Background: Diagnosing mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) are on the rise, but uncertainty surrounds the optimal number of cases needed to achieve acceptable yields. Objectives: To determine the threshold at which EBUS-TBNA reaches adequate yields among trainees and skilled bronchoscopists. Methods: We reviewed all EBUS-TBNAs performed at our medical center since implementing the use of EBUS (n = 222). Results: EBUS-TBNAs were performed in 222 patients (344 nodes). The percentage of adequate specimens sampled (diagnostic specimens or nodal tissue) rose from 66% in 2008 to 90% in 2012 (p < 0.01) and cancer yield improved from 34% in 2008 to 48% in 2012 (p < 0.01). Attending physicians who performed an average of more than 10 procedures per year had higher yields compared to those who performed fewer than 10 procedures per year (86 vs. 68%, p < 0.01). The yield of trainees also improved with every 10 procedures (79, 90 and 95%, p < 0.001) and that of attending physicians with experience (1-25 procedures: 78% yield, 26-50 procedures: 87% yield and 50+ procedures: 90% yield; p < 0.01). Among trainees, failure rates declined steadily. Conclusion: EBUS-TBNA yield (malignant and benign) increases with increasing experience amongst experienced bronchoscopists and trainees as early as the first 20-25 procedures. Pulmonary trainees had a rapid decline in failure rates. These findings suggest that in an academic environment a minimum of 20-25 procedures is needed to achieve acceptable yields.

Keywords:
Adequate specimen sampling, Endobronchial ultrasound, Lymphadenopathy, Procedural yield, Transbronchial needle aspiration
1.
Gompelmann D, Herth FJF: Role of endobronchial and endoscopic ultrasound in pulmonary medicine. Respiration 2014;87:3-8.
2.
Becker HD: EBUS: a new dimension in bronchoscopy. Respiration 2006;73:583-586.
3.
Herth F, Becker DH, Ernst A: Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial. Chest 2004;125:322-325.
4.
Plat G, Pierard P, Haller A, et al: Endobronchial ultrasound and positron emission tomography positive mediastinal lymph nodes. Eur Respir J 2006;27:276-281.
5.
Yasufuku K, Chiyo M, Sekine Y, et al: Real-time endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal and hilar lymph nodes. Chest 2004;126:122-128.
6.
Vincent BD, El-Bayoumi E, Hoffman B, et al: Real-time endobronchial ultrasound-guided transbronchial lymph node aspiration. Ann Thorac Surg 2008;85:224-230.
7.
Ernst A, Silvestri GA, Johnstone D: Interventional pulmonary procedures: guidelines from the American College of Chest Physicians. Chest 2003;123:1693-1717.
8.
Kemp SV, El Batrawy SH, Harrison RN, et al: Learning curves for endobronchial ultrasound using cusum analysis. Thorax 2010;65:534-538.
9.
Steinfort DP, Hew JM, Irving LB: Bronchoscopic evaluation of the mediastinum using endobronchial ultrasound: a description of the first 216 cases carried out at an Australian tertiary hospital. Intern Med J 2011;41:815-824.
10.
Groth SS, Whitson BA, D'Cunha J, Maddaus M, Alsharrif M, Andrade RS: Endobronchial ultrasound-guided fine-needle aspiration of mediastinal lymph nodes: a single institution's early learning curve. Ann Thorac Surg 2008;86:1104-1110.
11.
Hu Y, Puri V, Crabtree TD, et al: Attaining proficiency with endobronchial ultrasound-guided transbronchial needle aspiration. J Thoracic Cardiovasc Surg 2013;146:1387-1392.
12.
Wahidi MM, Hulett C, Pastis N, et al: Learning experience of linear EBUS among pulmonary trainees. Chest 2014;145:574-578.
13.
Folch E, Majid A: Point: are >50 supervised procedures required to develop competency in performing endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging? Yes. Chest 2013;143:888-891.
14.
Kinsey MC, Channick CL: Counterpoint: are >50 supervised procedures required to develop competency in performing endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging? No. Chest 2013;143:891-893.
15.
Bellinger C, Chatterjee A, Chin R, Conforti J, Adair N, Haponik E: Conventional and endobronchial ultrasound-guided transbronchial needle aspiration (TBNA): complementary procedures. South Med J 2012;105:625-629.
16.
Mirsadraee S, Oswal D, Alizadeh Y, Caulo A, van Beek EJR: The 7th lung cancer TNM classification and staging system: review of the changes and implications. World J Radiol 2012;4:128-134.
17.
Ost DE, Ernst A, Feller-Kopman D, et al: Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE Bronchoscopy Registry. Chest 2011;140:1557-1566.
18.
Haponik EF, Cappellari JO, Chin R, et al: Education and experience improve transbronchial needle aspiration performance. Am J Respir Crit Care Med 1995;151:1998-2002.
19.
Yarmus LB, Akulian JA, Gilbert C, et al: Comparison of moderate versus deep sedation for endobronchial ultrasound transbronchial needle aspiration. Ann Am Thorac Soc 2013;10:121-126.
20.
Mehta AC, Wang KP: Teaching conventional transbronchial needle aspiration. Ann Am Thorac Soc 2013;10:685-688.
21.
Stather DR, MacEachern P, Rimmer K, Hergott CA, Tremblay A: Validation of an endobronchial ultrasound simulator: differentiating operator skill level. Respiration 2011;81:325-332.
22.
Konge L, Annema J, Clemensten P, Minddal V, Vilmann P, Ringsted C: Using virtual reality simulation to assess performance in endobronchial ultrasound. Respiration 2013;86:59-65.
23.
Hsu L, Liu C, Ko J: Education and experience improve the performance of transbronchial needle aspiration: a learning curve at a cancer center. Chest 2004;125:532-540.
24.
Rodriquez de Castro F, Diaz Lopez F, Serda GJ, Lopez AR, Gilbert JF, Cabrera Narro P: Relevance of training in transbronchial fine-needle aspiration technique. Chest 1997;111:103-105.
25.
Raveglia F, Meda S, Conforti S, et al: Diagnostic value and learning curve of transbronchial needle aspiration in thoracic surgery. Minerva Chir 2006;61:459-466.
26.
Boonsarngsuk V, Pongtippan A: Self-learning experience in transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy. J Med Assoc Thai 2009;92:175-181.
27.
Hermens FH, Limonard GJ, Termeer R, et al: Learning curve of conventional transbronchial needle aspiration in pulmonologists experienced in bronchoscopy. Respiration 2008;75:189-192.
28.
Tutar N, Buyukglan H, Yilmaz I, et al: Learning curve of conventional transbronchial needle aspiration. Clin Respir J 2013;8:79-85.
29.
Bonifazi M, Zucctosat L, Trisolini R, Moja L, Gasparini S: Transbronchial needle aspiration: a systematic review on predictors of a successful aspirate. Respiration 2013;86:123-134.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.