Transbronchial Aspiration Research Articles

P1.03-031 Gynecological Malignancies and Imaging Patterns. An Interesting Case Report and Literature Surveillance

Gynecologic malignancies are a heterogeneous group of common neoplasms in women. Thoracic abnormal findings exhibit various imaging patterns and are usually associated with locally invasive primary neoplasms with intra-abdominal spread. It is not rare, thoracic involvement occurring years post first diagnosis or as an isolated finding in patients without evidence of intra-abdominal neoplastic involvement. Thoracic metastases from gynecologic carcinomas typically manifest as pulmonary nodules and lymphadenopathy. Ovarian cancer often presents small pleural effusions and subtle pleural nodules whereas metastatic lung lesions, lymph nodes, and pleura are thought to present calcification or mimicking granulomatous disease. Metastases from fallopian tube carcinomas have imaging features identical to ovarian cancers. Most cervical cancers are of squamous histology, and while solid pulmonary metastases are more common, the cavitary metastatic lesions occur more often. Metastatic choriocarcinoma to lung characteristically exhibits solid pulmonary nodules. There are also reported pulmonary metastases from gynecologic malignancies with characteristic features such as cavitation (as awaited in squamous cell cervical cancer) and the “halo” sign (in hemorrhagic metastatic choriocarcinoma lesions) at computed tomography. We report a case with a mass in left paratracheal area invading the lung hinting primary lung cancer. The female patient, 36 years old with previous medical history of resected cervical cancer, underwent endoscopy with aim to have transbronchial aspiration but unfortunately the samples taken were consistent of inflammation infiltration. Thus she underwent thoracotomy due to high SUV (12) uptake points at PET CT with intention to exclude lung cancer. She had the mass removed with all the surrounding lung parenchyma but unfortunately the final histologic report documented metastatic infiltration from cervical cancer in competence with her previous medical history 6 years ago (Ib stage with radiotherapy only treated in adjuvant basis). She recovered well and was initiated chemotherapy for the gynecological malignancy stated She is now 2 years later alive, with no residual disease The basic is that malignancies are always suspected to be primary originated but the medical previous history should not be ignored, even the imaging tests tend to resemble to other entities. Therefore, radiologists should consider the presence of locoregional disease in combination with elevated tumor marker levels when interpreting imaging studies and all previous medical history of the patient’s malignancy to exclude metastatic disease.

Complete diagnostic work-up and prognosis prediction for cardiac sarcoidosis with atrioventricular block: Importance of cardiac magnetic resonance image (MRI) and positron emission tomography (PET)

A 56-year old woman complained of chest discomfort and dyspnea on exertion for one month. She had been diagnosed as mediastinal lymph node sarcoidosis through endobronchial ultrasonography guided transbronchial lymph node aspiration. Electrocardiogram at presentation demonstrated sequential first and second degree 2:1 atrioventricular block. Further imaging study with gadolinium enhanced cardiac magnetic resonance image and 18F-fluoro-2-deoxyglucose positron emission tomography confirmed the diagnosis of sarcoidosis involving heart. Intravenous steroid therapy without pacemaker implantation improved conduction abnormality to normal sinus rhythm. Follow-up 18F-FDG-PET demonstrated full improvement of cardiac and extracardiac lesion with maintenance oral steroid therapy for 5-month.

