Anthracotic Pigment Research Articles

A Prospective Study Of Histo-Pathological Changes In Lungs, Liver And Kidneys In Burns Cases Autopsied At A Tertiary Care Hospital

Introduction: Medico legal deaths including burns claim a substantial number of lives in central Karnataka.‘A Prospective Study of Histo-Pathological changes in Lungs, Liver and Kidneys in Burns Cases’ was carried out at the Department of Forensic Medicine & Toxicology, SS hospital, SSIMS & RC, Davangere. Material & methods: The present study was carried out for the period of 3 years from January 2021 to December2023. Totally 100 cases with burns and scalds injuries brought to the mortuary for autopsy was the material for study and collection of tissues for histopathological examination. Observations & Results: In the present study, histopathological changes in lungs showed congestion, pulmonary edema, Diffuse alveolar damage or ARDS changes, bronchopneumonia, interstitial pneumonitis, anthracotic pigment, carbon laden macrophages, intravascular thrombi, septic emboli, interstitial & intra alveolar hemorrhage. Histopathological changes in liver showed congestion, fatty change, centrilobular necrosis, cloudy swelling, focal hemorrhage, necrosis, portal inflammation. Histopathological changes in kidneys showed ATN in majority of cases, cloudy degeneration, congestion, tubular casts and acute pyelonephritis in rest of the cases. Conclusion: The effect of burns on vital organs can be assessed through histopathological examination, which helps in determining the post burn complications and which aid in better treatment outcome of the burn’s patients.

Anthracofibrosis mimicking chronic thromboembolic pulmonary hypertension

AbstractWe present the case of a 78‐year‐old female undergoing pulmonary endarterectomy (PEA) because of suspected chronic thromboembolic pulmonary hypertension (CTEPH). During surgery firm black masses were encountered in the aortopulmonary window and on the cranial part of the right pulmonary artery (PA). After PA arteriotomy we visualized intraluminal black firm stenosing plaques at the orifices of the three right and of the left lingular and lower lobar branches. Since no dissection plane could be obtained the procedure was discontinued. Subsequent bronchoscopy visualized a submucosal dark black‐blue discoloration in both main bronchi. Pathological analysis revealed anthracofibrosis, which could be explained by biomass smoke exposure in the past. We are the first to provide intravascular pictures and pathologic images of this very rare entity. Moreover, we report stenoses at the orifices of the three right‐sided lobar and of the left‐sided lingular and lower lobe arteries, in contrast to three previous reports that report on single locations caused by extrinsic PA compression from lymphadenopathy. Our case, however, suggests extension of fibrosis with anthracotic pigment into the PA wall. We conclude that in the absence of a clear history of exposure to carbon smoke and with consequently no diagnostic bronchoscopy, anthracofibrosis of the lungs may mimic CTEPH not only by external compression but also by extension into pulmonary vascular structures. PEA‐surgery should not be attempted in these cases.

Evidence for Continuity of Interstitial Spaces across Tissue and Organ Boundaries in Humans

Bodies have continuous reticular networks, comprising collagens, elastin, glycosaminoglycans, and other extracellular matrix components, within and around all organs. Fibrous tissue coverings of nerves and blood vessels create structural continuity beyond organ boundaries. We recently validated fluid flow through human fibrous tissues, though whether these interstitial spaces are continuous through the body or discontinuous, confined within individual organs, remains unlcear. We investigated continuity of interstitial spaces using two approaches. Non‐biological particles (tattoo pigment, colloidal silver, anthracotic pigment) were tracked within colon, skin, and lung interstitial spaces and into adjacent fascia. Hyaluronic acid, a macromolecular component of interstitial spaces, was also visualized, analyzing skin and subcutaneous fascia, colon and mesenteric fascia, lung and pleura, gynecologic organs and their fascial sheathes, breast, and heart and great vessels. Both techniques demonstrate interstitial space continuity within and between organs including within perineurium and vascular adventitia traversing organs and the spaces between them. We suggest that there is a body‐wide network of fluid‐filled interstitial spaces that has significant implications for molecular signaling, cell trafficking, and the spread of malignant and infectious disease.

