Lung Biopsy Procedures Research Articles

Immunoprofiling bronchoalveolar lavage cells reveals multifaceted smoking-associated immune dysfunction.

Bronchoalveolar lavage (BAL) is an underutilised tool in the search for pulmonary disease biomarkers. While leukocytes with effector and suppressor function play important roles in airway immunity and tumours, it remains unclear if frequencies and phenotypes of BAL leukocytes can be useful parameters in lung cancer studies and clinical trials. We therefore explored the utility of BAL leukocytes as a source of biomarkers interrogating the impact of smoking, a major lung cancer risk determinant, on pulmonary immunity. In this "test case" observational study, BAL samples from 119 donors undergoing lung cancer screening and biopsy procedures were evaluated by conventional and spectral flow cytometry to exemplify the comprehensive immune analyses possible with this biospecimen. Proportions of major leukocyte populations and phenotypic markers levels were found. Multivariate linear rank sum analysis considering age, sex, cancer diagnosis and smoking status was performed. Significantly increased frequencies of myeloid-derived suppressor cells and PD-L1-expressing macrophages were found in current and former smokers compared to never-smokers. While cytotoxic CD8 T-cells and conventional CD4 helper T-cell frequencies were significantly reduced in current and former smokers, expression of immune checkpoints PD-1 and LAG-3 as well as Tregs proportions were increased. Lastly, the cellularity, viability and stability of several immune readouts under cryostorage suggested BAL samples are useful for correlative end-points in clinical trials. Smoking is associated with heightened markers of immune dysfunction, readily assayable in BAL, that may reflect a permissive environment for cancer development and progression in the airway.

Tract injection of autologous blood (intraparenchymal blood patching) in percutaneous transthoracic CT-guided lung biopsy and the incidence of pneumothorax: a retrospective analysis

Background: Pneumothorax is a common complication following percutaneous transthoracic computed tomography (CT)-guided lung biopsy. The purpose of this study is to determine if intraparenchymal blood (IPB) patching following the lung biopsy procedure causes a significant decrease in the incidence of post-biopsy pneumothorax, chest tube placement, and hospitalization.

Preoperative path planning algorithm for lung puncture biopsy based on path constraint and multidimensional space distance optimization

The quality of the clinician-planned puncture path significantly affects the success rate of percutaneous lung biopsy procedures. Therefore, a preoperative path planning algorithm for lung puncture biopsy is proposed to assist clinicians in planning the needle path of lung biopsy. First, lung tissues and organs are segmented based on CT images. Then, a multiple puncture target point approach is proposed to screen the target locations of suspected tumors. And the puncture needle path is determined after selecting the entry points on the skin. According to lung biopsy clinical requirements, three hard constraints are proposed to remove paths that do not meet clinical requirements. Additionally, six soft constraints and the Pareto optimization based on multidimensional space distance are proposed to obtain the optimal puncture paths. The experimental data were collected from 33 patients with suspected pulmonary nodules in the Zigong First People’s Hospital. In the experiments, physicians labeled 98.46 % of the paths planned by the algorithm as clinically feasible, indicating that the proposed algorithm can be applied to nodule cases of different sizes and that it follows the clinical constraints of lung puncture. The average distance between the optimal algorithmic path and the surgical path was (5.77 ± 3.85) mm, which indicates that the proposed algorithm could simulate the surgical path according to the clinical guidelines of the physicians. The experimental results demonstrated that the proposed algorithm could provide an objective and effective path planning method for lung puncture biopsy of different nodule sizes.

Comparison between computed tomography-guided core and fine needle lung biopsy: A meta-analysis.

