Can a pulmonologist who performs bronchoscopies (bronchs) obtain a sample from a periaortic lymph node?

From the Guidelines

No, a pulmonologist performing bronchoscopy cannot typically obtain a sample from a periaortic lymph node. Bronchoscopy allows access to the tracheobronchial tree and certain mediastinal lymph node stations through endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), but periaortic lymph nodes are located around the aorta in the retroperitoneum or deeper mediastinum, outside the reach of standard bronchoscopic techniques. These nodes are anatomically distant from the airways and would require alternative sampling approaches such as CT-guided percutaneous biopsy, endoscopic ultrasound (EUS), mediastinoscopy, or surgical methods like video-assisted thoracoscopic surgery (VATS) or laparoscopy depending on their exact location. The limitation is based on anatomical constraints, as bronchoscopes can only access structures within or adjacent to the respiratory tract. For periaortic lymph node sampling, referral to interventional radiology, thoracic surgery, or gastroenterology would be necessary, as seen in the guidelines provided by the European Society of Gastrointestinal Endoscopy (ESGE) and the European Respiratory Society (ERS) 1. Additionally, the American College of Chest Physicians (ACCP) lung cancer guidelines also support the use of EBUS-TBNA for mediastinal staging, but highlight the importance of anatomical location in determining the accessibility of lymph nodes for sampling 1. More recent guidelines, such as the Pan-Asian adapted clinical practice guidelines for the management of patients with metastatic non-small-cell lung cancer, also emphasize the role of bronchoscopy and EBUS-TBNA in diagnosis, while acknowledging the limitations in accessing certain lymph node stations 1.

From the Research

Sampling of Periaortic Lymph Nodes

• The ability of a pulmonologist to sample a periaortic lymph node using bronchoscopy is dependent on the location and accessibility of the node.
• Studies have shown that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be used to sample mediastinal and hilar lymph nodes, including those in the periaortic region 2, 3, 4, 5.
• However, the specific location of periaortic lymph nodes may limit their accessibility using EBUS-TBNA, as this technique is typically used to sample nodes in the paratracheal, subcarinal, and hilar regions.
• The use of combined endoscopic-endobronchial ultrasound-guided fine-needle aspiration may allow for the sampling of nodes in the periaortic region, but this would depend on the specific location and accessibility of the node 2.
• There is limited evidence to suggest that EBUS-TBNA can be used to sample periaortic lymph nodes specifically, and more research is needed to determine the efficacy and safety of this approach.

Diagnostic Performance of EBUS-TBNA

• EBUS-TBNA has been shown to have high diagnostic accuracy and sensitivity for the diagnosis of mediastinal and hilar lymph node metastases in patients with lung cancer 2, 3, 4, 5.
• The sensitivity of EBUS-TBNA for the diagnosis of mediastinal lymph node metastases has been reported to be between 77.78% and 96% in different studies 2, 3, 4, 5, 6.
• The negative predictive value of EBUS-TBNA has also been reported to be high, ranging from 75.36% to 95% in different studies 2, 3, 4, 5.