Pneumothorax Requiring Chest Tube Placement Research Articles

Combined antegrade and retrograde dilation (CARD) for management of complete esophageal obstruction: Multicenter case series.

Background and study aims Complete esophageal obstruction (CEO) is a rare complication of radiation therapy for esophageal or head and neck cancers and can be challenging to manage endoscopically. A rendezvous approach by combined anterograde and retrograde endoscopic dilation (CARD) can be used to re-establish luminal integrity in such cases. Our study aimed to review our experience with patients with CEOs managed by CARD. Patients and methods Six patients who had CARD for CEO were reviewed. The primary outcomes were immediate technical and clinical success of CARD. Secondary outcomes were adverse events (AEs) associated with the procedure and continued dependency on the percutaneous endoscopic gastrostomy (PEG)-or jejunostomy tube. Results The mean age was 59 years (range 38-83). Five patients had CEO secondary to neoadjuvant chemoradiotherapy for esophageal cancer, and one patient had complete obstruction secondary to neck trauma. CARD was technically successful in five patients (86%). Two patients had AEs. One had pneumomediastinum requiring no intervention, while the other had bilateral pneumothorax requiring chest tube placement. The median follow-up duration of repeated dilations to maintain liminal patency was 20 months. Four patients had improvement in dysphagia, tolerating oral intake, and mouth secretions after the procedure, with a mean functional oral intake scale (FOIS) score > 3 and an overall success rate of 83%. Conclusions The CARD approach to re-establish esophageal luminal patency in CEO is a safer alternative to high-risk blind antegrade dilation or an invasive surgical approach. It is usually technically feasible with improved swallowing ability in most patients.

Machine-Learned Algorithms to Predict the Risk of Pneumothorax Requiring Chest Tube Placement after Lung Biopsy

PurposeTo develop a machine-learned algorithm to predict the risk of postlung biopsy pneumothorax requiring chest tube placement (CTP) to facilitate preprocedural decision making, optimize patient care, and improve resource allocation. Materials and MethodsThis retrospective study collected clinical and imaging features of biopsy samples obtained from patients with lung nodule biopsy and included information from 59 procedures resulting in pneumothorax requiring CTP and randomly selected 67 procedures without CTP (convenience sample). The data were divided into 70 and 30 as training and testing sets, respectively. Conventional machine-learned binary classifiers were explored with preprocedural imaging and clinical data as input features and CTP as the output. ResultsThere was no single pathognomonic imaging or predictive clinical feature. For the independent test set under the high-specificity mode, a decision tree, logistic regression, and Naïve Bayes classifier achieved accuracies of identifying CTP at 0.79, 0.93, and 0.89 and area under receiver operating curves (AUROCs) of 0.68, 0.76, and 0.82, respectively. Under high-sensitivity mode, a decision tree, logistic regression, and Naïve Bayes achieved accuracies of identifying CTP of 0.60, 0.45, and 0.60 with AUROCs of 0.71, 0.81, and 0.82, respectively. High importance features included lesion character, chronic obstructive pulmonary disease, lesion depth, and age. A coarse decision tree requiring 4 inputs achieved comparable performance as other methods and previous machine learning prediction studies. ConclusionsThe results support the possibility of predicting pneumothorax requiring CTP after biopsy based on an automated decision support, reliant on readily available preprocedural information.

Diagnostic Accuracy and Complications Rate of CT-guided Core Needle Lung Biopsy of Solid and Part-solid Lesion: A Single-institution Experience

