JJ Shannon, RO Bude, JB Orens, FS Becker, RI Whyte, JM Rubin, LE Quint and FJ Martinez
Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, USA.

We conducted a randomized, controlled trial to prospectively confirm that ultrasound-directed transbronchial needle aspiration (USTBNA) results in: (1) improved sensitivity for detecting lymph nodes involved with neoplasm, and (2) a decreased number of aspirates needed to achieve a diagnosis as compared with standard transbronchial needle aspiration (TBNA). The study was conducted in a tertiary medical center on patients undergoing fiberoptic bronchoscopy in the evaluation of enlarged mediastinal lymph nodes. USTBNA or TBNA were followed by rapid, on-site cytopathology examination of the collected specimens. Measurements included the (1) age and sex of the patient, prior diagnosis of cancer, nodal short-axis diameter and node location as determined by computerized tomography (CT), and endobronchial abnormalities at bronchoscopy; (2) number, order, and location of transbronchial aspirates and results of on-site evaluation; (3) results of surgical exploration in patients with negative transbronchial needle aspiration; (4) sensitivity, specificity, and diagnostic accuracy of USTBNA and TBNA; (5) number of aspirates required for successful lymph node aspiration as well as for a diagnosis of cancer for both USTBNA and TBNA; and (6) multiple logistic regression analysis to determine the significance of combinations of clinical predictors and needle aspirate results. Eighty-two bronchoscopic examinations were performed on 80 patients. We found no significant difference between USTBNA and TBNA in sensitivity (82.6% versus 90.5%, respectively), specificity (100% for both), or diagnostic accuracy (86.7% versus 91.7%, respectively). The sensitivity, specificity, and diagnostic accuracy of USTBNA and TBNA were similarly high, regardless of node location (paratracheal or subcarinal). A decrease in the number of aspirates required for lymph node sampling approached statistical significance for all USTBNAs as compared with TBNAs (2.03 +/- 0.19 versus 2.62 +/- 0.25, p = 0.06), but this was not demonstrated for the number required to confirm cancer (1.95 +/- 0.47 versus 2.68 +/- 0.21, p = 0.17). The number of aspirates to successful lymph node aspiration decreased with USTBNA versus TBNA in paratracheal lymph nodes (2.00 +/- 0.20 versus 2.91 +/- 0.34, p = 0.03), but not to a diagnosis of cancer (1.93 +/- 0.25 versus 3.00 +/- 0.58, p = 0.11). No difference was seen in the number of aspirates for subcarinal nodes. The number of TBNA attempts for paratracheal lymph node sampling was inversely correlated with node size (r = 0.48, p = 0.02). No such relation was seen with USTBNA of paratracheal nodes (r = 0.09, p = 0.66), TBNA of subcarinal nodes, or USTBNA of subcarinal nodes. A similar relation was seen between the number of aspirates to a diagnosis of cancer. On multiple logistic regression analysis, a positive transbronchial aspirate was associated only with a larger lymph node and history of prior cancer. We conclude that: (1) in the setting of on-site cytopathology, transbronchial needle aspiration has a high sensitivity, specificity, and diagnostic accuracy in the evaluation of enlarged mediastinal lymph nodes suspected of harboring malignancy; (2) mediastinal anatomy, including vascular structures and lymph nodes, is clearly imaged with endobronchial ultrasonography; (3) a greater short-axis diameter of the mediastinal lymph node and history of a prior malignancy increase the likelihood of a positive transbronchial aspiration; (4) USTBNA exhibits a similarly high diagnostic yield to TBNA in the setting of rapid on- site cytopathology evaluation; (5) USTBNA decreases the number of aspirates required for paratracheal lymph node sampling, which may be particularly useful in sampling smaller paratracheal nodes or at institutions that do not utilize rapid on-site cytopathology evaluation.

