Peripheral Lung Lesions Research Articles

Risk factors for pulmonary hemorrhage following ultrasound-guided percutaneous biopsy of peripheral lung lesions.

Risk factors for pulmonary hemorrhage following ultrasound-guided percutaneous biopsy of peripheral lung lesions.

Bronchoscopic diagnosis of peripheral lung lesions.

Over the last decades, in addition to the traditional fluoroscopy, various and innovative guidance systems have been adopted in clinical practice for transbronchial approach to peripheral pulmonary lesions (PPLs). The aim of this article is to summarize the most recent data on available guidance systems and sampling tools, evaluating also advantages and limitations of each technique. Although several studies have been published over the last years, large randomized studies comparing the different techniques are scanty. Fluoroscopy is the traditional and still most widely utilized guidance system. New guidance systems (electromagnetic navigation bronchoscopy, ultrasound miniprobe, cone beam computed tomography) seems to provide a better sensitivity, especially for small lesions not visualized by fluoroscopy. Among the sampling instruments, there is a good evidence that flexible transbronchial needle provides the better diagnostic yield and that sensitivity may increase if more than one sampling instrument is used. Even if great progress has been done since the first articles on the transbronchial approach to PPLs, better scientific evidence and more reliable randomized trials are needed to guide interventional pulmonologists in choosing the best technique according to different clinical scenarios and source availability.

Ultrasound-guided lung biopsy with coaxial technique: pleural contact length affects the occurrence of pneumothorax after first puncture

PurposeTo assess prebiopsy characteristics influencing the occurrence of pneumothorax after first puncture of ultrasound (US)-guided lung biopsy with coaxial technique.Materials and methodsFrom January 2007 to September 2018, 180 peripheral lung lesions in 174 patients who underwent B-mode US-guided lung biopsy with coaxial technique at single institution were included in this study. Technical success was defined as the ability to make a diagnosis using the acquired sample with/without an adverse event of pneumothorax. Statistical analyses of prebiopsy characteristics were performed to identify the most important cutpoint and to evaluate the effect on diagnostic accuracy.ResultsOf the 180 lesions (mean size, 37 mm ± 26.2; mean pleural contact length, 38.2 mm ± 34.4), technical success rate was 97.2% (175/180 lesions) and diagnostic accuracy rate was 91.6% (165/180 lesions). Pneumothorax occurred immediately after first puncture for seven of 180 lesions. Classification and regression tree analysis and Fisher’s exact test showed the proportion of the pneumothorax immediately after first puncture was higher in lesions with pleural contact length less than 9.78 mm (p = 0.002). No significant difference was shown between the pneumothorax and non-pneumothorax after first puncture in technical success and final diagnosis success rate.ConclusionPleural contact length affects the occurrence of pneumothorax after first puncture of US-guided lung biopsy with coaxial technique.

O20‐4: Diagnostic yield and the number of tumor cells of ultrathin bronchoscopy for peripheral lung lesions: A comparison with thin bronchoscopy

O20‐4: Diagnostic yield and the number of tumor cells of ultrathin bronchoscopy for peripheral lung lesions: A comparison with thin bronchoscopy

Electromagnetic navigation bronchoscopy versus virtual bronchoscopy navigation for improving the diagnosis of peripheral lung lesions: analysis of the predictors of successful diagnosis.