Purpose: The aim of this study was to retrospectively analyze the diagnostic accuracy and risk factors of complications of percutaneous CT-guided transthoracic lung core needle biopsy (CT–TTLB) by stratifying pulmonary lesions by size and consistency. The secondary purpose of this study was to retrospectively evaluate the feasibility and safety of 1-hour patient discharge after (CT–TTLB). Methods: 170 lung biopsies were performed using a semi-automated true-cut needle. There were 116 (68.2%) male and 54 (31.8%) female patients, with a mean age of 60.9±14.24 years (19–91 years). The mean lesion's longest diameter was 6.08±3.33 cm. The lesions were stratified into solid and part-solid lesions. Diagnostic accuracy and adequacy were calculated for all biopsies and for each group separately, as well as the incidence of complications. Complications were stratified into early (discovered within the first hour after biopsy) and delayed (after 1 hour of biopsy) to assess the safety of 1 hour of patient discharge after (CT–TTLB). Results: The overall diagnostic accuracy was 80.6%, with no significant difference between small and large lesions, nor with solid and part-solid lesions. An adequate sample for NGS testing was obtained in 135 core biopsies (79.4%). The most frequent complication was perilesional intrapulmonary hemorrhage and the second most frequent complication was small pneumothorax; seen at a rate of 26% and 15.2% respectively. Large pneumothorax requiring chest tube placement occurred in one patient (1.1%). Most of the biopsy-related complications (98.9%) were discovered in the first hour of the biopsy with only two patients presenting to the ER with the delayed incidence of pneumothorax, which was treated conservatively. Conclusion: Diagnostic accuracy and adequacy were not affected by lesion characteristics or the number of samples. Larger gauge needles and smaller and deeply located nodules were found to have higher complication rates, compared to the larger size, solid, and peripherally located masses. Early discharge after CT-TTLB is associated with little morbidity and no mortality.

Variation in Incidence of Pneumothorax Complications After Percutaneous Lung Biopsies Among Veterans Health Administration Hospitals

Variation in Incidence of Pneumothorax Complications After Percutaneous Lung Biopsies Among Veterans Health Administration Hospitals

Risk of persistent air leaks following percutaneous cryoablation and microwave ablation of peripheral lung tumors.

To compare the incidence of persistent air leak (PAL) following cryoablation vs MWA of lung tumors when the ablation zone includes the pleura. This bi-institutional retrospective cohort study evaluated consecutive peripheral lung tumors treated with cryoablation or MWA from 2006 to 2021. PAL was defined as an air leak for more than 24h after chest tube placement or an enlarging postprocedural pneumothorax requiring chest tube placement. The pleural area included by the ablation zone was quantified on CT using semi-automated segmentation. PAL incidence was compared between ablation modalities and a parsimonious multivariable model was developed to assess the odds of PAL using generalized estimating equations and purposeful selection of predefined covariates. Time-to-local tumor progression (LTP) was compared between ablation modalities using Fine-Gray models, with death as a competing risk. In total, 260 tumors (mean diameter, 13.1mm ± 7.4; mean distance to pleura, 3.6mm ± 5.2) in 116 patients (mean age, 61.1years ± 15.3; 60 women) and 173 sessions (112 cryoablations, 61 MWA) were included. PAL occurred after 25/173 (15%) sessions. The incidence was significantly lower following cryoablation compared to MWA (10 [9%] vs 15 [25%]; p = .006). The odds of PAL adjusted for the number of treated tumors per session were 67% lower following cryoablation (odds ratio = 0.33 [95% CI, 0.14-0.82]; p = .02) vs MWA. There was no significant difference in time-to-LTP between ablation modalities (p = .36). Cryoablation of peripheral lung tumors bears a lower risk of PAL compared to MWA when the ablation zone includes the pleura, without adversely affecting time-to-LTP. • The incidence of persistent air leaks after percutaneous ablation of peripheral lung tumors was lower following cryoablation compared to microwave ablation (9% vs 25%; p = .006). • The mean chest tube dwell time was 54% shorter following cryoablation compared to MWA (p = .04). • Local tumor progression did not differ between lung tumors treated with percutaneous cryoablation compared to microwave ablation (p = .36).

Safety and efficacy of percutaneous liver ablation in gynecologic oncology patients with oligometastatic disease (543)

