Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : April | Volume : 17 | Issue : 4 | Page : OC22 - OC26 Full Version

A Comprehensive Cross-sectional Analysis on the Diagnostic Predictors of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration


Published: April 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/63198.17777
Shibini Pilakadan, Anand Madhava Nivas, Paulo Varghese Akkara, Rajagopal Thazhepurayil

1. Senior Resident, Department of Pulmonary Medicine, Government Medical College, Kozhikode, Kerala, India. 2. Associate Professor, Department of Pulmonary Medicine, Government Medical College, Kozhikode, Kerala, India. 3. Assistant Professor, Department of Pulmonary Medicine, Government Medical College, Kozhikode, Kerala, India. 4. Professor, Department of Pulmonary Medicine, Government Medical College, Kozhikode, Kerala, India.

Correspondence Address :
Dr. Anand Madhavanivas,
30/59-A, Madhavanivas, Medical College Post, Kozhikode-673008, Kerala, India.
E-mail: anand77m@rediffmail.com

Abstract

Introduction: Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a relatively new and minimally invasive procedure for sampling mediastinal and hilar lymph nodes. Various factors can influence the diagnostic yield of EBUS-TBNA and comprehensive studies evaluating them together are scarce.

Aim: To evaluate the factors predicting the diagnostic yield of EBUS-TBNA in sampling mediastinal and hilar lymph nodes.

Materials and Methods: A cross-sectional study was conducted at Institute of Chest Diseases, Government Medical College, Kozhikode , Kerala, India, from June 2019 to May 2020. The patients with enlarged mediastinal and hilar lymph nodes on Computed Tomography (CT) thorax underwent Fibre Optic Bronchoscopy (FOB) followed by EBUS-TBNA under conscious sedation. Patient and procedure related factors and ultrasonological features of lymph nodes were noted. Their relationships with EBUS-TBNA histopathological results were assessed. Statistical methods like Fisher’s exact test with significant p-value as <0.05 were used for analysis.

Results: The mean age was 60.78±13.664 years with 59 (81%) males. Out of 73 lymph node stations sampled, 49.3% were subcarinal, followed by right lower paratracheal (30.1%), left hilar (8.2%), left upper paratracheal (6.9%) and left lower paratracheal (5.5%). EBUS-TBNA Histopathology Report (HPR) came as positive in 68.5% (50/73) cases with squamous cell carcinoma found in 34%, adenocarcinoma in 32%, poorly differentiated carcinoma in 16%, tuberculosis in 14%, and non specific inflammation in 4% cases. Significant association was found with factors like moderate sedation, duration of procedure taking >30 minutes, lymph node size >1 cm and absence of hilar sign, more number of passes per node and use of suction while sampling lymph nodes and diagnostic yield by EBUS-TBNA (p-value <0.05). There was no significant association with lymph node stations, lymph node features like shape, margin, echogenicity, necrosis and Rapid On-Site Evaluation (ROSE) and diagnostic yield; so also is the case with patient related factors like age, sex, co-morbidities, FOB and CT findings.

Conclusion: The duration of the procedure, type of sedation, lymph node size and absence of hilar sign, number of passes per node and use of suction while sampling the node are the main factors predicting the diagnostic yield of EBUS-TBNA in sampling mediastinal and hilar lymph nodes.

Keywords

Bronchoscopy, Diagnostic yield, Histopathology, Lymph node, Sedation

Intrathoracic lymph node enlargement can be due to multiple causes which may either be benign or malignant, or just non specific reactive hyperplasia. The benign causes include common infections like mycobacterial, fungal and viral including Human Immunodeficiency Virus (HIV), rare infections like actinomycosis, anthrax and tularaemia and non infectious inflammatory conditions like sarcoidosis, rheumatological and autoimmune diseases, hypersensitivity pneumonitis, amyloidosis, Whipple disease, Castleman’s disease etc. The malignant causes may be either primary like lymphoma, myeloma, leukaemia etc., or secondary due to lymph node metastases from lung, gastrointestinal, breast, testicular or thyroid cancers. Many of these conditions are life threatening prompting early diagnosis for effective management. Traditionally, tissue diagnosis from these nodes was obtained by CT-guided fine needle aspiration/biopsy, mediastinoscopy, or thoracoscopy. These investigations have limitations in the form of invasiveness, specimen yield, safety, and cost.