To investigate if electromagnetic navigation bronchoscopy (ENB) improves the diagnostic yield for peripheral lung lesions from that achieved by virtual bronchoscopy navigation (VBN). This retrospective study compared the results of 100 ENB-transbronchial lung biopsies (TBLBs) with those of 50 VBN-TBLBs at a single institution. ENB improved the diagnostic yield significantly compared with VBN (64.0% for 19.4 ± 9.0mm tumors vs. 46.0% for 27.6 ± 8.9mm tumors; p < 0.0001). Irrespective of the bronchus sign, ENB was more favorable than VBN, with 81.0% (47/58) achieved by ENB vs. 60.0% (21/35) achieved by VBN in the presence of the positive bronchus sign (p = 0.0283), and 40.5% (17/42) achieved by ENB vs. 13.3% (2/15) achieved by VBN in the absence of the bronchus sign (p = 0.0431). Univariate analysis identified tumor size (p = 0.0048), amount of intravenous sedation (p = 0.0182), registration time (p = 0.0111), minimum distance to target (p = 0.0244), and the bronchus sign (p < 0.0001) as factors that affected the yield significantly for ENB. Multivariate analysis identified the bronchus sign (odds ratio 6.74; 95% CI 1.84-24.7) and the registration time (OR 1.01; 95% CI 1.00-1.02) as significant factors. Despite the bronchus sign being a significant factor, ENB improved the diagnostic yield of smaller lesions significantly, compared with VBN, regardless of the bronchus sign.

Multiple tumors on the pleura with pleural effusion mimicking malignant mesothelioma

A 68-year-old male presented with left chest pain and was referred to our hospital due to left-sided pleural effusion on a chest X-ray (Fig. 1 A). Initial laboratory data included a white blood cell count of 5650/μL and a C-reactive protein level of 0.36 mg/dL. CT during drainage of bloody effusion showed multiple tumors on the left chest wall and diaphragm, and residual effusion on the dorsal side, without hilar or peripheral lung lesions (Fig. 1B, C). No extrathoracic tumors were detected. Although effusion cytology was positive for malignancy, the histological type could not be determined even with cell block specimens.

Role of Ultrasound-Guided Tru-cut Biopsy in the Diagnosis of Peripheral Lung and Pleural Lesions

Abstract Background Transthoracic needle biopsy is a well-established technique for diagnosing pulmonary lesions. Computed tomography (CT) is usually used as guidance. Ultrasound (US)-guided biopsy is a relatively affordable modality for diagnosis of peripheral lung lesions (PLLs; also known as peripheral pulmonary lesions [PPLs]) and peripheral pleural lesions. Objectives The purpose of this study was to study the diagnostic yield of US guidance sampling a consecutive series of peripheral lung and pleural lesions and potential factors influencing the diagnostic yield with recording the occurrence of any complications. Patients and Methods This was a prospective study that was conducted at Ain Shams University Hospitals upon a population of 60 patients, during the period from September 2018 to August 2019. A special puncture transducer is used to perform US-guided biopsy with visualization of the biopsy needle and the lesion; facilitating the sampling procedure. Results The use of US-guided transthoracic needle biopsies across 60 patients was shown to have a yield of 75% which found the occurrence of 45 conclusive and 15 non-conclusive results From this study population, 70% (n = 42/45) were found to have malignant manifestations, of which 26 were undifferentiated high grade adenocarcinoma, and 9 were moderately differentiated adenocarcinoma. As for complications arising from the biopsy procedure, twenty percent 20% (n = 12) of patients suffered from complications in the form of hemoptysis in 8 which was controlled by hemostatic measures and 4 patients acquired pneumothorax, three (¾) of them received high flow oxygen and conservative treatment and only one (1/4) patient had intercostal tube placement. Diagnostic yield was significantly increased with the presence of Wedge shaped hypoechoic lesions(p &amp;lt; 0.001), hard Mass consistency was significantly highly associated with conclusive results (p &amp;lt; 0.001), as well as a significant link between the longitudinal diameter of masses that had a mean length of 45.05mm ±12.93mm (#x0003D; 0.029).It also showed that more biopsies taken were highly significant correlation with conclusive outcomes (p &amp;lt; 0.001). Conclusion US-guided biopsy is a robust and accurate procedure to effectively diagnose peripheral lung lesions, with a low incidence of complications and gradually improving results with the mastery of the procedure.