Background:This meta-analysis was conducted to compare the safety and diagnostic performance between computed tomography (CT)-guided core needle biopsy (CNB) and fine-needle aspiration biopsy (FNAB) in lung nodules/masses patients.Methods:All relevant studies in the Pubmed, Embase, and Cochrane Library databases that were published as of June 2020 were identified. RevMan version 5.3 was used for all data analyses.Results:In total, 9 relevant studies were included in the present meta-analysis. These studies were all retrospective and analyzed outcomes associated with 2175 procedures, including both CT-guided CNB (n = 819) and FNAB (n = 1356) procedures. CNB was associated with significantly higher sample adequacy rates than was FNAB (95.7% vs 85.8%, OR: 0.26; P < .00001), while diagnostic accuracy rates did not differ between these groups (90.1% vs 87.6%, OR: 0.8; P = .46). In addition, no differences in rates of pneumothorax (28.6% vs 23.0%, OR: 1.15; P = .71), hemorrhage (17.3% vs 20.1%, OR: 0.91; P = .62), and chest tube insertion (5.9% vs 4.9%, OR: 1.01; P = .97) were detected between these groups. Significant heterogeneity among included studies was detected for the diagnostic accuracy (I2 = 57%) and pneumothorax (I2 = 77%) endpoints. There were no significant differences between CNB and FNAB with respect to diagnostic accuracy rates for lung nodules (P = .90). In addition, we detected no evidence of significant publication bias.Conclusions:CT-guided CNB could achieve better sample adequacy than FNAB did during the lung biopsy procedure. However, the CNB did not show any superiorities in items of diagnostic accuracy and safety.

Optimization of the Lung Biopsy Procedure: A Primer

AbstractImage-guided lung biopsy plays a very important role in the diagnosis and management of lung lesions. As a diagnostic tool, it demands a high diagnostic yield and a low complication rate. It is imperative to balance the diagnostic yield and patient safety during lung biopsies. The aim of this article is to review the standard practice guidelines of lung biopsy, to describe the techniques used to minimize the complications associated with lung biopsy, and to describe the management of complications.

Abstract No. 25 ▪ FEATURED ABSTRACT Use of machine learning to predict the risk of pneumothorax requiring chest tube placement after lung biopsy

Pneumothorax is the leading complication after image-guided lung nodule biopsy (15-25%) with 4-6% resulting in a pneumothorax requiring chest tube placement . Risk factors associated with lung biopsy induced pneumothorax have been elucidated; however, currently no model exists to prospectively identify patients most at risk for pneumothorax necessitating chest tube placement. Development of a machine learning algorithm to predict patients at high risk for pneumothorax and chest tube placement may facilitate appropriate peri-procedural planning and optimize patient care. Retrospective chart review was performed on patients who underwent lung nodule biopsy between January 2018 and July 2019. From this data, we selected 58 lung biopsy procedures that resulted in pneumothorax requiring chest tube placement and then another 51 procedures without chest tube placement (convenience sample). For each procedure, we collected 12 clinical features that would be available prior to biopsy: age, gender, smoking history, prior asthma or COPD diagnosis, cancer history, pulmonary function tests, biopsy needle gauge, lesion size, lesion location, lesion character (solid or not), patient position during biopsy, and pleura to lesion distance. The data was divided 70/30 into training and testing sets. We explored several conventional machine-learned binary classifiers with the clinical data as input features and need for chest tube placement as the output. Summary statistics of the data reveal that several of the features have unique means between the chest tube placement positive and negative groups. For example, the set requiring tube placement versus not had a mean lesion depth of 30 ± 19 mm versus 13 ± 14 mm (P< 0.005). That said, there was no single pathognomonic imaging or clinical feature. On the independent test set, use of decision tree, logistic regression, and Naïve Bayes achieved accuracies of identifying tube placement of 0.76, 0.74, and 0.76 and had AUC’s of 0.83, 0.76, 0.78. The learned features of high importance included lesion character, COPD status, lesion depth, and patient age. A coarse decision tree requiring only 3 inputs achieved comparable performance as other methods. We identified an interpretable decision tree to predict chest tube placement post biopsy with an accuracy of 76% and AUC of 0.83. This work suggests that it may be possible to predict the risk of pneumothorax requiring chest tube placement based on an automated decision support tool reliant on easily available clinical and imaging features.