Chronic Necrotizing Aspergillosis

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Chronic Necrotizing Aspergillosis (CNA) is a term used to define an indolent, locally invasive form of pulmonary aspergillosis that often presents in the upper lobes among patients with either preexisting lung disease or immune suppression. It is usually characterized by chest pain, cough, sputum production, hemoptysis, and fatigue. Slow progression of disease is best characterized on CT scan. CASE PRESENTATION: A 58-year-old woman with ulcerative colitis (UC) on infliximab, initiated five months previous, and no history of lung disease presented with diarrhea, fatigue, and weight loss of a few weeks duration. Though she denied pulmonary complaints, save a chronic dry cough, CT of the abdomen revealed new cavitary lesions of the right lower lobe that were not present on previous CT. Her serum beta-d-glucan was >500 pg/mL. A bronchoaveolar lavage (BAL) galactomannan returned at 10.65 ng/mL. Serum antineutrophil cytoplasmic antibody titers, as well as histoplasma antigen, cultures for acid fast bacilli, viruses, and Legionella from her BAL returned negative. Fungal cultures grew Aspergillus niger. She was treated with voriconazole. CT at her three month follow up showed near-complete resolution of her cavitary lesions. DISCUSSION: Due to the nebulous nature of the disease, the diagnosis of CNA is often difficult. BAL, transbronchial, and percutaneous aspirates often fail to grow fungi. A diagnosis generally requires a combination of Aspergillus serology, radiographic evidence, and constitutional symptoms with exclusion of other common causes of cavitary lung lesions. BAL galactomannan is more specific for the diagnosis of pulmonary aspergillosis than a serum sample, especially if used at a higher cut off than the FDA standard. In a meta-analysis, a 1 ng/mL cutoff of galactomannan in fluid from a BAL yielded a sensitivity and specificity of 85% and 94% respectively, with a positive likelihood ratio of 14.29. CONCLUSIONS: Given the slowly progressive nature of CNA, diagnosis at an early stage can be difficult without a high degree of clinical suspicion. The initial nonspecific symptoms of weight loss and fatigue were initially thought secondary to her UC. It is fortunate that the CT abdomen detected the atypical presentation of lower lobe pulmonary cavities preventing treatment with high-dose steroids combined with continuing cycles of infliximab, which would have lead to disseminated aspergillosis and significant morbidity or death. It is essential to have a high clinical suspicion for opportunistic infections, such as CNA, in immunosuppressed patients as they are both at increased risk and more likely to manifest with an atypical presentation. Reference #1: Kousha, M., R. Tadi, and A.O. Soubani, Pulmonary aspergillosis: a clinical review. Eur Respir Rev, 2011. 20(121): p. 156-74. Reference #2: Guo, Y.L., et al., Accuracy of BAL galactomannan in diagnosing invasive aspergillosis: a bivariate metaanalysis and systematic review. Chest, 2010. 138(4): p. 817-24. DISCLOSURE: The following authors have nothing to disclose: Jeremy Gentile, Anne Chen No Product/Research Disclosure Information

原発性肺癌における経気管支針吸引細胞診 (Transbronchial Aspiration Cytology : TBAC) による縦隔リンパ節及び肺門リンパ節転移の術前質的診断の検討

原発性肺癌における経気管支針吸引細胞診 (Transbronchial Aspiration Cytology : TBAC) による縦隔リンパ節及び肺門リンパ節転移の術前質的診断の検討

Cell block samples from endobronchial ultrasound transbronchial needle aspiration provide sufficient material for ancillary testing in lung cancer-a quaternary referral centre experience.

Rapid on site examination (ROSE) is encouraged at endobronchial ultrasound transbronchial needles aspiration (EBUS-TBNA) to improve diagnostic yield. Due to new therapeutic options in lung cancer, it is not sufficient to merely distinguish between non-small cell lung carcinoma (NSCLC) and small cell lung carcinoma (SCLC). Immunohistochemistry (IHC) distinction is now standard practice, as well as additional molecular testing where clinically indicated. We investigated the diagnostic yield of on-site smears vs. cell block and the provision of cellular material for ancillary testing at our centre. A retrospective audit of all EBUS-TBNA procedures performed until July 2012 was undertaken. Diagnostic yield on smears versus cell block was recorded. Cell blocks were reviewed by an experienced pathologist to determine diagnostic accuracy and whether IHC and molecular testing were possible. In total, 234 procedures were recorded with 101 (43.2%) malignant cases, 107 (45.7%) benign cases and an initial 26/234 (11.1%) insufficient for diagnosis of which 11/234 (4.7%) were false negatives for malignancy after further follow up. The average number of passes was 4.5. For malignancies, smear diagnosis was possible in 95% (96/101) of cases and cell block diagnosis in 93.5% (87/93) of cases. There was sufficient material for IHC in 97.7% (85/87) of malignant cases. In 79.3% (69/87) of NSCLCs molecular testing for epidermal growth factor receptor (EGFR) mutation analysis was theoretically possible on samples obtained. Cell blocks are not inferior to smears for diagnostic accuracy and provide sufficient samples for histology. However, ROSE assists the physician on how best to manage samples for ancillary testing.