A RARE CASE OF EXTRA-PULMONARY ANTHRACOSIS

TOPIC: Occupational and Environmental Lung Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: We present a unique case of anthracosis, common in coal workers, which caused FDG-PET/CT positive mediastinal lymphadenopathy. The majority of cases are associated with malignancy, infectious processes, granulomatous disease, and benign conditions [1]. The exact prevalence of this disease is difficult to estimate because many people with anthracosis are asymptomatic, hence, many cases of anthracosis are discovered incidentally [2]. Endobronchial ultrasonography (EBUS) with transbronchial needle aspiration (TBNA), has been an important method frequently used both in the diagnosis and staging of mediastinal lesions with suspected malignancy and in the initial investigation of the diagnosis of benign lesions [3]. CASE PRESENTATION: 80-year-old male who was referred to the pulmonary clinic after an incidental finding of a lung nodule. The patient reported no symptoms at the time of visit. Past medical history was insignificant. Social history was pertinent for a 55 pack-year smoking history with last use one year before the presentation. The patient was a retired plumbing excavator. There was no known history of tuberculosis. Physical examination was unremarkable. Quantiferon testing was indeterminate, angiotensin-converting enzyme (ACE) test and fungal serum markers were negative. A recent CT chest without contrast identified a left lung nodule and mediastinal lymph nodes. A Follow-up FDG-PET scan demonstrated small and mildly enlarged hypermetabolic mediastinal lymph nodes. The right lower paratracheal lymph node measured 1.6 x 1.1 cm and had an SUV ranging from 7.8-10.7. EBUS guided lymph node biopsy showed found carbon-containing histiocytic aggregates and no malignant cells on cytopathology of the paratracheal lymph nodes, 4L, 4R. DISCUSSION: Extra-pulmonary anthracosis is a rare finding that requires accurate lymph-node sampling to establish a diagnosis. It's commonly due to the inhalation of coal dust, smoke, or pollution [4]. Our case is unique because not all elevated SUV is associated with malignancy and the bronchoscopy didn't show any anthracotic pigmentation or any narrowing of the airways [5]. CONCLUSIONS: We highlight the importance of complete workup for incidental nodules found on routine imaging. Based on the absence of malignant, granulomatous, and infectious processes in the presence of carbon-containing histiocytic aggregates, we confidently diagnosed extra-pulmonary anthracosis. REFERENCE #1: Hewitt RJ, Wright C, Adeboyeku D, Ornadel D, Berry M, Wickremasinghe M, Wright A, Sykes A, Kon OM. Primary nodal anthracosis identified by EBUS-TBNA as a cause of FDG PET/CT positive mediastinal lymphadenopathy. Respir Med Case Rep. 2013 Sep 27;10:48-52. Doi: 10.1016/j.rmcr.2013.09.005. PMID: 26029513; PMCID: PMC3920429. DISCLOSURES: No relevant relationships by Rabia Anees, source=Web Response No relevant relationships by Rosa Arancibia, source=Web Response No relevant relationships by Andrew Doodnauth, source=Web Response No relevant relationships by Khawaja Omar, source=Web Response

A retrospective observational study of benign anthracotic lymphadenitis and its association with PET avid lymph nodes in patients undergoing cancer evaluation.

BackgroundAccurate staging of newly diagnosed or recurrent malignancy is essential for effective treatment. An important first step in staging involves the use of PET/CT to identify areas of FDG avidity. PET/CT however has limitations, including false positive FDG uptake from benign causes. In this paper we characterize an uncommon yet clinically important cause of false positive PET/CTs, that of benign anthracotic lymphadenitis (BAL). We examine the clinical, radiographic and histologic characteristics of BAL in patients referred for endobronchial ultrasound (EBUS) guided biopsies and discuss its context in relation to existing literature.MethodsWe performed a retrospective observational case series of 20 patients who were referred for EBUS guided biopsies of PET positive mediastinal and hilar lymph nodes during the work-up or treatment of suspected malignancy.ResultsTo be included, all patients received PET imaging as well as an EBUS guided biopsy of FDG avid lymph nodes which demonstrated anthracotic pigment as the only histologic abnormality. The key findings were that 90% of patients in this cohort were born outside of the US, 90% had bilateral FDG avid lymph nodes with an average standardized uptake value (SUV) of 7.9±2.2. Most patients, based on their history, had a likely exposure to biomass fuel or urban pollution.ConclusionsBAL may be an underrecognized cause for PET positive lymph nodes in patients undergoing work-up for malignancy. These findings support the importance of sampling mediastinal and hilar lymph nodes even when SUVs are highly suggestive of malignancy.

