Extrathoracic Malignancies Research Articles

Importance of mediastinal granulomatous/sarcoid-like lymphadenopathy in extrathoracic malignancies.

In patients with extrathoracic malignancies (ETM), granulomatous lymph adenopathy called sarcoid-like reactions (SLR) can be seen in the regional or draining lymph nodes. We hypothesized that SLR may be a sign of imminent metastasis and investigated the clinical course and rate of recurrence in patients with ETM and granulomatous mediastinal lymphadenopathy (MLN). In this retrospective observational study, we reviewed the medical files of patients with known ETM and who underwent EBUS-TBNA for initial staging or detection of recurrence from 2011 to 2023. Patients with granulomatous MLN were included. Forty-one patients (29 female) enrolled in the study. Breast and colorectal carcinomas were the most common malignancies. A total of 81 lymph nodes were sampled. The final diagnosis of patients was five sarcoidosis, one tuberculosis, one second primary, one drug reaction, and 33 SLR. Among patients with SLR, in one patient lymph nodes progressed during the follow-up and were accepted as false-negative without confirmatory biopsy. The negative predictive value (NPV) of granulomatous MLN for metastasis was 97.05%. Granulomatous MLN may be due to tuberculosis, drug reaction, sarcoidosis, or SLR in patients with ETM. SLR has a high NPV in patients with ETM. Follow-up imaging rather than confirmatory biopsy is reasonable in these patients.

The characteristics of patients undergoing endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA): single-center experience

Aims: We aimed to present the features of our Endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) cases, the lymph nodes that were biopsied, their pathological diagnoses, and the complications that developed due to the procedure. Methods: All cases who underwent EBUS-TBNA between January 2016 and December 2023 in the chest diseases clinic of a training and research hospital were retrospectively screened. The patients who underwent the procedure (n=274) were included in the study. Cases in which fine needle aspiration biopsy was performed with EBUS-TBNA and the material obtained was not diagnostic (n=3) or in which the pathology result could not be obtained in the files (n=9) were excluded from the study. The design of our study was cross-sectional and planned as a descriptive study. Results: Of the 262 patients included in the analysis, 66.4% (n=174) were male and the average age of the population was 60.8±11.4 years. When EBUS-TBNA indications were evaluated, the procedure was performed for diagnostic purposes in 96.9% (n=254) and for re-evaluation after chemotherapy in 3.1%. EBUS-TBNA procedure was performed in 16.8% (n=44) patients due to mediastinal mass and in 83.2% (n=218) patients due to mediastinal lymphadenopathy. The most common stations where biopsy is performed with the EBUS-TBNA process are the subcarinal (7) and lower right paratracheal (4R) lymph node stations. When the biopsy results were evaluated, malignancy was reported in 54.6% (n=143) of the patients. The complications related to the EBUS-TBNA procedure were generally mild and trancient . Conclusion: EBUS-TBNA is a minimally invasive method used in the diagnosis and staging of lung cancer, the evaluation of non-endobronchial lesions, the diagnosis of benign diseases of the mediastinum, and the diagnosis of mediastinal metastases of extrathoracic malignancies. In experienced centers like our clinic, the diagnostic value of the procedure is high and the complication rates are very low.

Idiopathic dendriform pulmonary ossification as the phenotype of interstitial lung abnormalities: CT–pathologic correlation and prevalence

Background and purposeIdiopathic dendriform pulmonary ossification (DPO) is mostly asymptomatic, and detected incidentally in lung CT. There have been no reports on the precise CT–pathologic correlation and the prevalence of idiopathic DPO. This study aimed to clarify the histological background and prevalence of idiopathic DPO.Materials and methodsSixteen patients with histologically confirmed idiopathic DPO (12 men and 4 women; mean age, 38.8 years; range 22–56 years) were identified in a nationwide epidemiological survey. Local HRCT findings of pre-biopsy examinations, such as branching, round, linear structures with or without high attenuation were compared side by side with histological findings. The attenuation of branching, round, and linear structures was classified into three-point levels on bone window images (width, 2500 HU; level, 500 HU). Furthermore, we collected continuous pulmonary CT images of 8111 cases for checking up metastasis from extrathoracic malignancy at a single institution, and evaluated the prevalence of interstitial lung abnormalities (ILAs) and DPO.ResultsIn all 16 cases, branching (n = 15, 93%), round (n = 5, 31%), or linear (n = 5, 31%) structures were identified, histologically corresponding to dendriform ossification and cicatricial organizing pneumonia (OP)/fibrosis. Histologically, ossification was confirmed in all the 16 patients. However, in two cases, a highly attenuated structure could not be detected on the pre-biopsy CT of the same area. Regarding the prevalence of idiopathic DPO, 283 (3.5%) of 8111 patients had ILAs, of which a total of 26 (0.3% of all cases, 9.2% of ILAs cases) had DPO.ConclusionIdiopathic DPO showed linear or branching structures with or without high attenuation on CT, corresponded to ossification, cicatricial OP/fibrosis. DPO was seen in 9.2% of ILAs cases. Idiopathic DPO is one of pathologic phenotypes of ILAs.