Comparison of 19-gauge eXcelon and WANG MW-319 transbronchial aspiration needles.

Conventional transbronchial needle aspiration (TBNA) using 19-gauge needles can obtain larger histological specimens for hilar-mediastinal diagnosis. A new 19-gauge eXcelon needle was introduced in Taiwan in July 2012. We prospectively enrolled patients with hilar-mediastinal lesions and pathology results of suspected benign origin or lymphoproliferative processes, to perform TBNA using a 19-gauge eXcelon needle, between July 2012 and December 2012. The results were compared with historical control of TBNA using a WANG MW-319 needle between January 2011 and June 2012. The procedure was performed by the same pulmonologist, and rapid on-site cytologic evaluation was used. The 19-gauge eXcelon needle was used in nine patients with 15 lymph nodes aspirated, with a mean diameter of 23.3 ± 10.7 mm. The mean number of needle passes was 2.7 ± 1.4, with a diagnostic accuracy of 77.8%. The MW-319 needle was used in 12 patients with 18 lymph nodes aspirated, with a mean diameter of 21.3 ± 5.7 mm. The mean number of needle passes was 2.2 ± 0.4, with a diagnostic accuracy of 75.0%. Neither technical nor major clinical complications were noted in either group. We concluded that the 19-gauge eXcelon needle was as safe and effective as the MW-319 needle. A more adequate specimen could be obtained and fewer needle passes were required with the MW-319 needle, although the difference did not reach significance.

Transbronchial Catheter Aspiration and Transbronchial Needle Aspiration in the Diagnostic Workup of Peripheral Lung Lesions.

Increasingly frequent, it is clinically indicated to obtain tissue from a peripheral lung lesion (PLL) to yield a pathological diagnosis. The aim of the present study was to evaluate the diagnostic sensitivity of transbronchial needle aspiration (TBNA) and transbronchial catheter aspiration (TBCA) in addition to transbronchial forceps biopsy (TBB) at conventional bronchoscopy. Eligible patients showing a PLL on computed tomography scans were included in the study. In all patients, following TBB, TBNA and TBCA were employed in randomised order under fluoroscopy. Fourty-eight patients were enrolled, of whom 46 patients with 46 PLLs were included in the analysis. The mean ± SD diameter of the PLL was 27.0 ± 13.3 mm. The overall sensitivity for all modalities was 69.6%; PLL ≤20 or >20 and ≤30 mm in diameter showed a sensitivity of 60.0 and 72.2%, respectively. For malignant PLL (n = 33), the combined sensitivity of TBNA + TBCA versus TBB was significantly higher (63.6 vs. 33.3%, p ≤ 0.05), and could not further be improved by TBB. For benign PLL, TBB was superior to TBNA + TBCA (76.9 vs. 38.5%). TBB, TBNA and TBCA are complementary to one another. Combining the three techniques, even allows transbronchial specimen collection of PLL <3 cm in diameter at conventional bronchoscopy.

Evaluation of Mediastinal Lymph Nodes in Sarcoidosis, Sarcoid Reaction, and Malignant Lymph Nodes Using CT and FDG-PET/CT.

The aim of this study was to analyze the clinical, computed tomography (CT), and positron emission tomography (PET) findings of sarcoidosis, sarcoid reaction, and malignant lymph nodes (LNs) to the results of transbronchial LN aspiration and biopsy (TBNA).The TBNA results of mediastinal and hilar LNs of 152 patients in our hospital from July 2008 to March 2013 were retrospectively reviewed. Two independent radiologists measured the size and attenuation of LNs on CT and assessed the probability of the 3 categories: sarcoidosis (n = 36), sarcoid reaction (n = 25), or malignant LNs (n = 91). The total volume and attenuation of LNs were measured using Image J (NIH). The median maximum standardized uptake value (maxSUV) of the 3 mediastinal and hilar LNs on PET/CT was obtained.There was no significantly different CT finding between sarcoidosis and sarcoid reaction. Multivariate analysis showed that the age, total volume of LNs, and number of enlarged LNs significantly differed between sarcoid reaction and malignant LNs. Sarcoid reaction tends to be occurred in young patients (P = 0.007), the total volume of LNs was smaller (P = 0.04) than that of malignant LNs, and there were significantly more LNs >1 cm (P = 0.005). The median maxSUV of the 3 highest SUVs of the LNs did not significantly differ between the 3 entities.