Oil red O staining for lipid-laden macrophage index of bronchoalveolar lavage: interobserver agreement and challenges to interpretation

Oil Red O (ORO) staining on cytologic specimens with calculation of the lipid-laden macrophage index (LLMI) is used as a part of the workup in a number of clinical settings, particularly when aspiration is of concern. As a part of ongoing internal quality improvement measures, the objective of the present study was to evaluate the interobserver agreement of the LLMI calculation and to identify factors that affect the variability of the calculation. There were 9 study participants, which included 3 trainees, 3 cytotechnologists, and 3 cytopathologists. Each participant reviewed 100 ORO-stained bronchoalveolar lavage slides and assigned an LLMI score to each case. The scores were categorized into 3 groups according to the associated aspiration risk: low, LLMI <40; intermediate, LLMI 40 to 90; and high, LLMI >90. The participants were also requested to note any challenges to the calculation for each case. The interobserver agreement among all participants was fair (κ = 0.23). Stratified by participant group, the interobserver agreement among the trainees was fair (κ = 0.24), among cytotechnologists was fair (κ = 0.32), and among cytopathologists was moderate (κ = 0.60). In 70 cases, at least one participant scored the case at least one category higher than the other participants; in 47 cases there was a two category difference. A primary diagnostic challenge reported by participants was macrophage pigmentation (hemosiderin, anthracosis). We found only fair interobserver agreement among all 9 participants in the study. Hemosiderin and anthracotic pigmentation was a major factor impeding LLMI calculation resulting in overestimation of the LLMI.

Cytologic features and diagnostic value of PeriView FLEX transbronchial needle aspiration targeting pulmonary nodules.

Transbronchial needle aspiration (TBNA) of peripheral lung nodules can be difficult with conventional devices due to their limited flexibility. A promising new technology for accessing these lesions is the PeriView FLEX TBNA device, which has a flexible spiral-grooved needle. The present study reports the unique cytologic features, diagnostic value, and potential pitfalls of PeriView FLEX TBNA specimens. This study retrospectively evaluates 113 consecutive cases of lung nodules sampled using the PeriView FLEX device with radial endobronchial ultrasound guidance. PeriView FLEX specimens were satisfactory for evaluation in 111 of 113 cases (98%). A diagnosis of malignancy was made on 64 specimens (57%), with 100% specificity and 70% sensitivity for malignancy. In 4 cases, the PeriView FLEX sample was the only specimen from bronchoscopy that was diagnostic of malignancy. Of the 64 PeriView FLEX specimens with malignant cells, 58 (91%) were adequate for immunohistochemistry and 44 (69%) were adequate for molecular genetic testing. Potential pitfalls were largely ameliorated through education regarding the unique features of PeriView FLEX samples, such as the expected abundance of anthracotic pigment and the paucity of lymphocytes. TBNA using the PeriView FLEX device to sample pulmonary nodules contributed to the diagnostic value of bronchoscopy and tended to provide sufficient tissue for ancillary studies. Many of the possible pitfalls may be avoided through consideration of the unique cytologic features associated with this novel sampling method.

A BLACK DIAGNOSIS OUT OF THE BLUE: BRONCHIAL ANTHRACOFIBROSIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Bronchial anthracofibrosis (BAF) indicates blackening of the airways with concomitant scarring often due to exposure from cooking over an open fire. It often presents late in life with a COPD-like syndrome in non-smokers. BAF is progressive and can lead to obstruction of the bronchial tree. Here we present a case of BAF secondary to years of cooking over a charcoal stove. CASE PRESENTATION: A 74-year-old Turkish woman presented with a four month history of cough, hemoptysis, and dyspnea on exertion. She was a non-smoker, but reported she had cooked for many years over a charcoal stove in her home. A chest x-ray showed a right lower lobe opacity. A chest CT showed a right hilar obstructing peribronchial mass concerning for neoplasm. She was then referred to pulmonology for bronchoscopy. Initial bronchoscopy noted dark anthracotic-like pigment throughout the right bronchial tree and bronchial obstruction. Washes were negative for infectious or malignant etiologies. A repeat bronchoscopy with endobronchial ultrasound with fine needle aspiration of a pretracheal-subcarinal lymph node revealed abundant anthracotic pigment and no evidence of malignancy. She was started on inhaled corticosteroids and supplemental oxygen. Her symptoms slowly improved, and follow up imaging showed very slow progression of the obstruction. She did have positive interferon gamma release assay testing and was treated with INH. DISCUSSION: Anthracosis was initially associated with lung disease in coal miners, but has been associated with smoke exposure from open fire cooking and dust. Darkening of airway mucosa can be seen in smokers and tuberculosis as well. The presentation of bronchial anthracofibrosis is similar to COPD, with patients noting dyspnea on exertion, cough, and sometimes hemoptysis. It generally affects older patients, predominantly women. Pulmonary function testing generally reveals obstruction with normal DLCO. Imaging will often show airway obstruction as in malignancy and generally leads to bronchoscopy. Bronchoscopy reveals bluish-black pigmented mucosa and bronchial stenosis. Lymph nodes with a hypoechoic, scattered nodular pattern are unique to anthracosis. BAF can appear similar to tuberculosis, therefore patients should have complete workup and treatment for this. There are no clear treatment studies, but BAF is typically managed similarly to COPD. CONCLUSIONS: Bronchial anthracofibrosis should be suspected in older patients with COPD-like symptoms without history of tobacco use, but with exposure to biomaterials such as smoke and dust. Patients with BAF should also be ruled out for active tuberculosis. Reference #1: Mirsadraee M. Anthracosis of the lungs: etiology, clinical manifestations and diagnosis: a review. Tanaffos. 2014;13(4):1-13. DISCLOSURES: No relevant relationships by Gopal Punjabi, source=Web Response No relevant relationships by Lauren Thornton, source=Web Response