Impact of Respiratory Bacterial Findings on Patients with Chronic Pulmonary Aspergillosis.

Distinct bacterial strains may affect the prognosis of patients with chronic respiratory diseases. However, little is known about the clinical significance of respiratory bacteria in patients with chronic pulmonary aspergillosis (CPA), a progressive and debilitating disease caused by Aspergillus spp. This study aimed to analyze data obtained from CPA patients and their sputum or bronchial washing samples and investigate the prevalence and composition of respiratory bacteria and clinical implications. Patients and Methods. We retrospectively reviewed the data of patients diagnosed with CPA between March 2019 and February 2023 in a tertiary referral hospital. We assessed the clinical characteristics and overall and pneumonia-specific survival rates of patients with CPA based on the presence of bacteria. Results and Conclusions. We included 142 patients with CPA. The most commonly identified bacteria were Klebsiella pneumoniae (22.5%), followed by Pseudomonas aeruginosa (21.8%) and Escherichia coli (4.2%). Patients with isolated bacteria had a higher prevalence of older age, female sex, diabetes, and a history of extrathoracic malignancy than those without isolated bacteria (P = 0.024, 0.013, 0.021, and 0.034, respectively). Furthermore, over a median follow-up of 11 (4-21) months, the pneumonia-specific mortality rate was 13.4% (19/142), which was higher in patients with isolated bacteria than in those without (P = 0.045, log-rank test). Particularly, patients with the presence of P. aeruginosa had a significantly higher mortality rate from pneumonia than those without the presence of P. aeruginosa (adjusted hazard ratio, 3.34; P = 0.015). In conclusion, CPA patients with isolated bacteria, especially P. aeruginosa, showed higher mortality rates due to pneumonia. Performing tests to identify bacteria in the lower respiratory tract of patients with CPA may be helpful in predicting future prognosis. Further studies are required to validate these findings in diverse ethnic groups.

Thoracoscopic biopsy in the diagnosis of lung and pleural diseases

Background: Thoracoscopy is a useful procedure for evaluation and diagnosis of pleural effusion and other thoracic disorders. Our study aimed to evaluate the scope and use of thoracoscopic biopsy for the evaluation of thoracic disorders and report on the outcomes of this technique. Methods: Patients undergoing thoracoscopic biopsy procedure from March 2022 to May 2023 were analyzed for indications, complication and outcomes. Results: 85 patients underwent thoracoscopic biopsy over a period of 15 months, of which 38 (44.7%) were males and 47 (55.3%) were females. The mean age was 60 years. Cough, dyspnea and chest pain were the most common presenting symptoms. Thoracosopy was most commonly done on the right side (67.1%). Pleura (57.6%) was the most common biopsy site, followed by lungs (22.4%), lymph node (12.9%) and mediastinum (3.7%). One case was converted to open procedure. Post operative complication rate was 3.5%. Adenocarcinoma (31.8%) was the most common histology, followed by squamous cell carcinoma (9.4%). 36.5% patients had benign disease and 11.8% patients had metastatic extra-thoracic malignancy. Conclusion: Thoracoscopy is a safe and simple procedure for diagnosis of pleural and other thoracic disorders with the advantage of tissue sampling from lesion under direct visualization. It is a useful tool in the armamentarium of thoracic surgeons.

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration for diagnostic and staging purposes: a narrative review.

Transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is a feasible and well-tolerated modality that is increasingly used to diagnose intrathoracic lesions. This narrative review summarizes the current application of EUS-B-FNA for diagnosing lung cancer, thoracic sarcoidosis, and metastases from extrathoracic malignancies. A comprehensive and systematic online literature search via Medline/PubMed for the period January 2005 to December 2022 was conducted for articles published using the keywords "EUS-B-FNA", "endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)", "endoscopic ultrasound fine-needle aspiration (EUS-FNA)", "lung cancer", "staging", and "sarcoidosis". Recent data prove the efficacy and safety of EUS-B-FNA for providing complete lung cancer staging, when combined with EBUS-TBNA, and in the evaluation of para-esophageal lesions. EUS-B-FNA allows access to inferior mediastinal lymph nodes and para-esophageal masses that are not accessible by EBUS-TBNA. Additional advantages of using EUS-B-FNA include significantly lower doses of anesthetics and sedatives, a shorter procedural time, fewer incidents of oxygen desaturation due to a poor respiratory reserve, significantly less cough, and higher operator satisfaction. Moreover, this procedure can be performed sequentially in the same setting with EBUS-TBNA by one operator. Other benefits include a lower cost, a single setting, and scope use. As EUS-B-FNA and EBUS-TBNA have complementary access to the mediastinum, the diagnostic yield of EUS-B-FNA combined with EBUS-TBNA is higher than that of endosonographic techniques alone in the diagnostic workup of intrathoracic lesions.

