Transthoracic Aspiration Research Articles

Factors predict the adequacy of cervical mediastinoscopy in nonsmall cell lung carcinoma lymph node staging and comparison computed tomography and integrated positron emission tomography

Background Standard cervical mediastinoscopy (SCM) has traditionally been considered the reference standard for grading mediastinal involvement in lung cancer. The objective of this research is to evaluate the impact of surgeon experience and patient-related restrictions on the adequacy of mediastinal lymph node (LN) sampling. Additionally, we aim to assess the effectiveness of PET/computed tomography (CT) in comparison to ECM (extended cervical mediastinoscopy), particularly in identifying metastases in the aortopulmonary window (APW) LN. Methods This prospective cohort study involved sixty individuals diagnosed with nonsmall cell lung cancer (NSCLC). The participants underwent fine needle transthoracic aspiration biopsy or bronchoscopy and subsequently had ECM performed. All participants underwent various diagnostic procedures, including thoracic CT, posteroanterior chest radiograph, pulmonary function tests, PET/CT, electrocardiography, cranial magnetic resonance imaging, and laboratory investigations. Results In terms of our outcomes, we evaluated the specificity, positive predictive value (PPV), sensitivity, negative predictive value (NPV), and accuracy of ECM. The results for ECM were as follows specificity of 100.0%, PPV of 100.0%, sensitivity of 78.3%, NPV of 88.1%, and accuracy of 91.7%. For PET/CT, the results were: a specificity of 90.5%, PPV of 75.0%, sensitivity of 57.1%, NPV of 80.9%, and accuracy of 78.3%. Conclusion The ECM procedure is highly beneficial in identifying APW LN metastasis in individuals diagnosed with nonsmall cell lung cancer. It exhibits a favorable NPV and efficiency. Moreover, it can be easily performed by a team with the necessary experience.

Role of computed tomography guided transthoracic aspiration in diagnosing bronchogenic carcinoma

Role of computed tomography guided transthoracic aspiration in diagnosing bronchogenic carcinoma

After All, It was Not Lung Cancer: When The Evidence is Misleading.

Although complementary diagnostic exams are increasingly available and widely used, they may produce false positive or false negative results.A correct diagnostic approach can lead to an incorrect diagnosis.The preoperative diagnosis of pulmonary nodules can be a challenge.

After All, It was Not Lung Cancer: When The Evidence is Misleading

The aetiology of pulmonary nodules is varied, with malignant lesions being the most important and requiring rapid diagnosis and treatment. However, although clinical presentation and imaging may suggest a specific diagnosis, it should be kept in mind that some benign pathologies mimic more serious disease. A 50-year-old man presented with left pleuritic chest pain. A CT scan showed an ipsilateral pulmonary spiculated nodule. Pneumonia was assumed and the patient was started on antibiotic therapy. In the absence of improvement, positron emission tomography and a transthoracic aspiration biopsy were performed. Lung cancer was diagnosed and the patient underwent an upper lobectomy. However, examination of the surgical specimen showed no malignancy.

Diagnostic efficacy and suitability of trans-thoracic ultrasonography for pleural fluid detection – The future non-invasive gold-standard?