P02.05 Yield of Tumor Samples With A Guide-sheath in Endobronchial Ultrasound Transbronchial Biopsy For Non-small Cell Lung Cancer

Adequate tumor tissue is required to treatment for non-small cell lung cancer (NSCLC). Transbronchial biopsy (TBB) by endobronchial ultrasonography with a guide sheath (EBUS-GS) is useful to diagnose peripheral lung lesions. We can choose two different sizes of GS kits—large and small. The data of tumor cell number obtained by TBB using different sizes of GS are limited. It is also unclear which lesion can be diagnosed by TBB with large GS. We investigated the utility of a large GS kit to obtain many tumor cells in patients with NSCLC. We further assessed the characteristics of lesions that could be obtained by TBB with large GS. Patients with a peripheral lung lesion and suspected of NSCLC were prospectively enrolled. They underwent TBB with a 5.9-mm diameter bronchoscope with a large GS. When the lesion was invisible in EBUS, we changed to a thinner bronchoscope and TBB was performed with a small GS. We compared the tumor cell numbers prospectively obtained with a large GS (prospective large GS group) and those previously obtained with a small GS (small GS cohort). The primary endpoint was the tumor cell number per sample, and we assessed characteristics of lesions that could be obtained by TBB with large GS. Biopsy with large GS was performed in 55 of 87 patients (63.2%), and 37 were diagnosed with NSCLC. The mean number of tumor cells per sample of the large GS group tended to be more than that of the small GS cohort (658±553 vs. 532±526, p=0.32) (Fig.1A. B; The comparison of the counts of the slide containing the largest number of tumor cells among five samples). The mean sample size of the large GS group was significantly larger than that of the small GS cohort (1.75 mm2 vs. 0.83 mm2, p<0.001). (Fig.1C. D; The comparison of the largest sample size of five samples) Logistic regression analysis indicated that the bronchus generation was significantly associated with the change to a thinner bronchoscope. Of the 12 lesions involving a third or less bronchus generation, 10 (83.3%) were diagnosed by GS-TBB with large GS. There was no significant difference in tumor cell number between two sizes of GS, although the sample size obtained by large GS was significantly larger than that of small GS. The 5.9-mm diameter bronchoscope with large GS can be used for lesions involving a third or less bronchus generation.

INIITIAL EXPERIENCE WITH STEERABLE INSTRUMENTATION IN HUMAN CADAVERIC MODELS WITH SIMULATED TUMOR TARGETS

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Despite growing experience using advanced guided techniques, the diagnostic yield of bronchoscopy for peripheral pulmonary lesions remains suboptimal, particularly for lesions which are adjacent to peripheral bronchi. While recent publications have focused on improving bronchoscopic reach, access and precision in the lung periphery, few have addressed significant modifications to the instrumentation used to obtain biopsies. This exercise was performed to evaluate two novel, steerable instruments within human cadaveric lungs with simulated tumor targets. Instrument assessment included the ability of both instruments to access simulated tumor targets in all lobes of the lung, as well as to reposition instruments within tumor targets. METHODS: Artificial tumor targets were placed in all lobes of the lungs of two human cadaver torsos which were intubated, ventilated and underwent CT scanning. Bronchoscopists utilized a large caliber bronchoscope (BF-1TH190, Olympus, Tokyo, Japan) and steerable guide sheath (2.7mm OD)(SerpeX Medical, Santa Clara, CA) by advancing, rotating and articulating the distal end of the guide sheath towards the targeted lesion using fluoroscopic guidance and a reference CT scan. Radial probe endobronchial ultrasound (UM S20-17S, Olympus Tokyo, Japan) was used to confirm lesion localization prior to performing transbronchial needle aspiration (Periview Flex, Olympus, Tokyo, Japan) and transbronchial biopsy (Precisor Broncho Forceps, ConMed, Utica, NY). Following this, a standard diagnostic bronchoscope (BF-H190, Olympus, Tokyo, Japan) was used to advance a steerable needle (1.8mm OD)(SerpeX Medical, Santa Clara, CA) towards the same targeted lesions using insertion, rotation and articulation of the distal tip. RESULTS: Both the steerable sheath and steerable needle were successfully placed within simulated tumor targets in all lobes of two cadaveric lungs with diagnostic biopsy material obtained from all lobes. Additionally, manipulation of the distal end of the steerable sheath and steerable needle was successfully used to reposition each tool within different locations of the same lesion. CONCLUSIONS: This is an initial reporting of two fully articulating, steerable instruments designed to assist with bronchoscopic biopsy of peripheral lung lesions. In this exercise both instruments were successfully positioned within tumor targets in all lobes of two human cadaveric lungs. Additionally, articulation and rotation of the distal end of each of these instruments successfully repositioned biopsy instruments within different locations of targeted lesions. CLINICAL IMPLICATIONS: Steerable instrumentation may improve the bronchoscopist's ability to place biopsy tools within targeted peripheral lesions, thereby potentially improving diagnostic yield, particularly for lesions that are positioned adjacent to peripheral bronchi. DISCLOSURES: Consultant relationship with Serpex Please note: 2020-2021 Added 04/24/2021 by Alexander Chen, source=Web Response, value=Consulting fee Removed 04/27/2021 by Alexander Chen, source=Web Response Investigator relationship with Olympus Please note: 2020-2021 Added 04/27/2021 by Alexander Chen, source=Web Response, value=Grant/Research Support Consultant relationship with Boston Scientific Please note: 2020-2021 Added 05/10/2021 by Alexander Chen, source=Web Response, value=Consulting fee Consultant relationship with Olympus America, Inc Please note: 1/2019 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee Consultant relationship with Serpex Medical Please note: 1/2020 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee DSMB, consultant relationship with Novocure, Inc Please note: 1/2019 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee Consultant relationship with Olympus America Please note: 1/2019 to current Added 04/28/2021 by Andrew Haas, source=Web Response, value=Consulting fee No relevant relationships by Michael Machuzak, source=Web Response

