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Endobronchial ultrasound-guided transbronchial mediastinal cryobiopsy: series of 50 cases
Criobiopsia transbronquial mediastínica guiada por ultrasonografía endobronquial: casuística de 50 casos
E. Salcedo Lobera
, F.M. Páez Codeso, E. Casado Miranda
Corresponding author
Unidad de Gestión Clínica Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Regional Universitario de Málaga, Málaga, Spain
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Salcedo Lobera, F.M. Páez Codeso, E. Casado Miranda" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Salcedo Lobera" "email" => array:1 [ 0 => "esalcedolobera@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F.M. Páez" "apellidos" => "Codeso" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Casado Miranda" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Regional Universitario de Málaga, Málaga, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Criobiopsia transbronquial mediastínica guiada por ultrasonografía endobronquial: casuística de 50 casos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Transbronchial fine-needle aspiration guided by endobronchial ultrasonography (EBUS-TBNA) is considered one of the preferred techniques for studying mediastinal lesions, both benign and malignant, showing good yield and safety.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In fact, there are consensus guidelines recommending EBUS as the initial technique for investigating mediastinal pathology.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Transbronchial cryobiopsy is a recent endoscopic technique that has gained prominence in the study of diffuse interstitial lung diseases, playing a significant role in their diagnosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">5</span></a> On the other hand, transbronchial mediastinal cryobiopsy guided by endobronchial ultrasonography (EBUS-TBCB) involves obtaining biopsy samples from within lymph nodes or mediastinal masses using a cryoprobe and real-time endobronchial ultrasonographic guidance. It offers the advantage of providing larger samples and, therefore, improved diagnostic yield compared to EBUS-TBNA.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years, studies combining both techniques, EBUS-TBNA and EBUS-TBCB, have been published, harnessing the advantages of both procedures, enhancing performance, and avoiding more invasive procedures such as mediastinoscopy and its associated complications.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">6,7</span></a> There is still uncertainty about the technique in terms of its safety and yield; however, small case series of 4 and 3 patients, respectively, undergoing both EBUS-TBNA and EBUS-TBCB in a single procedure have recently been published in Spain, describing a very promising technique and preliminary results.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of our study has been to describe our experience, analyzing the procedure, the diagnostic yield in different pathologies studied, and the safety of the technique.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Descriptive study of the first 50 consecutive patients from April 2022 to April 2023 referred to our bronchopleural techniques unit at a tertiary hospital for the performance of an EBUS.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Adult patients with pathological adenopathy (>1<span class="elsevierStyleHsp" style=""></span>cm) suspected of malignant or benign mediastinal disease on imaging studies were included. All patients provided informed consent. The examinations were performed by the two usual bronchoscopists of the unit. Patients with uncorrectable hemostasis abnormalities, uncorrectable hypoxemia despite oxygen therapy or non-invasive mechanical ventilation, and those who did not provide informed consent were excluded.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During the procedure, oxygen saturation, heart rate, and blood pressure were monitored. Supplementary oxygen was administered via nasal cannula or Venturi mask. Sedation was provided with midazolam, fentanyl and propofol.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Both EBUS-TBNA and EBUS-TBCB were performed in a single procedure and at the same adenoopathy. The needles used were EBUS-TBNA Cook ECHO-HD-22-G in 70% of cases and the remaining used the Medi-Globe TopGain needle, along with a flexible 1.1<span class="elsevierStyleHsp" style=""></span>mm cryoprobe (ERBECRYO 20402-401, Tübingen, Germany).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The sampling technique followed the method developed by Ariza-Pallarés,8 and rapid on-site evaluation (ROSE) was not available. In cases where the final result was negative, patients were followed up. The collected variables included age, sex, type and dose of sedatives, ultrasound characteristics of biopsied lymph nodes, diagnostic yield, and complications.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Of the 50 patients, 74% were male with a mean age of 62.36<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.75 years. Conscious sedation by bronchoscopists was used in 54% of cases, with midazolam (average dose of 5.85<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.63<span class="elsevierStyleHsp" style=""></span>mg) and fentanyl (average dose of 0.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.091<span class="elsevierStyleHsp" style=""></span>mg). The remaining 46% received propofol anesthesia.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The ultrasound characteristics of the adenopathies are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. On average, 2 TBNA needle punctures and 4 cryobiopsies were performed.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">A definitive diagnosis through EBUS-TBCB was obtained in 45 cases (90%) compared to 32 cases (64%) through EBUS-TBNA, resulting in a difference of 26% (95% confidence interval: 14–40%, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). Concordance between both tests was found in 36% of cases, as shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In the 9 cases where the sample was insufficient by EBUS-TBNA, a definitive diagnosis was achieved through EBUS-TBCB (4 adenocarcinomas, 3 reactive histiocytosis, 1 small cell carcinoma, and 1 negative case for neoplasia).