PD-L1 expression in gastric cancer determined by digital image analyses: pitfalls and correlation with pathologist interpretation

Programmed death ligand-1 (PD-L1) immunohistochemistry is used to predict response to anti-PD-L1 therapy. However, intra- and inter-observer variability influence the prediction of PD-L1 expression. Unlike evaluations of non-small cell lung cancer according to PD-L1 expression determined by tumor proportion score, gastric cancer is evaluated using combined positive scores. We aimed to compare the results of digital image analysis and pathologists' interpretations for predicting response to pembrolizumab in gastric cancer patients. Gastric cancer tissues from patients enrolled in a clinical trial of pembrolizumab were reviewed, and 39 cases were analyzed. PD-L1 22C3 PharmDx (Dako) immunohistochemistry slides were interpreted by digital image analysis and by the consensus of two pathologists, and the results of interpretations were compared with the eventual clinical responses to pembrolizumab. In direct comparisons of digital image analyses and pathologists' interpretations, 33 (84.6%) out of 39 cases showed concordant results. In 6 (15.4%) cases, weak staining of PD-L1, anthracotic pigment deposits, or decalcification artifacts caused discordant results, and all the cases were challenging. In statistical analyses, PD-L1 expression as interpreted by pathologists and digital image analysis did not differ significantly for predicting responses to pembrolizumab (P = 0.1856). Digital image analyses and pathologists' interpretations showed concordant results for PD-L1 combined positive scores in most cases, and the prediction performances of each were not significantly different.

The role of nano-particulate carbon black in lung cancer development

Abstract Chronic inflammation induced by inhalation of airborne contaminants can contribute to cancer development. We have found that the anthracotic pigment in lungs of smokers is composed of nano-particulate carbon black (nCB), which accumulates in the antigen presenting cells (APCs) and promotes inflammation. Other occupational nCB exposures, such as coal-mining and carbon-black manufacturing, also raise the risk of chronic inflammatory lung diseases. No direct evidence establishes that nCB is a carcinogen; however, several cohort studies have shown a strong correlation between lung inflammation in carbon black industry workers and cancer. We examined whether nCB can promote non-small cell lung cancer (NSCLC) development. Using a novel non-Kras model of NSCLC, in which mice have airway epithelia-specific deletion of tumor suppressors Pten and Smad4 (Ptsd/d), we have found that intranasal challenge with nCB accelerates NSCLC progression. nCB exposure results in myeloid-derived suppressor recruitment and lactate accumulation to paralyze anti-tumor effects. Further, adoptive transfer of APCs from nCB exposed wild type mice (nCB-APC) to Ptsd/d mice showed increased incidences of lung tumor and metastasis, indicating a critical role for APCs in NSCLC progression. nCB-APC-induced immune suppression is in part mediated by expression of immunosuppressive enzymes and lactate production. Additionally, nCB-APCs express both pro-inflammatory and immunosuppressive cytokines to promote tumor growth. These findings suggest that nCB-APCs foster an immunosuppressive microenvironment, and indicate a mechanism responsible for environmental and occupational exposure to nCB in accelerating NSCLC progression.

Sentinel node biospy using intravital blue dye: An useful technique for identification of skip metastases in gastric cancer.