Using short-term prophylactic antibiotics for prevention of infectious complications after radial endobronchial ultrasound-guided transbronchial biopsy

BackgroundRadial endobronchial ultrasound-guided transbronchial biopsy (rEBUS-TBB) facilitates the diagnosis of peripheral lung lesions. However, methods to prevent infectious complications afterwards have not been well established. Therefore, we analyzed the efficacy of short-term oral antibiotics for preventing infectious complications. MethodsWe retrospectively analyzed 484 patients. Patients who underwent rEBUS-TBB from March 2018 to March 2019 did not receive prophylactic antibiotics (“no prophylactic” group, n = 233), while patients who underwent rEBUS-TBB from April 2019 to March 2020 did receive prophylactics (oral amoxicillin/clavulanate for 3 days; “prophylactic” group, n = 251). Multivariable logistic regression was used to identify independent factors for infectious complications. ResultsThe median age was 66 years (IQR: 59–74 years), and 58.9% were male. Slightly over half of the patients (54.4%) were previous or current smokers. In 13% (n = 63) of patients, the procedure was performed using a guide sheath. Infectious complications occurred in 12 (5.2%) and 2 (0.8%) cases in the no prophylactic and prophylactic groups, respectively. In multivariable analysis, infectious complications were significantly associated with a cavity or low-density attenuation (LDA) of the lesion, and with obstructive pneumonic consolidation, but not with prophylactic antibiotics. In subgroup analysis, infectious complications occurred less often when prophylactic antibiotics were used in patients with at least one risk factor (22.4% vs. 0%, p = 0.005). ConclusionsThe risk factors for infectious complications were cavities, LDA in the lesion, and obstructive pneumonic consolidation. Use prophylactic antibiotics might reduce incidence of infectious complications in the presence of these risk factors.

Effectiveness and Safety of Transthoracic Ultrasound in Guiding Percutaneous Needle Biopsy in the Lung and Comparison vs. CT Scan in Assessing Morphology of Subpleural Consolidations.

