Intrathoracic Lymphadenopathy Research Articles

Comparison between Endobronchial Ultrasound-Guided Transbronchial Node Biopsy and Transbronchial Needle Aspiration: A Meta-Analysis.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can be limited by the inadequacy of intact tissues, especially in patients with lymphoma, sarcoidosis, and lymph node tuberculosis. A novel technique called transbronchial node biopsy (TBNB) by forceps or cryoprobe has been proposed and studied to improve specimen quality and diagnostic yield. We performed a systematic review of studies describing the safety and sensitivity of EBUS-TBNB versus EBUS-TBNA in diagnosing intrathoracic lymphadenopathy/masses. We systematically searched MEDLINE, Embase, Cochrane, and China National Knowledge Infrastructure to identify studies focusing on the application of EBUS-TBNB for diagnosis of intrathoracic lymphadenopathy. The quality of each study was evaluated using the QUADAS-2 tool. Using inverse-variance (I-V) weighting, we performed a meta-analysis of diagnostic yield estimations. We also reviewed the complications related to the procedure. Thirteen studies were included in the final analysis. The meta-analysis yielded a pooled overall diagnostic yield of 77.80% (939/1,207) for EBUS-TBNA and 86.01% (834/958) for EBUS-TBNB, with an inverse-variance-weighted odds ratio of 3.13 (95% confidence interval [CI], 1.61-6.01; p = 0.0008) and I2 of 82%. The pooled diagnostic yield of EBUS-TBNB versus EBUS-TBNA for the diagnosis of malignancy (including primary lung cancer and extrapulmonary malignancy) was 84.53% (590/698) for EBUS-TBNA and 90.84% (476/524) for EBUS-TBNB, with an I-V-weighted OR of 2.33 (95% CI, 1.15-4.74; p = 0.02) and I2 of 64%. The pooled diagnostic yield of EBUS-TBNB versus EBUS-TBNA for the diagnosis of benignancy was 71.19% (252/354) for EBUS-TBNA and 86.62% (233/269) for EBUS-TBNB, with an I-V-weighted OR of 4.39 (95% CI, 2.00-9.65; p = 0.002) and I2 of 59%. The overall complications included bleeding (n = 11, 0.90%), pneumomediastinum (n = 6, 0.49%), pneumothorax (n = 6, 0.49%), pneumonia (n = 4, 0.33%), respiratory failure (n = 1, 0.08%), and haemoptysis (n = 1, 0.08%). The funnel plot analysis illustrated no major publication bias. EBUS-TBNB improves the overall diagnostic yield of sampling intrathoracic lymphadenopathy and mass lesions relative to EBUS-TBNA. The complication rate of EBUS-TBNB is higher than that of EBUS-TBNA but reportedly lower than that of surgical biopsies.

Yield and Complications of Endobronchial Ultrasound Using the Expect Endobronchial Ultrasound Needle

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) stands as the gold standard for sampling the mediastinum and possesses the capability to detect a diverse range of disease processes. The EBUS needle industry has been experiencing rapid advancement, characterized by numerous companies either enhancing existing needles or introducing innovative ones. The majority of EBUS studies to date have predominantly utilized the OlympusTM Vizishot needles, which are constructed from stainless steel. In this paper, we focus on the evaluation of a cobalt chromium needle, namely the ExpectTM EBUS needle, with a specific emphasis on its diagnostic efficacy and any associated complications. It is important to note that our investigation is conducted independently, and we do not provide a comparative analysis with other needle types available in the market. Methods: This is an institutional review board-approved retrospective analysis of all patients who have undergone an EBUS-TBNA lymph node sampling using the ExpectTM needle between August 2016 and September 2017 at the IU Health University Hospital. Comparisons of clinical characteristics by complications, diagnosis, needle gauge, and lymph node size were performed using chi-square test and Fisher’s exact test. Results: 75% of the 102 included patients had their procedures done with the 22-gauge needle which were majorly performed in the setting of suspected intrathoracic malignancy followed by sarcoidosis and lymphoma. 99% of the patients had no complications after their procedures which were almost all diagnostic with two cases of bronchoscope damage. Mutational analysis was successful with both the 22 and 25-Gauge needles. Conclusion: In this paper, we demonstrate that the ExpectTM 22 and 25-gauge needles are safe and effective when used for EBUS-TBNAs through the OlympusTM EBUS bronchoscope for the evaluation of intrathoracic lymphadenopathy.

Endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing intrathoracic lymphadenopathy in patients with nasopharyngeal cancer.

This study aimed to assess the efficacy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in detecting intrathoracic lymph nodes in patients with nasopharyngeal carcinoma (NPC). Retrospective data analysis was conducted on individuals who underwent EBUS-TBNA between June 2015 and June 2022. Patients with NPC and enlarged intrathoracic lymph nodes were included. Specimens were categorized as malignant or non-malignant, with final non-malignancy confirmation procedures, or 12 months of clinical follow-up. Among 97 patients, 59 (60.8%) had NPC with intrathoracic lymph node metastasis, 3 (3.1%) had primary lung cancer involving nodes, and 25 (25.8%) showed benign characteristics. Ten cases (10.3%) were false-negative on initial EBUS-TBNA but confirmed as metastatic on follow-up. For NPC patients with intrathoracic lymphadenopathy, EBUS-TBNA exhibited 86.1% sensitivity (62/72), 71.4% negative predictive value (25/35), and 89.7% accuracy (87/97). Multivariate analysis identified increased lymph node short axis (OR: 1.200, 95% CI: 1.024-1.407; P = 0.041), metachronous NPC (OR: 11.274, 95% CI: 2.289-55.528; P = 0.003), and synchronous lung lesions (OR: 19.449, 95% CI: 1.875-201.753; P = 0.001) as independent predictors of malignant intrathoracic lymphadenopathy. Longer lymph node short axis (OR: 1.305, 95% CI: 1.044-1.631; P = 0.019) was independently associated with EBUS-TBNA accuracy. EBUS-TBNA effectively diagnoses intrathoracic lymphadenopathy in NPC patients.

САРКОИДОЗ ВНУТРИГРУДНЫХ ЛИМФАТИЧЕСКИХ УЗЛОВ. КЛИНИЧЕСКОЙ СЛУЧАЙ ИЗ ПРАКТИКИ ТЕРАПЕВТА

Sarcoidosis is a multisystem inflammatory disease of unknown etiology. Thoracic radiography is used to detect pathological changes in the lungs or intrathoracic lymph nodes. The classic image finding of pulmonary sarcoidosis is bilateral, symmetrical hilar and mediastinal lymph nodes enlargement. Lymph nodes are spherical or ovoid shape and homogeneous structure, with smooth clear contours, and without perifocal infiltration and sclerosis. Atypical manifestations of intrathoracic lymphadenopathy in sarcoidosis can be detected rarely. The presented clinical case indicates the importance of high-resolution computed tomography in patients with intrathoracic lymphadenopathy syndrome. It has to be noted that the detection of unilateral or asymmetric enlargement of hilar lymph nodes, the enlargement of mediastinal and pericardial groups of lymph nodes does not exclude sarcoidosis as a possible cause of pathology and requires morphological confirmation of the diagnosis. The case is discussed from the standpoint of personalized medicine and clinical recommendations.

Xpert MTB/RIF assay for the differential diagnosis between sarcoidosis and tuberculosis intrathoracic lymphadenopathy

BackgroundThe aim of this study was to evaluate the role of Xpert MTB/RIF assay in the detection of Mycobacterium tuberculosis for differentiating tuberculosis intrathoracic lymphadenopathy from sarcoidosis intrathoracic lymphadenopathy.MethodsThe patients who were suspected to having sarcoidosis or tuberculosis intrathoracic lymphadenopathy at the Shanghai Pulmonary Hospital between October 1, 2020 and June 30, 2021 were retrospectively evaluated in this study. All patients underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and Xpert analysis. Differences in clinical and radiological features were recorded. The diagnostic performances of EBUS-TBNA Xpert, acid-fast bacilli, culture, and peripheral blood QuantiFERON-TB Gold (QFT) for differentiating sarcoidosis from tuberculosis intrathoracic lymphadenopathy were analyzed.ResultsA total of 119 patients were included in this analysis. Of those, 83 patients were finally diagnosed with sarcoidosis (N = 50) and tuberculosis (N = 33) intrathoracic lymphadenopathy. Young individuals were more likely to have tuberculosis versus sarcoidosis intrathoracic lymphadenopathy (P = 0.006). Markers of inflammation, including fever, leukocytes, and serum ferritin levels, were significantly higher in tuberculosis versus sarcoidosis intrathoracic lymphadenopathy (P < 0.01). Bilateral lung involvement and symmetry intrathoracic lymphadenopathy were more common in sarcoidosis intrathoracic lymphadenopathy (P < 0.01). In addition, the longest diameter of intrathoracic lymphadenopathy (in cm) was significantly larger in sarcoidosis intrathoracic lymphadenopathy (P = 0.001). However, the largest diameter of lung lesions was significantly shorter (P = 0.005). The sensitivity and specificity values of Xpert and QFT for differentiating these two diseases were 69.70% and 100%, and 96.43% and 91.84%, respectively.ConclusionXpert MTB/RIF is recommended for the diagnosis of tuberculosis intrathoracic lymphadenopathy using EBUS-TBNA samples. A negative QFT suggests the exclusion of the diagnosis of tuberculosis intrathoracic lymphadenopathy.

