Prospective Optimization of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Lymph Node Assessment for Lung Cancer: Three Needle Agitations Are Noninferior to 10 Agitations for Adequate Tumor Cell and DNA Yield

David Fielding; Andrew J Dalley; Mahendra Singh; Lakshmy Nandakumar; Katia Nones; Vanessa Lakis; Haarika Chittoory; Kaltin Ferguson; Farzad Bashirzadeh; Michael Bint; Carl Pahoff; Jung Hwa Son; Alan Hodgson; Sowmya Sharma; David Godbolt; Kylie Coleman; Lenore Whitfield; Nicola Waddell; Sunil R Lakhani; Gunter Hartel; Peter T Simpson

doi:10.1016/j.jtocrr.2022.100403

Prospective Optimization of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Lymph Node Assessment for Lung Cancer: Three Needle Agitations Are Noninferior to 10 Agitations for Adequate Tumor Cell and DNA Yield

JTO Clin Res Rep. 2022 Aug 30;3(10):100403. doi: 10.1016/j.jtocrr.2022.100403. eCollection 2022 Oct.

Authors

David Fielding^{1

2}, Andrew J Dalley², Mahendra Singh³, Lakshmy Nandakumar³, Katia Nones⁴, Vanessa Lakis⁴, Haarika Chittoory², Kaltin Ferguson², Farzad Bashirzadeh¹, Michael Bint⁵, Carl Pahoff⁶, Jung Hwa Son¹, Alan Hodgson⁷, Sowmya Sharma^{4

8}, David Godbolt⁷, Kylie Coleman⁷, Lenore Whitfield⁷, Nicola Waddell⁴, Sunil R Lakhani^{2

3}, Gunter Hartel⁴, Peter T Simpson²

Affiliations

¹ Department of Thoracic Medicine, The Royal Brisbane & Women's Hospital, Brisbane, Australia.
² UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
³ Pathology Queensland, The Royal Brisbane & Women's Hospital, Brisbane, Australia.
⁴ QIMR Berghofer Medical Research Institute, Brisbane, Australia.
⁵ Department of Thoracic Medicine, Sunshine Coast University Hospital, Birtinya, Australia.
⁶ Department of Respiratory Medicine, Gold Coast University Hospital, Southport, Australia.
⁷ Pathology Queensland, Prince Charles Hospital, Brisbane, Australia.
⁸ Medlab Pathology (ACL) Auburn, Sydney, Australia.

Abstract

Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) is an important means of obtaining a tissue for advanced lung cancer. Optimizing the EBUS TBNA needling technique is important to maintain procedural simplicity and maximize sample quality for emerging molecular diagnostics.

Methods: We prospectively explored three versus 10 agitations of the needle in sequential passes into the lymph node using separate needles. Resulting Diff-Quik cytology smears were quantitatively assessed using microscopic (tumor cell cellularity, abundance scores, erythrocyte contamination) and DNA yields. Microscopy was reported by two cytopathologists, and an inter-rater assessment was made by four additional cytopathologists.

Results: In 86 patients confirmed as having malignant disease by EBUS TBNA (45 males, 41 females), a mean of 5.3 smears were made per patient with a total of 459 smears scored by pathologists and 168 paired smears extracted for DNA. There was no significant difference between three versus 10 agitations for smear cellularity (p = 0.44), DNA yield (p = 0.84), or DNA integrity (p = 0.20), but there was significantly less contamination by erythrocytes from three agitations (chi-square p = 0.008). There was significantly more DNA in the first pass into the node using three agitations than with other passes and with 10 agitations (pass × agitations interaction, p = 0.031). Reviewing pathologists correctly classified smears as more than or equal to 25% cellularity 86.3% of the time (κ = 0.63 [95% confidence interval: 0.55-0.71]).

Conclusions: Three agitations are noninferior to 10 agitations for overall abundance of malignant cells and DNA content on smears. A smear with adequate DNA for panel sequencing could almost always be made with the first needle pass using three agitations.

Keywords: Cytology smears; EBUS TBNA; Lung cancer; Molecular testing.