Financial implications of CT-guided lung biopsy in a tertiary centre: a radiologists' perspective

To evaluate the financial costs of performing computed tomography (CT)-guided lung biopsies in a large tertiary centre to help guide service development. Local financial data were collected to create a balance sheet, considering all expenses as well as revenue sources associated with the procedure. Data were based on accurate pricing and income data and evaluated on a per-procedure basis, with consideration of additional costs arising from post-procedural complications. Revenue data were estimated based on reimbursement information. A small coding quality audit was also performed to check if reimbursement claims were filed correctly. This study demonstrated a healthy income generated from CT-guided lung biopsy procedures with a profit margin of 50%. Notably different financial impact was observed when comparing the same procedure undertaken on an outpatient as opposed to inpatient basis with inpatient procedures generating a net loss of - £2,146.79 a year. Overall, the activity generated a profit of £157,015.25, after accounting for loss generated by inpatient activity. This analysis furthered understanding of the financial impact from performing CT-guided lung biopsy and will enable better planning and expansion of the service in the future, with emphasis around day-case and ambulatory service development, the positive intended consequence being an improved patient pathway.

THE EFFICACY OF RADPAD AS A RADIATION PROTECTION TOOL IN CT FLUOROSCOPY GUIDED LUNG BIOPSIES.

Computed tomography fluoroscopy is now the preferred technique for percutaneous lung biopsies. However, concern regarding operator and patient radiation dose remains, which warrants further exploration into dose optimisation tools. This phantom-study aims to assess the dose reduction capabilities of RADPAD, a single-use patient drape designed to decrease staff exposure to scattered radiation. Dosemeters at the waist and eye levels were used to determine the whole-body and lens exposure during simulated lung biopsy procedures while using RADPAD and other combinations of personal protective equipment. RADPAD resulted in a 36% and 38% dose reduction for whole-body and eye exposure, respectively. However, when used in combination with radioprotective eyewear and aprons, RADPAD did not reduce the radiation dose further. Consequently, the use of standard personal protective equipment is a more cost-effective option for staff dose reduction. RADPAD is useful in the reduction of radiation dose to unprotected regions.

Airway management of transbronchial lung cryobiopsy: What is different in a paediatric patient?

Various modalities such as cryoprobe-transbronchial lung biopsy (TBLB)/transbronchial lung cryobiopsy (TBLC) have been described for lung biopsy procedure. However, anaesthetic concerns related to periprocedural planning for paediatric TBLC have not been previously reported in the literature as clinical experience with paediatric TBLC is just evolving. The airway and general anaesthetic management of TBLC in a 12-year-old girl is described. TBLC in a child requires rigid bronchoscopy under general anaesthesia by an experienced endoscopist who, along with the anaesthesiologist, is alert all the time to keep the peak airway pressures low to avoid barotrauma.

A retrospective analysis of the risk factors associated with systemic air embolism following percutaneous lung biopsy.

In the present study, the risk factors for systemic air embolism as a complication of percutaneous CT-guided lung biopsy were explored. Data from 2,026 percutaneous CT-guided lung biopsy procedures were retrospectively analyzed. All cases were divided into a concurrent air embolism group and a control group, depending on whether air embolism occurred during the puncture process. A systemic air embolism was confirmed when CT values <-200 Hounsfield units were observed in two sequential images. A total of 19 cases (0.9%) of air embolism were detected among the 2,026 patients subjected to percutaneous CT-guided lung biopsy procedures. The most frequently detected embolism site was the left ventricle (89.5%). Only 3 cases (15.8%) were accompanied by obvious clinical symptoms. The results indicated that a puncture location above the level of the left atrium and coughing during the procedure significantly altered the likelihood of embolism developing (P=0.002 and P=0.014 vs. control, respectively). In conclusion, a puncture lesion above the level of the left atrium and coughing during the procedure may be risk factors for air embolism development.

Increasing Numbers and Reported Adverse Events in Patients with Lung Cancer Undergoing Inpatient Lung Biopsies: A Population-Based Analysis.