Tract seeding in indwelling pleural catheter placement for the drainage of malignant pleural effusions: Incidence and related clinical and imaging factors

BackgroundThe incidence of tract seeding after the placement of indwelling pleural catheter (IPC) for malignant pleural effusion drainage has been variable in the literature. Research questionTo evaluate the incidence of IPC-related cancer tract seeding and find out related demographic, clinical or imaging factors to the tract seeding. Study design and methodsThis retrospective study included 124 consecutive patients seen between January 2011 and December 2021 who underwent IPC placement for malignant pleural effusion drainage. Chest radiographs before IPC placement and serial chest CT studies were obtained. One patient was diagnosed pathologically, and the other patients were diagnosed as tract seeding radiologically. The incidence of and related factors to tract seeding were assessed by reviewing medical records and imaging studies. ResultsThe incidence of IPC tract seeding was 21.7% (27 of 124 malignant effusions). Of 27 patients, 15 had primary lung cancer and remaining 12 had extra-thoracic malignancy. Adenocarcinoma (19 of 27, 70.3%) either from the lung (N = 12) or extra-thoracic malignancy (N = 7) was the most common cell type. Mean time elapsed until tract seeding occurrence after IPC placement was 96 days (ranges; 28–306 days). The survival in seeding group after IPC placement was 185 days (ranges, 32–457 days). On odd ratio analysis, the presence of mediastinal pleural thickening (OR [95% CI]; 9.79 (2.67–35.84), p = 0.001) was significantly related to the occurrence of tract seeding. Neither tumor volume within pleural space (p = 0.168), duration of IPC indwelling (p = 0.142), days of survival after IPC placement (p = 0.26), nor pleural effusion amount (p = 0.481) was related to the tract seeding. InterpretationIPC tract seeding is seen in 27 (21.7%) of 124 malignant pleural effusion patients, particularly with adenocarcinoma cytology. CT features of mediastinal pleural thickening are related to the occurrence of tract seeding.

Tumor-Related Factors Affecting the Success of Interventional Bronchoscopy in Malignant Airway Obstructions.

It is difficult to select patients who will benefit from endobronchial treatment (ET) in malignant central airway obstruction (MCAO). We aimed to determine the tumor-related factors that affect the success of MCAO treatment. ETs for MCAO between March 2019 and June 2021 were analyzed retrospectively. The relationships between the success of the procedure and the percentage of endoluminal obstruction, tumor size, and type of lesion were evaluated. Totally, 220 ETs were administered to 205 patients. Treatment was significantly more successful for the patients with pure endobronchial lesions than those with mixed lesions. The success rate was significantly lower when the tumor size was greater than 54.5 mm and the degree of endoluminal stenosis exceeded 92%; the area under the curve was 0.734 (0.625-0.842; P=0.001) and 0.733 (0.597- 0.870; P=0.001), respectively. There was no difference in the procedural success between lung cancer and extrathoracic malignancies and tumor treatment before the procedure. Mixed lesions, tumor size over 54.5 mm, and a degree of stenosis over 92% are risk factors for unsuccessful endoluminal obstruction procedures. These parameters should be considered when selecting patients for ET interventions.

Cytological, cell block and immunohistochemical analysis of spectrum of malignant pleural effusion with special reference to non-small cell lung carcinoma: A hospital based study of North East India

