Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of pathologies accessible by transbronchial needle aspiration requiring anatomopathological diagnosis

PICHON RIVIERE, A.; AUGUSTOVSKI, F.; GARCIA MARTI, S.; GLUJOVSKY, D.; ALCARAZ, A.; LOPEZ, A.; BARDACH, A.; CIAPPONI, A; REY-ARES, L.; CESARONI, S

Documento de Evaluación de Tecnologías Sanitarias

IECS

Año: 2012 p. 1 - 30

1668-2793

Transbronchial Needle Aspiration (TBNA) by bronchoscope may be used to obtain pathology samples from mediastinal and hilaradenopathies or that result in peripheral lung nodules, being its main purpose to diagnose and/or stage non-small cell lung cancer (NSCLC). Other pathologies that may be accessed by transbronchial aspiration, in which mediastinal tissue sample collection may be useful include sarcoidosis and lymphoma. TBNA may be performed conventionally (blindly) or with the aid of EBUS (Endobronchial Ultrasound). Ultrasound guidance is considered to improve the diagnostic result of blind TBNA and it would avoid more invasive procedures.TechnologyIt is a bronchoscopy technique that uses ultrasound to visualize the structures inside or adjacent to the bronchial tree thus allowing sample collection guidance. It may be carried out as an ambulatory procedure under local anesthesia with sedation. Complications are rare.The limitations of its use are that it only allows sample collection from paratracheal, subcarinal and hiliaradenopathies; it is difficult to use, it is not widely available and uses tiny gauge needles.PurposeTo assess the evidence available on the efficacy, safety and issues related with coverage policies on the use of endobronchial ultrasound in accessible pathologies by transbronchial needle aspiration requiring anatomopathological diagnosis.MethodsA bibliographic search was carried out on the main databases: DARE, NHS EED, on Internet general search engines, in health technology evaluation agencies and health sponsors. Priority was given to the inclusion of systematic reviews; controlled, randomized clinical trials (RCTs); health technology assessments and economic evaluations; clinical practice guidelines and coverage policies of other health systems.ResultsFour systematic reviews assessing the usefulness of EBUS for the study of mediastinaladenopathies, one on EBUS-TBNA to assess peripheral lung lesions, one study comparing EBUS versus mediastinoscopy, two retrospective studies evaluating EBUS for lymphoma diagnosis, one clinical trial comparing EBUS-TBNA versus conventional TBNA in patients with suspected sarcoidosis and 4 clinical practice guidelines were found.In 2011, one systematic review including 14 studies on the diagnosis of mediastinal and hilaradenopathies was published. The results reported sensitivity (S): 0.92, positive likelihood ratio (LR): 5.1 and negative LR: 0.13.In 2009, three systematic reviews on the use of EBUS for mediastinal staging in patients with suspected or diagnosed lung cancer were published. The number of papers included ranged from 11 to 14. In one of the reviews, the S to detect malignancy ranged from 0.85 to 1.00 and the negative predictive value (NPV) ranged from 11 to 97.4%. In another review, the results obtained were S: 0.88 (range of 0.33-0.96), Area Under the Curve: 0.99%, LR (+): 680.86 and LR (-): 0.12; the third review reported an S: 0.93 (range of 0.69 ? 1.00). One of the papers included in this review compared EBUS-TBNA versus cervical mediastinoscopy. Surgical lymphadenectomy was used as comparator; the values reported with EBUS were S: 0.87 and NPV: 78%, and with mediastinoscopy, S: 0.68 and NPV: 59%.In 2011, a study on 153 patients with suspected or diagnosed NSCLC in which EBUS-TBNA followed by cervical mediastinoscopy was carried out was published. If both procedures were negative, mediastinal lymphadenectomy was performed. EBUS-TBNA showed an S: 0.81 and NPV: 91% and the mediastinoscopy showed S: 0.79 and NPV: 90%. As to the use of EBUS in patients with suspected lymphoma, two studies were found. The results reported in the study published in 2007 were S: 0.91 and NPV: 92.9% and the one published in 2010 showed a S: 0.57 for lymphoma diagnosis. Two comparators were used, radiological progress of adenopathies during follow up or surgical biopsy.One study published in 2009 compared EBUS-TBNA versus TBNA in patients with suspected sarcoidosis. Mediastinoscopy, biopsy of the lungs or of other sites affected by the disease and radiological progress of adenopathies during follow up were used as comparators. The S with conventional TBNA was 0.61 and 0.83 with EBUS-TBNA.As regards peripheral lung lesions, one systematic review on the effectiveness and safety of EBUS-TBNA, including 16 studies, published in 2011, was found. The sensitivity to detect malignancy was 0.73 (range of 0.49-0.88) with an area under the curve of 0.9376, a LR(+): 26.84 and a LR(-): 0.28. One of the studies included in this review comparing fluoroscopy-guided TBNA versus ultrasound-guided TBNA did not report statistically significant differences in the rate of diagnostic material obtained. Most of the guidelines found agree that EBUS might be considered as a diagnostic alternative mainly in patients with suspected potentially-resectable lung cancer and mediastinal involvement shown in imaging procedures. Due to the high rate of false negatives, confirmation by more invasive techniques is recommended if results are negative or non-conclusive.ConclusionsBased on the evidence found, EBUS could be considered a safe technique with sensitivity and diagnostic results similar to those of mediastinoscopy and higher than blind TBNA when it comes to identification of mediastinal and hilaradenopathy invasion in patients with suspected or diagnosed non-small cell lung cancer and higher than conventional needle aspiration, but lower than percutaneous transthoraxic needle aspiration in patients with peripheral lung nodules. The main obstacles found in the reviewed studies were in relation with the comparator description and variability among studies.Due to the high rate of false negatives, confirmation by more invasive techniques is recommended if results are negative or non conclusive.