ABSTRACT
 Background: Conventionally Pleural effusions are suspected by history of pleuritis, evaluated by physical signs and multiple view radiography. Trans-thoracic pleural aspiration is done and aspirated pleural fluid is considered the gold-standard for pleural effusion. Chest sonography has the advantage of having high diagnostic efficacy over radiography for the detection of pleural effusion. Furthermore, ultrasonography is free from radiation hazards, inexpensive, readily available and feasible for use in ICU, pregnant and pediatric patients. This study aims to explore the diagnostic accuracy of trans-thoracic ultrasonography for pleural fluid detection, which is free of such disadvantages. The objective is to determine the diagnostic efficacy of trans-thoracic ultrasound for detecting pleural effusion and also to assess its suitability for being a non-invasive gold-standard. 
 Subject and Methods: This retrospective study of 4597 cases was conducted at pulmonology OPD-Gulab Devi Teaching Hospital, Lahore from November 2016 to July 2018. Adult patients with clinical features suggesting pleural effusions were included while those where no suspicion of pleural effusion, patients < 14 years and pregnant ladies were excluded. Patients were subjected to chest x-ray PA and Lateral views and chest ultrasonography was done by a senior qualified radiologist in OPD. Ultrasound-guided pleural aspiration was done in OPD & fluid was sent for analysis. At least 10ml aspirated fluid was considered as diagnostic for pleural effusion. Patient files containing history, physical examination, x-ray reports, ultrasound reports, pleural aspiration notes and informed consent were retrieved, reviewed and findings were recorded in the preformed proforma. Results were tabulated and conclusion was drawn by statistical analysis.
 Results: Out of 4597 cases, 4498 pleural effusion were manifested on CXR and only 2547(56.62%) pleural effusions were proved by ultrasound while 2050 (45.57%) cases were reported as no Pleural effusion. Chest sonography demonstrated sensitivity, specificity, PPV, NPV and diagnostic accuracy 100 % each.
 Conclusions: Trans-thoracic ultrasonography revealed an excellent efficacy that is why it can be considered as non-invasive gold standard for the detection of pleural effusion.

Lung nodules: A comprehensive review on current approach and management.

In daily clinical practice, radiologists and pulmonologists are faced with incidental radiographic findings of pulmonary nodules. Deciding how to manage these findings is very important as many of them may be benign and require no further action, but others may represent early disease and importantly early-stage lung cancer and require prompt diagnosis and definitive treatment. As the diagnosis of pulmonary nodules includes invasive procedures which can be relatively minimal, such as bronchoscopy or transthoracic aspiration or biopsy, but also more invasive procedures such as thoracic surgical biopsies, and as these procedures are linked to anxiety and to cost, it is important to have clearly defined algorithms for the description, management, and follow-up of these nodules. Clear algorithms for the imaging protocols and the management of positive findings should also exist in lung cancer screening programs, which are already established in the USA and which will hopefully be established worldwide. This article reviews current knowledge on nodule definition, diagnostic evaluation, and management based on literature data and mainly recent guidelines.

Evaluation of an HIV-Related Mortuary Surveillance System - Nairobi, Kenya, Two Sites, 2015.

Use of human immunodeficiency virus (HIV)-mortality surveillance data can help public health officials monitor, evaluate, and improve HIV treatment programs. Many high-income countries have high-coverage civil registration and vital statistics (CRVS) systems linked to case-based HIV surveillance on which to base HIV mortality estimates. However, in the absence of comprehensive CRVS systems in low- and medium-income countries, such as Kenya, mortuary surveillance can be used to understand the occurrence of HIV infection among cadavers. In 2015, a pilot HIV-related mortuary surveillance system was implemented in the two largest mortuaries in Nairobi, Kenya. CDC conducted an evaluation to assess performance attributes and identify strengths and weaknesses of the surveillance system pilot.Data collection: January 29-March 3, 2015; evaluation: November 2015.The surveillance system objectives were to determine HIV positivity among cadavers at two mortuary sites in Nairobi, Kenya, and to determine annual cause-specific and HIV-specific mortality rates among the cadavers. Cadavers of persons aged ≥15 years at death admitted to either mortuary during a 33-day period were included. Demographic information and place and time of death were entered into a surveillance register. Cardiac blood was collected using transthoracic aspiration, and blood specimens were tested for HIV in a central laboratory. Causes of death were abstracted from mortuary and hospital records. Of the 807 cadavers brought to the mortuaries, 610 (75.6%) had an HIV test result available. The overall unadjusted HIV-positivity rate was 19.5% (119/610), which differed significantly by sex (14.6% among men versus 29.5% among women).The evaluation was conducted using CDC guidelines for evaluating public health surveillance systems. The attributes of simplicity, flexibility, data quality (completeness and validity), acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability were examined. The evaluation steps included review of the surveillance system documents, in-depth interviews with 20 key informants (surveillance system staff, including mortuary and laboratory staff, and stakeholders involved in funding or implementation), and review of the surveillance database.Implementation of the pilot mortuary surveillance system was complex because of extensive paperwork and the need to collect and process specimens outside of business hours. However, the flexibility of the system accommodated multiple changes during implementation, including changes in specimen collection techniques and data collection tools. Acceptability was initially low among the mortuary staff but increased after concerns regarding workload were resolved. Timeliness of specimen collection could not be measured because time of death was rarely documented. Completeness of data available from the system was generally high except for cause of death (46.5%). Although the two largest mortuaries in Nairobi were included, the surveillance system might not be representative of the Nairobi population. One of the mortuaries was affiliated with the national referral hospital and included cadavers of admitted patients, some deaths might have occurred outside Nairobi, and data were collected for only 1 month.Mortuary surveillance can provide data on HIV positivity among cadavers and HIV-related mortality, which are not available from other sources in most sub-Saharan African countries. Availability of these mortality data will help describe a country's progress toward achieving epidemic control and achieving Joint United Nations Programme on HIV/AIDS 95-95-95 targets. To understand HIV mortality in high-prevalence regions, the mortuary surveillance system is being replicated in Western Kenya. Although a low-cost system, its sustainability depends on external funding because mortuary surveillance is not yet incorporated into the national AIDS strategic framework in Kenya.