EBUS-TBNA, first introduced in 2002, is a relatively new and minimally-invasive endobronchial technique that uses ultrasound probe incorporated into the tip of bronchoscope to visualise the airway wall and structures adjacent to it, and allows real-time guidance in the sampling of mediastinal and hilar lymph nodes, and tumours (1). It is a relatively quick and safe day care procedure and can be performed under conscious sedation.

Using EBUS-TBNA, enough samples can be obtained for histological diagnosis and Immunohistochemistry (IHC). EBUS-TBNA can shorten the duration of diagnosis and staging in lung cancer and can diagnose most of the benign aetiologies of mediastinal lymphadenopathy. In comparison to surgical mediastinoscopy, EBUS-TBNA has an excellent safety profile and cost advantages. Diagnostic sensitivity is often equivalent to surgical mediastinoscopy (2). EBUS-TBNA may obviate the need of invasive methods (3).

According to American College of Chest Physicians (ACCP) lung cancer guidelines, the overall median sensitivity and median negative predictive value of EBUS-TBNA in mediastinal staging of lung cancer is 89% and 91%, respectively. This guideline recommends ultrasound-guided, needle-based sampling techniques over surgical staging as the first step in the mediastinal staging of lung cancer (4).

Various questions are often raised about the optimal performance of the procedure and best conditions for a maximal diagnostic yield. Comprehensive studies considering all factors together to predict the diagnostic yield of EBUS-TBNA is lacking especially in Indian population. The present study aimed to evaluate both patient and procedure related factors to predict the diagnostic yield of EBUS-TBNA in sampling mediastinal and hilar lymph nodes.

Material and Methods

This was a cross-sectional study conducted at Institute of Chest Diseases, Government Medical College, Kozhikode, Kerala, India for a period of one year from June 2019 to May 2020. The study protocol was approved by the Institutional Ethics Committee (GMCKKD/RP 2019/IEC/162).

Inclusion criteria: All patients above 18 years of age with enlarged mediastinal and hilar lymph nodes on CT thorax who provided written informed consent within the study duration were included in the study.

Exclusion criteria: Those patients with hypoxia not corrected by supplemental oxygen, bleeding tendency or coagulation dysfunction, recent myocardial infarction or severe cardiac insufficiency, haemodynamic instability or who failed to provide informed consent were excluded from the study.

Patient related factors like age, sex, co-morbidities, vitals, respiratory system examination, pre procedure clinico-radiological diagnosis, CT and FOB findings were recorded.

Study Procedure

The procedures were performed under conscious sedation, using either dexmedetomidine or midazolam and fentanyl. EBUS-TBNA was done using a convex probe ultrasonic bronchoscope EB-530 US (Fujifilm, Tokyo, Japan). Scanning allowed for a penetration of 5 cm at a frequency of 7.5 MHz. TBNA was done by passing a dedicated 22- or 21-G needle (Cook Medical Echo Tip). The needle with central stylet was passed through the working channel of the bronchoscope, and then advanced through the airway wall, and into the lymph nodes under real-time ultrasound guidance. An integrated colour-power Doppler ultrasound (Fujifilm, Tokyo, Japan) was used to exclude vessels prior to needle puncture. After stylet removal, suction was applied using a syringe, while moving the needle back and forth approximately 10-20 times within the lesion. A minimum of three needle passes per lymph node were performed. After the sampling, suction was released slowly and the needle was retracted. Lymph node aspirates and core biopsy specimens were subjected to cytological, histopathological and microbiological examinations (Table/Fig 1),(Table/Fig 2).

Procedure related factors like depth of sedation, lymph node characteristics, stations, number of lymph node sampled, number of passes per node, needle type, specimen type, use of suction, duration of procedure, use of ROSE were assessed.

Statistical Analysis

Data were entered in Microsoft Excel and analysis was done by Statistical Package for the Social Sciences (SPSS) version 21.0. The categorical variables were expressed in proportion and continuous variables in mean and standard deviation. The appropriate statistical methods like Fisher’s-exact test and Chi-square test were used for analysis. The level of significance was estimated with 95% confidence interval. A p-value of <0.05 was considered statistically significant.