Malignant pleural effusions (MPE) can result from primary malignancies of the pleura or from underlying intrathoracic or extrathoracic malignancies that reach the pleural space by hematogenous, lymphatic, or contiguous spread. Conventional smear and cell block (CB) technique is one of the oldest methods for the evaluation of body cavity fluids. The principal advantage of cell block over conventional smears are an additional yield of malignant cells and obtaining multiple sections for ancillary tests such as immunohistochemistry (IHC). This study is a hospital-based cross-sectional study which was conducted for a period of 14 months from June 2021 to July 2022 in a tertiary care centre of North East India. Among 277 pleural effusion specimens 11.91% cases were positive for malignancy.Lung carcinoma was the most common cause of malignant pleural effusion. Non-small cell lung carcinoma comprised majority of lung carcinoma cases. Adenocarcinoma was the most common subtype of NSCLC with female preponderance. Cytological diagnosis had a Sensitivity of 76.19%, specificity of 100% andAccuracy of 96.5%. Immunohistochemistry of lung carcinoma in cell block preparation revealed 77.77% cases of adenocarcinoma of lung were positive for TTF-1(P<0.018). Immuno-expression of P63 and P40 showed positive expression in both the cases of squamous cell carcinoma. Conventional smear and cell block method with application of immunohistochemistry will help us in accurate diagnosis of primary site of the tumour aiding early treatment especially in resources restricted hospitals.

Evaluation of 18FDG PET-CT-positive mediastinal-hilar lymph nodes in extrathoracic malignancies by EBUS-TBNA; correlation of SUVmax, and short-axis diameter with the final diagnosis.

Intrathoracic lymph node metastasis from extrathoracic neoplasms are rare. Primary malignancies that metastasize to mediastinal-hilar lymph nodes are head and neck , carcinoma breast ,and genitourinary. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)/endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently the preferred modality for mediastinal lymph node sampling. Fifty seven patients with extrathoracic malignancies with maximum standardized uptake value (SUVmax) of mediastinal-hilar lymph nodes greater than or equal to 2.5 were taken up for EBUS-TBNA. The histo-cytopathological results obtained from EBUS-TBNA were compared with SUVmax value and short-axis diameter of a lymph node as noted on EBUS. Out of 74 sampled nodes, 49 (66.2%) were benign and 25 (33.8%) were malignant. The SUVmax range of benign nodes was 2.8-13 as compared to 3-18 of malignant nodes. The size range of malignant and benign nodes were 8-35 mm and 8-30 mm, respectively. The mean size of abnormal nodes (metastatic + granulomatous) was 17.5 (8-35 mm) and the mean SUVmax was 9.1 (3.4-18), and it was a statistically significant difference when compared to reactive (normal) nodes. At SUVmax cut-off 7.5, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) were 78.5%, 81.2%, 84.6%, and 74.2%, respectively for detecting abnormal nodes. At 13 mm size cut-off, sensitivity, specificity, PPV, NPV were 75.5%, 65%, 75%, and 72%, respectively, for detecting abnormal nodes. The majority of mediastinal-hilar nodes with increased metabolic activity are benign in nature. Size and SUVmax are poor predictors of metastasis in tuberculosis endemic region. There should be a restrictive attitude toward invasive diagnostic testing for mediastinal-hilar nodes in extrathoracic malignancies.

Endobronchial ultrasound-guided transbronchial needle aspiration in intrathoracic lymphadenopathy with extrathoracic malignancy.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of mediastinal and hilar lymph is poorly studied in patients with extrathoracic malignancies. To evaluate the value of EBUS-TBNA for the diagnosis of enlarged intrathoracic lymph nodes in patients with extrathoracic malignancies. This was a retrospective study of patients with extrathoracic malignancies who were referred to Peking University Cancer Hospital from January 2013 to December 2018 for EBUS-TBNA due to intrathoracic lymphadenopathy. The specimens were defined as positive for malignancy, negative for non-malignancy (tuberculosis, sarcoidosis, etc.), and without a definitive diagnosis. Sensitivity, negative predictive value (NPV) for malignancy, and overall accuracy were calculated. Complications were recorded. A total of 80 patients underwent EBUS-TBNA and had a final diagnosis, among which 50 (62.5%) were diagnosed with extrathoracic malignancy with intrathoracic lymph nodes metastasis, 14 (17.5%) were diagnosed with primary lung cancer with nodal involvement, and 16 (20.0%) exhibited benign behavior including tuberculosis, sarcoidosis and reactive lymphadenitis or who had benign follow-up. The diagnostic sensitivity, NPV, and accuracy of EBUS-TBNA for intrathoracic lymphadenopathy in patients with extrathoracic malignancy were 93.8% (n = 60/64), 80.0% (n = 16/20), and 95.0% (n = 76/80), respectively. In the multivariate analysis, longer short axis of the lymph node (OR: 1.200, 95%CI: 1.024-1.407; P = 0.024) and synchronous lung lesion (OR: 19.449, 95%CI: 1.875-201.753; P = 0.013) were independently associated with malignant intrathoracic lymphadenopathy. No characteristics of the lymph nodes and EBUS-TBNA were associated with the location of malignant intrathoracic lymphadenopathy, and no major complication was observed. EBUS-TBNA is a simple and accurate procedure for the diagnosis of intrathoracic lymphadenopathy with extrathoracic malignancy.