The use of molecular biomarkers to guide lung cancer management has led to increasing frequency and amounts of tissue required for repeat lung biopsies. While patient safety and reporting of adverse events has been increasingly emphasized in recent decades, the safety of lung biopsies in patients with lung cancer has only been studied in small cohorts. We therefore analyzed adverse events in patients with lung cancer undergoing lung biopsies in the National Hospital Discharge Survey (NHDS) database. Data were abstracted using ICD-9 lung cancer diagnosis (162.X) and lung biopsy procedure codes (33.20, 33.24, 33.25, 33.26, 33.27, 33.28) from 2001 to 2010. Agency for Healthcare Research and Quality (AHRQ) Patient-Safety Indicators (PSI) were used to identify hospital-acquired adverse events. Weighted analyses were performed using SAS version 9.4. A total of 540,747 patients were included for analysis. The number of biopsies increased over time, from 51,221 in 2001, to 63,239 in 2010 (P < 0.001). Overall, 159,683 (30%) patients suffered ≥ 1-PSI event during their hospitalization. Incidence of PSI varied by biopsy type: bronchoscopic (26%), percutaneous (34%), surgical (39%). The proportion of patients with ≥ 1 PSI event increased from 24% in 2001 to 38% in 2010 (P < 0.001). Patients with ≥ 1 PSI had longer length of stay (mean, 11.6 vs 8.1days; P < 0.001) and higher in-hospital mortality (adjusted odds ratio, 5.9, 95% CI 3.9-8.9; P < 0.001). The frequency of lung biopsies performed and rate of documented adverse events in hospitalized lung cancer patients have increased. These findings have policy, funding, research, and practice implications.

Clinical and pathological aspects of idiopathic pulmonary fibrosis in cats

ABSTRACT: Interstitial lung diseases are a group of diffuse parenchymal lung diseases that include interstitial lung fibrosis. The aim of this study is to characterize the clinical and pathological findings of idiopathic pulmonary fibrosis in three cats and to investigate possible etiological agents through bacteriological and mycological exams and immunohistochemistry. All three cats were female and aged from 10 to 14 years old, they presented with a clinical history of weight loss and dyspnea. The radiographic changes were similar in all cats and included increased pulmonary radiopacity with a mixed bronchointerstitial pattern progressing to an alveolar pattern. Two cats died during lung biopsy procedures. At necropsy, the lesions were limited to the pulmonary parenchyma and were firm, hypocrepitant with a multinodular appearance on the pleural surface; they failed to completely collapse when the thorax was opened. In the pleural region, there were multifocal star-shaped scarring lesions, with parenchymal retraction. Microscopically, all three cats had multifocal-to-coalescing fibrosis, type II pneumocyte hyperplasia, hypertrophy or hyperplasia of the smooth muscle tissue of terminal bronchioles and an accumulation of macrophages within the alveolar spaces. There was no growth on bacteriological or mycological cultures, and the immunohistochemical evaluations for the presence of viral etiological agents (FIV, FeLV, FCoV, FCV and FHV-1) were also negative.

Indicaciones de la biopsia pulmonar

Since 1964 (transbronchial lung biopsy), interstitial lung diseases diagnosis have improved exponentially. New sampling methodologies are available, and more accurate clinical, epidemiological, radiological and laboratorial criteria are being used. New diagnostic measures, more accurate imaging test assessment and the incorporation of innovative procedures, will determine the future. Nowadays three lung biopsy procedures are available: transbronchial biopsy, cryobiopsy and surgical biopsy.