Results

A total of 73 subjects with enlarged mediastinal and hilar lymphadenopathy on CT Thorax and posted for EBUS were enrolled in the study. The mean age of the patients was 60.78±13.664 years. There were 59 (81%) males and 14 (19%) females in the study group. The baseline characteristics of study subjects are shown in (Table/Fig 3). Dyspnoea (64.4%) followed by cough (54.8%) were the main symptoms. Other symptoms included haemoptysis (10.66%), hoarseness (8.2%), fever (6.9%) and wheezing (2.7%).

A total of 73 lymph node stations were sampled out of which 36 (49.3%) were subcarinal (station 7), 22 (30.1%) were right lower paratracheal (station 4R), 6 (8.2%) were left hilar (station 10L), 5 (6.9%) were left upper paratracheal (station 2L), and 4 (5.5%) were left lower paratracheal (station 4L). The overall diagnostic yield according to EBUS-TBNA HPR was 68.5% (50/73). Out of this squamous cell carcinoma was found in 17 (34%) cases, adenocarcinoma in 16 (32%) cases, poorly differentiated carcinoma in 8 (16%) cases, tuberculosis in 7 (14%) cases and non-specific inflammation in 2 (4%) cases. In 23 patients, histopathology results came as negative.

The procedure was done under moderate sedation using parenteral dexmedetomidine and fentanyl in 56 patients. Out of these patients, EBUS-TBNA histopathological report was positive in 43 patients (76.8%) compared to a diagnostic yield of 41.2% (7 out of 17) in those who underwent the procedure under mild sedation using parenteral midazolam and fentanyl. The difference in diagnostic yield was statistically significant with a p-value of <0.05. Significant association was not found between patient related factors like age, sex, co-morbidities, CT Thorax findings, FOB findings etc and diagnostic yield (Table/Fig 4).

In this study, the diagnostic yield was 80% (48/60) when the lymph node size was >1 cm. EBUS-TBNA HPR came positive only in 15.4% (2/13) cases when the lymph node size was <1 cm.The difference was significant with a p-value of <0.05. Significant association was also found with absence of Central Hilar Structure (CHS) and a diagnosis of malignancy (74.2%). There was no significant association with lymph node station and lymph node features like shape, margin, echogenicity, necrosis etc., and diagnostic rate (Table/Fig 5).

EBUS-TBNA HPR was positive in 18.2%, 28.6%, 81.6%, 100% following 3 passes, 4 passes, 5 passes, 6 passes per node, respectively with a significant value (p-value <0.05). Suction was used in 60 cases in which 48 (80%) cases yielded positive HPR (p-value <0.05). In this study, there was no association between ROSE and diagnostic yield (p=0.763). The procedure took more than 30 minutes in 55 cases. Out of these, HPR came positive in 44 (80%) cases compared to procedures which took <30 minutes (33.3%) with a significant difference (p-value <0.05) (Table/Fig 6).

Discussion

The overall diagnostic yield according to EBUS-TBNA HPR was 68.5% (50/73). Out of the 23 negative cases, 13 reports came as reactive mature lymphocytes, five reports came as sparsely cellular aspirate, three reports came as inconclusive and the remaining two reports came as clusters of spindle cells and fibroblasts. Most of the negative results came from small oval nodes <1 cm in size which usually favours benign aetiology sonologically. Thus, in this study, there were 68 (93.15%) adequate samples, with adequacy being defined as finding granuloma, atypical cells, reactive lymphoid tissue etc. The diagnostic yield and sample adequacy are consistent with real world data from the AQUIRE registry (5).

EBUS-TBNA histopathological report was positive in 76.8% patients (43 out of 56) who underwent the procedure under moderate sedation compared to a diagnostic yield of 41.2% (7 out of 17) in those who underwent the procedure under mild sedation. The difference was statistically significant with a p-value of <0.05. This may be due to patient comfort, stabilisation of airways and ease of doing the procedure under moderate sedation. But no difference was found overall between sedation groups according to studies done by Dal T et al., and Casal RF et al., (6),(7). According to Yarmus L et al., statistically significant association was found in employing deep sedation during EBUS with regard to diagnostic yield (Table/Fig 7) (6),(7),(8). So, it is prudent to consider moderate sedation employing parenteral dexmedetomidine and fentanyl during the procedure ideal for enhancing diagnostic yield.

