Background:The optimal method for specimen preparation of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) is still controversial. This study aims to compare several techniques available for EBUS-TBNA specimen acquisition and processing, in order to identify the best performing technique. Methods:We retrospectively reviewed the data of 199 consecutive patients [male, 73%; median age, 64 years (IQR: 52-74 years)] undergoing EBUS-TBNA at our institution from 2012 through 2014 for diagnosis of hilar-mediastinal lymph node enlargement suspect of neoplastic (n=139) or granulomatous (n=60) disease. All procedures were performed by two experienced bronchoscopists, under conscious sedation and local anaesthesia, using 21/22-Gauge (G) needle, without rapid on-site evaluation (ROSE). Five specimenprocessing techniques were used: cytology slides in 42 cases (21%); cell-block in 25 (13%); core-tissue in 60 (30%); combination of cytology slides and core-tissue in 51 (26%); combination of cytology slides and cell-block in 21 (10%). To assess the diagnostic accuracy of each tissue-processing technique we compared the EBUS-TBNA results to those obtained with surgical lymphadenectomy, or 1-year follow-up in non-operated patients.Results: Diagnostic yield, accuracy and area under the curve (AUC) were as follows. Cytology slides: 81%, 80%, 0.90; cell-block: 48%, 33%, 0.67; core-tissue: 87%, 99%, 0.96; cytology slides + core-tissue: 80%, 100%, 1.00; cytology slides + cell-block: 86%, 100%, 1.00. Cytology slides and core-tissue method showed non-significantly different diagnostic yield (P=0.435) and AUC (P=0.152).Conclusions: In our single-institution experience, cytology slides and core-tissue preparations demonstrated high and similar diagnostic performance. Cytology slides combination with core-tissue or cell-block showed the highest performance, however these combination methods were more resourceconsuming.

Background: Multi-institutional studies of endobronchial-ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging in lung cancer are scarce. It is unclear if the high diagnostic performance of EBUS-TBNA reported by experts' guidelines can be generally achieved. Methods: This is a retrospective study performed in five tertiary referral centers of thoracic surgery in Italy, to assess the EBUS-TBNA diagnostic performance in patients with non-small cell lung cancer (NSCLC). Patient inclusion criteria were: both genders; >18 years old; with suspect/confirmed NSCLC; undergoing EBUS-TBNA for mediastinal node enlargement at computed tomography (size >1 cm, ≤3 cm) and/or pathological uptake at positron emission tomography. Altogether we included 485 patients [male, 366; female, 119; median age, 68 years (IQR, 61-74 years)] undergoing mediastinal staging between January 2011 and July 2016.All EBUS-TBNAs were performed by experienced bronchoscopists, without pre-defined quality standards.Depending on usual practice in each center, EBUS-TBNA was done under conscious sedation, with 21-or 22-Gauge (G) needle, and specimen preparation was cell-block, or cytology slides, or core-tissue. Sampling was classified inadequate in absence of lymphocytes, or when sample was insufficient. We analyzed the EBUS-TBNA procedural steps likely to influence the rate of adequate samplings (diagnostic yield).Results: EBUS-TBNA sensitivity, negative predictive value (NPV) and accuracy respectively were 90%, 78% and 93% in the whole cohort. At multivariate analysis, use of 21-G needle was associated with better diagnostic yield (P<0.001). Center and specimen processing technique were not independent factors affecting EBUS-TBNA diagnostic yield. Conclusions: In this multicentric study, EBUS-TBNA was a highly sensitive and accurate method for NSCLC mediastinal node staging. Results indicate better performance of EBUS-TBNA with 21-G needle, and suggest that specimen processing technique could be chosen according to the local practice preference.

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The type of sedation for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) is a relevant issue. Optimal sedation contributes to optimizing both the EBUS-TBNA performance and the cost of care. Our study aims to assess the diagnostic performance and complications of EBUS-TBNA performed under bronchoscopist-directed conscious sedation.We retrospectively analysed the data of 396 consecutive patients [male, 75%; mean age 64±16 years (range 24-89)] who underwent EBUS-TBNA of suspected mediastinal lymph nodes during conscious sedation, with midazolam (mean dose, 3.5±1.1 mg) and fentanyl (mean dose, 0.015±0.001 mg) and with spontaneous breathing. Samples' rapid on-site evaluation was not done. In order to define EBUS-TBNA accuracy, aspirate cyto-histological findings were compared to lymphadenectomy results, or to radiological findings at one-year follow-up in non surgical cases.We sampled 532 lymph nodes [mean number of passes/node, 3±1; lymp node mean size, 1.9±1.4 cm (range 1.0-6.0)]. The procedure mean duration was 22±8 (range 8-65) minutes. EBUS-TBNA samplings were adequate for pathology interpretation in 363 (92%) cases. In 135 cases the diagnosis was malignant disease, in 43 granulomatous disease, in 185 normal lymph node. EBUS-TBNA diagnostic accuracy was 95%. Peri-procedural morbidity rate was 1.5% (6 minor, selflimited complications); mortality was nil.In conclusion, EBUS-TBNA under bronchoscopist-directed conscious sedation was a safe procedure, with high diagnostic accuracy, and averted general anaesthesia costs and risks.