English

English

Ultrasound for the Pulmonary Consultant.

Bedside ultrasonographic assessment of the lung and pleura provides rapid, noninvasive, and essential information in diagnosis and management of various pulmonary conditions. Ultrasonography helps in diagnosing common conditions, including consolidation, interstitial syndrome, pleural effusions and masses, pneumothorax, and diaphragmatic dysfunction. It provides procedural guidance for various pulmonary procedures, including thoracentesis, chest tube insertion, transthoracic aspiration, and biopsies. This article describes major applications of ultrasonography for the pulmonary consultant along with illustrative figures and videos.

Respiratory Cytology—Current Trends Including Endobronchial Ultrasound-Guided Biopsy and Electromagnetic Navigational Bronchoscopy: Analysis of Data From a 2013 Supplemental Survey of Participants in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology

Nongynecologic cytology (NGC) practices are expanding in relationship to historical gynecologic cytology screening programs. Bronchopulmonary cytology is experiencing an evolution regarding new procedural types. The College of American Pathologists (CAP) tracks practice patterns in NGC by developing questionnaires, surveying participants, and analyzing respondent data. To analyze responses to a 2013 CAP supplemental survey from the Interlaboratoy Comparison Program on bronchopulmonary NGC. The "NGC 2013 Supplemental Questionnaire: Demographics in Performance and Reporting of Respiratory Cytology" was mailed to 2074 laboratories. The survey response rate was 42% (880 of 2074) with 90% of respondents (788 of 880) indicating that their laboratories evaluated cytology bronchopulmonary specimens. More than 95% of respondents indicated interpreting bronchial washings (765 of 787) and bronchial brushings (757 of 787). A minority of laboratories (43%, 340 of 787) dealt with endobronchial ultrasound-guided samples, and an even smaller fraction of laboratories (14%, 110 of 787) saw cases from electromagnetic navigational bronchoscopy. Intraprocedural adequacy assessments by pathologists (and less often by cytotechnologists or pathologists-in-training) were routinely performed in percutaneous transthoracic aspiration cases (74%, 413 of 560) with less involvement for other case types. Most laboratories reported that newly diagnosed primary pulmonary adenocarcinomas were triaged for molecular testing of epidermal growth factor receptor and anaplastic lymphoma kinase. The parameters examined in this 2013 survey provide a snapshot of current pulmonary cytopathology practice and may be used as benchmarks in the future.

Coagulase Negative Staphylococcus Isolates from Clinical Specimens

Coagulase Negative Staphylococcus (ConS) hitherto considered as non-pathogenic are increasingly encountered in clinical material. 102 ConS were isolated from 500 clinical samples, which included wound swabs (184), blood (108), pus (94), sputum(33), transthoracic aspirations(14). Predominant organism isolated was Staph. epidermidis followed by Staph.saprophyticus, Staph. Saccharolyticus, Staph.intermedius, Staph.capitis, Staph.schleiferi, Staph.cohnii were less extent.