In this study, the diagnostic yield was 80% (48/60) with lymph node size >1 cm as opposed to 15.4% (2/13) when the lymph node size was <1 cm with a significant p-value of <0.05. According to Memoli JS et al., a statistically significant increase in presence of malignancy in a lymph node occurred as the size increased (9). They also confirmed that round shaped lymph nodes were more likely malignant than triangular or draping lymph nodes. But such an association between lymph node shape and diagnosis rate could not be demonstrated in this study. Fujiwara T et al., found that a round shape, distinct margins, heterogeneous echogenicity, and a central necrosis sign were independently predictive of malignancy. When all four factors were absent, 96% of the lymph nodes were benign (10).

There was significant association with absence of CHS and diagnosis of malignancy in this study (p-value=0.017), but not with lymph node echogenicity and necrosis. According to Jhun BW et al., absence of CHS was predictive of lymph node metastasis (11). Schmid-Bindert G et al., also reported ultrasound criteria for predicting nodal metastasis. According to this study nodal size >10 mm, round shape, heterogeneous echogenicity and absence of CHS could be predictive factors for metastasis (12).

According to Nakajima T et al., there was no statistically significant difference in diagnostic yield with the size of the needle used (13). The authors also found that the 21-gauge needle provided better histological structure with an increased number of tumour cells in the specimen, but it was associated with more blood contamination. Yarmus LB et al., could not find significant difference in sample adequacy or diagnostic yield. The use of the 21-gauge needle, when combined with the presence of ROSE, was associated with fewer needle passes per lymph node (3.5 versus 4.2; p-value <0.01), suggesting improved quality of specimen (14). 22 gauge needles performed better than 21 gauge needle in this study (73.8% versus 41.7%, p-value 0.035). 21 gauge needles were used in 12 patients only, mainly in those with small lymph nodes (<1 cm) to enhance tissue content in the samples. This along with a large difference in the sample size between the two groups may be the reasons for such an outcome.

According to a prospective study done by Wolters C et al., use of the 19-gauge needle resulted in significantly more tissue and tumour cells per slide with a safety profile similar to 22-G needles, but the diagnostic yield was similar in both groups (15). A randomised trial was done by Oki M et al., in 60 patients with hilar/mediastinal adenopathy or tumour adjacent to a central airway (16). There was no difference between needle gauges in outcome measure. This study also showed trend of inadequate samples with 21 gauge needles. (Table/Fig 8) shows the comparison of present study with previous studies done (4),(13),(14),(15),(16).

A randomised prospective trial conducted by Casal RF et al., comparing EBUS-TBNA with suction referred to as transbronchial needle capillary sampling (EBUS-TBNCS) versus EBUS-TBNA without the use of suction, found no significant differences between the two groups in specimen adequacy, diagnosis rate, or specimen quality regardless of node size. Concordance rates between the techniques were high for adequacy, diagnostic yield, and specimen quality ranging from 83.3-95.8% (17). In the prospective study by Mohan A et al., the addition of suction has not been shown to improve the diagnostic yield or sample adequacy when compared with either lower suction of 10 cm or higher suction of 20 cm or no suction at all (18). Using suction increased the tissue-core acquisition rate compared with the no suction group even though the difference in diagnostic yield was not statistically significant in a randomised controlled trial by Lin X et al., (Table/Fig 9) (19). This study showed significant association with suction use and diagnostic yield (p-value <0.05).

Sample adequacy was 90.1% after the first pass, 98.1% after two passes, and 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 according to Lee HS et al., study (20). This study demonstrated significant association between the number of needle passes and diagnosis yield (p-value <0.05). Such a relationship was also found between procedure duration and diagnosis rate (p-value <0.05) which was indirectly influenced by excess time spent for more needle passes per node.

