Endobronchial Ultrasound Biopsy Research Articles

Comparative analysis of the efficacy and safety of electromagnetic navigation bronchoscopy combined with x-ray or radial endobronchial ultrasound biopsy in the diagnosis of small peripheral pulmonary nodules.

To compare the clinical value and safety of electromagnetic navigation bronchoscopy (ENB) combined with radial endobronchial ultrasound (R-EBUS) or x-ray in the diagnosis of small peripheral pulmonary nodules that cannot be diagnosed by conventional bronchoscopy. Fifty-six patients with peripheral pulmonary nodules of <3 cm in diameter who underwent bronchoscopy at the First Affiliated Hospital of Soochow University and Dushu Lake Hospital of Soochow University from February 2019 to January 2022 were selected as the study subjects, including 24 patients who underwent ENB combined with x-ray and 32 patients who underwent ENB combined with R-EBUS. ENB was used as the guiding method in both groups, and x-ray group and R-EBUS group were combined with x-ray and R-EBUS, respectively, to determine whether the lesion was reached. In x-ray group, biopsy and brushing were performed under fluoroscopic guidance. Using the results of surgery, puncture pathology, or clinical follow-up 1 year as the gold standard, the diagnostic sensitivity, specificity, negative predictive value (NPV), diagnostic yield, negative likelihood ratio (LR-), Youden index, missed diagnosis rate, success rate, and κ value were compared between the two groups, and the occurrence of postoperative complications was also compared between the two groups. The negative predictive value of the R-EBUS group was significantly better than that of the x-ray group (p = 0.006). Even with smaller nodule diameters, the negative predictive value of ENB combined with R-EBUS were still higher than that of the x-ray group.

MO137: Sarcoidosis in a Living Kidney Donor Candidate: Case Report and Review of the Literature

Abstract BACKGROUND AND AIMS Sarcoidosis (SCD) is a granulomatous disease that mostly affects young adults, presenting with hilar adenopathy, lung reticular opacities and skin/joint/eye lesions. Incidence varies in Europe between 0.3% and 1.5%, higher in southern countries. Up to one-third of patients have extrathoracic manifestations. Renal involvement varies among different case series. Despite a prevalence of about 13% in autopsies on systemic SCD affected individuals, it is clinically evident in 0.7–4.3% of patients, with a reduced glomerular filtration rate associated with mild or absent urinary anomalies. It usually presents as a tubulointerstitial nephritis at kidney biopsy. Noncaseating granulomas are typical but not always present. Renal injury can also derive from hyperkalcaemia and hypercalciuria (secondary to vitaminD production in granulomas), which cause nephrocalcinosis or nephrolitiasis. A clinical presentation with hyperkalcaemia associates to a better response to therapy (prednisone 1 mg/kg/day for 6–12 weeks, tapered in 6–9 months). An Italian survey on SCD acute kidney injury (AKI) described female sex, hyperkalaemia and absence of granulomas at biopsy as positive prognostic factors, without any correlation between proteinuria and histological damage. SCD AKI evolved to CKD in over 60% of cases (37.5% without comorbidities at onset), with a mean GFR slope of 5 mL/min/year when granulomatous interstitial nephritis was present. METHOD We describe the case of a 55-year-old male, who proposed as a living kidney donor for his wife. His clinical history included a paranoid episode 20 years before, compensated and on psychiatric follow-up at the moment of the screening, dyslipidaemia and normal blood pressure. RESULTS Preoperative screening showed a renal function just above safety threshold for donation (cystatin C-creatinine CKD-EPI 80 mL/min/1.73 m2), a normal urinary sediment and no proteinuria. A thoracic and abdominal CT scan (Figure 1) described numerous aorto-caval adenopathies, stable at a second CT after 3 months. Lungs were unaffected, kidneys and the urinary tract were regular, without calcifications or stones. No infection was detected (negative QuantiFERON, HIV, EBV &amp;lt;1000 copies/mL), suggesting a differential diagnosis between lymphoma and SCD. Serum and urine electrophoresis, immunofixation, light chains, Bence Jones and peripheral blood lymphocyte typing were checked in parallel to ACE dosing; 24-h urine calcium, calcemia, vitamin D, dermatological and ocular examination all normal. An endobronchial ultrasound biopsy was performed, after a PET (Figure 2) to identify the targets with the highest SUV (3.9–6.7). Histology described normal lymphocytes, noncaseating granulomas with sarcoidosis epithelioid histiocytes. CONCLUSION Stage 1 pulmonary SCD without clinical renal involvement was confirmed. Although in a single case of living kidney donation from SCD affected subject was reported, data on GFR deterioration in the long term are lacking. Considering the baseline renal function of the potential donor and the not-quantifiable risk of future AKI, we decided to deem him unfit for donation, despite the absence of markers of disease activity at the moment of the screening. Kidney biopsy will be considered in the future in case of urinary abnormalities or GFR deterioration.