EBUS-TBNA in Extrathoracic Malignancies: Diagnostic and Prognostic Implications.

In patients with extrathoracic malignancies (EM) the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the assessment of abnormal mediastinal lymph nodes (MLN) is controversial. The aim of this study was to assess the diagnostic yield and prognostic significance of EBUS-TBNA in these patients. Retrospective analysis of patients with EM and abnormal MLN detected by Computed Tomography (CT) and/or Positron Emission Tomography (PET). A total of 161 patients with EM and abnormal MLN were included (93 males, 58%). The most common EM was melanoma (19%) and gastrointestinal cancer (17%). Assessed lymph nodes were mediastinal in 70% of cases and hilar in 30%. The most frequently sampled lymph nodes were subcarinal (45%) and lower right paratracheal (21%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EBUS-TBNA for the diagnosis of malignancy were 88%, 100%, 100% and 87%, respectively. These values were similar regardless the type of EM except for head and neck tumors where the NPV was particularly low (67%). The diagnosis of neoplastic involvement by EBUS-TBNA implied a worse prognosis in terms of overall survival (p < 0.02)and cancer-specific survival (p < 0.001). In patients with EM and abnormal MLN, EBUS-TBNA has a high diagnostic yield. However, the NPV decrease in patients with head and neck tumors. Neoplastic MLN detected by EBUS-TBNA has prognostic implications in these patients.

Predictors of Invasiveness in Adenocarcinoma of Lung with Lepidic Growth Pattern.

Lung adenocarcinoma with lepidic growth pattern (LPA) is characterized by tumor cell proliferation along intact alveolar walls, and further classified as adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA) and invasive lepidic predominant adenocarcinoma (iLPA). Accurate diagnosis of lepidic lesions is critical for appropriate prognostication and management as five-year survival in patients with iLPA is lower than in those with AIS and MIA. We aimed to evaluate the accuracy of CT-guided core needle lung biopsy classifying LPA lesions and identify clinical and radiologic predictors of invasive disease in biopsied lesions. Thirty-four cases of adenocarcinoma with non-invasive lepidic growth pattern on core biopsy pathology that subsequently were resected between 2011 and 2018 were identified. Invasive LPA vs. non-invasive LPA (AIS or MIA) was defined based on explant pathology. Histopathology of core biopsy and resected tumor specimens was compared for concordance, and clinical, radiologic and pathologic variables were analyzed to assess for correlation with invasive disease. The majority of explanted tumors (70.6%) revealed invasive disease. Asian race (p = 0.03), history of extrathoracic malignancy (p = 0.02) and absence of smoking history (p = 0.03) were associated with invasive disease. CT-measured tumor size was not associated with invasiveness (p = 0.15). CT appearance of density (p = 0.61), shape (p = 0.78), and margin (p = 0.24) did not demonstrate a significant difference between the two subgroups. Invasiveness of tumors with lepidic growth patterns can be underestimated on transthoracic core needle biopsies. Asian race, absence of smoking, and history of extrathoracic malignancy were associated with invasive disease.

Factors associated with concurrent malignancy risk among patients with incidental solitary pulmonary nodule: A systematic review taskforce for developing rapid recommendations.

To assess the association between prespecified factors and the malignancy risk of solitary pulmonary nodules (SPNs) to support the development of rapid recommendations for daily use in the Chinese setting. The expert panel for the rapid recommendations voted for 12 candidate factors based on published guidelines, selected publications, and clinical experiences. We then searched Medline, Embase, and Web of Science up to October 17, 2021, for studies investigating the association between these factors and the diagnosis of malignant SPNs in patients with CT-identified SPNs through multivariable regression analysis. The risk of bias was assessed using the Agency for Healthcare Research and Quality (AHRQ) Checklist. We pooled adjusted odds ratios (aOR) between candidate factors and the diagnosis of the malignant SPNs. A total of 32 cross-sectional studies were included. Nine factors were statistically associated with malignant SPNs: age (aOR 1.06, 95% confidence interval [CI]: 1.05-1.07), smoking history (2.83, 1.84-4.36), history of extrathoracic malignancy (5.66, 2.80-11.46), history of malignancy (4.64, 3.37-6.39), family history of malignancy (3.11, 1.66-5.83), nodule diameter (1.23, 1.17-1.31), spiculation (3.41, 2.64-4.41), lobulation (3.85, 2.47-6.01), and mixed ground-glass opacity (mGGO) density of the nodule (5.56, 2.47-12.52). No statistical association was found between family history of lung cancer, emphysema, nodule border, and malignant SPNs. Nine prespecified factors were associated with the concurrent malignancy risk among patients with SPNs. Risk stratification for SPNs is warranted in clinical practice.

