Just Because We Can, Does Not Always Mean We Should

“Step with care and great tact, and remember that Life’s a Great Balancing Act.” —Dr Seuss As treatment options for patients with thoracic malignancies expand, individualized therapy, particularly with targeted agents, demands definitive tissue diagnosis as a prerequisite to such therapies. The ancient dictum “primum non nocere” dictates that the safest and least invasive test with the best diagnostic yield should always be selected first. For malignant diseases in the thorax, the optimal choice of diagnostic procedure depends upon both the location of the disease process and the patient’s ability to tolerate the proposed procedure and possible complications. Endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA), a minimally invasive procedure, has been shown to be very safe and effective in sampling parabronchial structures. It is the preferred initial invasive modality for mediastinal staging of lung cancer1 and can be used to easily access and sample the upper paratracheal (2 R, 2 L), lower paratracheal (4 R, 4 L), subcarinal (7), hilar (10), and interlobar (11) lymph nodes. Traditionally, the technique seeks to avoid traversing any intervening blood vessels, but, as recent case reports and case series indicate, selected lesions can be sampled through the intervening vasculature to obtain a tissue diagnosis. This endobronchial ultrasound–guided transvascular fine needle aspiration (termed EBUS-TVNA by some authors) merits our attention for 2 reasons: concern for the potential complications and generalizability of the procedure. In this issue, Folch et al2 report a retrospective case series of EBUS-TVNA in 10 carefully selected patients from 7 different institutions to obtain a diagnosis of an enlarged lymph node or mass at station 5, the subaortic area according to the IASLC lung cancer staging map. The decision to perform this procedure was made with a multidisciplinary approach. No complications were seen in a 12-month follow-up period. In all patients, treatment was offered on the basis of the results obtained. Similarly, a prior retrospective case series of EBUS-TVNA was published in the October 2015 issue of JOBIP. In this single-center study by Panchabhai et al,3 10 patients with apparent contraindications to surgical sampling underwent TVNA of 9 left-sided and 1 right-sided lesion. One patient required a VATS biopsy to confirm the diagnosis, and 1 patient was diagnosed with histoplasmosis on the basis of serology. Again, no complications were seen in the subsequent 6 months. TVNA by endobronchial and esophageal approaches has been reported in the literature since the late 2000s.2–4 The technique allows sampling of lesions with intervening vessels between the needle entry point and the nodule, mass, or lymph node. It is clear at this point that it is feasible. The similarities in the published literature are striking. First, interventional pulmonologists with unique expertise in the technique of EBUS performed all of the bronchoscopic procedures. They were all performed in centers ostensibly well equipped to manage life-threatening hemorrhage. In the majority of the cases, only 1 needle pass was made through the vessel to obtain the sample. In our opinion, this is a critical safety point. With such a limited body of published literature regarding this technique, the salient question is whether the paucity of reported complications provides us with enough confidence in the safety of the procedure for widespread adoption. Intuitively, the puncture of a large vessel in a noncompressible location raises the concern for life-threatening hemorrhage. However, when performing conventional TBNA without EBUS, it is not uncommon to inadvertently puncture large vessels in the mediastinum and aspirate frank blood, leading to repositioning of the needle entry point, typically without major bleeding complications.5 From a multicenter registry study, we know that bleeding complications that require intervention in EBUS-TBNA occur in 0.2% of cases and that overall complications from EBUS-TBNA are low.6 Yet, there are known complications with EBUS-TBNA, such as hemorrhage (even fatal),7 pneumothorax, pneumomediastinum, and mediastinitis, and also rarer complications such as hemothorax8 and needle fracture.9 We can anticipate similar complications in EBUS-TVNA, but the magnitude of the consequences cannot be predicted from the available literature. Perhaps, there are risks unique to the transvascular approach. For example, bacteremia frequently occurs after standard flexible bronchoscopy.10 As EBUS-TVNA entails passing a nonsterile needle through the working channel of a bronchoscope that has passed through the oral cavity and tracheobronchial tree before passing through the vessel, we can speculate that a larger bacterial load may be delivered directly into the blood stream, resulting in more serious infectious complications. This is especially concerning in an immune-compromised host. Another potential risk of EBUS-TVNA is hematogenous dissemination of malignancy, and, although rare, needle tract seeding does occur in certain malignancies.11 These hypothetical complications are valid considerations when deciding to perform this procedure. We believe that deliberations regarding EBUS-TVNA have now moved from a question of “feasibility” (can you) to “sagacity” (should you). In the multicenter study described in this issue, 1 patient underwent a Chamberlain procedure to confirm the diagnosis of non–small-cell lung cancer and was treated with chemotherapy. Two patients subsequently underwent surgery to treat non–small-cell lung cancer. Overall, 30% of the patients subsequently underwent a surgical procedure without complications. Panchabhai and colleagues also report that 1 patient in their series underwent a video-assisted wedge resection. Details about treatment were not provided in that paper. There appears to have been a significant proportion of patients in these series who were subsequently able to undergo surgery. In hindsight, as these lesions were not accessible by bronchoscopy from a traditional standpoint, the question of whether the sequence of testing should have started with surgery arises. Of course, the care of all patients is fraught with unknowns, and physicians have to make the best decisions that they can, given the knowledge at hand. The absolute indications for EBUS-TVNA are typically few and far between as most patients do not have isolated disease at station 5. If EBUS-TVNA is being considered, the safety of the procedure likely depends on the ability and experience of the proceduralist in minimizing the number of vessel punctures. In addition, the expertise of the facility to manage life-threatening complications and patient factors, such as the ability to tolerate standard or surgical methods of sampling, the presence of coagulopathy, and pulmonary hypertension, are important considerations in the decision to proceed with EBUS-TVNA. Common sense suggests that the lack of reported complications thus far should not provide us with false confidence in the safety of the technique, particularly among patients who may be candidates for a safer alternative sampling procedure.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.