As the lymph node status remains the main prognostic factor of gastric cancer (GC), several lymph node-based staging systems have been recently proposed for an appropriate postoperative therapy. The identification of sentinel lymph nodes (SLNs) might improve the postoperative protocols. The aim of this study was to present our experience in detecting SLNs in GC using methylene blue dye.We have performed an observational study and retrospectively analyzed all of the consecutive cases of GC operated by the same surgical team and managed by the same pathologists during 2013 to 2015. In all of the cases SLN status was determined using the methylene blue that was intraoperatively administered in the peritumoral subserosal tissue. All blue colored nodes were histopathologically examined. In the node negative cases immunohistochemical stains using AE1/AE3 keratin were performed.The blue SLNs were identified in 48 out of the 50 cases included in the study, with a 96% sensitivity and 87.50% specificity. From the 48 cases, 34 (70.83%) presented positive SLNs; in the other 14 cases the SLNs were negative (29.17%). False negativity was observed in 6 of the 14 cases. In 2 of the cases the false negativity of the group 20 was induced by the anthracotic pigment. In other 2 false negative cases, although no regional metastases were founded, sentinel skip metastases in the group 8 and 15, respectively, were identified.Mapping of the SLNs is a simple and cheap method that might improve the accuracy of LN-based staging of patients with GC and favor identification of skip metastases.

Evaluation of chemical composition and anti-inflammatory, antioxidant, antibacterial activity of essential oil of Sardinian Santolina corsica Jord. & Fourr.

Santolina corsica Jord. & Fourr. Corsican-Sardinian is an endemism almost present all around Corsica; in Sardinia, it can only be found in Monte Albo (calcareous substratum and poor in nutrients). The aim of our study is to investigate the chemical composition of S. corsica essential oils from plants growing in three different stations located at different altitudes and evaluate the biological activity using anti-inflammatory, antioxidant and antimicrobial test. The composition of the essential oils was determined by gas chromatography and gas chromatography/mass spectrometry. The essential oils of the Sardinian-Corsican endemism S. corsica, growing in Monte Albo, showed a great variability, probably due to genetic characters different from the Corsican type. We found three different chemotypes: artemisia ketone-β-fellendrene; myrcene and β-fellandrene-myrcene. Standard microbiological assays demonstrated that the essential oils collected in the selected stations, compared with oil and compound with demonstrated antibacterial activity, don’t have any antibacterial activity. DPPH test carried out on the tree samples, compared with chatechin, demonstrated that the oils don’t have antioxidant activity.Regarding anti-inflammatory activity the study demonstrated that the essential oils have a good anti-inflammatory activity on the bronchial tract.The addition of essential oil make easy the exocytose and the histiocytes can expel the anthracotic pigment into the culture medium, purifying its cytoplasm and restoring its ability to phagocytize more material. With a higher concentration of granulocytes in the sample, the incubation of cells shows a non-specific inflammatory pattern in which the addition of the essential oils has a positive impact on the decrease of granulocytes.More experiments are requested to confirm the data, but on the basis of these first results S. corsica essential oil showed potential activity against respiratory infections.

Bronchial anthracofibrosis: The spectrum of radiological appearances.

Bronchial anthracofibrosis (BAF), caused by long-standing exposure to biomass fuel smoke, has emerged as a distinct pulmonary disease. It is usually seen in elderly females who have worked long hours in poorly ventilated kitchen full of smoke due to incomplete combustion of biomass fuel. The diagnosis is confirmed on bronchoscopic visualization of bluish-black anthracotic pigmentation along with narrowing/distortion of the affected bronchus. BAF has been associated with clinical conditions such as pulmonary tuberculosis, chronic obstructive pulmonary disease, pneumonia, and malignancy. Tuberculosis, once thought to be the causative agent for BAF, is now considered to be an association. BAF has a diverse radiological presentation and the presence of associated clinical conditions often confound the radiological picture. The imaging features of BAF include primary imaging characteristics, which pertains to the disease entity directly, and secondary features based on the presence of associated conditions. High-resolution computed tomography findings of multifocal bronchial narrowing and peribronchial cuffing are considered to be specific diagnostic features of BAF. In addition, the diagnostic probability is increased in the presence of mediastinal adenopathy and collapse/atelectasis with middle lobe syndrome being the most common presentation. This pictorial essay highlights the range of imaging appearances in patients with BAF.