PMD7 - Biopsy Procedures in Patients with Primary Lung Cancer

Biopsy is critical in diagnosis and staging of lung cancer. The study aims to assess the use of biopsy procedures, including the approaches, the frequency, and the associated costs, in the care pathway of diagnosis or monitoring of lung cancer. This study used Truven MarketScan® Database from 2013 to 2015. The 2014 data was used to identify baseline patients with primary diagnosis of lung cancer. We included patients who were ≥18 years old, had continuous enrollment of 12 months before and after the first recorded primary lung cancer diagnosis dated in 2014, and had ≥2 primary lung cancer diagnoses within two months. CPT, ICD-9-CM, and ICD-10-PCS codes were used to capture lung cancer diagnosis and biopsy procedures. The radiologic procedures (e.g. ultrasound, fluoroscopic, CT, or MR) for needle placement were excluded from biopsy enumeration. We identified three major biopsy approaches: surgical, percutaneous, and bronchoscopic. Descriptive statistics of frequency, duration and costs were performed for biopsies within a year before and after the primary diagnosis. Among 22,161 patients included in 2014, 14,280 (64.44%) patients had ≥1 biopsies within 1 year before or after the primary diagnosis; 17.59% surgical, 41.57% percutaneous, and 33.93% bronchoscopic. Specifically, 2,905 (13.11%) patients had 1 biopsy with an average procedure cost of $5,489 (standard deviation (SD): $22,593); 4,625 (20.87%) patients had 2 biopsies, with an average of 15.7 days from the first biopsy and an average procedure cost of $7,729 (SD: $4,664); and 6,750 (30.46%) patients had ≥3 biopsies with an average of 22.7 days between biopsies and an average procedure cost of $11,899 (SD: $15,438). All costs were significantly different (p<0.0001). More than 50% of patients with primary lung cancer had multiple biopsies with high costs in short time frame. Further research is needed to identify ways to reduce unnecessary biopsies.

Evaluation of safety and efficacy of regional anesthesia compared with general anesthesia in thoracoscopic lung biopsy procedure on patient with idiopathic pulmonary fibrosis

Background:Interstitial lung diseases are diseases that need histology diagnosis or obtaining a lung biopsy to establish the diagnosis. Surgical biopsies are performed usually using the thoracoscopy technique under general anesthesia (GA) although this procedure is still associated with morbidity rate. The aim of this study is to determine the effectiveness and safety of regional anesthesia (RA) compared with GA in thoracoscopic lung biopsy procedures done on patients with idiopathic pulmonary fibrosis (IPF).Subjects and Methods:This is a retrospective qualitative study based on adult cases of video-assisted thoracoscopy (VAT) lung biopsy on patients with IPF admitted in the division of Thoracic Surgery, Department of General Surgery, King Khalid University Hospital, Riyadh, KSA. We included 67 patients with IPF, 26 with RA, and 41 with GA, who underwent this procedure from January 2008 to December 2015. Procedures performed under RA were done using three different approaches, intercostal nerve blocks, extrapleural infusion, and paravertebral block while GA was performed using double-lumen endotracheal tube placement. For statistical analysis, SPSS program, version 21.0. Software used to analyze the obtained data. The statistical significance was defined as P < 0.05.Results:Sixty-seven patients underwent the procedure of thoracoscopic lung biopsy. Twenty-six of them (38.8%) underwent the procedure under RA and 41 (61.2%) under GA. The cross tabulation of the intercostal chest tube duration showed that it was significantly longer in GA group (6.23 ± 5.1 days) compared to RA group (3.12 ± 1.5 days), P = 0.004. Furthermore, for the Intensive Care Unit (ICU) stay, it was significantly longer in GA group (3.38 ± 2.1 days) compared to RA group (1.09 ± 0.7 days), P = 0.019. Regarding the relation between the number of biopsies taken and type of anesthesia performed, the probability values for GA group as well as RA group come out to be >0.05 (statistically independent) and the results of risk estimate also show that there was no significant association found between them. The cross tabulation of the representation of biopsies taken by the two methods showed that all biopsies taken under both settings were representative of the disease. Of 41 procedures done under GA, 16 of the total showed a number of complications. Likewise, of 26 procedures under RA, five cases showed complications. The significant (two-sided) value was (P = 0.110), there was no statistical significance between the risks of complications and the two types of anesthesia.Conclusion:There was a significant decrease in chest tube duration and ICU stay in RA group compared to the GA group. There was no statistical difference between both types of anesthesia in the number of biopsy, representation, and postoperative complications although the rate of these complications was much less in the RA group. Based on this outcome, we can conclude that VAT lung biopsy procedure on patients with IPF under RA is safe, representative, and effective operation. In addition, high-risk patients for GA can go through this procedure under RA as an alternative and safe option with no added complications.

Determining the Optimal Number of Core Needle Biopsy Passes for Molecular Diagnostics.