Murakami Y et al., study showed that ROSE did not have any impact on the diagnostic yield (99% with ROSE versus 90% without ROSE; p-value <0.1), rather it reduced the number of aspirates per procedure (mean 2.3 with ROSE versus 4.0 without ROSE; p<0.01) (21). The systematic review by Sehgal IS et al., also maintained that the use of ROSE neither improved the diagnostic yield nor reduced the procedure time during TBNA (22). ROSE did not influence diagnostic rate in this study.

Limitation(s)

The main drawback of this study was that the procedure was done by different operators and their operator skill varies which indirectly affected the diagnostic yield. Only 15 out of 23 patients with negative HPR could be followed-up for six months who improved clinico-radiologically thus avoiding further procedures in them. The results were also not compared with gold standard surgical biopsy.

Conclusion

EBUS-TBNA is a highly efficacious, first line diagnostic procedure in characterising mediastinal and hilar lymphadenopathy with results as good as gold standard surgical biopsy and significantly improved safety profile. Administration of moderate sedation, systematic analysis of nodal stations consuming sufficient time, lymph node size >1 cm and absence of hilar sign, five or more number of passes per node and use of suction while sampling lymph nodes, all can significantly increase the diagnostic yield of the procedure.

References

1.
Mohan A, Naik S, Pandey RM, Mills J, Munavvar M. Diagnostic utility of endobronchial ultrasound guided needle aspiration for mediastinal lesions: A prospective three year study, single centre analysis. Thorac Cancer. 2011;2(4):183-89. [PubMed]. [crossref][PubMed]
2.
Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393-400. [PubMed]. [crossref][PubMed]
3.
Steinfort DP, Liew D, Conron M, Hutchinson AF, Irving LB. Cost-benefit of minimally invasive staging of non-small cell lung cancer: A decision tree sensitivity analysis. J Thorac Oncol. 2010;5(10):1564-70. [PubMed]. [crossref][PubMed]
4.
Wahidi MM, Herth F, Yasufuku K, Shepherd RW, Yarmus L, Chawla M, et al. Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration: CHEST guideline and expert panel report. Chest. 2016;149(3):816-35. [PubMed]. [crossref][PubMed]
5.
Ost DE, Ernst A, Lei X, Kovitz KL, Benzaquen S, Diaz-Mendoza J, et al. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Am J Respir Crit. Care Med. 2016;193(1):68-77. [CrossRef] [Google Scholar]. [crossref][PubMed]
6.
Dal T, Sazak H, Tunç M, Sahin S, Yilmaz A. A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: A prospective, single-blind, randomized study. J Thorac Dis. 2014;6(6):742-51. [Google Scholar] [PubMed].
7.
Casal RF, Lazarus DR, Kuhl K, Nogueras-González G, Perusich S, Green LK, et al. Randomized trial of endobronchial ultrasound-guided transbronchial needle aspiration under general anesthesia versus moderate sedation. Am J Respir Crit Care Med. 2015;191(7):796-803. [CrossRef]. [crossref][PubMed]
8.
Yarmus L, Akulian J, Gilbert C, Mathai S, Sathiyamoorthy S, Sahetya S, et al. Comparison of moderate versus deep sedation for endobronchial ultrasound guided transbronchial needle aspiration. Ann Am Thorac Soc. 2013;10(2):121- 26. [CrossRef]. [crossref][PubMed]
9.
Memoli JS, El-Bayoumi, Pastis NJ, Tanner NT, Gomez M, Huggins JT, et al. Using endobronchial ultrasound features to predict lymph node metastasis in patients with lung cancer. Chest. 2011;140(6):1550-56. [PubMed]. [crossref][PubMed]
10.
Fujiwara T, Yasufuku K, Nakajima T, Chiyo M, Yoshida S, Suzuki M, et al. The utility of sonographic features during endobronchial ultrasound-guided transbronchial needle aspiration for lymph node staging in patients with lung cancer: A standard endobronchial ultrasound image classification system. Chest. 2010;138(3):641- 47. [PubMed]. [crossref][PubMed]