AN OUTBREAK OF FELINE INFECTIOUS PERITONITIS IN THREE RELATED SAND CATS (FELIS MARGARITA) IN HUMAN CARE.

Feline infectious peritonitis (FIP) is a systemic disease in felid species caused by infection with mutated forms of feline coronavirus (FCoV), and outbreaks can devastate exotic felid populations in human care. Feline infectious peritonitis was diagnosed in three of four related juvenile sand cats (Felis margarita) from a single institution over a 6-wk period. Case 1 was a 7-mon-old male found deceased with no premonitory signs. Case 2, an 8-mon-old male (littermate to Case 1), and Case 3, a 6-mon-old male (from a different litter with identical parentage), were evaluated for lethargy and anorexia 1 mon after Case 1. Both exhibited transient anisocoria and progressive lethargy, anorexia, and dehydration despite antibiotic and supportive treatment. Approximately 1 wk after initial presentation, Case 2 was humanely euthanized, and Case 3 was found deceased. Necropsy findings included intrathoracic and/or intra-abdominal lymphadenopathy (3/3 cases), bicavitary effusion (2/3), multifocal tan hepatic and intestinal nodules (1/3), and multifocal yellow renal nodules (1/3). Histologically, all cats had severe pyogranulomatous vasculitis in multiple organs, and the presence of FCoV antigen was confirmed using immunohistochemical staining. Next-generation sequencing of the virus from Case 3's affected kidney demonstrated ∼93% homology to the UG-FH8 virus, a serotype 1 feline alphacoronavirus isolated from Denmark. Future research will focus on comparative viral genomic sequencing with the goals of identifying potential sources of FCoV infection and identifying features that may have contributed to the development of FIP in this species.

Characteristics of new cases of infiltrative pulmonary tuberculosis in patients having HIV infection with multidrug resistance of the pathogen according to multi-layer spiral computed tomography

Background. Identification of the characteristics of the pulmonary tuberculosis process using multi-layer spiral computed tomography (MSCT) in patients with tuberculosis and HIV infection is important in the diagnosis of tuberculosis, determining the dissemination of the process and its dynamics during treatment. The aim. To determine the initial characteristics and dynamics of infiltrative tuberculosis according to MSCT in patients with and without HIV infection, with and without multidrug resistance (MDR) of Mycobacterium tuberculosis who were treated in a hospital. Materials and methods. 126 patients aged 19–59 years with tuberculosis, combined with HIV infection and without HIV infection were examined. For statistical processing, we used MS Excel (Microsoft Corp., USA) software package. Results. Patients with tuberculosis and HIV infection in comparison with patients with tuberculosis and without HIV had more expressed intoxication syndrome and respiratory impairement in the clinical picture (p &lt; 0.00001). Patients with coinfection were more likely to suffer from alcohol (p &lt; 0.05) and drug addiction (p &lt; 0.001). According to MSCT, the pathological process in HIV-positive patients with pulmonary tuberculosis was more disseminated (p &lt; 0.05), included severe intrathoracic lymphadenopathy (p &lt; 0.0001), more common pleural lesions (p &lt; 0.005), less common destructive changes (cavities) (p &lt; 0.001) and outcomes in form of fibro-cavernous tuberculosis (p &lt; 0.01). Process regression was slower in patients with tuberculosis and HIV (p &lt; 0.005). According to MSCT, extensive lung damage, intrathoracic lymphadenopathy were more often found in patients with MDR in coinfection (p &lt; 0.05). Cavities and fibro-cavernous tuberculosis outcomes were more common in patients with tuberculosis without HIV infection and with MDR (p &lt; 0.05). Conclusion. MSCT provides detailed information about the pathological process in the lungs and its dynamics under the treatment of tuberculosis and HIV infection.