</p><p id="par0070" class="elsevierStylePara elsevierViewall">In 6 patients, the sample obtained by EBUS-TBNA was considered negative for malignancy, but EBUS-TBCB provided a diagnosis in 4 cases of reactive histiocytosis, 1 neuroendocrine carcinoma, and 1 case of silicosis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the 9 samples taken by EBUS-TBNA that were deemed inadequate for diagnosis by the pathologist, a definitive result was obtained through EBUS-TBCB (5 reactive histiocytosis, 2 squamous carcinomas, 1 infection, and 1 small cell carcinoma).</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is worth ponting out that 5 patients with negative results through EBUS-TBCB had positive results in samples obtained through EBUS-TBNA, all of which were neoplasias.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally, EBUS-TBCB was more sensitive for diagnosing both malignant and inflammatory pathologies. It is also noteworthy that only 6 patients experienced complications, all of which were minor. Three cases involved mild bleeding, two experienced oxygen desaturation that promptly improved with increased oxygen supplementation, and one had vocal cord hematoma.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In 2013, a study evaluating the feasibility, effect, and safety of a new cryoprobe for intrathoracic lymph node puncture guided by EBUS in pigs was published. This was the first study to combine both techniques.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">6</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Years later, Zhang et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">10</span></a> performed the first human case, diagnosing primary mediastinal seminoma through transbronchial mediastinal biopsy using a cryoprobe. They created an incision with an electrocautery to create an opening in the mucosa before inserting the cryoprobe.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Subsequently, the same group presented the largest series published to date, including 197 patients who underwent both EBUS-TBNA and EBUS-TBCB, with an overall diagnostic yield of 79.9% and 91.8%, respectively (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001). Diagnostic yields were similar for metastatic adenopathy and benign lesions (94.1% vs. 95.6%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.58), while mediastinal cryobiopsy was more sensitive than EBUS-TBNA for rare tumors (91.7% vs. 25.0%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001) and benign disorders (80.9% vs. 53.2%, p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004). Regarding complications, they reported 2 cases of pneumothorax and 1 case of pneumomediastinum.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">11</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">This study inspired another group<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">12</span></a> to develop a less invasive and simpler method that does not require electrocautery incision, recently described as the Ariza-Pallares method.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">8</span></a> In their initial series of 50 patients, they achieved diagnostic yields of 82% for EBUS-TBNA and 96% for EBUS-TBCB. Diagnostic yields were similar for sarcoidosis, while cryobiopsy was more sensitive than TBNA for lymphomas and metastatic adenopathies. No complications occurred during the procedure or during patient follow-up. They concluded that EBUS-TBCB, following their method, is a minimally invasive, rapid, and safe technique that can be performed in a bronchoscopy suite under moderate sedation, with superior diagnostic yield compared to EBUS-TBNA, especially in cases of lymphoproliferative disorders and lymph node metastases or when more biopsy material is needed for molecular testing.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In our series, we achieved diagnostic yields of 64% and 90%, respectively. We were concerned about the low yield of EBUS-TBNA, which we attributed to the small number of samples obtained per puncture (an average of 2), with 70% of these performed using cytology needles and without ROSE. However, in terms of diagnostic yield, viability, and safety of the EBUS-TBCB technique, our results are comparable to those currently published. As explained in the material and methods section, we used the technique described by Ariza-Pallares<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">12</span></a> in our study, which enhances the safety and simplicity of the procedure by eliminating the need for incision and electrocautery.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Moreover, sample quality is essential for achieving a good diagnostic yield. Maturu et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">13</span></a> observed an increase in diagnostic yield of 59.3% with EBUS-TBCB in patients with inadequate samples by EBUS-TBNA. Therefore, we believe that the larger size and better preservation of tissue architecture in samples obtained through EBUS-TBCB are the significant advantages of cryobiopsies. In our series, the average size of cryobiopsies was 0.47<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.28<span class="elsevierStyleHsp" style=""></span>cm, compared to 0.18<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.16<span class="elsevierStyleHsp" style=""></span>cm for puncture-obtained samples.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Cases diagnosed as neoplasms (including lymphoproliferative syndromes) were very similar between EBUS-TBNA and EBUS-TBCB, with 19 and 21 cases, respectively. The difference in diagnostic yield was much more favorable for EBUS-TBCB in benign (infectious/inflammatory) pathologies: 7 cases compared to 24 mediastinal cryobiopsies. Most of these cases were related to adenopathy with sinus histiocytosis and reactive lymphadenitis, including a case of tuberculosis and one of Actinomyces infection. These cases were monitored over time to confirm the benign nature of the findings.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Our study, conducted in 50 patients with mediastinal adenopathies, demonstrates that the use of EBUS-TBCB significantly improves diagnostic yield compared to EBUS-TBNA, with a low number of procedure-related complications, all of which were minor. Furthermore, our findings are consistent with those reported in the current literature.