<b>Objectives:</b> To describe the safety and efficacy of percutaneous liver ablation (PA) performed by interventional radiology (IR) in gynecologic oncology patients with liver-dominant oligometastatic disease. <b>Methods:</b> This retrospective cohort included all adult women (>21 years) with a gynecologic malignancy who underwent PA for liverdominant oligometastatic disease from August 2016 to June 2021 at our institution. Age, Charlson comorbidity index (CCI), diagnosis, performance status (PS), prior cancer therapies, technical details of PA, complications, tumor response (complete, stable disease, and progression), and recurrence were evaluated. Descriptive statistics were performed using SPSS v. 26. <b>Results:</b> Thirteen women (median age: 63 [range: 45-77]; median CCI: 8 [range: 6-11]; median PS=0 [range: 0-2]) were included who underwent 21 PAs. Eight patients (61.5%) had recurrent ovarian cancer, while five patients (38.5%) had recurrent endometrial cancer. All patients had liver-dominant, oligometastatic disease with treated tumors ranging from 1.3-4.5cm. The median number of procedures was one (range: 1-4). Three women had multiple procedures. Patients most commonly underwent microwave ablation (<i>n</i>=17/21; 81%) or cryoablation (<i>n</i>=4/21; 19%). Patients had received a median of three anticancer therapies (range: 1-6) prior to PA in addition to primary surgery, with the most common being chemotherapy. About 66.7% of PA procedures (<i>n</i>=14/21) resulted in a complete response to treatment. Three procedures (14.3%) resulted in stable disease. Thus, 17/21 procedures (81%) resulted in local control. Four patients (19%) had disease progression in the liver consisting of new metastases not targeted during the PA ablation procedure. Eight out of 13 patients (61.5%) had no further evidence of liver metastases during their disease or treatment course. There were two major complications: a grade 3 liver abscess requiring drain placement and IV antibiotics and a grade 3 pneumothorax requiring chest tube placement. Two minor complications included a perihepatic hematoma (grade 1) and an asymptomatic pneumothorax (grade 1). PA did not result in any complication with permanent sequelae or grade 4 or 5 adverse events. <b>Conclusions:</b> PA is an effective therapeutic option for gynecologic oncology patients with liver-dominant oligometastatic disease. More than 80% of procedures result in disease control, and two-thirds of procedures achieve a complete response with an acceptable safety profile. This image-guided, minimally-invasive procedure provides an additional tool for managing oligometastatic disease in the liver for appropriately-selected patients. A multi-disciplinary approach is crucial in treating these complex patients.

Randomized Trial of Protective Lung Ventilation in Organ Donors

<h3>Purpose</h3> A protective ventilation strategy that targeted lower tidal volume (TV) and higher positive end expiratory pressure (PEEP) improved lung utilization in European donors but has not been tested in a US donor population. We conducted a randomized trial of an open lung protective ventilator (OLPV) strategy with lower TV, higher PEEP and protocolized recruitment maneuvers (RM) compared to a conventional ventilator (CV) strategy with higher TV and lower PEEP in deceased donors in Northern California. The primary outcome was donor lung utilization for transplantation. <h3>Methods</h3> Donors were eligible for inclusion if greater than 13 years of age and PaO₂/FiO₂ was between 150 and 400. Eligible donors were randomized to volume control ventilation with OLPV [TV 6 ml/kg predicted body weight (PBW), PEEP 10, protocolized RM] or CV [TV 10ml/kg PBW, PEEP 5, RM only after vent disconnect] for the duration of donor management. Lungs were evaluated for transplant potential on standard ventilator settings in both arms [TV 10ml/kg PBW, PEEP 5, FiO₂ 1.0]. <h3>Results</h3> Between July 2018 and December 2019, 153 donors were randomized (74 to OLPV, 79 to CV) and included in the final analysis. The trial stopped early due to changes in donor management at the participating OPO. Donor demographics were similar by treatment arm and compliance with the ventilator protocols was excellent. Median duration of treatment was 49.5 hours and did not differ by arm. Among 153 donors, 33 became lung donors, 16/74 (21.6%) in the OLPV arm and 17/79 (21.5%) in the CV arm, P = 0.99. Change in donor oxygenation as measured by PaO₂/FiO₂ from enrollment to procurement did not differ by treatment arm; median change (IQR) in OLPV versus CV was 53 (-5 to 139) vs 46 (-77 to 117), P = 0.14. Change in static compliance of the respiratory system also did not differ by treatment arm. There was no difference in need for vasopressors between arms. One serious adverse event that was possibly related to the study intervention occurred in the CV arm with expansion of a pneumothorax requiring chest tube placement. Among 29 lung recipients in whom detailed data were available, duration of mechanical ventilation, ICU stay and hospital stay did not differ by donor treatment arm. <h3>Conclusion</h3> An open lung protective ventilator strategy was safe but did not improve donor lung utilization or oxygenation compared to a conventional ventilator strategy in a population of US organ donors. Funding: NIH HL126176

CT fluoroscopy-guided biopsy of pulmonary lesions contacting the interlobar fissure: An analysis of 72 biopsies

