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A Randomized Prospective trial of theA Randomized Prospective trial of the

Utility ofUtility ofRapid On-Site EvaluationRapid On-Site Evaluation ofof

Transbronchial Needle AspirateTransbronchial Needle Aspirate

SpecimensSpecimens

J Bronchol Intervent Pulmonol 2011;18:121-127

Lonny Yarmus, D,!""P, #homas $an %er &loot, 'D, (oah Lech)*n, 'D, 'ar+ (a*er,'D, Doulas Dressel, 'D, an% Dav*%

!eller-+oman,'D,!""P


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BackgroundBackgroundPrevious studies havePrevious studies havesuggested an increased diagnostik yield forsuggested an increased diagnostik yield forflexible bronchoscopic (FB) transbronchialflexible bronchoscopic (FB) transbronchial

needle aspirate (TBNA) specimens fromneedle aspirate (TBNA) specimens fromlymph nodes hen using rapid on!sitelymph nodes hen using rapid on!siteevaluation ("#$%) by cytophatologyevaluation ("#$%) by cytophatology

!b"ective!b"ective to determine the effect of "#$%to determine the effect of "#$%on the diagnostic poer of TBNA&on the diagnostic poer of TBNA&

#ethods#ethodsThe study is a prospectiveThe study is a prospectiverandomi'ed controlled trial&randomi'ed controlled trial&


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FB is the most common modality used toFB is the most common modality used todiagnose lung cancerdiagnose lung cancer

TBNA biopsy is a biopsy technique used duringTBNA biopsy is a biopsy technique used duringbronchoscopy which involves passing abronchoscopy which involves passing acatheter containing a needle through thecatheter containing a needle through thetrachea or bronchial wall into the lymph nodestrachea or bronchial wall into the lymph nodesor masses to obtain samples for Cytopathologicor masses to obtain samples for Cytopathologicassesment.assesment.

Conventional TBNA is a blind procedure in that theConventional TBNA is a blind procedure in that thestructures external to the bronchial wall are notstructures external to the bronchial wall are notdirecly visualied. To addres this concern !direcly visualied. To addres this concern !"#$% of spesimens has been carried out."#$% of spesimens has been carried out.

..

Intro%uct*on


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&ith "#$% biopsy material is prepared and&ith "#$% biopsy material is prepared andstained during the bronchoscopystained during the bronchoscopy

'f the cytopathologist determine that the biopsy'f the cytopathologist determine that the biopsywas unuccessful! futher TBNA passed canwas unuccessful! futher TBNA passed canbe made during the same procedure!be made during the same procedure!potentially sparing the patient repeated orpotentially sparing the patient repeated oralternative invasive procedure and theiralternative invasive procedure and theirassociated ris( of complication.associated ris( of complication.

Intro%uct*on


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0atients were randomied at the time of0atients were randomied at the time of

bronchoscopy into the "#$% or the no/"#$%bronchoscopy into the "#$% or the no/"#$%groupgroup Before the procedure a sub1ective pretestBefore the procedure a sub1ective pretest

clinical probability of malignancy wasclinical probability of malignancy wasdetermined based on the bronchoscopist2sdetermined based on the bronchoscopist2s

clinical suspicion * 0atient age! tobaccoclinical suspicion * 0atient age! tobaccohistory! medical history! 3 radiographichistory! medical history! 3 radiographicimagingimaging

The location of TBNA! number of needleThe location of TBNA! number of needlepasses sie of needle *,4 gauge or 55 gauge!passes sie of needle *,4 gauge or 55 gauge!duration of procedure!effect of on/siteduration of procedure!effect of on/siteassessment! amount of sedative and topicalassessment! amount of sedative and topicalanasthetic medication used were recordedanasthetic medication used were recordedusing a standardied data collection sheet.using a standardied data collection sheet.

Pat*ent .

metho%s


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Total of 9- patients with median age of 9- yearsTotal of 9- patients with median age of 9- years

*range7 65 to -- years old were randomied for*range7 65 to -- years old were randomied for

the study between February 5::; and


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ATS NodalStation

R!S$ N!%R!S$

5 1 1

) 15 1.

