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Leading edge technology in respiratory medicine

Posted: 17 December 2019

Picture of respiratory team

- Offering high quality biopsies and accurately predicting benign/malignant assessment with a sensitivity of 95%, a specificity of 98% and a positive predictive value of 99%

- Success rate for ‘Next Generation Sequencing,’ looking at 20+ genes in parallel at 91.1% which compares favourably with other European centres

- Saving patients up to 20 needle passes, meaning less time spent in hospital and same-day discharge

A cutting-edge diagnostic service at Watford General Hospital means patients have shorter procedures, a smaller number of biopsies and fewer complications.

WHHT’s respiratory department uses an Endobronchial Ultrasound (EBUS) supported by Rapid Onsite Evaluation (ROSE).

The ultrasound is performed under moderate sedation or general anaesthesia and involves a special bronchoscope being inserted into the trachea and bronchi. This provides real-time imaging of the surface of the airways, blood vessels, lungs, and lymph nodes.

The minimally invasive but highly effective procedure is used to check for lung cancer, other cancers suspected of spreading to the lymph nodes, lymphoma and also non-cancerous conditions such as sarcoidosis or tuberculosis.

The images allow the physician to easily view otherwise difficult-to-reach areas and to access more, and smaller, lymph nodes for biopsy than through conventional mediastinoscopy.

The accuracy and speed of the procedure lends itself to Rapid Onsite Evaluation (ROSE) when pathologists in the operating room can process and examine biopsy samples as they are obtained and request additional samples to be taken immediately if needed. Patients recover quickly and can usually go home the same day.

This speedy, effective service means shorter procedures, a reduction in required biopsies and fewer complications. It’s relatively uncommon, with only ten hospitals across the country working in this way. To have it at a General Hospital is very unusual.

Respiratory Consultant Dr Andrew Barlow said:

Picture of social media post"Rapid Onsite Evaluation is a technique whereby a small amount of the material sampled by the needle is examined under the microscope in the bronchoscopy suite to see if there is malignant material or not. The principle is to provide assurance, at the time of the procedure, that the best possible material has been obtained for the likely investigations that the patient requires, whether this is in cancer cases or non-malignant cases.

"We introduced this equipment at the hospital six years ago and it’s a very real game changer; once we had it on site, we realised the very big difference it makes.

It’s like comparing a digital camera to an old fashioned one. It enables us to perform much more targeted procedures and allows us to know within two to three minutes if the patient has cancer or not."

In June this year WHHT’s data was detailed in an oral presentation at the European Congress of Cytology in Malmo, Sweden. See below:

- ROSE accurately predicts final benign/malignant assessment (after examining all material harvested) with a sensitivity of 95%, a specificity of 98% and a positive predictive value of 99%

- The material used for ROSE is a very small proportion of all material harvested (median 1.2% in malignant nodes, 3.5% in benign nodes), leaving the major part for DNA and other analysis, thus our success rate for next generation sequencing (NGS, which looks at 20+ genes in parallel, including EGFR) is 91.1%, which compares favourably with other European centres

- The use of ROSE enables reduction in the number of sites sampled, with 56% of patients having only 1 site sampled, 32% having 2 sites sampled and no patients having more than 4 sites sampled. This contrasts with guidelines suggesting at least three sites should be sampled (in the absence of ROSE).

Cellular Pathology Consultant Dr Anthony Maddox added:

"Most centres do not offer this rapid onsite evaluation service for thoracic EBUS because it is resource-intensive; most centres that do offer it, like ours, use a pathologist and a biomedical scientist (BMS). Though ROSE is commonly performed by a pathologist and a biomedical scientist, there are increasing numbers of BMSs acquiring more extensive skills in Diagnostic Cytology and we aim to develop our local ones to provide this service, thus retaining quality and reducing cost.

“There is good evidence from ourselves and other centres that this service allows you to reduce the number of sites which need targeting, for the obvious reason that you can assess, as you go along, what material is being obtained, and maximise material from the first node that is involved with cancer.

“There is a perception amongst some that material is “wasted” making slides that could be better put into fixative for later analysis. However, we have shown that ROSE uses a tiny proportion of the material (thus leaving most for DNA analysis) and still accurately predicts the final outcome of the procedure.”


Notes to editors

  1. For more information, please contact the communications team on: 01923 436280 or email: Out of hours, please call 07900 228031.
  2. WeWest Hertfordshire Hospitals NHS Trust serves people from across Hertfordshire, north London and further afield. It operates from three hospitals; Watford General, St Albans City and Hemel Hempstead. The trust has a catchment area of over 500,000 people and is one of the largest employers locally, with around 5,000 staff and volunteers.
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