PurposeThe purpose of this study was to evaluate retrospectively the safety and diagnostic yield of computed tomography (CT) fluoroscopy-guided biopsy for pulmonary lesions with interlobar fissure contact. Materials and methodsSeventy-two lesions showing interlobar fissure contact (mean size, 15.2 ± 5.3 [SD] mm [range: 5.3–27.0 mm]; mean length of interlobar fissure contact, 8.9 ± 3.6 [SD] mm [range: 2.6–17.5 mm] in 72 patients (33 men, 39 women; mean age, 69.7 ± 10.3 [SD] years; age range: 37–91 years) were evaluated. Multiple variables were assessed to determine the risk factors for diagnostic failure and pneumothorax. Additionally, these variables were compared between these 72 lesions and randomly selected controls (i.e., non-contact lesions). ResultsAll biopsies were technically successful using the transfissural (n = 14) or conventional routes (the route into the lung lobe with the target) with (n = 35) or without (n = 23) possible risk of needle insertion into the interlobar fissure after penetrating the target lesion. Sixty-eight (94.4%) procedures succeeded diagnostically and four (5.6%) failed. There were 27 grade I pneumothorax (37.5%), one (1.4%) grade II bleeding, and five (6.9%) grade IIIa pneumothorax requiring chest tube placement. Groups with and without pneumothorax did not differ significantly in patient-, lesion-, or procedure-related variables. Diagnostic yields and pneumothorax occurrence showed no significant differences between lesions with interlobar fissure contact and controls. ConclusionCT fluoroscopy-guided biopsy of pulmonary lesions with interlobar fissure contact is a safe procedure with a high diagnostic yield. Furthermore, because of potential complications, the transfissural route should be used only when a safer route is not possible.

QUALITY IMPROVEMENT INITIATIVE TO REDUCE THE RATES OF CHEST TUBE FAILURE IN MANAGEMENT OF IATROGENIC PNEUMOTHORAX FOLLOWING CT-GUIDED LUNG BIOPSY

TOPIC: Procedures TYPE: Original Investigations PURPOSE: Iatrogenic pneumothorax following Interventional Radiology (IR) CT-guided transthoracic lung biopsy is a frequent complication with reported rates between 12-45% of which 2-15% will require thoracostomy tube placement. Recently, smaller tube sizes have been made commercially available, but it is unclear if these tubes are as efficacious and safe as larger chest tubes in the management of iatrogenic pneumothorax following lung biopsy. A previous quality assessment project at our institution demonstrated higher failure rates in chest tubes of less than 10 French (Fr). Our objective was to reduce the incidence of chest tube failure when managing iatrogenic pneumothorax after CT-guided lung biopsy via IR. METHODS: After demonstrating a failure rate in smaller bore chest tubes, we met with our interventional radiology colleagues and decided to place 10 Fr chest tubes or larger after iatrogenic pneumothorax following CT-guided lung nodule biopsies. As with our previous quality assessment project, we then retrospectively completed a chart review from January 2018 to March 2021 on all IR CT-guided lung nodules biopsied and identified cases of iatrogenic pneumothorax requiring chest tube placement and those with chest tube failure. We again defined chest tube failure as expanding pneumothorax requiring additional chest tube insertion or tension pneumothorax. RESULTS: In the pre-intervention group, there were a total of 7 chest tubes of less than 10 Fr and 5 chest tube failures in the 78 cases that required chest tube insertion (9% & 6% respectively). In the post-intervention group, no catheters smaller than 10 Fr were placed and there were no chest tube failures in the 54 cases that required chest tube insertion (0%); 6 (11%) individuals had a 10 Fr, 7 (13%) had a 12 Fr, and the remaining 41 (76%) had a 14 Fr chest tube inserted. The absence of chest tubes smaller than 10 Fr in the post-intervention group was statistically significant (p=0.02). There were no failures in the post-intervention group compared to 6% in the pre-intervention group (p=0.06). CONCLUSIONS: This analysis suggests a reduction in complication rates with the use of chest tubes 10 Fr or larger in management of iatrogenic pneumothorax from CT guided lung biopsy. This quality improvement project has demonstrated a significant change in practice habits with a trend toward reduced failure rates. A larger analysis will be needed to examine the statistical significance of reduced complications after intervention. CLINICAL IMPLICATIONS: This study demonstrated a change in practice habits toward larger sized chest tubes in the management of iatrogenic pneumothorax from CT-guided lung nodule biopsy. A larger analysis will be needed to demonstrate optimal chest tube size. DISCLOSURES: No relevant relationships by hassan Al-Balas, source=Web Response No relevant relationships by Stephen Bujarski, source=Web Response No relevant relationships by Sunjay Devarajan, source=Web Response No relevant relationships by James Ramey, source=Web Response No relevant relationships by Sarah Tuthill, source=Web Response