This article has been cited by other articles:

				W A H Wallace, H M Monaghan, D M Salter, M A Gibbons, and K M Skwarski Endobronchial ultrasound-guided fine-needle aspiration and liquid-based thin-layer cytology J. Clin. Pathol., April 1, 2007; 60(4): 388 - 391. [Abstract] [Full Text] [PDF]

				T.-Y. Chao, C.-H. Lie, Y.-H. Chung, J.-L. Wang, Y.-H. Wang, and M.-C. Lin Differentiating peripheral pulmonary lesions based on images of endobronchial ultrasonography. Chest, October 1, 2006; 130(4): 1191 - 1197. [Abstract] [Full Text] [PDF]

				D. Baram, R. B. Garcia, and P. S. Richman Impact of Rapid On-Site Cytologic Evaluation During Transbronchial Needle Aspiration Chest, August 1, 2005; 128(2): 869 - 875. [Abstract] [Full Text] [PDF]

				K. Kanoh, T. Miyazawa, N. Kurimoto, Y. Iwamoto, Y. Miyazu, and N. Kohno Endobronchial Ultrasonography Guidance for Transbronchial Needle Aspiration Using a Double-Channel Bronchoscope Chest, July 1, 2005; 128(1): 388 - 393. [Abstract] [Full Text] [PDF]

				S. Gupta, K. Seaberg, M. J. Wallace, D. C. Madoff, F. A. Morello Jr, K. Ahrar, R. Murthy, and M. E. Hicks Imaging-guided Percutaneous Biopsy of Mediastinal Lesions: Different Approaches and Anatomic Considerations RadioGraphics, May 1, 2005; 25(3): 763 - 786. [Abstract] [Full Text] [PDF]

				E. Kikuchi, K. Yamazaki, N. Sukoh, J. Kikuchi, H. Asahina, M. Imura, Y. Onodera, N. Kurimoto, I. Kinoshita, and M. Nishimura Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions Eur. Respir. J., October 1, 2004; 24(4): 533 - 537. [Abstract] [Full Text] [PDF]

				K. Yasufuku, M. Chiyo, Y. Sekine, P. N. Chhajed, K. Shibuya, T. Iizasa, and T. Fujisawa Real-time Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of Mediastinal and Hilar Lymph Nodes Chest, July 1, 2004; 126(1): 122 - 128. [Abstract] [Full Text] [PDF]

				C M Richardson and M D Peake Endoscopic (oesophageal) ultrasound guided fine needle aspiration (EUS-FNA) Thorax, July 1, 2004; 59(7): 546 - 547. [Full Text]

				L.-H. Hsu, C.-C. Liu, and J.-S. Ko Education and Experience Improve the Performance of Transbronchial Needle Aspiration: A Learning Curve at a Cancer Center Chest, February 1, 2004; 125(2): 532 - 540. [Abstract] [Full Text] [PDF]

				F. Herth, H. D. Becker, and A. Ernst Conventional vs Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Randomized Trial Chest, January 1, 2004; 125(1): 322 - 325. [Abstract] [Full Text] [PDF]

				M Krasnik, P Vilmann, S S Larsen, and G K Jacobsen Preliminary experience with a new method of endoscopic transbronchial real time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions Thorax, December 1, 2003; 58(12): 1083 - 1086. [Abstract] [Full Text] [PDF]

				P. P. Massion and D. P. Carbone From Clinical and Pathologic to Molecular Staging of Lung Cancer Am. J. Respir. Crit. Care Med., June 15, 2003; 167(12): 1587 - 1588. [Full Text] [PDF]

				A. Ernst, G. A. Silvestri, and D. Johnstone Interventional Pulmonary Procedures: Guidelines from the American College of Chest Physicians Chest, May 1, 2003; 123(5): 1693 - 1717. [Full Text] [PDF]

				J. K. LeBlanc, R. Espada, and G. Ergun Non-small Cell Lung Cancer Staging Techniques and Endoscopic Ultrasound: Tissue Is Still the Issue Chest, May 1, 2003; 123(5): 1718 - 1725. [Abstract] [Full Text] [PDF]

				A. Fritscher-Ravens, K. H. Bohuslavizki, L. Brandt, C. Bobrowski, C. Lund, W. T. Knofel, and A. Pforte Mediastinal Lymph Node Involvement in Potentially Resectable Lung Cancer: Comparison of CT, Positron Emission Tomography, and Endoscopic Ultrasonography With and Without Fine-Needle Aspiration Chest, February 1, 2003; 123(2): 442 - 451. [Abstract] [Full Text] [PDF]

				F. J. Herth, H. D. Becker, and A. Ernst Ultrasound-Guided Transbronchial Needle Aspiration: An Experience in 242 Patients Chest, February 1, 2003; 123(2): 604 - 607. [Abstract] [Full Text] [PDF]