EComment: Pulmonary artery sarcoma: a challenging diagnostic dilemma

Bhagwat and colleagues have reported on the successful surgical treatment of a patient with primary pulmonary artery sarcoma [1]. We would like to share our experience relating to a 62 year female and to add a brief comment as well [2]. We reported on a patient with primary pulmonary artery sarcoma presenting initially with weight loss, shortness of breath, palpitations, and dysphagia. The diagnostic approach consisted of echocardiography, CT scan, MRI and coronary angiogram, and the differential diagnosis included pulmonary emboli, chronic thromboembolic disease and pulmonary artery tumour. The patient underwent exploratory median sternotomy under cardiopulmonary bypass (CPB), logistic EuroSCORE 6%, and the entire tumour was resected with an extensive tumour endarterectomy. However, as a fibrotic area in the right ventricle was left, this was considered to be a palliative procedure and the patient was referred for chemotherapy and radiotherapy [2]. Pulmonary artery sarcoma presents a diagnostic challenge, as the main presenting complaint of patients is progressive dyspnoea. Dyspnoea is a quite common symptom in diseases of the heart and lungs and therefore a high index of suspicion is necessary to make the diagnosis early, and to proceed with surgery and radiotherapy and/or chemotherapy [2]. Since 1923, when the first case was described, until 2006, no more than 210-220 cases have been reported [2]. Pulmonary artery sarcomas arise from pluripotent intimal cells. They are most frequently located within the pulmonary trunk, spreading into the proximal and distal pulmonary arteries. Typical onset age is 45-55 years, with reported age ranging from 13 to 86 years and a female to male ratio equal to 2:1. Due to the rarity of these tumours, they are often initially misdiagnosed as chronic thromboembolic disease leading to unnecessary anticoagulation of affected patients [2]. Preoperative histological diagnosis is generally not possible although, rarely, biopsy may be obtained via CT-guided transthoracic aspiration or, alternatively, via transvenous catheter suction biopsy with pulmonary angioscopy, as well as by transbronchial biopsy [2]. Endarterectomy via median sternotomy and CPB, with dissection of the intima and most of the media, may result in complete tumour removal and is the most commonly used and widely acceptable surgical strategy. Although in unilateral disease it is possible to attempt a pneumonectomy, in bilateral disease it seems to be of limited value [2]. Alternative surgical methods include total excision of pulmonary trunk with reconstruction, and heart and lung transplantation for unresectable tumours [3,4]. Palliative treatment includes debulking of the tumour, endovascular stent or bypass procedure [2,5]. The prognosis is poor: without surgery survival is 1.5 months. The median survival has been significantly improved with radical surgical resection and multimodality treatment [1,2]. Surgical treatment remains the cornerstone of management, offering definite diagnosis, improvement of symptoms and the best outcome. However, if curative resection is not possible, palliative resection still provides good symptom relief and can improve survival [2]. A high index of suspicion for early diagnosis is the key to successful treatment and prolonged survival for these patients presenting with no specific symptoms. Conflict of Interest: None declared

Classification of Non-small Cell Lung Carcinoma in Transthoracic Needle Specimens Using MicroRNA Expression Profiling