* 5( 5)

1+ ) (

11 + +

#ass ) 5

AT$=american thoracic society> TBNA7 Transbroncial needle

aspiration

#ale 2: #B( natom*c s*te locat*ons


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Table ( #ain Results

/3 (-/3

P

#B( D*anost*c Y*el%456

9 1,0

#B( %*anos*s o lunneolasma 456

1,0

#B( %*anos*s o anyneolasma 456

0,80

#B( a%e


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Table ) Procedural 8ata

/3 ((-/3

s*rates>*te =,=7 =,1=

#*me4m*n6 2, 27,

'*%a)olam4m6 =,98 ,0

!entanyl4mc6 107 111

L*%oca*ne 154mL6

22,9 22,8

?*stoloy nee%le41 aue6 456

98 =1


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Table - Number of Transbronchial Biopsies Performed

R!S$ N!N%

R!S$

Transbronchial biopsiesperformed

9 1-

No transbronchial biopsiesperformed

5. 10


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Both group were followed up for period ofBoth group were followed up for period of

up to 5 years after the initial bronchoscopyup to 5 years after the initial bronchoscopy

was performedwas performed

There are no significant statisticalThere are no significant statistical

differences in final TBNA diagnosis! finaldifferences in final TBNA diagnosis! final

tissue diagnosis! and typed of neoplasmatissue diagnosis! and typed of neoplasma

or benign disease diagnosed between theor benign disease diagnosed between the

5 group5 group


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Tabel . final diagnosis

:inal

8iagnosis

R!

S$

TB

NA

!ther 8iagnostic

Testing

N!

N%

R!

S$

!ther 8iagnostic

Testing

NS363 11 - &T5, B1, BB1,

TT1'

15 ) &BB1, ;('

S363 ( 1 &$1' ) +

Sarcoid ( ( &T1,#5' 5 ) &T1, #('

#elanoma 1 + + +

6ymphoma 1 + + +

A:B + 1&;1' + +

True

Negative

% . , ;5, 35' % 9 ,3.'


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?'$C@$$'#N?'$C@$$'#N

TBNA has become very valuable for theTBNA has become very valuable for the

diagnosis and staging of mediastinal use. Fromdiagnosis and staging of mediastinal use. From"#$% during bronchoscopy has previously"#$% during bronchoscopy has previouslybeen reported to result in improved diagnosticbeen reported to result in improved diagnosticresults for TBNA.results for TBNA.

'n a randomied controlled trial comparing'n a randomied controlled trial comparingprospective "#$% without on/site assessmentprospective "#$% without on/site assessmentof Cytopathology *no/"#$%! we found noof Cytopathology *no/"#$%! we found nobenefit on the adequacy of the diagnostic resultsbenefit on the adequacy of the diagnostic resultsor related to use of the "#$% specimensor related to use of the "#$% specimens

owever! there are chances of decresingowever! there are chances of decresingnumber of transbronchial biopsy is needed innumber of transbronchial biopsy is needed inthe group "#$%.the group "#$%.


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?'$C@$$'#N?'$C@$$'#N

'n this study! the use of "#$% was not'n this study! the use of "#$% was not

associated with an improved diagnosticassociated with an improved diagnosticyield or specimen adequacy! reduced oryield or specimen adequacy! reduced orincreased procedure time! or withincreased procedure time! or withamount of sedation topical anasthesiaamount of sedation topical anasthesiarequired and there no difference inrequired and there no difference inmalignancy rates between the "#$%malignancy rates between the "#$%and no/"#$% procedure. 'ts suggestingand no/"#$% procedure. 'ts suggestingthan randomiation may havethan randomiation may haveprevented a preferential use of "#$% inprevented a preferential use of "#$% in

patients with malignant versus benignpatients with malignant versus benignlymadenopathylymadenopathy


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ConclusionConclusion

The "#$% procedure should beThe "#$% procedure should be

used on a case by case basis.used on a case by case basis.

arger studies investigating thearger studies investigating the

utility of "#$% on %B@$/TBNA andutility of "#$% on %B@$/TBNA andthe incremental yield of %B@$/the incremental yield of %B@$/

TBNA over standard TBNA whenTBNA over standard TBNA when

performed by experienced providersperformed by experienced providers

are neededare needed


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