A Case of Synchronous Multiple Lung Cancer Diagnosed by Transbronchial Aspiration Biopsies of the Right #11i Lymph Node and Transbronchial Biopsies of a Left B^3c Tumor

A Case of Synchronous Multiple Lung Cancer Diagnosed by Transbronchial Aspiration Biopsies of the Right #11i Lymph Node and Transbronchial Biopsies of a Left B^3c Tumor

Bronchoscopic training and practice in australia and New Zealand is inconsistent with published society guidelines.

The Australasian practice and training in bronchoscopy has not previously been reported and procedure volumes among Australasian respiratory consultants and trainees are unknown. We surveyed the current practice of flexible bronchoscopy in Australasia and determined adherence to published recommendations. Adult physician and trainee members of the Thoracic Society of Australia New Zealand (TSANZ) were e-mailed a web-link to an online survey. Survey responses were benchmarked against TSANZ recommendations. The response rate was 42% overall and 78% among trainees. Forty-nine percent of consultants performed less than the recommended 50 procedures per year. Sixty percent of trainees were unlikely to achieve the recommended 200 supervised bronchoscopies during training. Less than 20% of trainees received adequate training in advanced bronchoscopic techniques such as transbronchial lymph node aspiration. The majority of physicians performing such advanced techniques were not performing sufficient numbers to satisfy published recommendations. A large proportion of Australasian bronchoscopists do not meet "numbers-based" recommendations. This empirical data support the 2012 TSANZ interventional guidelines' call to move beyond procedural volume as the sole determinant of technical competence. There is an urgent need to explore alternative means of developing and defining bronchoscopic proficiency.

EBUS-transbronchial fine needle aspiration cytology of lymph node in patient with pulmonary cryptococcosis: a case report

Cryptococcal infection in humans most commonly appears as a disease of the central nervous system, and also causes disease of lung, bone, skin and rarely lymph nodes (LNs). We present a fine needle aspiration cytology of cryptococcal lymphadenitis in a 39-year-old female with a mass-like lesion in the lung and multiple LN enlargements. The patient was diagnosed as cryptococcosis in supraclavicular LN biopsy, and the diagnosis was reconfirmed by following endobronchial ultrasound (EBUS) transbronchial LN aspiration cytology. Her chest computed tomography (CT) scan showed the patchy consolidation about 3cm in diameter in the right lower lobe of the lung and multiple LN enlargements in both supraclavicular and mediastinal area. She had undergone US-guided aspiration biopsy of the supraclavicular LN and it turned out cryptococcal infection. Fiber optic bronchoscopy revealed no endobronchial lesion, but EBUS transbronchial LN aspiration cytology on enlarged mediastinal LN confirmed the yeast, consistent with Cryptococcus. Then, the patient responded well to the parenteral antifungal therapy. This is a rare case in a patient with pulmonary cryptococcosis and involvement of the supraclavicular LN.

Late-stage Use of Low-dose Corticosteroids Aid Recovery of Severe H1N1 Viral Pneumonia

Abstract The role of corticosteroids in the management of severely ill patients with influenza A (H1N1) viral infection is unclear and controversial. Two critically ill cases with influenza A (H1N1) infections complicated with organizing pneumonia (OP) in 2011 successfully treated with low dose corticosteroids were reported here. After initial clinical improvement, the condition of both patients aggravated 20-23 days after the onset of illness. Chest X-ray and computed tomographies (CT) showed an increment of lung infiltrates. Cultures of blood, pleural fluid and transbronchial aspirate were negative for bacteria and fungi. Organizing pneumonia was diagnosed clinically and both patients were successfully treated with low-dose corticosteroids. Low-dose corticosteroids initiated during convalescence may be beneficial for severe swine-origin influenza A H1N1 pandemic 2009 virus (S-OIV) infections.