Emerging targeted lung cancer therapies require the accurate morphologic subclassification of non-small cell lung cancer (NSCLC), even in scant and distorted specimens obtained by transthoracic needle aspiration (TTNA). MicroRNAs (miRNAs) are small noncoding genes recently reported as useful in differentiating squamous cell carcinoma (SCC) from adenocarcinoma (AD) in resected tumor specimens. We investigated their ability to do so in TTNA specimens. Smears, immunocytochemistry slides, and corresponding cell blocks of 31 NSCLC TTNA specimens were retrieved and classified as AD or SCC based on their cytologic features and immunocytochemical profiles. Data on EGFR and K-RAS mutational status were available for all cases of AD. We quantified the hsa-let-7 family and hsa-miR-205 by quantitative reverse transcription-polymerase chain reaction and compared the miRNA expression levels in AD and SCC using Student t test. Eighteen cases were classified as AD and 13 as SCC by light microscopy and immunocytochemistry. miRNA expression profiles demonstrated considerable, statistically significant differences between AD and SCC, showing an upregulation of hsa-let-7a, hsa-let-7b, hsa-let-7c,hsa-let-7f, hsa-let-7g, hsa-let-7i, and hsa-miR-98 and a downregulation of hsa-miR-205 in AD specimens (all P < .05; t test). Profiling the hsa-let-7 family and hsa-miR-205 is a promising method for differentiating AD from SCC, even in such small specimens as transthoracic aspirates. Subject to the validation of these findings in further, larger studies, this could prove to be a reliable, standardizable tool for the subclassification of NSCLC.

Transthoracic lung aspiration for the aetiological diagnosis of pneumonia: 25 years of experience from The Gambia [Review article

Pneumonia remains the leading cause of death in young children worldwide. Global pneumonia control depends on a good understanding of the aetiology of pneumonia. Percutaneous transthoracic aspiration culture is much more sensitive than blood culture in identifying the aetiological agents of pneumonia. However, the procedure is not widely practised because of lack of familiarity with it and concerns about potential adverse events. We review the diagnostic usefulness and safety of this procedure over 25 years of its use in research and routine practice at the UK Medical Research Council (MRC), The Gambia, and give a detailed description of the procedure itself. Published materials were identified from the MRC's publication database and systematic searches using the PubMed/Medline and Google search engines. Data from a current pneumonia aetiology study in the unit are included together with clinical experience of staff practising at the unit over the period covered in this review. A minimum of 500 lung aspirates were performed over the period of review. Lung aspiration produces a greater yield of diagnostic bacterial isolates than blood culture. It is especially valuable clinically when pathogens not covered by standard empirical antibiotic treatment, such as Mycobacterium tuberculosis and Staphylococcus aureus, are identified. There have been no deaths following the procedure in our setting and a low rate of other complications, all transient. Lung aspiration is currently the most sensitive method for diagnosing pneumonia in children. With appropriate training and precautions it can be safely used for routine diagnosis in suitable referral hospitals.

CT-guided Percutaneous Large-needle Aspiration and Bleomycin Sclerotherapy for Bronchogenic Cyst: Report of Four Cases

Fine needle aspiration alone has been used as a treatment for bronchogenic cysts, but is subject to a high rate of recurrence. The purpose of this study was to review our experience with computed tomography (CT)-guided percutaneous large-needle aspiration and bleomycin sclerotherapy of bronchogenic cysts in four patients. Four patients with bronchogenic cysts at subcarinal (n = 1), paraspinal (n = 1), or intrapulmonary (n = 2) sites were treated at two medical centers with percutaneous transthoracic aspiration with a 17.5-gauge needle and sclerotherapy with use of bleomycin as the sclerosant agent. Clinical symptoms were seen in three of the four patients: recurrent cough in two and recurrent chest discomfort and palpitation in one. CT was used to guide the procedures. After sclerotherapy, the sizes of ablated cysts were followed by CT. At a median follow-up of 10 months (range, 6-14 months), all three patients with symptoms had symptomatic relief and all four patients showed a nearly complete regression of bronchogenic cyst on follow-up CT. No recurrence was encountered. Minor complications included a small asymptomatic pneumothorax at the end of the procedure in one patient and a mild fever (38.0 degrees C-38.5 degrees C) on the first day after sclerotherapy in one patient, which resolved spontaneously without treatment. No major complications occurred. CT-guided percutaneous treatment of bronchogenic cysts with large-needle aspiration and bleomycin sclerotherapy was safe and effective in this limited series. Further investigation of this technique is warranted.

Aspiration of mediastinal hydatid cyst – A case report

Mediastinal hydatid cyst is very rare and has been only anecdotally reported in the literature. Because of surrounding vital structures, the cyst should be treated without delay, surgery being the mainstay of treatment. Here we report a case of hydatid cyst of the mediastinum which was managed by trans-thoracic aspiration followed by albendazole therapy.