CLEAR CELL CARCINOMA OF LUNG 19 YEARS AFTER NEPHRECTOMY

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Lung is one of the most frequent site for metastasis from renal cell carcinoma (RCC). There is about 93% chance of recurrence of RCC and is usually in the first 5 years following nephrectomy. We report a case of pulmonary metastasis from RCC presenting as a solitary mass which occurred after 19 years of surgical resection. CASE PRESENTATION: A 71-year-old man with history of RCC status post right nephrectomy in 2000, diabetes and hypertension was evaluated in the pulmonary clinic for a new 3.4 x 3.1 cm spiculated right middle lobe (RML) mass which was incidentally detected on CT abdomen done for lower urinary tract symptoms. He underwent endobronchial ultrasound biopsy (EBUS) of the subcarinal(S7) lymph node and navigational bronchoscopy of the mass. The transbronchial biopsy was not diagnostic and the lymph node was negative for malignancy. As malignancy was still high on the differential, decision was made to perform resection of the mass after a multidisciplinary discussion. PET was done prior to surgery which showed mild activity in the mass and no other metastatic lesion. He underwent right middle lobectomy and L11 excision. Pathology showed metastatic clear renal cell carcinoma with positive immunohistochemical marker PAX-8. Repeat CT chest after 3 months showed no new recurrence with plan for imaging surveillance. DISCUSSION: Pulmonary metastasis from RCC can present after a long disease-free period post definitive treatment. The longest period of pulmonary metastasis reported is 37 years after nephrectomy. The mechanism for the late presentation is complex and is related to the host immune response. RCC is slow growing and there is acceleration of the microscopic metastasis when the immune system is compromised. Most pulmonary metastasis are peripheral and subpleural and easily amenable to surgery. Complete resection of pulmonary metastasis has been shown to be an independent prognostic factor for survival in patients with RCC. In our patient the working diagnosis was a new primary lung malignancy so we chose curative surgical resection as he was a candidate for surgery and had no evidence of disease spread (negative EBUS and PET). However, after histopathology we detected a late metastasis of RCC. CONCLUSIONS: 1.Metastasis from RCC should be in the differential of a new pulmonary mass or nodule even decades after nephrectomy and metastasectomy offers curative treatment and has good prognosis. 2.In the absence of a preoperative histology diagnosis the plan for solitary mass must be as of a resectable primary pulmonary malignancy. Reference #1: Alessandro Tamburrini, Aurelio Majorino, Simon Duggan, Sanjay Jogai, and Aiman Alzetani (A record-breaking lung metastasis from renal cell carcinoma 37 years after nephrectomy) Journal of Surgical Case Reports, 2017;10, 1–3 Reference #2: Tsakiridis K, Visouli AN, Zarogoulidis P, et al. Lost in time pulmonary metastases of renal cell carcinoma: complete surgical resection of metachronous metastases, 18 and 15 years after nephrectomy. J Thorac Dis. 2012;4 Suppl 1(Suppl 1):69-73. DISCLOSURES: No relevant relationships by Dushyant Damania, source=Web Response No relevant relationships by Samir Fahmy, source=Web Response No relevant relationships by shahistha hameed, source=Web Response No relevant relationships by Suchit Khanijao, source=Web Response No relevant relationships by padmanabhan krishnan, source=Web Response No relevant relationships by Qasim Sajawal, source=Web Response No relevant relationships by Ayla Zubair, source=Web Response

Ground glass opacity on chest CT scans from screening to treatment: A literature review.

