title: Endobronchial Ultrasound-Guided Cautery-Assisted Transbronchial Forceps Biopsies: Safety and Sensitivity Relative to Transbronchial Needle Aspiration.
abstract: BACKGROUND
  Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is important in the evaluation of thoracic lymphadenopathy. Reliably providing excellent diagnostic yield for malignancy, its diagnosis of sarcoidosis is inconsistent. Furthermore, TBNA may not suffice when larger "core biopsy" samples of malignant tissue are required. The primary objective of this study was to determine if the sequential use of TBNA and a novel technique called cautery-assisted transbronchial forceps biopsy (ca-TBFB) was safe. Secondary outcomes included sensitivity and successful acquisition of tissue.
  
  
  METHODS
  The study prospectively enrolled 50 unselected patients undergoing convex-probe EBUS. All lymph nodes exceeding 1 cm were sequentially biopsied under EBUS guidance using TBNA and ca-TBFB. Safety and sensitivity were assessed at the nodal level for 111 nodes. Results of each technique were also reported for each patient.
  
  
  RESULTS
  There were no significant adverse events. In nodes determined to be malignant, TBNA provided higher sensitivity (100%) than ca-TBFB (78%). However, among nodes with granulomatous inflammation, ca-TBFB exhibited higher sensitivity (90%) than TBNA (33%). On the one hand, for analysis based on patients rather than nodes, 6 of the 31 patients with malignancy would have been missed or understaged if the diagnosis were based on samples obtained by ca-TBFB. On the other hand, 3 of 8 patients with sarcoidosis would have been missed if analysis were based only on TBNA samples. In some patients, only ca-TBFB acquired sufficient tissue for the core samples needed in clinical trials of malignancy.
  
  
  CONCLUSIONS
  The sequential use of TBNA and ca-TBFB appears to be safe. The larger samples obtained from ca-TBFB increased its sensitivity to detect granulomatous disease and provided adequate specimens for clinical trials of malignancy when specimens from needle biopsies were insufficient. For thoracic surgeons and advanced bronchoscopists, we advocate ca-TBFB as an alternative to TBNA in select clinical scenarios.
authors.affiliation: Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Kyle
authors.initials: K
authors.lastname: Bramley
authors.affiliation: Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Pisani
authors.affiliation: Claude D. Pepper Older Americans Independence Center at Yale, Program on Aging, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Terrence E
authors.initials: TE
authors.lastname: Murphy
authors.affiliation: Claude D. Pepper Older Americans Independence Center at Yale, Program on Aging, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Katy L
authors.initials: KL
authors.lastname: Araujo
authors.affiliation: Department of Surgical Pathology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Homer
authors.affiliation: Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut. Electronic address: jonathan.puchalski@yale.edu.
authors.forename: Jonathan T
authors.initials: JT
authors.lastname: Puchalski
mesh_terms: D000328:Adult; D000368:Aged; D001707:Biopsy, Needle / Q000009:adverse effects / Q000379:methods*; D001999:Bronchoscopy; D002425:Cautery; D061765:Endoscopic Ultrasound-Guided Fine Needle Aspiration / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006099:Granuloma / Q000175:diagnosis; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D017565:Sarcoidosis, Pulmonary / Q000175:diagnosis; D012680:Sensitivity and Specificity; D013525:Surgical Instruments