Original article
Cost-effectiveness and safety of mediastinal transbronchial cryobiopsy guided by endobronchial ultrasonography (CRYO-EBUS) in 110 cases
Rentabilidad y seguridad de la criobiopsia transbronquial mediastínica guiada por ultrasonografía endobronquial (CRYO-EBUS) en 110 casos
Esperanza Salcedo Lobera
, Francisco M. Páez Codeso, Estefania Casado Miranda
Corresponding author
Unidad de Gestión Clínica Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Regional Universitario de Málaga, Málaga, Spain
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Páez Codeso, Estefania Casado Miranda" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Esperanza" "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" => "Francisco M." 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This technique, very recently described,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> obtains larger samples with a higher diagnostic yield.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim, given the limited number of publications on CRYO-EBUS,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> has been to describe our accumulated experience, previously published with a shorter series of cases,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> analysing the cost-effectiveness of CRYO-EBUS versus EBUS-TBNA 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="par0020" class="elsevierStylePara elsevierViewall">Descriptive study of 110 patients referred for EBUS in 2023. Adults with mediastinal lesions or lymphadenopathy detected by imaging techniques were included. Participants signed an informed consent form.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The procedure is performed by first making a needle puncture (EBUS-TBNA) in the lesion and then, through the tunnelling achieved by the needle, introducing a cryoprobe to obtain a cryobiopsy sample (CRYO-EBUS).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The needles used for puncture were 70% Cook® ECHO-HD-22-G and the rest the Medi-Globe TopGain® needle with crown tip and a 1.1 mm cryoprobe (ERBECRYO® 20402-401, Tübingen, Germany). The method was as described by Ariza-Prota et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient underwent at least six months of follow-up in cases that tested negative for neoplastic cells.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The variables collected were: age, sex, type and dose of sedatives, ultrasound characteristics of the biopsied mediastinal lesions, diagnostic yield, diagnoses obtained and complications.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">Seventy per cent were male, mean age 63.2 ± 11.5 years.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Sedation was performed by the bronchoscopist in 76 patients, the remainder by the anaesthesiologist.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the 76 patients, a variable combination of midazolam (mean dose 5.6 ± 2.2 mg), fentanyl (mean dose 150 ± 50 mcg) and ketamine (mean dose 33.6 ± 10.4 mg) was used at the discretion of the physician.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The mediastinal lesions examined were 69 subcarinal lymphadenopathies, 20 hilar lymphadenopathies, 9 right paratracheal, 2 in the aorto-pulmonary window and 9 masses.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding the ultrasonographic morphological characteristics of the lymphadenopathies, all were larger than one centimetre in the short axis, 72.7% had delimited margins, 62.7% were ultrasonographically homogeneous, 52.7% multilobar, 28.1% oval and 19% rounded.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The mean number of TBNA punctures and cryobiopsy samples were 1.5 ± 1.2 and 3.1 ± 1.2, respectively. The mean sample size in centimetres was 0.14 ± -0.10 for EBUS-TBNA and 0.42 ± 0.22 for CRYO-EBUS.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The overall diagnostic yield was 60% for EBUS-TBNA and 94.5% for CRYO-EBUS (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Complications were one breakage of the Cook® ECHO-HD-22-G needle and one case of pneumomediastinum observed at 24 h, which could not be specifically attributed to the puncture or the biopsy but was resolved conservatively. There were 11 cases of occasional oxygen desaturation and one case of neurological symptoms of psychomotor agitation, which we attributed to the sedatives rather than the technique itself.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The first case (a primary seminoma of the mediastinum) was diagnosed in 2020 by Zhang et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> using a transbronchial mediastinal biopsy with a cryoprobe. They made an incision with an electrocautery knife to create a hole in the bronchial wall and then penetrated the cryoprobe into the lesion.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The same group<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> reported the two largest series published to date, with 197 and 271 patients undergoing the combination of EBUS-TBNA and CRYO-EBUS, reporting an overall diagnostic yield in the first study of 79.9% and 91.8%, respectively. In the second study, with 271 patients, the overall yield was 81% vs. 93%. Mediastinal cryobiopsy was clearly more sensitive than EBUS-TBNA in rare tumours (91.7% vs. 25%) and benign disorders (94% vs. 67%).</p><p id="par0095" class="elsevierStylePara elsevierViewall">A Spanish series of 50 patients showed a cost-effectiveness of 82% and 96% for EBUS-TBNA and CRYO-EBUS, respectively. There were no complications during the procedure or at follow-up. They conclude that CRYO-EBUS is a safe technique with a higher diagnostic yield than EBUS-TBNA, especially in cases of lymphoproliferative disorders and lymph node metastases or when larger biopsy samples are needed for molecular determinations.