Assessment of endobronchial ultrasound-guided bronchoscopy (EBUS) intranodal forceps biopsy added to EBUS 19-gauge transbronchial needle aspiration: A blinded pathology panel analysis.

Endobronchial ultrasound-guided (EBUS) transbronchial needle aspiration (TBNA) has significantly improved the diagnostic workup for intrathoracic lymphadenopathies. More recently, EBUS intranodal forceps biopsy (IFB) has been developed in an attempt to maximize diagnostic yield by providing additional tissue. In this study, we aimed to assess the improvement of diagnostic yield with EBUS-TBNA combined with EBUS-IFB, compared to EBUS-TBNA alone. Consecutive patients who had 19-G EBUS-TBNA and EBUS-IFB from August 30, 2018, to September 28, 2021, were included. Four senior pathologists retrospectively analyzed, independently and blindly, first, only the EBUS-TBNA samples (cell block), then, at least 1 month later, both samples from EBUS-TBNA and from EBUS-IFB together. Fifty patients were included in the study and 52 lymph nodes were analyzed. Diagnostic yield was 77% (40/52) for EBUS-TBNA alone and 94% (49/52) when combined with EBUS-IFB (p = 0.023). Malignancy was diagnosed with EBUS-TBNA combined with EBUS-IFB in 25/26 cases (96%), versus 22/26 (85%) with EBUS-TBNA alone (p = 0.35); and 4/5 (80%) versus 2/5 (40%) for lymphoma specifically. Kappa interobserver agreement was 0.92 for EBUS-IFB and 0.87 for EBUS-TBNA alone. Nonmalignant condition was diagnosed with EBUS-TBNA combined with EBUS-IFB in 24/26 cases (92%), versus 18/26 (69%) for EBUS-TBNA alone (p = 0.07). The use of EBUS-IFB combined with 19-G EBUS-TBNA improves the mediastinal lymph node diagnostic yield However the benefit appears to be mainly restricted to nonmalignant histology.

AB1700 RHEUMATOLOGIST’S ASSESSMENT OF ACUTE SARCOIDOSIS

BackgroundLöfgren syndrome (LS) is the acute form of sarcoidosis, characterized by erythema nodosum (EN), joints involvement, fever and intrathoracic lymphadenopathy. LS clinical polymorphism leads to diagnostic errors.ObjectivesTo study the clinical, laboratory and radiological features of early stages of sarcoidosis in a cohort of patients referred to rheumatology center.MethodsThe study included 135 patients (107 females and 28 males, mean age 37 ± 9,4 y) with clinical and radiological features of LS. All patients were referred to rheumatology center with EN diagnosis. The median duration of disease was 1 [0,5–2,0] months. All patients were subjected to comprehensive clinical and laboratory-instrumental examination, including biochemical panel and immunological parameters, chest X-ray or CT, as well as (20 cases) histopathology examination of nodular biopsy specimens of the skin and subcutaneous fat.ResultsIn 97 % pts EN involved the lower legs, mostly the anterior surface, in 35 % - the hips, in 25 % - the upper limbs and in 3 % - the trunk. Symmetric lesions were documented in 50% of patients. Confluence of nodules forming conglomerates was registered in 48% pts. The involvement of more than 50 % of lower leg surface (68 %) was directly associated with the number of nodules (p&lt; 0.002; r = 0.54) and C-reactive protein level (p= 0.005; r = 0,34). There was a direct correlation between the number of nodules and EN duration (p= 0.03; r = 0.20), and also the tendency to nodules confluence (p&lt; 0.001; r = 0,37). Joint involvement was documented in 115 (85 %) patients, with predominantly ankle (67,4%) and knee (40%) joints affected. Asymmetry of joint involvement was documented in 9% pts. Articular manifestations preceded the emergence of EN in 51 (38 %) patients by mean 9 ± 4 days. There was a significant direct correlation between the duration of articular syndrome and appearance of nodules and their number (p= 0.01; r = 0.42). Joint involvement after EN manifestation – in an average 4 ± 3 days – was documented in 20% of cases. Male gender (odds ratio (OR) 6.5; confidence interval (CI) 1.2–35;p= 0,024) and presence of nodular conglomerates (OR 4,8; CI 1.4 - 16.1;p= 0.01) were the key predictors of ground glass opacity CT phenomenon. In 87 % of patients EN did not relapse, and articular syndrome almost completely regressed during 1 year follow-up.ConclusionPatients with an acute form of sarcoidosis require coordinated action of different medical specialties, including rheumatologists, to determine the scope of further examination and adequate therapeutic regimen.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Usefulness of Routine Bronchial Aspirate of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

IntroductionEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used for the study of intrathoracic lymphadenopathy and centrally tumours but no report has discussed the contribution of routine cytological and microbiological BA during the procedure. The aim of the study was to analyse the diagnostic yield of BA during EBUS, and to determine the potential cost reduction. MethodsA prospective study of cytological and microbiological BA collected during EBUS-TBNA was conducted between January 2021 and June 2022. Demographic data, indication, previous BA bronchoscopy or EBUS diagnosis were recorded. The main variable tested was the number of patients in which the result of the BA obtained through EBUS-TBNA determined a change in the diagnosis. ResultsA total of 450 (70.9% male) patients were included. BA cytology showed abnormal cells in 33 (7.3%) of patients, and only 1 case (0.2%) provided a previously unknown diagnosis. All these cases were patients with suspected malignancy. BA microbiological samples found germens in 30 (6.7%) patients but only in 5 cases (1.1%) found microbiological specimens not detected in previous bronchoscopy. None of them received antibiotics and evolved correctly. The potential total cost reduction during the study period at our centre if routine BA was deleted would be 21,937.50€ for routinely combined study. ConclusionsThe low diagnostic yield of cytological and microbiological bronchial aspirate in EBUS-TBNA supports the idea of not performing routine BA. Although the potential for cost savings in caring for an individual patient is modest, many centres routinely perform BA, so the potential savings could be significant.

ATYPICAL PRESENTATION OF PULMONARY TUBERCULOSIS

Tuberculosis may have wide range of clinical presentation. Here, we present one of atypical presentation of pulmonary tuberculosis. A 41 years male presented to Medical OPD of Chitwan Medical College &amp; Teaching Hospital, tertiary level hospital located in central Terai region of Nepal with chief complaints of generalized body swelling for 4 days and failure to pass urine for 10 hours. Clinical findings revealed pulse 80 bpm, BP 110/70 mmHg and gross edema present all over body. On investigation, his urine examination showed protein +, pus cells plenty and serum albumin 1.4 gm/dl. So, initial diagnosis of Nephrotic syndrome and Urinary Tract Infection was made. 24 hour urinary protein was sent which didn’t suggest Nephrotic syndrome. Patient was treated initially with antibiotics for UTI, potassium supplement and diuretics. In addition, he developed fever on 3rd day of admission which did not subside even after 5 days of antibiotic therapy. His chest examination revealed crackles bilaterally on infraclavicular and subscapular regions. Initially chest X-ray and later on CECT chest were done which showed multiple enlarged intrathoracic lymph nodes. His initial clinical examination had not revealed any enlarged peripheral lymph nodes but after doing CECT, retrospective clinical examination revealed enlarged right supraclavicular lymph nodes, FNAC of which suggested tubercular lymphadenopathy. Anti-Tubercular Therapy was started on 2023/01/25 and after 5 days of treatment his fever subsided, appetite and general health being also improved. So, generalized intrathoracic lymphadenopathy can be atypical presenting feature of tuberculosis which is generally confused with malignancy and sarcoidosis.

Real time endobronchial ultrasound transbronchial needle aspiration for the diagnosis of tuberculous intrathoracic lymphadenopathy: Saudi Arabian Western region experience.

To assess the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for presumptive tuberculosis (TB) patients with intrathoracic enlarged lymph nodes in a country with low to moderate TB incidence. Thirty-one patients with clinical features of TB and intrathoracic lymphadenopathy, who had EBUS-TBNA sampling and final confirmation of intrathoracic TB lymphadenopathy, were retrospectively reviewed over an 8-year period. Routine clinical and laboratory evaluations including computerized tomography scans were performed before the EBUS-TBNA. Sociodemographic characteristics, clinical profile, pathological, and microbiological findings were collected. The EBUS-TBNA confirmed TB diagnosis in 26 (83.9%) subjects with a consistent pathological finding or positive culture of Mycobacterium tuberculosis. Pathological analysis had findings consistent with TB in 25 (80.6%) patients. Culture of the EBUS-TBNA sample was positive for Mycobacterium tuberculosis in 12 (38.7%) patients. Other supportive investigations like purified protein derivative (PPD) skin test was positive in 28 (90.3%) participants. Overall, the sensitivity of the EBUS-TBNA alone was 83.9%. No complications were recorded during the procedure. The EBUS-TBNA aspirate culture positivity was significantly related to having a larger size lymph node (p=0.048) only, while PPD positivity was significantly related to baseline and clinical features of the participants. The EBUS-TBNA demonstrated effective utility and safety in the evaluation and diagnosis of intrathoracic TB lymphadenopathy among individuals with compatible symptoms in a country with low-moderate TB-incidence.