Lung cancer is the most common cause of cancer death in the world. However, recent studies have found that patients with pulmonary ground-glass opacity (GGO) have a better prognosis. Considering its low invasiveness, sublobar resection may be an appropriate treatment of choice. Low-dose computed tomography (CT) is recommended for the high-risk groups of lung cancer. Patients with nonsolid nodule are suggested to take annual low dose CT following-up. For part-solid or solid nodules, the solid component size less or more than 8 mm is the watershed of surgical treatment. Increasing tumor size is a hint of malignancy. Biopsy can be performed for clinically highly suspected malignant nodules. The endobronchial ultrasound biopsy, CT-guide biopsy, or surgical excision are the mainstream for the diagnosis of lung nodules. But for treatment, the sublobar resection is the mainstream of pulmonary GGO. A precise localization technique makes surgeons get enough resection margin and preserve more pulmonary function of the patients. The different localization technique is suitable for different kind nodular position. For patients with pure pulmonary GGO, annual low dose CT checkup is suitable. If the tumor size or solid part of the tumors increased gradually, adequate sublobar resection after tumor localization technique may provide good prognosis and preserve more pulmonary function of the patients.

Memory problems and weight loss: A case report

This interesting case report illustrates a paraneoplastic syndrome presenting as dementia. A 75-year-old Malaysian lady with a 45-pack year smoking history presented with unintentional weight loss of three stone in three months with generalised aches and pains and short-term memory problems. Her inflammatory markers were raised, liver function tests were deranged, and her thyroid stimulating hormone was low. Cerebrospinal fluid examination revealed a mild increase in protein. On the Addenbrookes Cognitive Scale her score was 39/100 and she also had clinical features to suggest mild depression. A Computed Tomography of the thorax showed a 34mm mass anterior to the trachea and an enlarged right para-tracheal lymph node. Subsequent endo-bronchial ultrasound biopsy confirmed metastatic small-cell lung cancer. She had positive autoantibodies for anti-Hu and anti-Sox 1; indicating a paraneoplastic syndrome or limbic encephalitis. Paraneoplastic syndromes are rare and difficult to diagnose. In this case, the paraneoplastic manifestations mimicked a dementia illness.

Multiple benign schwannomas mimicking metastatic lung cancer lesions on 18 FDG PET/CT on a 50-year-old-smoker patient

Multiple intrathoracic schwannomas are rare and can look like a metastatic lung cancer, particularly in smoker patients, on CT and 18FDG PET/CT. A 50-year-old-smoker patient with no medical history has developed an intrathoracic mass. A CT scan has been firstly performed where a 6-cm-isodense-intrathoracic mass has been found with regular contours associated to other nods with regular contours. In addition, centimetric mediastinal lymph nods have been identified. There was no other extra-thoracic localizations. Besides this atypical presentation, we have realized a 18FDG PET/CT showed a significant intense uptake of 18FDG of the mass (SUVmax = 6,5) and a significant intense uptake of 18 FDG (SUVmax = 8,1) of the other intrathoracic nods and of the lymph nods (SUVmax = 5,2). There was no other extra-thoracic localizations. So we have performed a biopsy of the mass and it has highlighted “a growing of fusiform cell arranged in a beam associated to nuclear palisading pattern and the positivity of S-100 making the diagnosis of schwnnoma” and an endobronchial ultrasound biopsy for lymph nodes that has showed “inflammation and the absence of tumoral cells.”. After surger, the definitive histopathology confirmed the diagnosis of benign schwannoma.