S22 The Effect Of Needle Gauge On Characterisation Of Histology Samples At Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA)

IntroductionEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal node sampling technique used for lung cancer staging and diagnosis of malignant and benign lesions. Sampling is done with...

“The petals and thorns” of ROSE (rapid on‐site evaluation)

In this article, the authors discuss the advantages (“petals”) and disadvantages (“thorns”) of rapid on‐site evaluation (ROSE) performed for minimally invasive procedures such as computed tomography (CT)‐guided and endoscopic‐guided fine‐needle aspiration with a focus on deep‐seated lymph nodes. One of the main advantages is increased diagnostic accuracy. Disadvantages include the need for highly trained professionals and a lack of adequate reimbursement.

Roles of EBUS-TBNA in non-small cell lung cancer.

Endobronchial ultrasound-guided transbronchial aspiration (EBUS-TBNA) has the potential to improve nodal diagnosis and staging in non-small cell lung cancer (NSCLC). This study was performed to explore the roles of EBUS-TBNA in NSCLC. From 2007 to 2009, 164 NSCLC patients were examined by EBUS-TBNA. The patients were divided into a diagnosis group (n = 64) and a staging group (n = 100). For all patients, the diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 92.3%, 100%, 100%, 88.2%, and 95.1%, respectively. In the diagnosis group, the diagnostic sensitivity, specificity, PPV, NPV, and accuracy were 89.7%, 100%, 100%, 86.2%, and 94.4%, respectively. Thirty five patients (54.7%) positive for malignancy as determined by EBUS-TBNA avoided surgery. In the staging group, the diagnostic sensitivity, specificity, PPV, NPV, accuracy, and surgery avoidance rate were 93.8%, 100%, 100%, 89.7%, 96%, and 61%, respectively. EBUS-TBNA is a feasible and effective tool for NSCLC diagnosis and staging that also reduces surgery rates. Patients with NSCLC should initially undergo the less invasive EBUS-TBNA procedure for diagnosis and staging of NSCLC. However, negative findings must be confirmed by surgery.

P19 GeneXpert MTB.Rif assay improves the diagnostic yield of EBUS-TBNA in smear-negative intra-thoracic tuberculous lymphadenopathy

Introduction and ObjectivesTuberculosis notifications in the UK continue to rise and the diagnosis of both disease and drug resistance can be challenging. Endobronchial ultrasound (EBUS) and EBUS-guided transbronchial nodal aspirates...

Treatment of Bronchogenic Cyst Surgical Versus Transbronchial Drainage?

Bronchogenic cysts are congenital abnormalities of the bronchial tree and present with a wide range of clinical and radiologic manifestations. Asymptomatic bronchogenic cysts may become symptomatic and produce complications with passage of time. Therefore, removal of the cyst is advised. We present a case that was diagnosed as asymptomatic bronchogenic cyst. Therapeutic drainage of cystic fluid through a bronchoscope was attempted, which led to rupture of the cyst and leakage of cystic fluid into the mediastinum and pleural space, leading to complications. Finally, thoracotomy was performed, and the bronchogenic cyst was surgically removed. After surgery, the patient recovered completely. It has been concluded that transbronchial aspiration of cystic fluid may be an ineffective procedure and may lead to complications and require surgical intervention.