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Abstract. The aim: to study the prevalence of respiratory symptoms and pulmonary function (PF) in patients with various chronic lymphoproliferative diseases (CLPD) in the Dnipro region of Ukraine. Methods. In all patients who were included in this prospective single-center study, complaints and anamnesis data were collected, anthropometric and general physical examinations, mMRC and CAT questionnaires, analysis of the results of high-resolution computed tomography of the chest organs to determine the presence of intrathoracic lymphadenopathy (ITLAP) were performed. In all patients, parameters of PF were determined using computer spirometry, and when signs of bronchial obstruction were detected, a test with a bronchodilator was performed to determine its reversibility. We analyzed the level of FEV1 , FVC and the ratio of FEV1 /FVC, PEF, MEF25, MEF50 and MEF75. Patients with a confirmed diagnosis of bacterial or viral pneumonia (including patients with COVID-19) were excluded from the study. The methods of descriptive and analytical statistics of the software product STATISTICA v.6.1 (Statsoft Inc., USA) (license number AGAR909E415822FA) were used to process the obtained results. Results. The study found that 37.8 % of patients had complaints from the respiratory system, and 42 % of all patients had significant severity of respiratory symptoms according to the CAT questionnaire. At the same time, only 4.4 % of patients, according to the anamnesis, had established diagnoses of respiratory comorbidity. Among the examined patients with CLPD, 54.4 % had PF disorders, and 81.6 % of them had only obstruction or mixed disorders with a predominance of obstruction (52.5 % mild obstruction, 37.5 % moderate obstruction, and 10 % severe obstruction) and 12.5 % of cases had a positive bronchodilation test. The ratio of FEV1 /FVC was found to be significantly lower in patients with multiple myeloma than in patients with chronic lymph leucosis and lymphomas, which may hypothetically be related to the formation of fibrosis of the bronchial wall; however, the proportions of patients with obstructive PF disorders were equivalent in the groups. ITLAP was detected in 42.2 % of patients. The presence of ITLAP in patients with lymphomas was significantly associated with a lower FEV1 , while in patients with chronic lymph leucosis, who had bronchial obstruction in 43.4 % of cases, the presence of ITLAP had a tendency, but was not statistically significantly associated with the presence obstruction or a lower FEV1 level. Conclusions The obtained results indicate the need for a thorough examination of the respiratory organs, including chest computed tomography and spirometry, in all patients with CLPD, even in the absence of known respiratory comorbidity. According to the obtained results, the presence of PF violations of the obstructive type and the presence of ITLAP are among the main factors that affect the severity of respiratory symptoms in CLPD, therefore, they require careful diagnosis and, in the presence of bronchial obstruction, the appointment of appropriate broncholytic therapy, which can potentially improve the quality life of this category of patients. Key words: multiple myeloma, chronic lymphocytic leukemia, lymphoma, pulmonary function, respiratory symptoms.

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.

Feasibility of Modified Endobronchial Ultrasound-Guided Intranodal Forceps Biopsy: A Retrospective Analysis