September 2021 Pulmonary Case of the Month: A 45­-Year-Old Woman with Multiple Lung Cysts

No abstract available. Article truncated after the first 150 words. History of Present Illness A 45-year-old woman presented with increasing dyspnea on exertion and a history of recurrent pneumothoraces. In March 2018 she had laparoscopic ovarian cyst removal and noted some subsequent shortness of breath. In August 2018 she developed a right pneumothorax requiring chest tube placement. In September 2018 she had recurrent right pneumothorax and had video-assisted thoracoscopic surgery (VATS) with a right pleurodesis. The operative note from the outside VATS indicates a RUL bleb was removed and a wedge biopsy was done from posterior segment of the RUL. Pathology from the wedge biopsy reported “minimal emphysematous disease without other diagnostic abnormality”. She continued to be short of breath after the operation. PMH, SH, and FH • In 1975 she reportedly had pulmonary tuberculosis. • In 2018 the pneumothoraces, pleurodesis and the right ovarian cyst resection noted above. She is a never smoker and has no family history…

Diagnostic accuracy and complication rates of percutaneous CT-guided coaxial needle biopsy of pulmonary lesions.

The aim of this retrospective study was to evaluate and compare diagnostic accuracy and complication rates of percutaneous computed tomography (CT)-guided biopsies of pulmonary lesions 10-35 mm, 35-50 mm, and >50 mm, using the coaxial biopsy technique. Over a 4-year period, 235 lung biopsies were performed using the coaxial biopsy technique with 18G semi-automated true-cut needle. There were 163 (69.4%) male and 72 (30.6%) female patients, with a mean age of 64.01±9.18 years (18-85 years). The mean lesion size was 59.6±29.3 mm. The lesions were stratified into three groups according to size: lesions <35 mm (n=42, 17.9%), lesions 35-50 mm (n=53, 22.5%), and lesions >50 mm (n=140, 59.6%). Diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for all biopsies, and for each group separately, as well as the incidence of complications. The overall diagnostic accuracy was 95.4%, with 95.52% sensitivity, 100% specificity, 100% PPV, and 47.37% NPV. For lesions <35 mm, diagnostic accuracy, sensitivity, and PPV were 100%. The lowest diagnostic accuracy was 93.9% in lesions >50 mm, with 93.65% sensitivity, 100% specificity, 100% PPV, and 42.86% NPV. An adequate sample was obtained in 219 core biopsies (93.2%), while 16 biopsies (6.8%) were nondiagnostic due to necrosis (4.25%) and insufficient biopsy material (2.55%). The most frequent complication was minor pneumothorax, which was seen at a rate of 19.1%; pneumothorax requiring chest tube placement occurred in 3 patients (1.3%). Diagnostic accuracy decreased with increasing lesion size. On the other hand, complication rates were higher in smaller lesions, more distanced from the pleura.

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.

Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis

BackgroundMore than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH. Materials and methodsWe retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients’ satisfaction and side effects were also evaluated. ResultsOf the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group. ConclusionsCompared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.

Tissue Adequacy and Safety of Percutaneous Transthoracic Needle Biopsy for Molecular Analysis in Non-Small Cell Lung Cancer: A Systematic Review and Meta-analysis