The number of core biopsy passes required for adequate next-generation sequencing is impacted by needle cut, needle gauge, and the type of tissue involved. This study evaluates diagnostic adequacy of core needle lung biopsies based on number of passes and provides guidelines for other tissues based on simulated biopsies in ex vivo porcine organ tissues. The rate of diagnostic adequacy for pathology and molecular testing from lung biopsy procedures was measured for eight operators pre-implementation (September 2012-October 2013) and post-implementation (December 2013-April 2014) of a standard protocol using 20-gauge side-cut needles for ten core biopsy passes at a single academic hospital. Biopsy pass volume was then estimated in ex vivo porcine muscle, liver, and kidney using side-cut devices at 16, 18, and 20 gauge and end-cut devices at 16 and 18 gauge to estimate minimum number of passes required for adequate molecular testing. Molecular diagnostic adequacy increased from 69% (pre-implementation period) to 92% (post-implementation period) (p<0.001) for lung biopsies. In porcine models, both 16-gauge end-cut and side-cut devices require one pass to reach the validated volume threshold to ensure 99% adequacy for molecular characterization, while 18- and 20-gauge devices require 2-5 passes depending on needle cut and tissue type. Use of 20-gauge side-cut core biopsy needles requires a significant number of passes to ensure diagnostic adequacy for molecular testing across all tissue types. To ensure diagnostic adequacy for molecular testing, 16- and 18-gauge needles require markedly fewer passes.

Biopsy Procedures and Molecular Testing Utilization and Related Costs in Patients with Metastatic Lung Cancer.

Epidermal growth factor receptor (EGFR) gene mutations and anaplastic lymphoma kinase (ALK) gene rearrangements are key therapeutic targets for biomarker-driven treatment with an EGFR or ALK tyrosine kinase inhibitor (TKI) in patients with metastatic non-small cell lung cancer (NSCLC). To appropriately guide treatment decisions, since 2011, the National Comprehensive Cancer Network and the American Society of Clinical Oncology therefore recommend EGFR and ALK analysis in tumor samples obtained at the time of diagnosis in patients with non-squamous NSCLC. Currently, there are limited data on utilization patterns and cost of biopsy procedures and biomarker tests in patients with metastatic NSCLC who receive an EGFR or ALK TKI. To (a) describe utilization patterns and costs associated with biopsy procedures and biomarker testing in patients with NSCLC who received erlotinib or crizotinib between 2009 and 2012 and (b) investigate the timing of these procedures relative to the erlotinib or crizotinib index date. Adult patients with metastatic lung cancer were identified by ICD-9-CM diagnostic codes within the Truven Health Analytic MarketScan database. Patients were included in the analysis if they had an index erlotinib or crizotinib claim between January 1, 2009, and September 30, 2012 (index period) and were continuously enrolled for ≥ 12 months before the index claim. Because there is no specific ICD-9-CM diagnostic code for NSCLC, patients with metastatic lung cancer who received erlotinib or crizotinib were considered to have metastatic NSCLC. Using CPT and ICD-9-CM codes, lung biopsy procedures performed during the 24 months before or 12 months after the index claim date were identified. For every patient, biomarker testing claims for EGFR and ALK were identified using the molecular pathology stacked CPT code during the 2 months before or 1 month after the index date. The frequency of claims for biopsy procedures and biomarker testing was analyzed descriptively. The overall summary measures for biomarker testing, especially frequency of EGFR testing in patients receiving erlotinib, was also described as before and after 2011, the year when biomarker testing became part of the guidelines. Per patient and overall costs for biopsy procedures and biomarker testing were calculated from payer and patient perspectives. Of the 4,926 identified patients, 4,801 (97.5%) received erlotinib, and 125 (2.5%) received crizotinib. Biopsy procedure claims were identified for 3,579 (72.7%) patients, including 3,503 (73.0%) erlotinib recipients and 76 (60.8%) crizotinib recipients. Biomarker testing claims were identified for 675 (13.7%) patients, including 634 (13.2%) erlotinib recipients and 41 (32.8%) crizotinib recipients. Overall, most biomarker testing procedures (476 of 741) were identified in 435 (of 675) patients after year 2011. Also, among erlotinib recipients, percentage of patients receiving EGFR testing was increased over the index period. Per patient mean (SD) numbers of biopsy procedures and biomarker tests were 1.2 (1.1) and 0.2 (0.4), respectively. In the outpatient setting, per patient mean (SD) cost per biopsy procedure was $1,223 ($1,899) from the payer perspective and $60 ($147) from the patient perspective, whereas in the inpatient setting, it was $8,163 ($18,712) and $180 ($691), respectively. Among patients receiving at least 1 biomarker test, the per patient mean (SD) cost for the overall population was $891 ($1,062) and $43 ($229); for erlotinib recipients, it was $906 ($1,084) and $42 ($228); and for crizotinib recipients, it was $664 ($576) and $55 ($243) in payer and patient perspectives, respectively. This study provides insight into the use and cost of biopsy and biomarker testing procedures in patients with metastatic NSCLC. The low frequency of biomarker testing highlights the need for more awareness of testing to guide treatment decisions in these patients. Costs associated with biopsy procedures and biomarker testing provide insight into the economic impact on metastatic NSCLC patients treated with targeted therapy. This study was sponsored by Merck & Co. Shinde is a study manager working for Merck under contract with AllSourcePPS, an Agile 1 company in Huntington Beach, California. Cao and Kothari are employees of Merck & Co., Kenilworth, New Jersey. Study concept and design were contributed primarily by Shinde and Kothari. Data analysis was performed by Cao. Data interpretation was performed by Shinde, Cao, and Kothari. Shinde wrote the manuscript with assistance from Cao and Kothari. The revision was completed primarily by Shinde and Kothari.