Diagnosis and Management of Malignant Pleural Effusion: A Decade in Review.

Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality. Treatment is mainly palliative, with symptomatic management achieved via effusion drainage and pleurodesis. Pleurodesis may be hastened by administering a sclerosing agent through a thoracostomy tube, thoracoscopy, or an indwelling pleural catheter (IPC). Over the last decade, several randomized controlled studies shaped the current management of MPE in favor of an outpatient-based approach with a notable increase in IPC usage. Patient preferences remain essential in choosing optimal therapy, especially when the lung is expandable. In this article, we reviewed the last 10 to 15 years of MPE literature with a particular focus on the diagnosis and evolving management.

Diagnostic accuracy and clinical impact of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in Positron Emission Tomography - Computed Tomography (PET-CT)-positive mediastinal lymphadenopathies in patients with thoracic or extra-thoracic malignancies

BackgroundThe high sensitivity of PET-CT can identify hypermetabolic mediastinal adenopathies during cancer management, but specificity is low and a biopsy is sometimes required to eliminate benign adenopathies. MethodsThis prospective diagnostic accuracy study included patients with hypermetabolic mediastinal lymphadenopathies revealed on PET-CT during either the initial management of a cancer, treatment evaluation, or monitoring. All patients underwent EUS-FNA. Diagnoses of malignancy based on cytological analysis following EUS-FNA were compared with clinical and radiological follow-up information. The treatment strategy decided before the results of the EUS-FNA pathology reports (Multidisciplinary Team Meeting [MTM-1]) was recorded and compared to the treatment strategy decided once pathological data from EUS-FNA were available (MTM-2). Main findingsBetween 2013 and 2018, 75 patients were included with 47 eligible and evaluable patients. Sensitivity, specificity, and positive and negative predictive values of EUS-FNA were 93%, 100%, 100% and 90%, respectively. The concordance value between the therapeutic strategies determined for MTM-1 and MTM-2 was 44.7%. There were no significant differences in the intensity of fixation on PET-CT between malignant and benign lesions. ConclusionThe diagnostic accuracy of the minimally invasive EUS-FNA procedure is sufficiently robust to avoid the need for diagnostic surgery. The combination of PET-CT and EUS-FNA may alter the therapeutic strategy that would be considered after PET-CT alone. REGISTRATIONNCT01892501

Computer tomography guided thoracoscopic resection of small pulmonary nodules in the hybrid theatre.

Thoracic surgeons are currently asked to resect smaller and deeper lesions which are difficult to detect thoracoscopically. The growing number of those lesions arises both from lung cancer screening programs and from follow-up of extrathoracic malignancies. This study analyzed the routine use of a CT-aided thoracoscopic approach to small pulmonary nodules in the hybrid theatre and the resulting changes in the treatment pathway. 50 patients were retrospectively included. The clinical indication for histological diagnosis was suspected metastasis in 46 patients. Technically, the radiological distance between the periphery of the lesion and the visceral pleura had to exceed the maximum diameter of the lesion for the patient to be included. A spiral wire was placed using intraoperative CT-based laser navigation to guide the thoracoscopic resection. The mean diameter of the lesions was 8.4 mm (SD 4.27 mm). 29.4 minutes (SD 28.5) were required on average for the wire placement and 42.3 minutes (SD 20.1) for the resection of the lesion. Histopathology confirmed the expected diagnosis in 30 of 52 lesions. In the remaining 22 lesions, 9 cases of primary lung cancer were detected while 12 patients showed a benign disease. Computer tomography assisted thoracoscopic surgery (CATS) enabled successful resection in all cases with minimal morbidity. The histological diagnosis led to a treatment change in 42% of the patients. The hybrid-CATS technique provides good access to deeply located small pulmonary nodules and could be particularly valuable in the emerging setting of lung cancer screening.