Background: Endobronchial ultrasound (EBUS)-guided intranodal forceps biopsy (IFB), a diagnostic bronchoscopic technique for intrathoracic lymphadenopathy, is performed following EBUS-guided transbronchial needle aspiration (TBNA). The current EBUS-IFB technique is complex and provides small sample volumes. We modified this technique to allow the use of standard-sized forceps. Objectives: The aim of this study was to assess the feasibility of the modified EBUS-IFB technique, which combines standard-sized forceps with standard EBUS-TBNA equipment. Method: This retrospective analysis included consecutive patients scheduled for EBUS-TBNA with attempted additional IFB between July 2020 and March 2021. The feasibility indices of IFB, technical success rate, diagnostic accuracy, and major complications were retrospectively investigated. We performed semi-quantitative evaluation of the histological specimens and univariable analyses to identify factors associated with IFB failure. Results: During the study period, 295 patients underwent 307 EBUS-TBNAs; 195 cases were included in the analyses. Target lesions were mainly mediastinal lymph nodes (134 cases, 68.7%); the most frequent sites were #7 (61 cases) and #4R (50 cases). The median lesion size was 16.1 mm, the technical IFB success rate was 90.8%, and the diagnostic accuracy of the TBNA and IFB combination was 99.5%. One patient was lost to follow-up. Univariable analyses did not identify any factors involved in technical IFB failure. Major complications of pneumonia and pneumothorax occurred in 2 cases (1.0%). The median histological score was significantly higher in the IFB group than in the TBNA group (1.67 vs. 1.50, p = 0.032). Conclusions: Modified EBUS-IFB, combining standard-sized forceps with common EBUS-TBNA equipment, is feasible with few major complications.

RF30 | PSAT177 A Case of Hypercalcemia Related to Immune Checkpoint Inhibitor-Induced Sarcoidosis-like Granuloma

Abstract Background Immune checkpoint inhibitor (ICI) is an essential part of the treatment of various advanced cancers, but its use can be associated with a number of side effects, including hypercalcemia. The mechanism through which hypercalcemia arises is not well established. One proposed mechanism is through sarcoidosis-like reactions. Here we present an illustrative case. Clinical Case A 75-year-old female with past medical history notable for stage IV endometrial adenocarcinoma treated with surgery plus adjuvant chemotherapy, presently on pembrolizumab for 9 months, hypertension, and diabetes was admitted with generalized fatigue, difficulty ambulating, slow movements, and slow speech. Stroke was ruled out with negative neurologic imaging. Blood work revealed elevated calcium 13.8 mg/dL (8.6-10.4 mg/dL) and ionized calcium 1.64 mmol/L (1.09-1.29 mmol/L). Additional workup showed suppressed PTH 7 pg/mL (11-51 pg/mL), 25-OH vitamin D 19 ng/mL (20-50 ng/mL), elevated 1,25(OH)2 vitamin D of 114 pg/mL (19.9-79.3 pg/mL), elevated angiotensin converting enzyme (ACE) level 90 U/L (12-69 U/L), and normal PTHrP, suggestive of PTH-independent hypercalcemia mediated by 1,25(OH)2D as seen in sarcoidosis. Two months prior to admission and seven months after starting pembrolizumab, surveillance CT found improvement in tumor burden but new intrathoracic lymphadenopathy. Lymph node biopsy via bronchoscopy identified non-caseating granulomas suggestive of a sarcoidosis-like reaction. The patient's moderate hypercalcemia was treated with intravenous fluids, calcitonin, and zoledronic acid 4 mg with normalization of calcium levels. Glucocorticoid therapy was initially deferred to avoid counteracting the effect of pembrolizumab, however prednisone 10 mg daily was started 1 month after discharge when calcium rose again to 11.1 mg/dL. Prednisone was tapered off over 8 weeks as her calcium and 1,25(OH)2D levels normalized. She then restarted pembrolizumb, but after the third month she had recurrence of hypercalcemia (calcium 10.8 mg/dL) with elevated 1,25(OH)2D (89.5 pg/mL). She was again treated with prednisone 10 mg daily which was tapered off over 6 weeks with resolution of hypercalcemia. Her calcium levels remained normal off pembrolizumab. The temporal correlation in our case strongly suggests that ICI administration caused sarcoidosis-like granulomas and hypercalcemia. Conclusion Immune checkpoint inhibitors are known to occasionally cause hypercalcemia, although the mechanisms are not well established. In our case, moderate hypercalcemia was likely caused by ICI-induced sarcoid-like granulomas that responded promptly to glucocorticoids and interruption of ICI-therapy. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Monday, June 13, 2022 1:12 p.m. - 1:17 p.m.

