The Essential cTBNA Bronchoscopist

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and have a prognosis similar to patients with multiple positive N1 lymph nodes. If this patienthas lung cancer, the extent of N2 disease or presence of N3 disease should be confirmed orruled out before final therapeutic decisions are made. To address this query, EBUS-TBNA islikely warranted. as its yield for mediastinal staging is equivalent to mediastinoscopy whenEBUS-TBNA is performed using a standardized approach (N3 nodes sampled first, then N2,then N1; sampling any lymph node greater than 5 mm in the short axis). In the absence of easyaccess to EBUS-TBNA, however, this patient can be managed using results from cTBNA andROSE. We know the patient has a PET positive 4L lymph node. Overall, PET-CT positivepredictive value is reportedly 63% and specificity is 88%. PET positive lymph nodes should beconfirmed because PET positivity can be associated with postobstructive pneumonia, or beassociated with infection, sarcoidosis, anthrocosis, or neoplasia. We also know that PET can benegative in involved nodes (the sensitivity of PET scanning for detecting mediastinal lymphnode involvement is approximately 80%). Because the sensitivity of cTBNA is similar to that ofEBUS-TBNA at station 4R, sampling this station by cTBNA and ROSE is a reasonable approachto diagnose N3 disease (if 4R nodes are positive the patient’s tumor would be upstaged to stageIIIB, altering the treatment strategy.) If ROSE is used during cTBNA and station 4R is negative,then stations 7 and 4L (both N2 nodes) should be sampled next. The sensitivity of cTBNA issimilar to that of EBUS-TBNA at station 7, though not quite as good as EBUS at station 4L. Ifsamples from stations 4L (left lower paratracheal) or 7 (subcarinal) are positive, N2 diseasewould be confirmed, changing the surgical therapeutic approach to one of neoadjuvant therapyor definitive chemoradiation therapy. In addition to obtaining samples for diagnosis andoptimizing diagnostic yield by using ROSE, sufficient tissue should be obtained for molecularanalysis using proper aspiration and tissue processing techniques. This is increasingly relevantas targeted treatments continue to be developed and tissue requirements for comprehensivemolecular testing (i.e. next generation sequencing) will likely continue to increase. Highconcordance in molecular tests between aspirates (e.g. cTBNA) and biopsies has been reported.Taking a direct biopsy of the left-sided tumor to make a diagnosis of cancer, without nodalsampling or sending specimens for molecular analysis would not be considered optimal patient52
management.References1. Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guidedtransbronchial needle aspiration: a randomized trial. Chest. 2004;125:322-325.2. Diagnosis and management of Lung Cancer, 3º Ed: ACCP Guidelines. Chest2013;143:e211S-50S.3. Sun PL, Jin Y, Kim H, et al. High concordance of EGFR mutation status betweenhistologic and corresponding cytologic specimens of lung adenocarcinomas. CancerCytopathol. 2013;121:311-319.4. Munden RF, Swisher SS, Stevens CW et al. Imaging of the patient with non-small celllung cancer. What the clinician wants to know. Radiology 2005;237:803-818.5. Rami-Porta R, Crowley JJ, Goldstraw P. The revised TNM staging for lung cancer. AnnThorac Cardiovasc Surg 2009;15:4-9.53
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FIRST EDITIONThe EssentialcTBNA Bro
Page 4 and 5: The Essential cTBNABronchoscopistCo
Page 6 and 7: Bronchoscopy International, Laguna
Page 8 and 9: Funding statementFunding for The Es
Page 11 and 12: MODULE 1THIRTY MULTIPLE CHOICE QUES
Page 13 and 14: Question I.1 The right pulmonary ar
Page 15 and 16: Question I.3 While performing trans
Page 17 and 18: Question I.5 Where are the right pa
Page 19 and 20: Aortic archNeedle through bifurcati
Page 21 and 22: Question I.8 Which of the following
Page 23 and 24: needle through the airway wall. Onc
Page 25 and 26: Question I.11 A patient with subcar
Page 27 and 28: Question I.12 Flexible bronchoscopy
Page 29 and 30: Proposed indications include stagin
Page 31 and 32: Question I.15 Which of the followin
Page 33 and 34: Question I.17 After two aspirates f
Page 35 and 36: Question I.18 While performing cTBN
Page 37 and 38: Question I.19 A patient is referred
Page 39 and 40: Question I.20 While performing cTBN
Page 41 and 42: Question I.22 A 39-year-old man wit
Page 43 and 44: Question I.23 During a cTBNA stagin
Page 45 and 46: may develop unless flow, respirator
Page 47 and 48: helps identify multiloculation and
Page 49 and 50: Example of an endobronchial lesion
Page 51 and 52: Example of transbronchial needle as
Page 53: Question I.29 A 69 year old smoker
Page 57 and 58: insertion depth of the needle. By t
Page 59 and 60: CONGRATULATIONSYou have now complet
Page 61 and 62: The Essential cTBNA BronchoscopistM
Page 63 and 64: Question 8.Each of the following is
Page 65 and 66: ANSWERSTO MODULE 1, TWELVE QUESTION
Page 67 and 68: CONGRATULATIONSYou have now complet
Page 69 and 70: CONTRIBUTORSHenri Colt M.D. is Prof
Page 71: THE ESSENTIAL cTBNA BRONCHOSCOPIST
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