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion, EBUS-TBCB is a viable, cost-effective, and safe technique for diagnosing mediastinal lesions, both malignant and, especially, benign ones that require high-quality histological samples. It could potentially obviate the need for repeat procedures (rebiopsies) or other more invasive and costly surgical interventions. However, the technique is of very recent description, and the literature remains limited, necessitating further studies to establish its role in the diagnosis of mediastinal lesions accessible via bronchoscopy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">14</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2010096" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1721999" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2010097" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1722000" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1721999" "palabras" => array:3 [ 0 => "Transbronchial mediastinal cryobiopsy" 1 => "Endobronchial ultrasound-guided" 2 => "Mediastinal lesions" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1722000" "palabras" => array:3 [ 0 => "Criobiopsia transbronquial mediastínica" 1 => "Ultrasonografía endobronquial" 2 => "Lesiones mediastínicas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Endobronchial ultrasonography-guided transbronchial fine-needle aspiration (EBUS-TBNA) has the drawback of providing small sample sizes for accurate diagnosis. Transbronchial mediastinal cryobiopsy (EBUS-TBCB), which allows for larger samples, could improve diagnostic yield.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We prospectively studied 50 patients with mediastinal lymphadenopathy who underwent EBUS-TBNA and EBUS-TBCB in a single procedure.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">EBUS-TBCB improved the diagnostic performance compared with EBUS-TBNA from a definite diagnosis of 32 (64%) patients to 45 (90%) patients [difference 26% (95% confidence interval: 14-40%, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). EBUS-TBCB was more sensitive to both malignant and inflammatory diseases. EBUS-TBCB produced 6 mild complications resolved during the same procedure.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">EBUS-TBCB is a cost-effective and safe technique superior to EBUS-TBNA. Future studies could confirm our findings.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La aspiración transbronquial con aguja fina guiada por ultrasonografía endobronquial (EBUS-TBNA) tiene el inconveniente de ofrecer tamaños de muestra pequeños para un diagnóstico preciso. La criobiopsia mediastínica transbronquial (EBUS-TBCB), que permite obtener muestras de mayor tamaño, podría mejorar el rendimiento diagnóstico.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudiamos prospectivamente a 50 pacientes con adenopatías mediastínicas a los que se les realizó EBUS-TBNA y EBUS-TBCB en un solo procedimiento.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">EBUS-TBCB mejoró el rendimiento diagnóstico en comparación con EBUS-TBNA desde un diagnóstico definitivo de 32 (64 %) pacientes a 45 (90%) pacientes [diferencia 26% (95% intervalo de confianza: 14–40%, p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,05). EBUS-TBCB fue más sensible tanto para diagnóstico de enfermedades malignas como inflamatorias. EBUS-TBCB produjo 6 complicaciones leves resueltas durante el mismo procedimiento.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">EBUS-TBCB es una técnica rentable y segura superior a EBUS-TBNA. Futuros estudios pueden confirmar nuestros hallazgos.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0520" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subcarinal: 35 casesLeft hilum: 7 casesRight hilum: 4 casesRight paratracheal: 3 casesMediastinal mass: 1 case \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sonographic appearance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Homogeneous: 29 casesHeterogeneous: 21 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shape \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polilobulated: 23 casesOval: 21 casesRounded: 6 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3336943.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sonographic characteristics of studied adenopathies.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0525" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">EBUS-TBNA, Transbronchial fine-needle aspiration guided by ultrasonography; EBUS-TBCB, Transbronchial cryobiopsy guided by ultrasonography.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EBUS-TBNA \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EBUS-TBCB \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sample size (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.18<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>−0.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.47<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neoplasms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 cases (1 lymphoma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 cases (1 lymphoma) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inadequate samples \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insufficient for study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative for malignancy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 case \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reactive histiocytosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sarcoidosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Silicosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 case \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3336942.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Results obtained via EBUS-TBNA and EBUS-TBCB.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic accuracy of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) for mediastinal lymph node staging of lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Torre" 1 => "M. Reda" 2 => "V. Musso" 3 => "F. Danuzzo" 4 => "S. Mohamed" 5 => "S. Conforti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.21037/med-21-2" "Revista" => array:5 [ "tituloSerie" => "Mediastinum." "fecha" => "2021" "volumen" => "5" "paginaInicial" => "15" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35118321" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration CHEST guideline and expert panel report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.M. Wahidi" 1 => "F. Herth" 2 => "K. Yasufuku" 3 => "R.W. Shepherd" 4 => "L. Yarmus" 5 => "M. 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