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A. Tsui



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    P1.17 - Poster Session 1 - Bronchoscopy, Endoscopy (ID 182)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pulmonology + Endoscopy/Pulmonary
    • Presentations: 1
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      P1.17-009 - What is the rate of surgical upstaging following negative EBUS-TBNA of mediastinal lymph nodes for NSCLC? (ID 2621)

      09:30 - 16:30  |  Author(s): A. Tsui

      • Abstract

      Background
      Mediastinal lymph node evaluation is a critical determinant of treatment strategy in NSCLC. Many staging modalities, both invasive and non-invasive, have been evaluated over the past few decades with varying degrees of accuracy. Despite the fact that CT imaging is the preliminary investigation for diagnosis of lung cancer, various studies have shown that CT scanning is less accurate (sensitivity of 41% to 63%, a specificity of 43% to 57%, and an accuracy of 39% to 59%) for the detection of mediastinal nodal metastasis. According to a meta analysis looking at nodal disease, the sensitivity for PET is 79% to 84% and its specificity is 89% to 91%.The ability of PET CT to provide morphologic and functional information enhances the diagnostic accuracy of mediastinal nodal staging in NSCLC . Most guidelines would however need tissue confirmation which can be obtained by EBUS- TBNA. This procedure has the advantage that it can be performed under sedation , however , the downside to this is the small samples without accurate anatomical definition. In our institute we perform PET-CT scan followed by EBUS TBNA for pre operative staging of the mediastinal lymph node {in selected cases}. However, in cases where EBUS-TBNA of mediastinal lymph nodes is negative for malignancy, there is still a possibility that metastases to these lymph nodes are found at surgery. This will result in an upstaging of the NSCLC following surgery. We aimed to determine the rate of surgical upstaging following negative EBUS-TBNA of mediastinal lymph nodes for NSCLC.

      Methods
      This is a retrospective study. From January 2009 till May 2013, we identified 304 patients who underwent surgery for NSCLC. All the patients who were planned for surgical resection underwent a staging CT scan thorax or a PET CT scan. Only those patients with suspicious lymph nodes on either of the imaging, were subjected to EBUS TBNA. These lymph nodes were then re-evaluated by histopathology following surgery. Of these 65 patients who had EBUS-TBNA prior to surgery , fifty-three patients had negative EBUS-TBNA and they formed the basis of this report.

      Results
      Out of the 53 patients with a negative EBUS-TBNA, nine of them (17%) demonstrated positive lymph nodes in surgery, giving a negative predictive value of 83% for EBUS-TBNA in this selected group. The negative predictive value of PET CT was around 77% whereas negative predictive value for EBUS TBNA was 83%.

      Conclusion
      Our study confirms a negative predictive value (83%) of EBUS-TBNA in excluding N2/3 disease in patients diagnosed with NSCLC which is higher than PET CT scan (77%). The slightly lower negative predictive value of EBUS TBNA may be attributed to the fact that not all the surgical candidates were staged with a pre operative histological confirmation of the mediastinal lymph nodes. However a combination of PET CT scan and EBUS TBNA is a reasonable pre operative staging for mediastinal lymph nodes with low complication rates.

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    P3.17 - Poster Session 3 - Bronchoscopy, Endoscopy (ID 185)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track:
    • Presentations: 1
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      P3.17-007 - Rapid On-Site Cytologic Evaluation (ROSE) of bronchial brushings during bronchoscopic investigation of peripheral pulmonary lesions: diagnostic accuracy and impact on procedure time (ID 2749)

      09:30 - 16:30  |  Author(s): A. Tsui

      • Abstract

      Background
      Rapid on-site evaluation (ROSE) of transbronchial needle aspirates is cost-effective due to its ability to reduce biopsy number and complication rates without compromising diagnostic yield. Use of ROSE during sampling of peripheral pulmonary lesions (PPLs) has not previously been examined. We aimed to determine the ability of ROSE performed on transbronchial brushings of peripheral pulmonary lesions to accurately determine final procedural diagnosis. To determine if use of ROSE impacts on procedural time or procedural complication rates.

      Methods
      Prospective cohort of patients undergoing radial probe endobronchial ultrasound-guided bronchoscopy for investigation of PPLs. ROSE was performed using a Rapid Romanowsky stain. If ROSE demonstrated diagnostic malignant material the procedure was determined to be successful and no further sampling was undertaken. Non-diagnsotic ROSE assessment resulted in further sampling including transbronchial lung biopsy, and possibly sampling from different locations.

      Results
      Specimens obtained from 128 lesions in 118 consecutive patients in whom radial EBUS successfully localized a peripheral pulmonary lesion. Final procedural diagnoses included non-small cell lung cancer (n=76), carcinoid (3), metastatic malignancy (n=3), benign inflammatory/infective infiltrate (n=46). Positive predictive value of ROSE for a malignant bronchoscopic diagnosis was 97% (63/65). Two patients had positive diagnoses made on ROSE but final procedural diagnosis was “reactive bronchial cells” however both of these patients were subsequently confirmed to have NSCLC following alternate biopsy procedures. Procedure times were significantly shorter in those in whom ROSE specimens demonstrated malignancy than in those in whom ROSE was non-diagnostic (19+8 minutes vs. 31+11 minutes, respectively. p<0.0001) In four procedures, initial negative ROSE results prompted redirection of sampling from alternate bronchial segments resulting in positive diagnostic tissue being obtained.

      Conclusion
      ROSE examination of brushings specimen had high positive predictive value for bronchoscopic diagnosis of cancer. ROSE of brushings specimens has the potential to shorten bronchoscopy times, reduce complications and is likely to be cost-effective. It may also improve diagnostic performance via live feedback, allowing proceduralists to redirect subsequent sampling procedures.