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We report our first 110 cases, one of the largest series reported to date, resulting in a CRYO-EBUS yield of 94.5%, with a very low complication rate. These results are comparable to what has been published to date.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The quality of histological samples is critical to obtain a good diagnostic yield, meaning a result that provides histological aetiology and also allows for future immunohistochemical and molecular studies on the tissue sample, which are so important for guiding cancer treatment. Thus, Maturu et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> observed an increase in diagnostic yield of 59.3% with CRYO-EBUS in those patients with inadequate EBUS-TBNA samples. In our series, while 26 samples collected by EBUS-TBNA were reported as inadequate by the pathologist, only three CRYO-EBUS were inadequate.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In our series, moreover, the mean size of the cryobiopsies was 0.42 ± 0.22 cm, compared to 0.14 ± 0.10 cm for those obtained by puncture. The larger size and better preservation of the tissue architecture of the specimens is a great advantage to the pathologist when it comes to a reliable aetiological determination of CRYO-EBUS biopsies compared to those obtained by puncture.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In terms of the number and type of neoplasms diagnosed, most were related to bronchogenic carcinoma, one case of thyroid cancer, one renal cancer, one colon cancer and three lymphomas; here the results were more similar between EBUS-TBNA and CRYO-EBUS, although clearly in favour of cryobiopsy.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In relation to non-neoplastic pathology, the CRYO-EBUS technique has proved to be the most useful; the most common diagnosis is reactive lymphadenitis. Infections included one case of tuberculosis and one case of <span class="elsevierStyleItalic">Actynomyces</span> infection. All these cases had follow-up to ensure the benign nature of the findings.</p><p id="par0125" class="elsevierStylePara elsevierViewall">With regard to the safety of the procedure, we only consider relevant one case of pneumomediastinum which was resolved conservatively. In relation to sedation, there were minor haemorrhages that did not require special manoeuvres and oxygen desaturations that were not severe and could be corrected with increased oxygen flow or positive nasal ventilation systems. These findings are consistent with published literature.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Analysing the first 50 of the 110 cases, we found a yield of 90% by obtaining a definitive diagnosis by CRYO-EBUS in 45 of these 50 cases. The cost-effectiveness of the current study (110 cases) is 94.5%, which is very close, so we believe that this technique has a fast-learning curve for doctors with good previous experience in performing endobronchial ultrasound, in any case below 50 procedures.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Mediastinal cryobiopsy samples in cases where immunohistochemistry and molecular biology studies were necessary proved very useful.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The only systematic review on this new technique analyses seven studies, totalling 555 patients, 365 of whom had mediastinal tumour involvement, corroborating the greater overall diagnostic utility of CRYO-EBUS compared to EBUS-TBNA (92% vs. 80%), being especially useful in cases of lymphomas or non-pulmonary carcinomas (83% vs. 42%) and those of benign pathology (87% vs. 60.1%).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">We conclude that this procedure has proven to be feasible, cost-effective and safe. That the new CRYO-EBUS technique represents a promising procedure in the diagnostic algorithm for both malignant and especially benign hilar/mediastinal involvement, and that it could be used as an adjunct to endobronchial ultrasound, in which mediastinal tissue samples are obtained with a needle, avoiding repeat procedures (re-biopsies) or other more invasive and costly surgical procedures such as mediastinoscopy.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">We declare that no funding was required for this work.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2235425" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1871119" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2235426" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1871118" "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" => "Funding" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-11-22" "fechaAceptado" => "2024-03-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1871119" "palabras" => array:3 [ 0 => "Mediastinal transbronchial cryobiopsy" 1 => "Endobronchial ultrasonography" 2 => "CRYO-EBUS" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1871118" "palabras" => array:3 [ 0 => "Criobiopsia transbronquial mediastínica" 1 => "Ultrasonografía endobronquial" 2 => "CRYO-EBUS" ] ] ] ] "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="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transbronchial needle aspiration guided by endobronchial ultrasonography (EBUSTBNA) has the disadvantage of sometimes offering samples of an unsuitable size for an accurate histo-molecular diagnosis. Transbronchial mediastinal cryobiopsy (CRYOEBUS) is a very novel and additional technique to EBUS-TBNA that allows us to obtain larger and quality samples, improving diagnostic performance.