96% (p=0.67) in the ROSE group. The number of punctures was similar between the groups. No major complications were reported. CONCLUSION: Rapid on-site cytopathological examination, even when performed by the endosonographer, may improve the diagnostic performance in the diagnosis of solid pancreatic lesions, regardless of the slight increase in the number of punctures. .

Prostate cancer volume estimations based on transrectal ultrasonography-guided biopsy in order to predict clinically significant prostate cancer

Tumor diameter is a reliable parameter to estimate tumor volume in solid organ cancers; its use in prostate cancer is controversial since it exhibits a more irregular pattern of growth. This study aimed to examine the association between the tumor volume estimations based on transrectal ultrasound (TRUS) guided biopsy results and the tumor volume measured on the pathological specimen.