Diagnostic usefulness of transbronchial aspiration and bronchial lavage for pulmonary tuberculosis

Fiberoptic bronchoscopy is a well established methods as a useful tool in the diagnosis of pulmonary tuberculosis with smear negative cases. In order to get the early and definite diagnosis of pulmonary tuberculosis, we performed transbronchial aspiration and bronchial lavage by a fiberoptic bronchoscope in 97 patients. All patients (1) were clinically suspected of having active tuberculosis; (2) showed abnormal chest roentgenogram suggesting tuberculosis; (3) showed negative sputum smears of acid-fast bacilli, or had no sputum. The results of the study were summarized as follows: 1) Final diagnosis of study subjects were 90 patients of active pulmonary tuberculosis, and 7 patients of pulmonary atypical mycobacteriosis. 2) Sputum culture of acid-fast bacilli was positive in 22 out of 90 patients with active pulmonary tuberculosis. 3) Smear and culture examination of acid-fast bacilli of transbronchial aspirates were positive in 9 and 28, respectively out of 90 patients. 4) Smear and culture examination of acid-fast bacilli of bronchial lavage were positive in 12 and 39, respectively out of 90 patients. 5) A rapid and definite diagnosis was made in 16 out of 90 patients by transbronchial aspirates or bronchial lavage. 6) Atypical mycobacteria were detected in 7 out of 97 patients by transbronchial aspirates or bronchial lavage. 7) There were no serious complications such as pneumonia and exacerbation of pulmonary tuberculosis. These results suggested that transbronchial aspiration and bronchial lavage were useful procedures for rapid and definite diagnosis of pulmonary tuberculosis.

The application and diagnostic utility of immunocytochemistry on direct smears in the diagnosis of pulmonary adenocarcinoma and squamous cell carcinoma

The importance of subclassifying pulmonary nonsmall cell carcinoma (NSCLC) in cytologic material is becoming increasingly paramount. Occasionally, cell blocks traditionally used for ancillary studies are sparsely cellular or acellular. Hence, we investigated the diagnostic utility of immunocytochemistry for Napsin-A, TTF-1, and p63 on direct smears of NSCLC. Immunohistochemistry for Napsin-A was initially tested on a tissue microarray (TMA) composed of pulmonary adenocarcinoma. Subsequently, in 25 cases, immunocytochemistry for Napsin-A, TTF-1, and p63 was performed on cytologic direct smears. Smears were prepared from tumor cells scraped from lung resection specimens (n = 10), endobronchial ultrasound-guided transbronchial fine-needle aspirates (n = 13), and pelleted cell material from pleural effusions (n = 2). Immunohistochemistry utilizing the TMA revealed Napsin-A positivity in 73% of pulmonary ADCs. Next, immunocytochemistry on direct cytologic smears demonstrated a Napsin-A(+)/TTF-1(+) immunophenotype in 15 of 18 adenocarcinomas; p63 was completely negative (n = 12) or only focally positive (n = 3) in these 15 adenocarcinomas. The remaining three adenocarcinomas were negative for all three markers. All six squamous cell carcinomas were Napsin-A(-)/TTF-1(-) and diffusely p63(+). In conclusion, direct smears represent a feasible and robust source of cellular material for immunocytochemical studies to diagnose pulmonary ADC and SQC. Our method allows the cytologist to confirm on site that material for diagnostic immunocytochemistry is present thereby serving as a safeguard in instances where the cell block is of insufficient cellularity.

Accuracy of cell typing in nonsmall cell lung cancer by EBUS/EUS-FNA cytological samples

Endoscopic ultrasound-guided transbronchial or transoesophageal lymph node aspiration is increasingly used as a method of diagnosing nonsmall cell carcinoma. Data validating the accuracy of cell typing of nonsmall cell carcinoma using these cytological samples has not been assessed. 23 samples were identified in Edinburgh, UK and a further 25 in Cambridge, UK, with matching histological samples. The morphological cell type, as assessed on the cytological preparations and cell blocks, was recorded and immunohistochemical staining was performed, where possible, as an adjunct. The final cell type, as assessed by morphology with or without immunohistochemistry, was correlated with that reported in the paired histological samples. Cell blocks with tumour were available in 39 out of 48 cases. The accuracy of cell typing when no cell block was available was four out of nine cases. This increased to 25 out of 39 when a cell block was available, increasing to 33 out of 39 with the addition of immunohistochemistry. The overall accuracy of classification was 37 out of 48 cases. Accurate cell typing of nonsmall cell carcinomas can be performed using endoscopically derived fine-needle aspirates. The importance of obtaining sufficient material for the production of cell blocks is critical in allowing optimal assessment.