Mediastinal small-cell lung carcinoma after right lung transplant for pulmonary interstitial fibrosis.

Pulmonary carcinoma is uncommon after lung transplant, but doubtlessly affects recipient survival independently of other complications. Small cell lung cancer is much rarer after transplant than non-small cell lung cancer. We report a case of mediastinal small cell lung carcinoma confirmed by endobronchial ultrasound biopsy that occurred 18 months after a single lung transplant for interstitial pulmonary fibrosis in a 58-year-old male nonsmoker. The patient died shortly after of distant metastasis. Our report confirms the usefulness of tumor markers and positron-emission tomography-computed tomography as routine tests for earlier detection of malignant disease after lung transplant.

Endobronchial and Endoscopic Ultrasound-Guided Transvascular Biopsy of Mediastinal, Hilar, and Lung Lesions

Endoscopic techniques, including endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS), are the initial approach for the diagnosis and staging of lung cancer and the diagnosis of mediastinal and hilar lesions. Historically, the transvascular approach has been avoided because of concerns of bleeding. Here we review our experience with EBUS and EUS transvascular biopsy of mediastinal, hilar, and lung lesions. A prospective research database was used to retrospectively identify and review the records 33 consecutive patients who underwent EBUS and EUS transvascular biopsy in an outpatient setting over 4 years. Complications were identified as significant hematoma seen with endoscopic ultrasound, hemothorax, hemoptysis other than minor, hemodynamic instability, hospital admission, and death. The biopsies in 14 patients were performed through branches of the pulmonary artery, and 19 were done through the aorta. All EUS biopsies were performed with a 22-gauge needle, and all EBUS biopsies were performed with a 21-gauge needle. Malignancy was diagnosed with specimens from a transvascular biopsy in 16 patients (48.5%). Samples from 8 biopsies (24%) were described as negative for malignancy, and 9 specimens (27%) were described as insufficient. No complications were seen in the immediate postprocedural period, and all 33 patients were discharged home the same day. The median follow-up after the procedure was 12 months, with no complications described. The overall yield was 73%. In this series, EBUS- and EUS-guided transvascular approach for biopsy of mediastinal, hilar, and lung lesions was not associated with significant complications. However, careful selection of potential candidates and close periprocedural observation are mandatory.

Atrial fibrillation as the first clinical presentation of an adenoid cystic bronchial carcinoma.

A previously healthy 50-year-old man was admitted with a repeated rapid heartbeat. Electrocardiograph on admission detected atrial fibrillation with an irregular ventricular rate of 170 beats/min for the first time. Transthoracic and transoesophageal echocardiography showed a 5 × 3.5 cm large sessile mass attached to the lateral wall of the left atrium (Fig. 1a) and a mild pericardial effusion. Computed tomography scan of the chest showed a lobulated lymphoma-like infracarinal mass 7.5 × 5 × 5 cm in size compromising the oesophagus and the left atrium, further enlarged hilar lymph nodes in the pathway of draining lymph ducts and bilateral pleural effusion (Fig. 1b). Cranial and abdominal CT was normal. An endobronchial ultrasound biopsy of the enlarged lymph nodes was performed. Histological and immunocytochemical examination confirmed an adenoid cystic bronchial carcinoma (Fig. 1c, d). The patient was immediately transferred to an oncology centre for further treatment. Fig. 1 Transoesophageal echocardiogram (a) showing a left atrial mass (arrows). CT scan of the chest shows a polycyclic infracarinal tumour (arrows) with enlarged hilar lymph nodes and bilateral pleural effusion (b). An adenoid cystic bronchial carcinoma characteristically ... Secondary cardiac neoplasms with an incidence of up to 1 % at autopsy are more than 20 times more common than primary cardiac tumours [1, 2]. The most common secondary malignant cardiac tumours including both metastasis and local extension were bronchial carcinoma, oesophageal carcinoma, carcinoma of the breast and lymphoma [3, 4]. Certain patients with cardiac neoplasms manifest only recurrent supraventricular or ventricular arrhythmias, most likely due to the irritative effect of tumour invading cardiac muscle [5]. Rarely, cardiac involvement may be the first clinical feature of malignancy. We present a case of an intrathoracic malignancy encroaching upon the heart and causing atrial fibrillation as its first presenting symptom.