METASTATIC COLORECTAL CANCER PRESENTING AS AN OBSTRUCTING ENDOBRONCHIAL LESION

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Colorectal cancer is one of the most common malignancies worldwide with the pulmonary parenchyma a common site for distant metastasis. Colorectal endobronchial metastases, however, are exceedingly rare. We present a patient with previously resected colon cancer who was found to have an obstructing endobronchial colorectal metastasis. CASE PRESENTATION: A 66-year-old male with a 12 pack-year smoking history presented with dyspnea. On routine colonoscopy 4 years prior, he was diagnosed with moderately differentiated colorectal adenocarcinoma with negative tumor margins and without any lympho-vascular involvement. Imaging was without evidence of regional or distant metastases so he underwent hemicolectomy. Medical oncology recommended no adjuvant chemotherapy and 1 year follow-up. The patient did not follow-up. Four years later, he presented with fever, dyspnea, cough, and pleuritic chest pain. CT pulmonary angiography demonstrated a RUL mass with RML lobe collapse, a moderate right-sided pleural effusion, and no pulmonary embolism. He was started on empiric antibiotics. Thoracentesis revealed an exudative effusion with negative cultures and cytology. Bronchoscopy demonstrated a fungating endobronchial lesion completely occluding the right middle lobe for which cryobiopsy and cryo-excision were performed. Pathology was consistent with metastatic moderately differentiated colorectal adenocarcinoma, with morphology and histology identical to his prior colorectal cancer. Transbronchial needle aspiration using endobronchial ultrasound of the station 7 mediastinal lymph node was negative for malignant cells. Patient left against medical advice before further work-up was completed. DISCUSSION: About 20% of patients with colorectal cancer have distant metastases at presentation, with the lungs being a common site, usually involving the pulmonary parenchyma and very rarely as an endobronchial lesion. In fact, endobronchial metastases from extra-thoracic malignancies account for 1% of all endobronchial tumors, with the most common being colorectal, breast and renal. These patients may present with a variety of non-specific respiratory symptoms. It is also not uncommon for endobronchial metastasis to occur after resection of the primary tumor and without other signs of metastases. One should consider the possibility of endobronchial involvement of a tumor in a patient with a history of an extra-thoracic malignancy who presents with vague respiratory symptoms, as timely bronchoscopic intervention can improve quality of life and help mitigate the risk of post obstructive complications. CONCLUSIONS: Endobronchial metastasis from extra-thoracic malignancies are very rare, accounting for 1% of all endobronchial tumors. Diagnosis can be difficult due to vague respiratory complaints. Bronchoscopic intervention can assist in diagnosis, management, and it can lead to substantial improvement in pulmonary symptoms. REFERENCE #1: Akoglu S, Uçan ES, Celik G, et al. Endobronchial metastases from extrathoracic malignancies. Clin Exp Metastasis. 2005;22:587–591. REFERENCE #2: Coriat R, Diaz O, de la Fouchardiere C, et al. Endobronchial metastases from colorectal adenocarcinomas: clinical and endoscopic characteristics and patient prognosis. Oncology. 2007;73:395-400. REFERENCE #3: Lin CY, Chung FT. Central airway tumors: interventional bronchoscopy in diagnosis and management. J Thoracic Dis. 2016;8(10):E1168-E1176. DISCLOSURES: Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: $5001 - $20000 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer-Ingelheim Pharmaceuticals Please note: 2014-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Vapotherm, Inc Please note: 2019-Present Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria Advisory Committee Member relationship with Vapotherm, Inc Please note: 2020 Added 04/21/2021 by Jaime Betancourt, source=Web Response, value=Honoraria No relevant relationships by Ken Dekitani, source=Web Response No relevant relationships by Michael Lewis, source=Web Response No relevant relationships by Roberto Mempin, source=Web Response No relevant relationships by Scott Oh, source=Web Response

Prospective Study of Low- and Standard-dose Chest CT for Pulmonary Nodule Detection: A Comparison of Image Quality, Size Measurements and Radiation Exposure.

To comprehensively and accurately analyze the out-performance of low-dose chest CT (LDCT) vs. standard-dose CT (SDCT). The image quality, size measurements and radiation exposure for LDCT and SDCT protocols were evaluated. A total of 117 patients with extra-thoracic malignancies were prospectively enrolled for non-enhanced CT scanning using LDCT and SDCT protocols. Three experienced radiologists evaluated subjective image quality independently using a 5-point score system. Nodule detection efficiency was compared between LDCT and SDCT based on nodule characteristics (size and volume). Radiation metrics and organ doses were analyzed using Radimetrics. The images acquired with the LDCT protocol yielded comparable quality to those acquired with the SDCT protocol. The sensitivity of LDCT for the detection of pulmonary nodules (n=650) was lower than that of SDCT (n=660). There was no significant difference in the diameter and volume of pulmonary nodules between LDCT and SDCT (for BMI <22 kg/m2, 4.37 vs. 4.46 mm, and 43.66 vs. 46.36 mm3; for BMI ≥22 kg/m2, 4.3 vs. 4.41 mm, and 41.66 vs. 44.86 mm3) (P>0.05). The individualized volume CT dose index (CTDIvol), the size specific dose estimate and effective dose were significantly reduced in the LDCT group compared with the SDCT group (all P<0.0001). This was especially true for dose-sensitive organs such as the lung (for BMI <22 kg/m2, 2.62 vs. 12.54 mSV, and for BMI ≥22 kg/m2, 1.62 vs. 9.79 mSV) and the breast (for BMI <22 kg/m2, 2.52 vs. 10.93 mSV, and for BMI ≥22 kg/m2, 1.53 vs. 9.01 mSV) (P<0.0001). These results suggest that with the increases in image noise, LDCT and SDCT exhibited a comparable image quality and sensitivity. The LDCT protocol for chest scans may reduce radiation exposure by about 80% compared to the SDCT protocol.

