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Atypical cells in pathology of endobronchial ultrasound-guided transbronchial biopsy of peripheral pulmonary lesions: incidence and clinical significance

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Atypical cells may occasionally be the only pathologic finding in radial-probe endobronchial ultrasound (EBUS)-guided transbronchial biopsy (TBB) of peripheral pulmonary lesions (PPLs); however, it is uncertain how often we encounter such a situation and what clinical features can be used to identify these ambiguous PPLs, which are more likely to be malignant.


From 2009 to 2016, consecutive patients referred for EBUS-guided TBB of PPLs and with pathology reports indicating atypical cells alone were included. Medical records were reviewed to extract patient demographics, clinical characteristics, procedural details and complications. The primary outcome was the final diagnosis of the PPLs on subsequent investigation. Multivariate logistic regression analysis was used to identify independent factors associated with a final malignant diagnosis.


One hundred sixty-five (7.2%) of 2291 patients had non-diagnostic TBB showing atypical cells. Benign and malignant diagnoses were subsequently obtained in 45 (27%) and 120 (73%) patients, respectively. The leading malignancy was lung adenocarcinoma; of note, a variety of benign lesions revealed cellular atypia on pathology, in particular, chronic inflammation, tuberculosis and pneumonia. Multivariate analysis indicated lesion appearance [solid vs. others; odds ratio (OR) 7.93; 95% confidence interval (CI) 2.94–21.40; P < 0.001] and probe position (adjacent to vs. within; OR 3.36; 95% CI 1.11–10.15; P = 0.032) were two significant factors predictive of a final diagnosis of malignancy.


One out of 14 EBUS-guided TBB procedures for PPLs exhibited atypical cells on pathology. Meticulous management strategies should be formulated to deal with these instances after taking into consideration lesion appearance, probe position and patient preferences.

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We thank the staff of the Eighth Core Lab, Department of Medical Research, National Taiwan University Hospital, for technical support during the study.

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Correspondence to Chao-Chi Ho.

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Drs. Chun-Ta Huang, Yi-Tu Tsai, Chao-Chi Ho, and Chong-Jen Yu have no conflicts of interest or financial ties to disclose.

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Huang, C., Tsai, Y., Ho, C. et al. Atypical cells in pathology of endobronchial ultrasound-guided transbronchial biopsy of peripheral pulmonary lesions: incidence and clinical significance. Surg Endosc 33, 1783–1788 (2019).

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  • Biopsy
  • Bronchoscopy
  • Endobronchial ultrasound
  • Pathology
  • Peripheral pulmonary lesion