				E. M. Toloza, L. Harpole, F. Detterbeck, and D. C. McCrory Invasive Staging of Non-small Cell Lung Cancer: A Review of the Current Evidence Chest, January 1, 2003; 123(1_suppl): 157S - 166S. [Abstract] [Full Text] [PDF]

				S. Beckh, P. L. Bolcskei, and K.-D. Lessnau Real-Time Chest Ultrasonography: A Comprehensive Review for the Pulmonologist Chest, November 1, 2002; 122(5): 1759 - 1773. [Abstract] [Full Text] [PDF]

				F.J.F. Herth, A. Ernst, and H.D. Becker Endobronchial ultrasound-guided transbronchial lung biopsy in solitary pulmonary nodules and peripheral lesions Eur. Respir. J., October 1, 2002; 20(4): 972 - 974. [Abstract] [Full Text] [PDF]

				R. Chin Jr., T. W. McCain, M. A. Lucia, J. O. Cappellari, N. E. Adair, J. F. Lovato, D. P. Dunagan, M. A. Brooks, H. P. Clark, and E. F. Haponik Transbronchial Needle Aspiration in Diagnosing and Staging Lung Cancer: How Many Aspirates Are Needed? Am. J. Respir. Crit. Care Med., August 1, 2002; 166(3): 377 - 381. [Abstract] [Full Text] [PDF]

				S. Omori, Y. Takiguchi, K. Hiroshima, N. Tanabe, K. Tatsumi, H. Kimura, K. Nagao, and T. Kuriyama Peripheral Pulmonary Diseases: Evaluation with Endobronchial US— Initial Experience Radiology, August 1, 2002; 224(2): 603 - 608. [Abstract] [Full Text] [PDF]

				H. Okamoto, K. Watanabe, A. Nagatomo, H. Kunikane, H. Aono, T. Yamagata, and M. Kase Endobronchial Ultrasonography for Mediastinal and Hilar Lymph Node Metastases of Lung Cancer* Chest, May 1, 2002; 121(5): 1498 - 1506. [Abstract] [Full Text] [PDF]

				J.F. Beamis, H.D. Becker, S. Cavaliere, H. Colt, J.P. Diaz-Jimenez, J.F. Dumon, E. Edell, K.L. Kovitz, H.N. Macha, A.C. Mehta, et al. ERS/ATS statement on interventional pulmonology: Chairmen: C.T. Bolliger, P.N. Mathur Eur. Respir. J., February 1, 2002; 19(2): 356 - 373. [Full Text] [PDF]

				M. Patelli, L. L. Agli, V. Poletti, R. Trisolini, A. Cancellieri, N. Lacava, F. Falcone, and M. Boaron Role of fiberscopic transbronchial needle aspiration in the staging of N2 disease due to non-small cell lung cancer Ann. Thorac. Surg., February 1, 2002; 73(2): 407 - 411. [Abstract] [Full Text] [PDF]

				Y. Nishimura, H. Osugi, K. Inoue, N. Takada, M. Takamura, and H. Kinosita Bronchoscopic Ultrasonography in the Diagnosis of Tracheobronchial Invasion of Esophageal Cancer J. Ultrasound Med., January 1, 2002; 21(1): 49 - 58. [Abstract] [Full Text] [PDF]

				M. J. Wiersema, E. Vazquez-Sequeiros, and L. M. Wiersema Evaluation of Mediastinal Lymphadenopathy with Endoscopic US-guided Fine-Needle Aspiration Biopsy Radiology, April 1, 2001; 219(1): 252 - 257. [Abstract] [Full Text]

				C. S. White, E. A. Weiner, P. Patel, and E. J. Britt Transbronchial Needle Aspiration : Guidance With CT Fluoroscopy Chest, December 1, 2000; 118(6): 1630 - 1638. [Abstract] [Full Text] [PDF]

				S. N. Goldberg, V. Raptopoulos, P. M. Boiselle, K. J. Edinburgh, and A. Ernst Mediastinal Lymphadenopathy: Diagnostic Yield of Transbronchial Mediastinal Lymph Node Biopsy with CT Fluoroscopic Guidance-Initial Experience Radiology, September 1, 2000; 216(3): 764 - 767. [Abstract] [Full Text]

				U. B. S. Prakash Advances in Bronchoscopic Procedures Chest, November 1, 1999; 116(5): 1403 - 1408. [Abstract] [Full Text] [PDF]