UNILATERAL PLEURAL NODULES AS MANIFESTATION OF OVARIAN ADENOCARCINOMA 29 YEARS POST-TREATMENT

TOPIC: Lung Cancer TYPE: Fellow Case Reports INTRODUCTION: The incidence of recurrence in advanced stage ovarian cancer is 70% with a median interval to first recurrence of 18-24 months after treatment with surgery, chemotherapy, and radiation. Of these, 77.6% of cases reoccur in the abdominal or pelvic cavity. Only 1.8% of recurrent cases present intrathoracic metastases and recurrence 20+ years after treatment has rarely been reported. We present a case of recurrent ER+ ovarian adenocarcinoma presenting with diffuse pleural nodules 29 years post treatment. This is the only reported case in literature where pleural nodules are the primary site of ovarian adenocarcinoma recurrence more than 20 years post-treatment. CASE PRESENTATION: A 72 year old female presented to the emergency department complaining of weakness and increasing shortness of breath over several weeks. On physical exam, she was hypoxic and pale in appearance with diminished breath sounds in the right lower lobe. Labs were remarkable for Hgb of 4. CXR at that time revealed a loculated R pleural effusion and an intact chemotherapy port from prior treatment 30 years ago. Chest CT imaging was obtained, revealing nodular densities throughout the right hemithorax suggestive of pleural neoplasm. CT-guided pleural biopsy was obtained, revealing neoplastic cells demonstrating immunoreactivity with CK7, ER, Pax-8, and CA-125, suggestive of Mullerian Primary Adenocarcinoma. PET-CT demonstrated increased activity in numerous right pleural nodules. The patient was diagnosed with Stage FIGO IVB Ovarian Adenocarcinoma. The 5-year survival rate for distantly metastasized epithelial ovarian cancer is 31%. Treatment options for patients with distant metastases diagnosed with FIGO Stage IVB Ovarian Adenocarcinoma include neoadjuvant chemotherapy followed by surgery, adjuvant therapy, and maintenance therapy. Due to the indolent nature of the disease, and after discussion with the patient regarding goals of care, conservative therapy with frequent imaging and oncologic observation was the selected clinical approach. DISCUSSION: On initial presentation with unilateral pleural nodules and respiratory symptoms, primary tumors of pleural such as malignant mesothelioma was considered highly on the differential, but on further studies including staining with TTF- 1, histologic findings were found to be consistent with Mullerian primary, despite the patient having completed treatment 29 years prior and having had no recurrence or symptoms since then. CONCLUSIONS: Although malignant unilateral pleural nodules may raise suspicion for primary lung or pleural neoplasms, recurrence of extra-thoracic malignancy must always be considered when evaluating pleural nodules, regardless of how remote the primary occurrence emerged. This is the only reported case in literature where pleural nodules are the primary site of ovarian adenocarcinoma recurrence more than 20 years post-treatment. REFERENCE #1: UshijimaK. (2010). Treatment for recurrent ovarian cancer-at first relapse.Journal of oncology,2010, 497429. REFERENCE #2: Menczer, J., Schreiber, L., Peled, O., & Levy, T. (2015). Very late recurrence (after more than 20 years) of epithelial ovarian carcinoma: case report and literature review.Archives of gynecology and obstetrics,291(6), 1199–1203. REFERENCE #3: Tajik, P., van de Vrie, R., Zafarmand, M. H., Coens, C., Buist, M. R., Vergote, I., Bossuyt, P., & Kenter, G. G. (2018). The FIGO Stage IVA Versus IVB of Ovarian Cancer: Prognostic Value and Predictive Value for NeoadjuvantChemotherapy.International journal of gynecological cancer : official journal of the International Gynecological Cancer Society,28(3), 453–458. DISCLOSURES: No relevant relationships by Abdulmetin Dursun, source=Web Response No relevant relationships by Badri Giri, source=Web Response No relevant relationships by Emily Smallwood, source=Web Response