(1) Background: The aim of this study was to conduct a prospective analysis on the diagnostic accuracy of transthoracic ultrasound-guided percutaneous needle biopsy (TUS-PNB) for the histological assessment of peripheral lung lesions and to assess the performance of transthoracic ultrasound (TUS) examination vs. chest CT (gold standard) in the differentiation between malignant and benign peripheral lung lesions. (2) Methods: A total of 961 consecutive patients with subpleural pulmonary lesions were enrolled. All the patients received a CT scan with contrast; 762 patients underwent TUS-PTNB for suspicion of malignancy, and the remaining 199 enrolled patients underwent only TUS examination as a part of routine follow-up for known non-malignant subpleural consolidations. (3) Results: Among the 762 TUS-guided biopsies, there were 627 (82.28%) malignant lesions, 82 (10.76%) benign lesions, and 53 (6.96%) indeterminate lesions. The overall diagnostic accuracy was 93.04%. The rates of pneumothorax not requiring chest-tube insertion and self-limited hemoptysis were 0.79 and 0.26%, respectively. Patients were divided into two groups based on the benign or malignant nature of the subpleural consolidations. On TUS, both malignant and benign lesions showed mostly irregular margins and a hypoechoic pattern, but no differences were assessed in terms of sonographic margins and pattern between the two groups. There was poor agreement between TUS and chest CT in assessing air bronchograms and necrotic areas. The only finding in the detection of which TUS showed superiority compared to chest-CT was pleural effusion. (4) Conclusions: TUS-PNB was confirmed to be an effective and safe diagnostic method for peripheral pulmonary consolidation, but their sonographic pattern did not allow to rule out a malignant nature. A pre-operative evaluation on CT images, combined with the possibility of performing additional immunohistochemical and cytological investigations and the experience of the medical staff, may improve the diagnostic yield of TUS-guided biopsies.

The Adding Role and Accuracy of Chest Ultrasound and Doppler in Peripheral Lung Lesions

Abstract Background: Chest ultrasound (US) and color Doppler sonography play important roles in the diagnosis and charac-terization of different pathologies of peripheral lung lesions, especially in the emergency setting. Aim of Study: The aim of this study is to assess the role of chest US and Doppler examination in the assessment of peripheral lung lesions in comparison with chest CT, which is the gold standard for chest diagnosis. Subjects and Methods: This cross-sectional study involved 120 patients who underwent chest CT examination, full chest US, and Doppler. Results were assessed blindly and compared with CT. Results: The main lung lesions assessed by US and Doppler were lung collapse, consolidation, interstitial lung changes, and peripheral pulmonary nodules, with the estimated sensi-tivity, specificity, positive predictive value, negative predictive value, and accuracy of detection ranging from 63.9%-76.9%, 94%-95%, 79.2%-95%, 85.9%-91.5%, and 85%-93.3% re-spectively. There was a significant correlation between US and Doppler in comparison with CT. Conclusion: Chest US proved its value as a complementary tool for the diagnosis of peripheral lung lesions, with high specificity and accuracy. This finding was enforced by Doppler, history, and clinical suspicion, although the use of CT to obtain the final diagnosis would be more applicable.

Diagnostic Performance of Electromagnetic Navigation Bronchoscopy-Guided Biopsy for Lung Nodules in the Era of Molecular Testing.

Electromagnetic navigation bronchoscopy (ENB) is an emerging technique used to evaluate peripheral lung lesions. The aim of this study was to determine the diagnostic yield, safety profile, and adequacy of specimens obtained using ENB for molecular testing. This single-center, prospective pilot study recruited patients with peripheral pulmonary nodules that were not suitable for biopsy via percutaneous transthoracic needle biopsy methods. The possibility of molecular testing, including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed death ligand 1 (PD-L1), was identified with non-small cell lung cancer (NSCLC) tissue obtained using ENB. ENB-guided biopsy was performed on 30 pulmonary nodules in 30 patients. ENB-guided biopsy was successfully performed in 96.6% (29/30) of cases, but one case failed to approach the target lesion. The diagnostic accuracy of ENB-guided biopsy was 68.0% (17/25). Biopsy-related pneumothorax occurred in one patient and there was no major bleeding or deaths related to the procedure. Among 13 patients diagnosed with NSCLC, molecular testing was successfully performed in 92.3% (12/13). ENB-guided biopsy demonstrated acceptable accuracy and excellent sample adequacy, with a high possibility of achieving molecular testing and a good safety profile to evaluate peripheral pulmonary nodules, even when the percutaneous approach was difficult and/or dangerous.