Spectral sensing for tissue diagnosis during lung biopsy procedures: The importance of an adequate internal reference and real-time feedback

ObjectivesDifficulties in obtaining a representative tissue sample are a major obstacle in timely selecting the optimal treatment for patients with lung cancer or other malignancies. Having a modality to provide needle guidance and confirm the biopsy site selection could be of great clinical benefit, especially when small masses are targeted. The objective of this study was to evaluate whether diffuse reflectance spectroscopy (DRS) at the tip of a core biopsy needle can be used for biopsy site confirmation in real time, thereby enabling optimized biopsy acquisition and improving diagnostic capability. Materials and methodsWe included a total of 23 patients undergoing a routine computed tomography (CT) guided transthoracic needle biopsy of a lesion suspected for lung cancer or metastatic disease. DRS measurements were acquired during needle insertion and clinically relevant parameters were extracted from the spectral data along the needle paths. Histopathology results were compared with the DRS data at the final measurement position. ResultsAnalysis of the collective data acquired from all enrolled subjects showed significant differences (p<0.01) for blood content, stO2, water content, and scattering amplitude. The identified spectral contrast matched the final pathology in 20 out of 22 clinical cases that could be used for analysis, which corresponds with an overall diagnostic performance of 91%. Three cases underlined the importance of adequate reference measurements and the need for real time diagnostic feedback. Continuous real time DRS measurements performed during a biopsy procedure in one patient provided clear information with respect to the variation in tissue and allowed identification of the tumour boundary. ConclusionsThe presented technology creates a basis for the design and clinical implementation of integrated fibre-optic tools for a variety of minimal invasive applications.

Severe Thrombocytopenia Does Not Increase Bleeding Complications in Patients Undergoing Bronchoscopy

