Endobronchial Ultrasound Guided Intranodal Biopsies Improves Rapid On-Site Evaluation Compared to Fine Needle Aspiration Alone

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Abstract RATIONALE: While endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) has excellent diagnostic yield ranging from 72-95% in mediastinal and hilar lymph nodes, these yields often refer to the final diagnosis made by the pathologist long after the procedure is completed. However, it is the preliminary pathology result reported by rapid on-site evaluation (ROSE) while the procedure is occurring that has the potential to alter whether additional diagnostics are performed, for example via navigational bronchoscopy. Whether intranodal biopsy touch preps improve ROSE results remains unknown. METHODS: We conducted a retrospective analysis to investigate whether adding intranodal forceps biopsy touch preps improved the yield of ROSE when initial FNA was non-diagnostic. A total of 42 consecutive adult patients with mediastinal or hilar lymphadenopathy (43 lymph nodes) were included in this retrospective study conducted at Sentara Princess Anne Hospital from February 2021 to January 2023. EBUS-FNA ROSE was considered negative if blood, lymphocytes, bronchial epithelial cells or atypical cells were reported. Alternatively, multinucleated giant cells, neoplasm, or granulomas were considered positive results. RESULTS: Ultimately, 31 lymph nodes with ROSE-negative FNA went on to have forceps biopsy touch preps done within the same node. The biopsy touch prep for 14 lymph nodes (14/31=45%) revealed potentially clinically meaningful results, e.g. neoplasm, granuloma, and multinucleated giant cells. Final pathology was largely concordant between the forceps specimen and the FNA with 34 of the 43 lymph node specimens being identical. Six diagnoses (6/31=19%) on final pathology were made by biopsy alone, mainly noncaseating granulomas. There were 3 diagnoses made by FNA alone. No significant bleeding occurred in the 42 patients who underwent intranodal biopsy; specifically, no cold saline or epinephrine administration was utilized. One pneumothorax occurred but this was more likely related to the transbronchial biopsy performed during the same procedure. CONCLUSION: EBUS-guided intranodal biopsy is safe and improves the yield of both the ROSE as well as the final diagnosis among patients with initially negative EBUS-FNA ROSE potentially eliminating the need for additional diagnostic interventions.

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