Indication of Flexible Fiberoptic Bronchoscopy and the Histopathological Examination in 500 Patients

Introduction: The importance of flexible fiberoptic bronchoscopy (FFB) for diagnosis of pulmonary diseases is well known. The aim of this study was to evaluate the indications of 500 FFBs performed in Imam Reza hospital, Mashhad, Iran as well as examination of the histopathological and radiological findings.Material and Methods: This was a retrospective analysis of the medical records and chest radiologic examinations of 500 patients who had undergone FFB using Olympus BFP20 instrument by local anesthesia in, Mashhad, Iran. The indications for procedures, demographic data, and clinical symptoms were recorded and analyzed in addition to radiological and histopathological findings.Results: The most common indication for FFB was found to be bronchogenic carcinoma (n=20), followed by tuberculosis (TB; n=16), sarcoidosis (n=2), and hydatid cyst (n=2). A total of 70 anthracosis cases were reported to be accompanied with other pulmonary disorders and findings such as chronic granulomatous bronchitis suspicious of TB (n=16), squamous cell carcinoma (SCC; n=5), non-specific macrophage cells in cytology (n=19), anthracotic pigment with no risk of lung cancer (n=20), anthracofibrosis (n=4), severe anthracotic pigment with undetectable mucus layer (n=2), anthracotic pigment with non-specific inflammation (n=1), mild squamous metaplasia (n=1), and chronic bronchitis with mild squamous metaplasia (n=2). Lung cancer showed higher frequency in women and patients in the sixth and seventh decades of their lives and was associated with smoking. It is worthy to note that SCC was the most prevalent cancer among the smokers. Twenty cases were diagnosed as bronchogenic carcinoma by clinical findings, eighteen of which also being confirmed by the histological examinations. Moreover, two cases of sarcoidosis diagnosis using FFB were approved by biopsy. Out of 297 bronchial biopsies, the most common indication for FFB were airway collapse and unknown pulmonary opacity.Conclusion: Considering the important role of FFB in the diagnosis of pulmonary diseases, especially cancers, it seems that various diagnostic measures should be taken into consideration before disease progression. According to our evaluations, patient screening by the family physicians is recommended for the patients with cancer or TB as the two most prevalent diseases in our study.

Does anthracosis reported in endobronchial ultrasound-guided transbronchial needle aspiration exclude metastasis?

OBJECTIVES: In some studies, it has been hypothesized that anthracotic pigmentation in mediastinal lymph nodes is a sign of benign conditions and excludes metastasis from thoracic and extrathoracic malignancies. The aim of this study was to evaluate the clinical significance of mediastinal lymph node anthracosis in cancer patients who underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). MATERIALS AND METHODS: In this study, medical data of patients with lung cancer or extrathoracic cancer who underwent EBUS-TBNA for investigation of mediastinal lymph node metastasis were evaluated retrospectively. EBUS-TBNA cytology reported as anthracotic pigmentation was included in this study. Patients were excluded from the study if cytology of aspirated lymph nodes reported as “benign,” “malignancy,” or “granulomatous inflammation.” RESULTS: There were 50 eligible patients. Thirty-one (62%) patients underwent EBUS-TBNA for lung cancer staging and 19 (38%) for evaluation of extrathoracic metastasis. A total of 120 lymph nodes were sampled. The most sampled station was subcarinal. EBUS-TBNA was false negative in eight of 31 (25.8%) lung cancer patients and one of 19 (5.2%) extrathoracic malignancy patients. CONCLUSIONS: Anthracotic pigmentation of lymph nodes in EBUS-TBNA cannot exclude metastasis in lung cancer patients and mediastinoscopy should be performed before surgery in this group. In patients with extrathoracic malignancy, anthracotic pigmentation is associated with benign conditions. However, further investigation with larger cohort is needed.

Pulmonary hypertension associated with combined fibrosing mediastinitis and bronchial anthracofibrosis: A retrospective analysis in a single Chinese hospital.

Both fibrosing mediastinitis (FM) and bronchial anthracofibrosis (BAF) are unique diseases. The combined appearance of FM and BAF is extremely rare. The aim of this study was to investigate the clinical features of patients with coexisting FM and BAF. Between January 2003 and December 2015, a total of eight patients were diagnosed at the Peking Union Medical College Hospital as having combined FM and BAF. The clinical presentations, radiographic features and bronchoscopic findings of the eight patients were reviewed. The patients were five women and three men with a median age of 64 years (range 56-86 years). Symptoms included dyspnea (eight patients), cough (seven patients), chest pain (two patients), hemoptysis (two patients) and so on. Chest CT of all eight patients showed mediastinal soft-tissue lesions, with multiple narrowed or obliterated lobar or segmental bronchi and arteries. Bronchoscopy showed that all of the patients had multiple stenoses of lobar or segmental bronchi with anthracotic pigmentation on the mucosa. Echocardiography showed that all of the patients had elevated pulmonary arterial systolic pressure (median 81 mm Hg, range 51-107 mm Hg). Each of the eight patients had a history of exposure to, or infection with, tuberculosis, although there was no evidence of active disease. All of the eight patients had long-term exposure to indoor coal or biomass fuel smoke. FM can coexist with BAF, characterized by prominent pulmonary hypertension. The possible etiological factors are tuberculosis and coal or biomass fuel exposure.