Clinical value of an electromagnetic navigation system for CT-guided percutaneous lung biopsy of peripheral lung lesions.

BackgroundThe purpose of this study was to retrospectively evaluate the clinical value of an electromagnetic navigation system for CT-guided percutaneous lung biopsy of peripheral lung lesions.MethodsThis was a retrospective study. Patients with peripheral lung lesions in our institution between January 2019 and December 2020, who underwent lung biopsy assisted by the electromagnetic navigation system were included in Group A, and those who underwent lung biopsy using conventional CT-guided percutaneous lung biopsy were included in Group B. The general features and clinical and technical information of each patient were collected and evaluated in both groups.ResultsA total of 141 patients were included in Group A (78 males and 63 females; median age, 65 years; range, 32–79 years), and 96 patients were included in group B (57 males and 39 females; median age, 65 years; range, 34–80 years). The technical success rate was 100% in both groups. The technical efficacy rate was 92.9% and 90.6% in Groups A and B (P=0.525), respectively. There was no significant difference in surgical time and the number of CT scans between the two groups, and only grade 1–2 complications occurred in the patients.ConclusionsThe electromagnetic navigation system is an effective and safe auxiliary tool for CT-guided percutaneous lung biopsy of peripheral lung lesions.

An evolving role for endobronchial ultrasonography in the intensive care unit.

Endobronchial ultrasound (EBUS) bronchoscopy is an established minimally-invasive modality for visualization, characterization, and guidance of sampling of paratracheal and parabronchial structures and tissues. In the intensive care unit (ICU), rapidly obtaining an accurate diagnosis is paramount to the management of critically ill patients. In some instances, diagnosing and confirming terminal illness in a critically ill patient provides needed closure for patients and their loved ones. Currently available data on feasibility, safety, and yield of EBUS bronchoscopy in critically ill patients is based on single center experiences. These data suggest that in select ICU patients convex and radial probe-EBUS bronchoscopy can serve as useful tools in the evaluation of mediastinal lymphadenopathy, central airway obstruction, pulmonary embolism, and peripheral lung lesions. Barriers to the use of EBUS bronchoscopy in the ICU include: (I) requirement for dedicated equipment, prolonged procedure time, and bronchoscopy team expertise that may not be available; (II) applicability to a limited number of patients and conditions in the ICU; and (III) technical difficulty related to the relatively large outer diameter of the convex probe-EBUS bronchoscope and an increased risk for adverse cardiopulmonary consequences due to intermittent obstruction of the artificial airway. While the prospects for EBUS bronchoscopy in critically ill patients appear promising, judicious patient selection in combination with bronchoscopy team expertise are of utmost importance when considering performance of EBUS bronchoscopy in the ICU setting.

Hand-Held Ultrasound of the Lung: A Systematic Review.

Background: The ultrasound examination is a surface technique with an accurate diagnosis of pathological processes adjacent to the pleural line. The purpose of the study was to evaluate the role of hand-held ultrasound devices (visual stethoscopes) in the diagnosis of peripheral lung disease. Methods: We conducted a systematic search of literature comparing the diagnostic accuracy of truly hand-held ultrasound devices compared to conventional high-end ultrasound devices, chest X-rays, thoracic CT (computer tomography), or physical examinations to diagnose peripheral lung lesions. ScienceDirect, PubMed, and PubMed Central bibliographic databases were searched within a time limit of 15 years. Results: The applied search strategy retrieved 439 studies after removing duplicates; 34 were selected for full-text review, and 15 articles met all inclusion criteria and were included in the analysis. When comparing hand-held ultrasound devices to chest X-rays, negative predictive values were above 90%, while positive predictive values tended to be lower (from 35% to 75.8%). Hand-held ultrasound reached a correlation of 0.99 as associated with conventional ultrasound with a Bland–Altman bias close to zero. Conclusions: Being accessible, radiation-free, and comparatively easy to decontaminate, hand-held ultrasound devices could represent a reliable tool for evaluating peripheral lung diseases. This method can be successfully employed as an alternative to repeated X-ray examinations for peripheral lung disease monitoring.