Prospective Study of Focused Neck US by Respiratory Physicians in Patients With Pulmonary Disease and Intrathoracic Lymphadenopathy

The supraclavicular fossa (SCF) harbors lymph nodes (LNs) that have lymphatic connections with various thoracic, abdominal, and pelvic structures and can be involved in malignant, inflammatory, and infiltrative diseases of the thorax.1 In the presence of LN enlargement, 40% to 70% of lung cancer patients will have SCF node involvement.2 When routine neck ultrasound (NUS) is performed, 47% of patients with pulmonary sarcoidosis have enlarged SCF LNs, which on biopsy show noncaseating granuloma.3

Panhypopituitarism as the first manifestation of sarcoidosis: case report

Sarcoidosis is a systemic inflammatory disease of unknown etiology characterized by the formation of noncaseating granulomas in various organs and tissues and the activation of T-cells at the site of granulomatous inflammation with the release of various chemokines and cytokines [1]. The incidence on average ranges from 10 to 20 per 100,000 population [2]. Most often in patients with sarcoidosis, lesions of the lungs and intrathoracic lymph nodes are detected. Significantly less often (in about 5-20% of patients) damage to the nervous system is noted [6,7,9]. In 9-18% of patients with neurosarcoidosis, involvement of the pituitary gland, pituitary infundibulum and hypothalamus is found, which is manifested by a variety of clinical symptoms [8,10]. We observed a patient with sarcoidosis whose disease debuted with clinical symptoms of hypogonadism, followed by the development of signs of secondary hypothyroidism, adrenal insufficiency, and diabetes insipidus, which was initially regarded as panhypopituitarism against the background of a hypothalamic lesion of unknown origin. Later, additional examination revealed signs of intrathoracic lymphadenopathy and focal changes in the lung parenchyma on CT, as well as skin lesions. Despite the biochemical compensation of hypopituitarism, the clinical efficacy of hormonal therapy with cabergoline, testosterone, hydrocortisone and levothyroxine sodium was insufficient, and the patient's condition improved after the addition of immunosuppressive and anti-inflammatory therapy with methotrexate and methylprednisolone.

CLINICAL AND RADIOLOGIC CHARACTERISTICS IN PATIENTS WITH ANTHRACOTIC INTRATHORACIC LYMPH NODE

TYPE: Late Breaking Abstract TOPIC: Disorders of the Mediastinum PURPOSE: To study incidence, clinical and radiologic characteristics in patients with anthracotic intrathoracic lymph node, and to evaluate for predictors. METHODS: A total of 145 patients with intrathoracic lymphadenopathy (yielding 299 nodes) who underwent EBUS-TBNA at a single institution during 2018 were retrospectively reviewed. They were classified into anthracosis, and control group. Baseline characteristics and comparison of radiographic findings from CT or PET/CT between group were assessed. Univariale and multivariable logistic regression analysis was used to assess for possible predictors of anthracotic LN. RESULTS: Of 145 patients, 55 patients (38%) had anthracotic LN. There was no difference in baseline characteristics between group. On comparison of radiographic findings, the anthracotic LN appeared shorter long-axis diameter (16.57mm. VS 22.92mm.; p<0.001), had ill-defined margin (30.1% VS 15%; p=0.004), and lesser uptake SUV (2.73 VS 7.23; p=0.001). Multivariable logistic regression analysis showed that predictors for anthracotic LN included age, long-axis diameter, and ill-defined margin appearance (odd ratio 1.04 [1.01-1.06], 0.96 [0.93-0.98], 2.04 [1.1-3.83], respectively). CONCLUSIONS: Anthracotic LN is common. Distinguishing between anthracotic LN and other diagnoses from imaging is difficult. Possible predictors for anthracosis included age, long axis diameter, and ill-defined margin appearance. Anthracotic LN also illustrated positive FDG uptake resembling cancer. CLINICAL IMPLICATIONS: Anthracotic lymph node may resemble malignancy, clinicians and radiologist might consider the condition in differential diagnosis. DISCLOSURE: No significant relationships. KEYWORD: Anthracotic lymph node

Renal cell carcinoma, MiTF/TFE3 family translocation-associated subtype

A 20-year old male presented with right flank pain and hematuria. Initial workup for nephrolithiasis by CT imaging revealed a right renal lower pole mass. Biopsy of the renal mass revealed “clusters of spindle cells and mature fat” with no malignant cells found. Subsequent MRI imaging confirmed the presence of the mass, with concern for an infiltrative process. Therefore, the patient underwent a robotic-assisted right nephrouretectomy that revealed a Micropthlamia Family of Transcription Factor (MiTF) translocation tumor involving the Xp11.2 TFE3 transcription factor, without lymph node involvement. The patient remains asymptomatic without evidence of abdominopelvic or intrathoracic metastatic disease or lymphadenopathy two years post nephrouretectomy