The concomitant occurrence of pulmonary tuberculosis with bronchial anthracofibrosis

BackgroundBronchial anthracofibrosis (BAF), diagnosed bronchoscopically, is a clinical entity which is now beginning to emerge from obscurity. This is commonly encountered in elderly females with history of long-standing exposure to biomass fuel smoke in poorly ventilated kitchens. As awareness of BAF has increased in recent times, distinct clinicoradiological and bronchoscopic features of the disease have emerged. Diagnosis is achieved by visualisation of bluish-black mucosal hyperpigmentation along with narrowing/distortion of the affected bronchus on fibreoptic bronchoscopy (FOB). BAF was first recognised nearly a decade ago in India, when a 65-year-old female who presented with a middle lobe syndrome (MLS) was diagnosed with concomitant pulmonary tuberculosis and BAF. Pulmonary tuberculosis, seen in up to one-third of patients with BAF, is now considered to be an associated condition rather than a causative agent, as was initially postulated. MethodsRespiratory symptomatics with a history of biomass fuel smoke exposure underwent high-resolution computed tomography (HRCT) of chest as well as FOB to establish a diagnosis of BAF. In patients who were diagnosed with BAF, an association with tuberculosis was also sought for. ResultsOf the 31 patients diagnosed with BAF in one unit, four had an associated diagnosis of tuberculosis. Cough was the most common presenting symptom seen in all four patients. Imaging revealed consolidation in 3/4 subjects, nodular lesions in one and in another one multifocal narrowing on HRCT, a feature characteristic of BAF. One patient had a diagnosis of MLS. FOB, in all four subjects, visualised anthracotic pigmentation along with narrowing/distortion of the affected bronchi with the left upper lobe bronchus being most commonly affected. Stains and cultures of the bronchial aspirate for Mycobacterium tuberculosis were positive in all four patients while GeneXpert performed in three was positive in all. Rifampicin resistance was not detected. One patient had an actively caseating form of endobronchial tuberculosis as evidenced by oedematous, hyperemic mucosa along with whitish cheese-like material affecting the right middle lobe as was seen on FOB. ConclusionOnce a diagnosis of tuberculosis is established in a patient with long-standing exposure to biomass fuel smoke, invasive procedure required for the diagnosis of BAF is usually not considered and the diagnosis would remain confined to pulmonary tuberculosis. This study highlights the need to recognise BAF and to exclude pulmonary tuberculosis in such patients.

Adequacy Criteria of Rapid On-Site Evaluation for Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Simple Algorithm to Assess the Adequacy of ROSE

Rapid on-site evaluation (ROSE) for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been advocated to qualitatively diagnose biopsy samples. However, adequate ROSE criteria during EBUS-TBNA are unclear. The aim of this study was to determine adequacy criteria of ROSE in EBUS-TBNA samples and suggest an appropriate algorithm. Patients who underwent EBUS-TBNA for nodal evaluation between March and July 2013 at Seoul National University Hospital were included prospectively. The ROSE slides were reviewed independently by two pathologists, and the results were compared to the final pathologic results. Diagnostic yields, sensitivity, specificity, and accuracy were calculated in order to make nodal evaluations. EBUS-TBNA was performed on 300 lymph nodes in 133 patients. Samples were nondiagnostic in 7.7%, 6.3%, and 1.7% of the cytologic, histologic, and overall pathologic results, respectively. On the ROSE slides, a large tissue core size (≥2 cm), microscopic anthracotic pigment (MAP), and increased lymphocyte density (LD; ≥40 cells/field [40×, mean of 10 fields]) were significantly associated with adequate final cytologic or histologic results. Malignant cells were not statistically associated with adequacy but were considered a parameter indicating an adequate diagnosis. Using four sequential criteria, tissue core size, the presence of malignant cell, MAP, and LD ≥40 cells/field, the sensitivity and accuracy rates of ROSE increased from 64.4% to 98.6% and from 64.7% to 97.3%, respectively. A high adequacy rate of ROSE in EBUS-TBNA can be achieved by sequentially applying four criteria: tissue core size, malignant cells, MAP, and increased LD.

Necrotizing Sarcoid Granulomatosis (NSG): A Diagnostic Pitfall to Watch Out For!