Importance of histological verification of mediastinal lymphadenopathy in exact staging of non-small cell bronchogenic carcinoma.

Diagnostics and treatment of bronchogenic non-small cell lung carcinoma is a severe clinical problem. Radical surgery is the major treatment modality with the highest chance for a long-time survival. The aim of the study was to map metastasizing of bronchogenic non-small cell lung carcinoma into homolateral mediastinal lymph nodes and to assess the importance of histological verification of mediastinal lymphadenectomy for exact staging and treatment. Study of 29 patients with non-small cell lung carcinoma in stage IIIa, IIIb and IV (TNM classification) diagnosed from September 2006 to March 2007, with mediastinal lymph nodes invasion according to CT, and with subsequent mediastinal lymph node dissection during autopsy. 50% of the right upper lobe tumors metastasized into group 1 nodes (N1-N4) and 50% into group 3 (N7). 66% of the right lower lobe tumors metastasized into group 3 nodes (N7) and 33.3% into group 1 (N1-4). 20.0% of the left upper lobe tumors metastasized into group 1 nodes (N1-4), 33.0% into group 2 (N5-6), 25.0% into group 3 (N7) and 16.7% into group 4 (N8-9). 23.5% of the left lower lobe tumors metastasized into group 1 nodes (N1-4), 23.5% into group 2 (N5-6), 23.5 % into group 4 (N8-9) and 29.5% into group 3 (N7). 27.6% of examined patients had false positivity of lymph node metastasis according to CT. Histological verification of suspect mediastinal lymph nodes via Endobronchial Ultrasound Biopsy (EBUS) or mediastinoscopy or thoracoscopy is crucial for determining the stage of the disease according to the TNM classification. False positivity of imaging methods in diagnostics of non-small cell brochogenic carcinoma can contraindicate up to quarter of potentially operable patients (Tab. 3, Ref. 11).

One-port (uniportal) video-assisted thoracic surgical resections—A clear advance

One-port (uniportal) video-assisted thoracic surgery (VATS) consists of approaching an intrathoracic target lesion through a sagittal, craniocaudal plane through 1 single-port incision. The use of articulating instruments inserted parallel to the videothoracoscope enables the surgeon to mimic inside the chest the maneuvers that are usually performed during open surgery. Through this VATS approach, several thoracic conditions can be addressed, including lung cancer in selected patients. Unlike conventional, 3-port VATS, the uniportal VATS technique enables the surgeon to bring the operative fulcrum inside the chest when the target lunge lesion is approached through a sagittal plan, thanks to articulating instruments. Uniportal wedge VATS resections of peripheral nodules can help in solving diagnostic dilemmas, be of therapeutic benefit, and provide tissue for biomolecular studies.

Mediastinal Small-Cell Lung Carcinoma after Right Lung Transplant for Pulmonary Interstitial Fibrosis

Pulmonary carcinoma is uncommon after lung transplant, but doubtlessly affects recipient survival independently of other complications. Small cell lung cancer is much rarer after transplant than non-small cell lung cancer. We report a case of mediastinal small cell lung carcinoma confirmed by endobronchial ultrasound biopsy that occurred 18 months after a single lung transplant for interstitial pulmonary fibrosis in a 58-year-old male non-smoker. The patient died shortly after of distant metastasis. Our report confirms the usefulness of tumor markers and positron-emission tomography-computed tomography as routine tests for earlier detection of malignant disease after lung transplant.

