ankara university school of medicine department of thoracic surgery ankara

TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY (TBNAB) AND THE VALUE OF ON-SITE CYTOPATHOLOGICAL EXAMINATION FOR LUNG

CANCER AND MEDIASTINAL LYMPHADENOPATY: “85 CASES”

Serkan ENÖN, Cabir YÜKSEL, Koray CEYHAN, Ayten KAYI CANGIR, Nezih ÖZDEMİR, Murat AKAL

Ankara University School of Medicine

Department of Thoracic Surgery Ankara

TBNA

• 1950 Brouet and Euler: Rigid bronchoscopy

• 1978 Wang: Flexible bronchoscopy

TBNAB

Diagnosis and staging of lung cancer Diagnosis of mediastinal

lymphadenopathy Alternative to mediastinoscopy? Less invasive Cost effective Secure Diagnostic procedure

TBFNAB is not performed worldwide

• In 1990’s it is performed in US %12, • in UK % 27• Recent years % 54

WHY ? Difficult technique Experimentation need No onsite diagnosis Low specificity and sensitivity

AIM

Aim of this study is to determine the diagnostic value of TBNAB and on-site cytopathological examination

PATIENTS-METHODS

February 2004 - February 2007 Ankara University School of Medicine,

Department of Thoracic Surgery TBNAB was performed to 85 cases

with lung cancer and mediastinal LAP

PATIENTS-METHODS

• Under general anesthesia, laryngeal mask

• FOB and 12mm length/19-22G Wang needles,

• Accompanying same cytopathologist.

PATIENTS-METHODS

• During the operation, sufficiency assignment was done by the cytopathologist through the biopsy materials.

• Finding out lymphoid cells or tumor infiltration was accepted as a sufficiency criteria.

• Surgical procedures were done in other cases not including these criteria, then.

RESULTS

•Male : 57 (%67,1)•Female : 28 (%32,9)

•Age(med) : 51,74(14-76)

RESULTS

–47 malign (%55,3)

–38 benign (%44,7)

MALİGN CASES:47

(%)

– Adenocarsinoma...................................: 16 %34– Squamaus cell carsinoma....................: 13 %27,7– Small cell cancer..................................: 9 %19,2– Large cell carsinoma...........................: 5 %10,7– Non small cell carsinoma ..................: 1 %2,1– Hodgkin disease...................................: 2 %4,2– Malign peripheral nerve sheat tm...: 1 %2,1

BENIGN CASES: 38

Granuloma:28 (%73,7)•18 sarcoidosis •7 tuberculosis •2 reactive granuloma(tm or Behçet disease

reaktive ) •1 granulomateous angitis

Reaktive lymphoid hyperplazi:10 (%26,3)

THE RATIO OF DIAGNOSIS

• MALIGN: 46/47 (%97,87) – Non-diagnostic : 1 patient -> biopsy

LCNEC

• BENIGN: 32/38 (%84.21) – Non diagnostic: 6 patients

• 3 tbc (2 necrosis, 1 reaktive lymphoid hyperplasia)

• 3 reaktive lymphoid hyperplasia)

Difficulty in diagnosis: 7 pts

• 4 non-diagnostic (on-site)– 3 reaktive lymphoid hyperplasia – 1 large cell carsinoma

• 2 necrosis (on-site)– Tissue diagnosis: tbc

• 1 reaktive lymphoid hyperplasia (on-site) – Tissue diagnosis: tbc

TOTAL

• Correct Diagnosis 78/85 ( %91.76)

EVALUATION OF LYMPH NODES

• Lymph node size :22,75 mm (7-70 mm)

• Lymph n ode biopsy n: 126• Correct diagnosis n: 104

• Diagnostic ratio: 104/126 (%82.53)

CORRECT DIAGNOSIS ACCORDING TO LYMPH NODES

• Lymph node no 2 : 14/17 (%82,4)• Lymph node no 3 : 7/12 (%58,3)• Lymph node no 4 : 10/15 (%66,7)• Lymph node no 7 : 66/74 (%89,2)• Lymph node no 10 : 2/2 (%100)• Lymph node no 11 : 5/6 (%83,3)

Method Sensitivity %

Spesivity %

FalsePositive(%)

False Negative(%)

Mediastinoscopy 81 100 0 9

Chamberlein 87 100 0 15

TTNA 91 100 0 22

EUS-NA 88 91 2 23

TBNA(910 pts) 76 96 0 29

How should be correct diagnosis of TBNAB increased?

• Experience – Min 2-3 years and 50 TBNAB

• Size of LAP – > 20 mm diagnostic ratio %80

• Number of procedure– At least 5

• Localisation of LAP – Subkarinal LAP

How should be the sensitivity of TBNAB increased?

• Diamater of the needle – 18-19 g : Able to co-investigation of cytology and

histology

• Radiological support– Endobronchial USG, BT-fluroscopy , Endoscopic

USG

• Accompaniment of cytopatholog (on-site cytopathologic examination)

On-site cytopathologic examination

• Decreases inadequate results • Prevents unncessary manipulations

therefore minimizes the complications

• Increases the sensivity significantly (%50 %80)

CONCLUSION

TBNAB is an efficient and reliable method for diagnosing and/or staging the lung cancers and mediastinal LAP

CONCLUSION

The ability and experience of bronchoscopist and on-site cytopathologic examination are the most important factors for the success of procedure

CONCLUSION

• When these factors come together, diagnostic accuracy increases over 90% and the patients can be preserved from invasive surgical procedures such as mediastinoscopy or thoracotomy.