Due to a 6 month history of recurrent bronchitis associated with shortness in breath a female patient in the mid-50s was referred for radiographic evaluation. The radiographic examination of chest showed rounded lesions at the level of the right central lobe and increased interstitial reticular opacity [Table/Fig-1]. The patient’s history and the radiographical findings described were suspicious for malignant disease. Thus, the patient was admitted and subjected to further work-up (tumour search). A CT scan of the lungs confirmed the presence of intrapulmonary rounded nodular opacities of up to 1.5 cm in diameter corresponding to the X-ray findings [Table/Fig-2]. For histocytopathological confirmation of the origin of the nodules, a bronchoscopy was initiated. Unfortunately, the bronchoscopy with brush biopsy yielded the unspecific finding of an alveolar hyperplasia accompanied by lymphocytic and granulocytic inflammatory reaction. Finally, the patient was submitted to diagnostic partial lung resection. The histopathological evaluation of the resected, paraffin-embedded tissue revealed an overlaying, nearly confluent nodular structure of strongly hyalinized tissue with anthracotic pigmentation and peripheral accumulation of epitheloid cell granulomas accompanied by infiltration of lymphoid cells. No PAS-positive micro-organisms were detectable [Table/Fig-3a&b]. [Table/Fig-1]: Plain chest X-ray showing the presence of increased interstitial pronounced opacity (in PA and lateral view) [Table/Fig-2]: Axial CT scan of the chest showing several rounded opacities in various sizes (up to 1.5 cm in diameter) [Table/Fig-3a,b]: (a) Histopathological work-up (5x) of resected lung tissue showing sterile, nodular epitheloid cell granulomas, (b) increased fibro-hyalinized tissue with anthrotic pigmentation and peripheral accumulation of inflammatory cell infiltrates Necrotizing sarcoid granulomatosis (NSG) is a rare condition related to the family of sarcoidosis [1]. In imaging it can be confused with a malignant aetiology. Thus, patients may be confronted with the suspicion of suffering from malignant disease. Based on imaging direct referral to oncology centers and even initiating therapy might be discussed before further differential diagnoses are considered. However, not all suspicious pulmonary nodules are malignant. The diagnosis still has to be made by histopathology of cellular material from broncho-alveolar lavage (cytological examination) or trans-bronchial biopsy. Unfortunately, in our case, these procedures did not yield a clear diagnosis. A diagnostic lung resection had to be performed. The diagnosis was Necrotizing sarcoid granulomatosis of the lungs. The patient was accordingly treated with anti-inflammatory agents (non-steroidal antirheumatic drugs) and symptoms were regressive thereafter. NSG is a rare but generally benign disease that shares similarities with pulmonary vasculitis and classical sarcoidosis [2]. It can reveal as benign cause of seemingly deleterious situation. It should always be taken into consideration, as differential diagnosis for intrapulmonary or systemic disease, alone or in association with other entities [3].

Nonoccupational anthracofibrosis/anthracosilicosis from Ladakh in Jammu and Kashmir, India: A case series.

Background:Nonoccupational anthracosis and silicosis has been reported from various parts of the world including Ladakh in Jammu and Kashmir, India; however, anthracosilicosis has only been reported in industrial workers till date.Materials and Methods:Six cases from the Ladakh region in Jammu and Kashmir, India with similar clinico-radiological-pathological features, i.e., anthracosilicosis/anthracofibrosis have been analyzed. Of these, four were analyzed retrospectively and two prospectively.Result:All the patients were homemakers and resided in Ladakh in Jammu and Kashmir, India since birth with an age range of 42–62 years and an average age of 56 years. Their average duration of symptoms was 4 years. Spirometry showed small and/or large airway disease in 5/6 cases. On computed tomography (CT), 4/6 cases showed progressive massive fibrosis (PMF) with calcified mediastinal lymph nodes. There were random or centrilobular nodules in all the six cases. Bronchoscopy in 5/6 cases showed multiple anthracotic pigments with narrowing and distortion of the bronchus (anthracofibrosis). Malignancy was suspected clinico-radiologically in four cases and pathologically in two cases. On histopathology, anthracosis was demonstrated in all and silicosis in three cases.Conclusion:Anthracosilicosis can occur due to environmental exposure. Ladakh in Jammu and Kashmir, India is the only place across the globe with unique environmental features having the presence of both free silica and biomass fuel. The disease was observed predominantly in older women. Awareness would prevent unnecessary investigation for malignancy. Treatment with the bronchodilator is useful as it has evidence of airway disease. Finally, environmental measures and a proper study need to be undertaken for knowing the relative role of silica versus soot in causing the lung disease and preventing this irreversible condition.