ObjectiveWe conducted a systematic review and meta-analysis of the tissue adequacy and complication rates of percutaneous transthoracic needle biopsy (PTNB) for molecular analysis in patients with non-small cell lung cancer (NSCLC).Materials and MethodsWe performed a literature search of the OVID-MEDLINE and Embase databases to identify original studies on the tissue adequacy and complication rates of PTNB for molecular analysis in patients with NSCLC published between January 2005 and January 2020. Inverse variance and random-effects models were used to evaluate and acquire meta-analytic estimates of the outcomes. To explore heterogeneity across the studies, univariable and multivariable meta-regression analyses were performed.ResultsA total of 21 studies with 2232 biopsies (initial biopsy, 8 studies; rebiopsy after therapy, 13 studies) were included. The pooled rates of tissue adequacy and complications were 89.3% (95% confidence interval [CI]: 85.6%–92.6%; I2 = 0.81) and 17.3% (95% CI: 12.1%–23.1%; I2 = 0.89), respectively. These rates were 93.5% and 22.2% for the initial biopsies and 86.2% and 16.8% for the rebiopsies, respectively. Severe complications, including pneumothorax requiring chest tube placement and massive hemoptysis, occurred in 0.7% of the cases (95% CI: 0%–2.2%; I2 = 0.67). Multivariable meta-regression analysis showed that the tissue adequacy rate was not significantly lower in studies on rebiopsies (p = 0.058). The complication rate was significantly higher in studies that preferentially included older adults (p = 0.001).ConclusionPTNB demonstrated an average tissue adequacy rate of 89.3% for molecular analysis in patients with NSCLC, with a complication rate of 17.3%. PTNB is a generally safe and effective diagnostic procedure for obtaining tissue samples for molecular analysis in NSCLC. Rebiopsy may be performed actively with an acceptable risk of complications if clinically required.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up

Introduction Malignant peritoneal mesothelioma (MPM) is a lethal cancer, with approximately 2% of diagnoses occurring in patients less than 40 years of age. The purpose of this study is to report the only long-term follow up and survival of pediatric patients with MPM after multi-modality therapy including cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Methods We retrospectively investigated a prospectively maintained database including patients <21 years old who underwent CRS and HIPEC from 1994 through 2014. Follow-up information was available through 2019 and is included in this report. Results Seven young patients underwent CRS and HIPEC. Final histology was epithelioid in all patients. Three patients had received neo-adjuvant systemic chemotherapy. At the time of the operation Peritoneal Cancer Index ranged from 6 to 25. Completeness of cytoreduction score after CRS was 0 in 4 patients, 1 in two patients, and 2 in one patient. Post-operative complications included acute kidney injury (n = 1), hyperbilirubinemia (n = 1), bilateral pleural effusions (n = 1) and pneumothorax requiring chest tube placement (n = 1). At last available follow-up, 71% of patients (n = 5) were alive with minimal or no evaluable disease. The remaining two patients had passed away from their disease at 14 and 26 months, respectively, following CRS and HIPEC. Overall survival ranged between 14 and 281 months. Conclusion Our surgical experience shows that CRS and HIPEC is a feasible and safe treatment option in pediatric patients, potentially improving overall survival.

3:45 PM Abstract No. 151 Factors affecting adverse events in percutaneous lung biopsy for lesions contacting to pleura

To retrospectively evaluate factors affecting adverse events in percutaneous lung biopsy for lesions contacting to pleura. From August 2016 to July 2019, 132 consecutive patients with lung tumors measuring 0.6 to 15.0 cm (median, 3.1 cm) and contacting to the pleura underwent percutaneous needle biopsy. There were 87 males and 45 females with their median age of 73-years-old (range, 32–91 years-old). Biopsy was performed under CT fluoroscopic guidance using an 18-gauge end-cut needle. Factors affecting adverse events (AEs) were evaluated by uni- and multivariate analysis including variables such as patient demography, tumor backgrounds, emphysema, puncture number, and needle trajectory (trans-lung or direct puncture). Diagnosis was malignant in 104 patients (78.8%), and benign in 28 patients (21.2%). As a major AEs, pneumothorax requiring chest tube placement developed in 5 patients (3.8%, 5/132), and bacterial or tumor pleural dissemination in 6 patients (2 mycobacterial tuberculosis and 4 carcinoma dissemination) (4.3%, 6/132). Bacterial dissemination developed until 2 weeks after biopsy, and tumor dissemination until 7.9 months (median, 6.2 months). Trans-lung approach was found to be a significant factor for the former AE in both uni- (P = 0.004) and multivariate analysis (P = 0.004). Although there was no significant statistic difference found, the latter AE was only found in patients with direct puncture biopsy {7.0%, 6/86, P = 0.09 as compared with patients with trans-lung biopsy (0%, 0/46)}. Although direct puncture of the target lesion significantly reduces the major pneumothorax rate, it might be associated with a higher risk of tumor or bacterial pleural dissemination in lung lesions contacting to the pleura.