Optimizing Diagnostic and Staging Pathways for Suspected Lung Cancer: A Decision Analysis

The optimal diagnostic and staging strategy for patients with suspected lung cancer is not known.What diagnostic and staging strategies are most cost-effective for lung cancer?A decision model was developed by using a hypothetical patient with a high probability of lung cancer. Sixteen unique permutations of bronchoscopy with fluoroscopy, radial endobronchial ultrasound, electromagnetic navigation, convex endobronchial ultrasound with or without rapid-onsite evaluation (ROSE), CT-guided biopsy (CTBx), and surgery were evaluated. Outcomes included cost, complications, mortality, time to complete the evaluation, rate of undetected N2-3 disease at surgery, incremental cost-complication ratio, and willingness-to-pay thresholds. Sensitivity analyses were performed on primary outcomes.For a peripheral lung lesion and radiographic N0 disease, the best bronchoscopy strategy costs $1,694 more than the best CTBx strategy but resulted in fewer complications (risk difference, 14%). The additional cost of bronchoscopy to avoid one complication from a CTBx strategy was $12,037. The cost and cumulative complications of bronchoscopy strategies increased compared with CTBx strategies for small lesions. The cost and cumulative complications of bronchoscopy strategies decreased compared with CTBx strategies when a bronchus sign was present, but bronchoscopy remained more costly overall. For a central lesion and/or radiographic N1-3 disease, convex endobronchial ultrasound with ROSE followed by lung biopsy with incremental cost-effectiveness ratio, if required, was more cost-effective than any CTBx strategy across all outcomes. Strategies with ROSE were always more cost-effective than those without, irrespective of scenario. Trade-offs also exist between different bronchoscopy strategies, and optimal choices depend on the value placed on individual outcomes and willingness-to-pay.The most cost-effective strategies depend on nodal stage, lesion location, type of peripheral bronchoscopic biopsy, and the use of ROSE. For most clinical scenarios, many strategies can be eliminated, and trade-offs between the remaining competitive strategies can be quantified.

Bronchoscopic needle-based confocal laser endomicroscopy (nCLE) as a real-time detection tool for peripheral lung cancer

IntroductionDiagnosing peripheral lung cancer with the bronchoscope is challenging with near miss of the target lesion as major obstacle. Needle-based confocal laser endomicroscopy (nCLE) enables real-time microscopic tumour visualisation at...

Cone-beam CT and Augmented Fluoroscopy-guided Navigation Bronchoscopy: Radiation Exposure and Diagnostic Accuracy Learning Curves.

The endobronchial diagnosis of peripheral lung lesions suspected of lung cancer remains a challenge from a navigation as well as an adequate tissue sampling perspective. Cone-beam computed tomography (CBCT) guidance is a relatively new technology and allows for 3-dimensional imaging confirmation as well as navigation and biopsy guidance, but, also involves radiation. This study investigates how radiation exposure and diagnostic accuracy in the CBCT-guided navigation bronchoscopy evolves with increasing experience, and, with a specific tailoring of CBCT and fluoroscopic imaging protocols towards the procedure. In this observational clinical trial, all 238 consecutive patients undergoing a CBCT-guided navigation bronchoscopy from the start of our CBCT-guided navigation bronchoscopy program (December 2017) until June 2020 were included. Procedural dose characteristics and diagnostic accuracy are reported as a function of time. Procedural radiation exposure as measured by the dose area product initially was 47.5 Gy·cm2 (effective dose: 14.3 mSv) and gradually reduced to 25.4 Gy·cm2 (5.8 mSv). The reduction in fluoroscopic dose area product was highest, from 19.0 Gy·cm2 (5.2 mSv) to 2.2 Gy·cm2 (0.37 mSv, 88% reduction), despite a significant increase of fluoroscopy time. The diagnostic accuracy of navigation bronchoscopy increased from 72% to 90%. A significant learning effect can be seen in the radiation safety and diagnostic accuracy of a CBCT-guided and augmented fluoroscopy-guided navigation bronchoscopy. With increasing experience and tailoring of imaging protocols to the procedure, the procedural accuracy improved, while the effective dose for patients and staff was reduced.