▪IntroductionProphylactic platelet transfusions are often performed prior to bronchoscopy or broncho-alveolar lavage (BAL) to prevent bleeding in thrombocytopenic patients. There is a paucity of data to validate this approach, with a platelet transfusion threshold of <50,000/mm3 largely based on expert opinion. We conducted a retrospective study on the incidence of bleeding complications in thrombocytopenic patients undergoing bronchoscopy.MethodsWe identified 150 consecutive patients with platelet counts <100,000/mm3 who underwent bronchoscopy and/or BAL from January 2009 to May 2014 at our institution. Bronchoscopies performed in patients with frank hemoptysis and trans-bronchial lung biopsy procedures were excluded. Patient characteristics, underlying diagnosis, platelet count prior to bronchoscopy, administration of platelet transfusions and bronchoscopy details were recorded. Factors affecting bleeding risk including presence of renal dysfunction (defined as BUN >30 and/or Cr>2.0) and coagulation studies (PT, PTT, INR) were identified. The British Thoracic Society guidelines1 were used to categorize bleeding as a result of bronchoscopy. Data were analyzed using descriptive statistics.ResultsThe median age was 59 years (range 27-90), with two-thirds of patients (63%) being male. One hundred and seventeen (78%) patients had underlying malignancy and 55 (37%) had thrombocytopenia related to malignancy. Fellows and residents under the supervision of a bronchoscopy certified attending performed all but 4 of the bronchoscopies. Infection (40%) was the primary indication for bronchoscopy with BAL performed in 127 (85%) patients. Fifty-eight of 89 (65%) patients with baseline platelet counts <50,000/mm3 received prophylactic transfusions compared to 8% of those with platelet counts >50,000/mm3. The platelet count did not rise to >50,000//mm3 in many transfused patients.Seventy patients (47%) had counts <50,000/mm3 and eighty patients (53%) had counts >50,000/mm3 at the time of bronchoscopy. 49% were receiving immunosuppressive medications, 45% had renal dysfunction and 8% had INR >1.5. Bloody lavage that resolved spontaneously without continuous suctioning (Grade 0) was observed in 9 (6%) patients. Bleeding that required continuous suctioning but then resolved spontaneously (Grade 1) was noted in 1 patient with a platelet count of 61,000/mm3. Of 10 total bleeding events, 7 occurred in patients who were intubated. Two additional patients with platelet counts of 30,000/mm3 and 53,000/mm3 had diffuse alveolar hemorrhage, which was present before bronchoscopy. “Old” blood and blood clots were observed in 6 patients.DiscussionThe low incidence of bleeding complications from bronchoscopy +/- BAL even in patients with platelet counts <30,000/mm3 (3 episodes in 31 patients, all grade 0) demonstrates that bronchoscopy can be safely done in severely thrombocytopenic patients. Adopting a lower threshold for prophylactic transfusions could save a considerable number of platelet units and translate into significant cost savings and decreased risk of transfusion-related complications.Table 1Platelet count, transfusion history and bleeding complications during bronchoscopyPlatelet count at the time of bronchoscopyNumber (n) and percentage (%) of patients who underwent bronchoscopyNumber of patients who received prior platelet transfusionBleeding during bronchoscopyn%0-15,000/mm396% (9/150)5Grade 0=1 pt16-292215%16Grade 0=2 pts30-391711%9Grade 0=1 pt40-492215%9Grade 0=3 pts50-754429%14Grade 1=1 pt76-1003624%10Grade 0=2 ptsTotal15063Grade 0=9 pts,Grade 1=1 pt.1.Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013:68 Suppl 1:i1-i44 DisclosuresNo relevant conflicts of interest to declare.

Thoracoscopy: beyond the key hole

Background Lateral thoracotomy or median sternotomy causes significant morbidity. Thoracoscopy reduces the morbidity of the incision and provides a clear and magnified display of anatomy. It involves a learning curve. Objectives To evaluate the safety, efficacy and advantages of thoracoscopy. Method A retrospective analysis of 67 thoracoscopic procedures performed at the university surgical unit, Teaching Hospital, Peradeniya. Results The total number of 67 procedures included thymectomy, lymph node biopsy, lymph node dissection, excision of retrosternal goitre, sympathectomy, splanchnicectomy, oesophagectomy, lung biopsy and diagnostic procedures. The time taken was acceptable with minimum blood loss and selective use of intercostal drainage. There were no conversions. Intensive care was needed only for oesophagectomy, thymectomy and excision of retrosternal goiter. The need for narcotic analgesics was minimal. Feeding, mobilization and discharge from hospital were early except after oesophagectomy. There was a mortality of 13% in the oesophagectomy group. No morbidity or mortality was recorded among others. Conclusion Thoracoscopy permitted a wide range of surgeries to be done safely with reduced morbidity. DOI: http://dx.doi.org/10.4038/sljs.v32i1.6869 The Sri Lanka Journal of Surgery 2014; 32(1): 29-34