Computed tomography fluoroscopy-guided cutting needle biopsy of pulmonary nodules ≤8 mm: A retrospective study including 117 nodules

PurposeTo evaluate the diagnostic yield and safety of computed tomography (CT) fluoroscopy-guided cutting needle biopsy (CNB) for pulmonary nodules ≤ 8 mm. MethodData of CT fluoroscopy-guided CNB for pulmonary nodules ≤ 8 mm performed in a single institution were retrospectively analyzed. One hundred and seventeen biopsy procedures for 117 pulmonary nodules (mean size, 7.4 mm) in 114 patients were included in the study. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall diagnostic accuracy were calculated. Univariate analyses were performed to elucidate the risk factors for diagnostic failure (i.e., non-diagnostic, false-positive, or false-negative results). Complications were graded per the Clavien-Dindo Classification. ResultsOne (0.9 %) non-diagnostic biopsy result was found. The diagnostic accuracy was 95.7 % (112/117). The sensitivity and specificity were 95.8 % (91/95) and 95.5 % (21/22), respectively. PPV and NPV were 98.9 % (91/92) and 87.5 % (21/24), respectively. Univariate analyses showed that nodules in the lower lobes (p = 0.006) and prone biopsy position (p = 0.021) were the significant risk factors for diagnostic failure. The incidence of pneumothorax requiring chest tube placement (Grade IIIa) was 6.8 % (8/117). No Grade IIIb or higher complications were observed. ConclusionCT fluoroscopy-guided CNB for pulmonary nodules ≤ 8 mm showed a high diagnostic yield without severe complications.

Clinical Outcomes and Techniques for Radiofrequency Ablation of Lung Tumors Smaller than 1 cm.

Purpose: To evaluate the outcomes of radiofrequency ablation (RFA) on lung tumors < 1 cm in maximum diameter. Materials and Methods: Twenty-eight patients (12 male, 16 female; median age, 59 years; mean age, 58 ± 16 years; range, 16-78 years) who underwent RFA for lung tumors < 1 cm in diameter between November 2009 and September 2018 were included in this study. Thirty-five tumors (median size, 8.4 mm; mean size, 7.7 ± 1.9 mm; range, 3.6-9.9 mm) were treated with 33 sessions of RFA. Technique efficacy and safety were subsequently evaluated. Initial and secondary technique efficacy were defined as complete ablation without residual tumor or local tumor progression after initial and repeat RFA, respectively. Safety was evaluated according to the Common Terminology Criteria for Adverse Events, version 5.0. Results: Residual tumor remained for 1 tumor (3%, 1/35) and local tumor progression was found in 2 tumors (6%, 2/35). Initial technique efficacy rate was therefore 91% (32/35). The remaining 3 tumors were treated by repeat RFA (secondary technique efficacy rate: 100%, 35/35). Initial technique efficacy rate was significantly lower for tumors treated with starting energy ≥ 20 W (P = 0.02) and showing a quick increase in tissue impedance (P = 0.01). There were 4 grade 2 adverse events (12%, 4/33) comprising pneumothorax requiring chest tube placement, and 14 grade 1 adverse events comprising self-limiting pneumothorax (36%, 12/33) and pulmonary parenchymal hemorrhage (6%, 2/33). Conclusion: To achieve good outcomes for lung tumors < 1 cm, radiofrequency energy should be started at < 20 W. Application of manual mode ablation might be considered when delivery of power cannot be continued due to a quick increase in tissue impedance.

Initial Clinical Experience with Swiss LithoClast Trilogy During Percutaneous Nephrolithotomy.

Introduction and Objective: Current available lithotrites have clinical stone clearance rates averaging 24 to 32 mm2/minute. The objective of this study was to critically evaluate the initial experience with the Swiss LithoClast® Trilogy lithotrite during percutaneous nephrolithotomy (PCNL). Methods: We prospectively enrolled patients with a minimum of 15 mm of stone in axial diameter at three locations (Indiana University, University of California Davis, and University of California San Diego) scheduled to undergo PCNL for nephrolithiasis over a 60-day trial period. We assessed objective measures of stone clearance time, stone clearance rate, device malfunction, stone-free rate, and complications. Each surgeon also evaluated subjective parameters from each case related to the use of Trilogy on a 1 to 10 scale (10 = extremely effective), and compared it with their usual lithotrite on a 1 to 5 scale (5 = much better). Results: We included 43 patients and had 7 bilateral (16.3%) cases, for a total of 50 renal units. One case was a mini-PCNL. Two cases experienced device malfunctions requiring troubleshooting but no transition to another lithotrite. The mean stone clearance rate was 68.9 mm2/minute. The stone-free rate on postoperative imaging was 67.6% (25 of 37 patients with available imaging). The lowest subjective rating was the ergonomic score of 6.7, and the highest subjective rating was the ease of managing settings score of 9.2. The surgeon impressions of ultrasound (7.3), ballistics (8.1), combination of ultrasound and ballistics (8.7), and suction (8.4) were high. One patient experienced an intraoperative renal pelvis perforation, one patient required a blood transfusion, one patient had a pneumothorax requiring chest tube placement, and one patient had a renal artery pseudoaneurysm requiring endovascular embolization. Conclusions: This multi-institutional study evaluated a new and efficient combination lithotrite that was perceived by surgeons to be highly satisfactory, with an excellent safety and durability profile.