Single and Multiple Effects of COVID-19 Post-Acute Sequelae: 6-Month Follow-Up Cohort Study

Background: Medical research is progressing to clarify the full spectrum of sub-acute and long-term effects of post-acute sequelae of COVID-19. However, most manuscripts published to date only analyze the effects of long COVID in patients discharged from hospital, which may induce significant bias. This work aims to analyze the single and multiple association between long-term post-COVID features and patients with/without previous respiratory diseases, hospitalized or not, and the abnormalities of chest CT images. Methods: The cohort study was conducted at the University Hospital Virgen de la Nieves, one of the hospitals assigned for patients with COVID-19 in Granada, Spain. Two visits were scheduled in the follow-up period from May to October 2020. The first follow-up consultation (FFuC) was two months after the diagnosis of COVID-19 infection. Here, the basal, clinical, and physical examination parameters were collected. Chest HRCT scan images were recorded at mm intervals in the supine position, including the serology for SARS-CoV-2 for patients with radiological or clinical involvement with dyspnea. The results were evaluated separately by two independent reviewers. The second follow-up consultation (SFuC) — 6-months after the initial diagnosis — the patients were re-appointed with laboratory tests, pulmonary function, and chest HRCT according to the criteria set forth above. Findings: At the first consultation, 217 patients after infection with SARS-CoV2 — from February to April 2020 — were referred to the University Hospital Virgen de la Nieves. The second consultation was carried out from July to September 2020, and 207 of the 217 attended. The median age and BMI were 59 (interquartile range, 49-68) and 28 (26-32), respectively, of which 116 (53·5%) were men. The most frequent features were: dyspnea, fatigue, dry cough, myalgia, loss of taste/smell, air loss as clinical characteristics; emotional affectation, depression, the cognitive deficit as mental health affectations; hemoglobin, ferritin, and d-dimer as abnormal laboratory indices. The clinical features were more frequent in women than in men. However, mental affections were more frequent in females in the first consultation and more frequent in males in the second consultation. Bivariate or multivariate logistic adjustments showed a strong statistically significant association of the following characteristics: abnormal body mass index, former smoker, dyspnea, fatigue, emotional affectation, depression, FEV1, DLCO, and FEV1/FVC below their normal limits with pre-existing respiratory diseases; male sex, age>59 years, non-heath worker, fatigue, and venous thrombosis with hospitalization status. Bilateral lung involvement, subpleural reticulum, ground-glass opacity, peripheral lung lesions, and bronchiolectasis were the most common findings from the high-resolution chest CT images. A strong statistically significant association was found between male sex, age>59 years, ex-smoker, non-smoker, and abnormal radiographs with an abnormal result of CT images. Interpretation: At six months follow-up, PASC characteristics fatigue, arthralgia, fever, breathlessness, emotional disturbance, depression, cognitive deficit, hemoglobin, total bilirubin, and ferritin are correlated with the gender of the patient. Patients with previous respiratory diseases and abnormal BM, ex-smoker, and dyspnea had a robust statistically significant association. Non-hospitalized patients may suffer more. Funding: None to declare. Declaration of Interest: The authors declared no conflict of interest. Ethical Approval: The study was conducted in accordance with the requirements of the Declaration of Helsinki (Tokyo revision, October 2004), and the Spanish Data Protection Act of 15/1999. The study was approved by the Center's Ethics Committee.