Bronchoepidural Fistula in a Man with Actinomycosis Complicated Non-small Cell Lung Cancer

A 63-year-old man was diagnosed with stage IV squamous cell lung carcinoma after presentation with mid-thoracic back pain. Staging computed tomography (CT) chest, abdomen, and pelvis confirmed a cavitating right lower lobe lesion, T3 vertebra, and bilateral adrenal metastatic disease (Figure 1A). An endobronchial ultrasound biopsy of his subcarinal lymph node confirmed the diagnosis of poorly differentiated squamous cell carcinoma. He received a dose of 30 Gy in 10 fractions of radiotherapy to his right lower lobe primary lesion including T1-8 vertebral, which was boosted by a further 6 Gy in two fractions. He was commenced on gemcitabine and carboplatin 1 month later. The restaging CT after his first cycle of chemotherapy showed progressive disease involving his hilar and mediastinal lymphadenopathy and bilateral adrenal and skeletal metastases, but the cavitating right lower lobe lesion remained unchanged. A second cycle of chemotherapy was precluded due to prolonged pancytopenia lasting 25 days, and therefore he was commenced on erlotinib. He presented to the Emergency Department within 1 week of commencement with breathlessness, high-grade fevers (38.6°C), and worsening mid-thoracic back pain. A thoracic CT demonstrated progressive cavitation of the primary lung lesion, with interval development of a transpleuroparenchymal fistulous communication from the right main bronchus to the T6 and T7 vertebral bodies, adjacent intervertebral discs, and the anterior epidural space (Figure 1B). The distant metastatic diseases remained unchanged. Blood cultures were positive for Eikenella corrodens and Actinomyces odontolyticus. Due to poor performance status and prognosis, surgery was considered inappropriate. He was commenced on intravenous ticarcillin/ tazobactam; however, his condition deteriorated and died 3 weeks later. The bronchoepidural fistula was thought to be secondary to infection on the basis of positive blood culture and the interval development of a fistula without evidence of disease progression at other sites. A. odontolyticus infection is unusual in immunocompetent hosts but may occur in association with prolonged pancytopenia. *Department of Medical Oncology, †Department of Radiology, and ‡Ludwig Institute of Cancer Research, Austin Health, Heidelberg, Victoria, Australia. Disclosure: The authors declare no conflicts of interest. Address for correspondence: Mun Sem Liew, MBBS, BMedSci, Department of Medical Oncology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia. E-mail: semliew@hotmail.com Copyright © 2011 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/11/0610-1761

Endobronchial Ultrasound Biopsy Experience at a Noninterventional Pulmonary Academic Center

PURPOSE: Endobronchial ultrasound guided biopsy is rapidly becoming a pervasive technique for sampling mediastinal lymph nodes. The majority of published series to date investigating yield are from interventional pulmonary supported centers. Our purpose was to report the results of the first 100 endobronchial ultrasound (EBUS) guided biopsies at an academic center performed by non-interventional pulmonary trained clinicians.

Transmission of Multidrug-resistant Tuberculosis Confirmed by Endobronchial Ultrasound Biopsy of a Mediastinal Lymph Node and DNA Fingerprinting Analysis

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was recently introduced for sampling of mediastinal masses and nodes, for staging of lung cancer, and for diagnosing other benign diseases including tuberculosis (TB). However, EBUS-TBNA has not been used to date to confirm the presence of multidrug-resistant TB (MDR-TB). We here describe the diagnosis of MDR-TB of a mediastinal lymph node by EBUS biopsy. MDR-TB had been transmitted to our patient from her son who had pulmonary TB, and the diagnosis of MDR-TB was confirmed by a restriction fragment length polymorphism analysis of the IS6110 segment of Mycobacterium tuberculosis isolates. Our findings highlight the use of EBUS-TBNA in diagnosing TB, including MDR-TB, and malignancies, in a TB-endemic area.