UNIQUE CASE OF ENDOBRONCHIAL VALVE IN TB BRONCHOPLEURAL FISTULA

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: A bronchopleural fistula (BPF) is a pathological connection between bronchial tree and the pleural space. BPF is a well-known complication of pulmonary tuberculosis (PTB). Endobronchial valve (EbV) are conventionally used to treat persistent air leaks (PAL) in the setting of non-surgical bronchopleural fistula. EbV are not routinely used in BPF secondary to active PTB. We describe a unique case where EbV was used to treat BPF secondary to active cavitatory pulmonary tuberculosis CASE PRESENTATION: A 30-year-old Spanish-speaking female, emigrated from Honduras 5 years ago presented to the emergency department with worsening productive cough and anorexia for two months. On admission patient was noted to be in respiratory distress and saturating 88% on room air. She once cachectic had poor inspiratory effort and bilateral rhonchorous breath sounds. Chest imaging was significant for bilateral upper lobe thick walled cavitatory lesions. Mycobacterium tuberculosis without rifampin resistance was detected, and patient was started on antituberculous therapy. On day 7 patient developed acute respiratory distress secondary to large right-side pneumothorax requiring chest tube placement. Patient required mechanical ventilation for hypercarbic respiratory failure, felt secondary to significant air leak. Bronchoscopy with balloon occlusion was performed, BPF with air leak was identified in right upper lobe with complete disappearance of air leak on occlusion of all three segments of right upper lobe (RUL). On day14 patient underwent endobronchial valve placement with complete occlusion of RUL. The hypercapnia, hypoxia improved, and patient stabilized clinically. Unfortunately, patient had complicated ICU course with failure to thrive and venous thromboembolism. On day 35 family requested terminal extubation and comfort care. DISCUSSION: There is very limited literature on utility and safety of EbV in patients with BPF and PAL secondary to active cavitatory PTB. Since their first description in 2005 by Snell (1), EbV have been in use for more than a decade now. The main indication of EbV is non-surgical management of BPF and PAL. PAL have been associated with significant morbidity, mortality and prolonged hospital stay(2). There is recent literature in multidrug resistant tuberculosis where EbV was used safely to treat cavernous tuberculosis with improved cavity closure and bacteriological conversion (3). In our patient the main reason for EbV placement was to improve minute ventilation and hypercapnia secondary to PAL. Endobronchial valve placement stabilized the clinical status in our patient without any associated adverse events. CONCLUSIONS: We need more literature and randomized controlled trials to evaluate safety and long-term complications of EbV in pulmonary tuberculosis associated BPF. Our case highlights that EbV could be a safe option for BPF in patients with active pulmonary tuberculosis. Reference #1: Snell, G., Holsworth, L., Fowler, S., Eriksson, L., Reed, A., Daniels, F.. (2005) Occlusion of a broncho-cutaneous fistula with endobronchial one-way valves. Ann Thorac Surg 80: 1930–1932. Reference #2: Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128:3955–65. Reference #3: Denis Krasnov, Yana Petrova, Sergei Skluev, Irina Felker, Vladimir Krasnov, Nikolay Grischenko. Endobronchial valve in complex treatment of patients with destructive pulmonary TB/HIV co-infection.European Respiratory Journal 2016 48: PA775; https://doi.org/10.1183/13993003.congress-2016.PA775 DISCLOSURES: No relevant relationships by Sean Dikdan, source=Web Response No relevant relationships by Boyd Hehn, source=Web Response No relevant relationships by MRINALINI VENKATA SUBRAMANI, source=Web Response