Objective: The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA.
Methods: We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed.
Results: EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA ($1195 vs $808; P < 0.001).
Conclusions: EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.
1. Herth F, Becker DH, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized control trial. Chest 2004; 125: 322–325.
2. Plat G, Pierard P, Haller A, et al. Endobronchial ultrasound and positron emission tomography positive mediastinal lymph nodes. Eur Respir J 2006; 27: 276–281.
3. Yasufuku K, Chiyo M, Sekine Y, et al. Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004; 126: 122–128.
4. Vincent BD, El-Bayoumi E, Hoffman B, et al. Real-time endobronchial ultrasound-guided transbronchial lymph node aspiration. Ann Thorac Surg 2008; 85: 224–230.
5. Adams K, Shah PL, Edmonds L, et al. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: systematic review and meta-analysis. Thorax 2009; 64: 757–762.
6. Wang KP, Haponik EF, Gupta PK, et al. Flexible transbronchial needle aspiration. Technical considerations. Ann Otol Rhinol Laryngol 1984; 93: 233–236.
7. Ost DE, Ernst A, Lei X, et al. Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE bronchoscopy registry. Chest 2011; 140: 1557–1566.
8. Wang KP, Brower R, Haponik EF, et al. Flexible transbronchial needle aspiration for staging of bronchogenic carcinoma. Chest 1983: 5; 571–576.
9. Chin R, McCain TW, Lucia MA, et al. Transbronchial needle aspiration in diagnosing and staging lung cancer: how many aspirates are needed? Am J Respir Crit Care Med 2002: 166; 377–381.
10. Cetinkaya E, Yildiz P, Altin S, et al. Diagnostic value of transbronchial needle aspiration by Wang 22-gauge cytology needle in intrathoracic adenopathy. Chest 2004; 125: 527–531.
11. Hsu L, Liu C, Ko J. Education and experience improve the performance of transbronchial needle aspiration: a learning curve at a cancer center. Chest 2004; 125: 532–540.
12. Haponik EF, Cappellari JO, Chin R, et al. Education and experience improve transbronchial needle aspiration performance. Am J Respir Crit Care Med 1995; 151: 1998–2002.
13. Hermens FH, Limonard GJ, Termeer R, et al. Learning curve of conventional transbronchial needle aspiration in pulmonologists experienced in bronchoscopy. Respiration 2008; 75: 189–192.
14. Phua G, Rhee K, Koh M, et al. A strategy to improve the yield of transbronchial needle aspiration. Surg Endosc 2010; 24: 2105–2109.
15. Tremblay A, Stather D, Maceachern P, et al. A randomized controlled trial of standard vs endobronchial ultrasonography-guided transbronchial needle aspiration in patients with suspected sarcoidosis. Chest 2009; 136: 340–346.
16. Gomez M, Silvestri GA. Endobronchial ultrasound for the diagnosis and staging of lung cancer. Proc Am Thorac Soc 2009; 6: 180–186.
17. Punamiya V, Mehta A, Chhajed PN. Bronchoscopic needle aspiration in the diagnosis of mediastinal lymphadenopathy and staging of lung cancer. J Cancer Res Ther 2010; 6: 134–141.
18. Harrow EM, Abi-Saleh W, Blum J, et al. The utility of transbronchial needle aspiration in the staging of bronchogenic carcinoma.Am J Respir Crit Care Med 2000; 161: 601–607.
19. Chin R, Cappellari JO, McCain TW, et al. Increasing use of bronchoscopic needle aspiration to diagnose small cell lung cancer.Mayo Clin Proc 2000; 75: 796–801.
20. Medford A, Agrawal S, Free C, et al. A prospective study of conventional transbronchial needle aspiration: performance and cost utility.Respiration 2010; 79: 482–489.
21. Steinfort DP, Liew D, Conron M, et al. Cost-benefit of minimally invasive staging of non-small cell lung cancer: a decision tree sensitivity analysis.J Thorac Oncol 2010; 5: 1564–1570.
22. Bowling MR, Perry D, Chin R, et al. Endobronchial ultrasound in the evaluation of lung cancer: a practical review and cost analysis for the practicing pulmonologist.South Med J 2008; 101: 534–538.
23. Pastis NJ, Simkovich S, Silvestri GA. Understanding the economic impact of introducing a new procedure: calculating downstream revenue of endobronchial ultrasound with transbronchial needle aspiration as a mode. Chest 2012; 141: 506–512.
24. Rivera MP, Mehta MB. Initial diagnosis of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132: 131S–148S.