guided transbronchial needle aspiration (EBUS-TBNA) in adults is an essential tool for investigating mediastinal and hilar lymphadenopathy. It is now integral to the diagnostic and staging algorithm for lung cancer [1], as well as the diagnosis of other malignancies, lymphoma and non-malignant granulomatous conditions, such as sarcoidosis and tuberculosis. The comparable diagnostic yield, along with decreased complications, has reduced the requirement for previously standard surgical biopsy sampling [2,3].There remains a paucity of data on convex probe (linear) EBUS in paediatric populations [4, 5] and no large European case series. The pathology in paediatric patients is distinct from adults due to the absence of lung cancer and logistical challenges, such as patient tolerance and scope diameter. We hypothesised that EBUS can be performed safely in the paediatric population and provide diagnostic material, obviating the need for more invasive procedures in most cases. The purpose of our study was to review the utility, safety and outcomes of paediatric EBUS in our centres.A retrospective review of prospectively maintained bronchosopy and cytology databases was performed at two UK centres, Manchester Royal Infirmary and Guys and St Thomas's Trust, between May 2008 and November 2018. Cases aged ⩽18 years at time of procedure were included.Procedures were performed by operators with experience of ⩾200 EBUS procedures in adults. EBUS-TBNA was performed using a standard EBUS bronchoscope (BF-UC180F-OL8, Olympus, Tokyo, Japan or EB-530US, Fujifilm, Japan). Lymph nodes were sampled using 22-guage needles employing a two-person technique, with a dedicated bronchoscopist but separate needle handler and labelled using the International Association for the Study of Lung Cancer lymph node map. Rapid on-site evaluation (ROSE) was used for all procedures, with consultant cytopathologist feedback on adequacy of lymph node sampling and preliminary diagnosis including presence of granuloma. All material was sent for microbiological analysis, including acid-fast bacilli (AFB).Medical and anaesthetic records were reviewed for patient's demographics, ethnicity, indication for the procedure, final diagnosis, sedation, ventilation and any additional procedures or complications. Procedure, cytology and microbiology reports were reviewed to determine nodes sampled, nodal size, number of passes, immediate complications, as well as sample adequacy, cytology diagnosis, AFB stains and tuberculosis (TB) culture. Cases were considered to have a final diagnosis of TB if either culture positive or "clinically confirmed TB" if culture negative with granuloma on cytology and clinical response to TB treatment. Major complications were defined as death, bleeding requiring transfusion, advanced intervention or vasopressors, need for reversal agents, pneumothorax, mediastinitis or need for level 2-3 care.All cases undergoing the procedure under general anaesthesia utilised a laryngeal mask airway size 4 or 5 performed with paediatric anaesthetists ...

IntroductionEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a pivotal test in lung cancer staging and diagnosis, mandating robust audit and performance monitoring of EBUS services. We present the first regional cancer alliance EBUS performance audit against the new National EBUS specification.MethodsAcross the five EBUS centres in the Greater Manchester Cancer Alliance, data are recorded at the point of procedure, when pathological results are available and at 6 months postprocedure to review any further pathological sampling (eg, at surgical resection) and the outcome of clinical–radiological follow-up. Outcomes across all five centres were compared with national standards for all lung cancer EBUS procedures from 01 January 2017 to 31 December 2018.Results1899 lung cancer staging or diagnostic EBUS procedures were performed across the five centres during the study period; 1309 staging EBUS procedures and 590 diagnostic EBUS procedures. Major complications were seen in six cases (<1%). All five trusts demonstrated performance above that set national standards in key metrics for both staging and diagnostic EBUS, however the provision of adequate tissue for predictive marker testing was below national standards at one trust. Across Greater Manchester, 72% and 64% of patients had their EBUS procedure performed within 7 days of referral in 2017 and 2018, respectively. Only one out of five trusts met the national targets of >85% of procedures performed within 7 days of referral.ConclusionThe National EBUS service specification is an important framework to drive the quality of EBUS services across the UK. Our data provide assurance of appropriate performance and safety while also highlighting specific areas for attention that can be addressed with the support of the cancer alliance.

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transplant 11 years previously and at presentation was immunosuppressed with tacrolimus and mycophenolate mofetil. Her symptoms started whilst sailing in Crete, prior to which she had travelled extensively in southern China for 8 weeks in 2016. She is a lifelong nonsmoker and for the last several years has been sailing around the Mediterranean with frequent trips back to the UK. A computed tomography scan of the chest was performed in Greece which revealed a large left upper lobe (LUL) mass. A subsequent positron emission tomography/computed tomography in the UK showed a highly avid 10.4-cm left upper lobe necrotic mass with a very high fluorodeoxyglucose uptake, standardised uptake value max 21.4, suggestive of primary lung malignancy. There were also sub-centimetre station 5 and 6 nodes with high fluorodeoxyglucose uptake (standardised uptake value max up to 6.0), suspicious of involvement. Diagnostic EBUS-TBFNA and transoesophageal endoscopic ultrasound-guided (EUS) FNA were performed. Samples were obtained from station 11L lymph nodes via EBUS-TBFNA and the LUL mass via both EBUS-TBFNA and EUS-FNA. Detailed methods relating to specimen preparation were as described previously. 3 ROSE revealed no malignant cells from the station 11L node.Five aspirates from the LUL mass via EBUS-TBFNA were prepared as five air-dried Rapi-Diffâ stained direct spreads that at ROSE showed necrotic debris. Thereafter, a further five aspirates were performed by EUS-FNA, which revealed granulomatous inflammation. In light of these ROSE findings, an additional two aspirates were taken for microbiology assessment.Within the cytoplasm of both the single macrophages and the granulomas, numerous organisms were identified at ROSE on the air-dried slides ( Figure 1A) and subsequently on the SurePathâ slide ( Figure 1B). These microorganisms had both pale and dark staining poles. They stained positive with Grocott's methenamine silver staining, confirming their fungal nature ( Figure 1C) and were noted to be oval in shape with a transverse septum dividing the hyphae ( Figure 1D). Microbiological assessment revealed organisms with a typicalTaralomyces micromorphology with fungal hyphae undergoing conidiation at 30°C. In addition, culture of the sample on a Sabouraud agar slope at 30°C produced a red, diffusing pigment characteristic for T. marneffei ( Figure 1E,F).Clinically, T. marneffei infection is a challenging diagnosis. As demonstrated in this case, taralomycosis may be suspected in cytological specimens based on its characteristic morphology. The organisms are oval, spherical and sausage-shaped, 2-6 µm, display lighter and darker staining poles and have a central transverse septum, which stains densely with silver stain. 4,5 These features are similar to those of another intracellular pathogen, Histoplasma capsulatum, which is also a dimorphic fungus and an AIDS defining infection. The key differentiating features are the sizes of the organisms and the culture patterns.