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descriptive study of 110 patients with lesions and/or mediastinal lymphadenopathy who underwent EBUS-TBNA and CRYO-EBUS in a single procedure. Our objective was to analyze the diagnostic profitability and safety of the technique.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CRYO-EBUS obtained samples of 0.42 cm on average compared to 0.14 cm obtained by EBUS-TBNA. The overall diagnostic performance of the techniques was 60% for EBUS-TBNA and 94.5% for CRYO-EBUS. Furthermore, the latter was more sensitive for the diagnosis of both malignant and benign diseases. With a very high security profile.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The CRYO-EBUS technique is cost-effective and safe, and is superior to EBUS-TBNA. Future studies may confirm our findings.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and 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="spar0045" class="elsevierStyleSimplePara elsevierViewall">La aspiración transbronquial con aguja guiada por ultrasonografía endobronquial (EBUS-TBNA) tiene el inconveniente de ofrecer en ocasiones unas muestras de tamaño no idóneo para un diagnóstico histo-molecular precisos. La criobiopsia mediastínica transbronquial (CRYO-EBUS), es una técnica muy novedosa y adicional al EBUS-TBNA que nos permite obtener muestras de mayor tamaño y calidad, mejorarando el rendimiento diagnóstico.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo de 110 pacientes con lesiones y/o adenopatías mediastínicas a los que se les realizó EBUS-TBNA y CRYO-EBUS en un solo procedimiento. Nuestro objetivo fue analizar la rentabilidad diagnóstica y seguridad de la técnica.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El CRYO-EBUS obtuvo muestras de 0,42 cm de media frente a 0,14 cm obtenidas por EBUS-TBNA. El rendimiento diagnóstico global de las técnicas fue del 60% para el EBUS-TBNA y del 94,5% para el CRYO-EBUS. Además, éste último fue más sensible tanto para el diagnóstico de enfermedades malignas como benignas. Con un perfil de seguridad muy alto.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La técnica CRYO-EBUS resulta rentable y segura, y es 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" => "Material y 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" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CRYO-EBUS: transbronchial mediastinal cryobiopsy; EBUS-TBNA: endobronchial ultrasonography-guided transbronchial needle aspiration.</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">Final diagnoses \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">CRYO-EBUS \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">Neoplasm \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">39 \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">53 \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">Infectious (<span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> and <span class="elsevierStyleItalic">Actynomyces</span>) \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 \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 \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 (blood sample) \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">26 \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">3 \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">Suggestive/Inconclusive \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">18 \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">3 \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 neoplastic cells \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 \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">16 \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">Inflammatory/reactive \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 \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">32 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3643977.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Results and diagnoses of punctures and cryobiopsies.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CRYO-EBUS: transbronchial mediastinal cryobiopsy; EBUS-TBNA: endobronchial ultrasonography-guided transbronchial needle aspiration.</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">Benign pathology \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">CRYO-EBUS \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">Non-necrotising granulomatosis \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 \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">7 \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 sinus 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 \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 \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">Infectious (<span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> and <span class="elsevierStyleItalic">Actynomyces</span>) \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 \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 \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">Other \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 \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 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3643978.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Diagnoses of a non-malignant nature.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary mediastinal seminoma achieved by transbronchial mediastinal cryobiopsy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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