11.
Jhun BW, Um SW, Suh GY, Chung MP, Kim H, Kwon OJ, et al. Clinical value of endobronchial ultrasound findings for predicting nodal metastasis in patients with suspected lymphadenopathy: A prospective study. J Korean Med Sci. 2014;29(12):1632-38. [PubMed]. [crossref][PubMed]
12.
Schmid-Bindert G, Jiang H, Saur S, Henzler T, Wang H, Ren S, et al. Predicting malignancy in mediastinal lymph nodes by endobronchial ultrasound: A new ultrasound scoring system. Respirology. 2012;17(8):1190-98. [PubMed]. [crossref][PubMed]
13.
Nakajima T, Yasufuku K, Takahashi R, Shingyoji M, Hirata T, Itami M, et al. Comparison of 21-gauge and 22-gauge aspiration needle during endobronchial ultrasound-guided transbronchial needle aspiration. Respirology. 2011;16(1):90- 94. [PubMed]. [crossref][PubMed]
14.
Yarmus LB, Akulian J, Lechtzin N, Yasin F, Kamdar B, Ernst A, et al. Comparison of 21-gauge and 22-gauge aspiration needle in endobronchial ultrasound-guided transbronchial needle aspiration: Results of the American College of Chest Physicians quality improvement registry, education, and evaluation registry. Chest. 2013;143(4):1036-43. [CrossRef] [PubMed]. [crossref][PubMed]
15.
Wolters C, Darwiche K, Franzen D, Hager T, Bode-Lesnievska B, Kneuertz PJ, et al. A prospective, randomized trial for the comparison of 19-G and 22-G endobronchial ultrasound-guided transbronchial aspiration needles; introducing a novel end point of sample weight corrected for blood content. Clin Lung Cancer. 2019;20(3):e265-73. [CrossRef] [PubMed]. [crossref][PubMed]
16.
Oki M, Saka H, Kitagawa C, Kogure Y, Murata N, Ichihara S, et al. Randomized study of 21-gauge versus 22-gauge endobronchial ultrasound-guided transbronchial needle aspiration needles for sampling histology specimens. J Bronchology Interv Pulmonol. 2011;18(4):306-10. [PubMed]. [crossref][PubMed]
17.
Casal RF, Staerkel GA, Ost D, Almeida FA, Uzbeck MH, Eapen GA, et al. Randomized clinical trial of endobronchial ultrasound needle biopsy with and without aspiration. Chest. 2012;142(3):568-73. [PubMed]. [crossref][PubMed]
18.
Mohan A, Iyer H, Madan K, Hadda V, Mittal S, Tiwari, P, et al. A randomized comparison of sample adequacy and diagnostic yield of EBUS-TBNA using various suction pressures. Adv Respir Med. 2021;89(3):268-76. [CrossRef] [PubMed]. [crossref][PubMed]
19.
Lin X, Ye M, Li Y, Ren J, Lou Q, Li Y, et al. Randomized controlled trial to evaluate the utility of suction and inner-stylet of EBUS-TBNA for mediastinal and hilar lymphadenopathy. BMC Pulm Med. 2018;18(1):192. [CrossRef]. [crossref][PubMed]
20.
Lee HS, Lee GK, Lee HS, Kim MS, Lee JM, Kim HY, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal staging of non-small cell lung cancer: How many aspirations per target lymph node station? Chest. 2008;134(2):368-74. [PubMed]. [crossref][PubMed]
21.
Murakami Y, Oki M, Saka H, Kitagawa C, Kogure Y, Ryuge M, et al. Endobronchial ultrasound- guided transbronchial needle aspiration in the diagnosis of small cell lung cancer. Respir Investig. 2014;52(3):173-78. [PubMed]. [crossref][PubMed]
22.
Sehgal IS, Dhooria S, Aggarwal AN, Agarwal R. Impact of Rapid On-Site cytological Evaluation (ROSE) on the diagnostic yield of transbronchial needle aspiration during mediastinal lymph node sampling: Systematic review and meta-analysis. Chest. 2018;153(4):929-38. [PubMed].[crossref][PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/63198.17777

Date of Submission: Feb 02, 2023
Date of Peer Review: Feb 09, 2023
Date of Acceptance: Mar 16, 2023
Date of Publishing: Apr 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 07, 2023
• Manual Googling: Feb 22, 2023
• iThenticate Software: Mar 11, 2023 (16%)

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