The Safety and Feasibility of Endobronchial Ultrasound Bronchoscopy–guided Intranodal Forceps Biopsies (EBUS-INF)

Traditionally, endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) has been used for the diagnosis of malignant and benign diseases of the lung involving the mediastinum. Unfortunately, obtaining adequate tissue collection, which is necessary for genetic testing in the setting of malignant disease, can pose a challenge using transbronchial needle aspiration. Endobronchial ultrasound–guided intranodal forceps (EBUS-INF) biopsy is a novel technique that can safely and effectively obtain larger tissue samples when paired with EBUS-TBNA. This technology could allow for more timely diagnosis in both malignant and granulomatous diseases. The aim of this study was to describe EBUS-INF as a safe and effective technique for obtaining intranodal lymph node biopsies when used in conjunction with EBUS-TBNA. A secondary aim was to determine concordance between EBUS-TBNA and EBUS-INF on the basis of diagnostic yield. This was a single-center, retrospective, descriptive analysis of 88 EBUS-INF cases for mediastinal and/or hilar lymphadenopathy in 84 patients. A standard endobronchial ultrasound bronchoscopy was performed with EBUS-TBNA and followed by EBUS-INF biopsy to determine concordance of any given diagnosis. The EBUS-INF procedure was performed using the 1.2 mm Boston Scientific Microforceps or Olympus pediatric forceps. Overall agreement between 2 procedures was assessed using Cohen κ where agreement for each individual diagnosis was tested using McNemar test. The EBUS-INF procedure was safely performed in 88 cases and was concordant with the results of the transbronchial needle aspiration biopsies in 86.1% of cases after excluding nondiagnostic cases (Cohen κ=0.82) with only 1.1% complication rate. The one complication was minimal radiographic pneumomediastinum noted on postprocedure chest radiograph. The patient did not require further intervention. This study suggests that EBUS-INF is an effective and safe method for the sampling of mediastinal and/or hilar lymph nodes when performed in conjunction with EBUS-TBNA. There is a trend toward higher likelihood of a diagnosis of granulomatous disease or lymphoma when EBUS-INF is used compared with EBUS-TBNA alone.