Masse médiastinale antérieure d’étiologie rare

Hydatid cyst of the mediastinum is very uncommon. The diagnosis, usually evident in endemic regions in the case of a typical clinical-radiological presentation, is rather more difficult in certain atypical forms. We report a case of a 19-year-old man who presented with a mass of tumour like appearance in the anterior mediastinum. The diagnosis of mediastinal hydatid cyst was established by transthoracic needle biopsy and endoscopic bronchial aspiration revealed hydatid membranous debris. The diagnosis was confirmed when the mediastinal cyst ruptured into a bronchus. Thoracotomy was carried out with an uneventful post-operative recovery. This observation illustrates the diagnostic difficulties when a mediastinal hydatid cyst presents the appearances of a tumour. This possibility must be included in the differential diagnosis of every mediastinal mass, particularly in endemic regions.

Veillonella as a cause of chronic anaerobic pneumonitis

Anaerobes are not well recognized as a cause of chronic respiratory infections. A 44-year-old man was referred for evaluation of a progressive pulmonary disease of 7-month duration characterized by hemoptysis and fever. For these complaints, based on the radiological picture, he had already received antituberculous therapy without any relief. He was also subjected to bronchial artery embolization prior to referral. Evaluation of the patient led to a diagnosis of chronic anaerobic pneumonitis. Anaerobic culture of the computed tomography-guided transthoracic aspirate grew Fusobacterium and Veillonella species. Within 2 weeks of therapy with oral clindamycin, there was a dramatic relief in hemoptysis. This was accompanied by remarkable radiological clearance. This report underscores the importance of Veillonella species as a potential respiratory pathogen. A high index of suspicion is required to diagnose chronic anaerobic pneumonitis, which can mimic pulmonary tuberculosis, especially in tuberculosis endemic regions.

Pneumatocele as a Complication of Bronchoscopy: A Case Report and Review of Literature

We report a case of pneumatocele (PC) caused by bronchoscopy and bronchoalveolar lavage performed in a patient with human immunodeficiency virus infection. We speculate that coughing during the bronchoscopy may have contributed to the pathophysiology. A PC is a gas-filled cystic cavity in the lung parenchyma and the mechanism of formation is a 1-way valve that only allows airflow into the cavity. PCs have been described as a congenital malformation, in necrotizing infections, in chronic obstructive pulmonary disease, in hydrocarbon ingestion with aspiration, in human immunodeficiency virus positive adults with Pneumocystis jiroveci pneumonia, and as a result of blunt thoracic trauma. These lesions frequently resolve spontaneously. Most investigators suggest that the treatment is conservative with close follow-up, and invasive approaches should be reserved for patients who develop complications. Features such as fever, cough, and tachypnea, more than 50% involvement of hemithorax, persistent atelectasis, presence of a bronchopleural fistula, and infection in a PC should prompt image-guided transthoracic aspiration and catheter drainage or surgery.

Immunoglobulin Deficiency in Cavalier King Charles Spaniels with Pneumocystis Pneumonia

Serum concentrations of immunoglobulin G (IgG), IgM, and IgA were measured in 9 Cavalier King Charles Spaniels with pneumonia caused by Pneumocystis sp that were examined at 4 veterinary surgeries in the United Kingdom (UK) between September 2001 and November 2002. Pneumocystis pneumonia was confirmed in all dogs by visualization of the organism in bronchoalveolar lavage fluid or a transthoracic lung aspirate. Two dogs had a history of demodicosis. Immunoglobulin concentrations also were measured in breed-and age-matched dogs sampled over the same period. IgG concentrations were significantly (P = .000) lower in the affected dogs (median 3.2 mg/mL) than in the control dogs (median 8.5 mg/mL). IgM concentrations were significantly (P = .002) higher in the affected dogs (median 1.95 mg/mL) than in the control dogs (median 1.12 mg/mL). One affected dog had no change in IgG concentration more than 3 months after resolution of infection or vaccination, but did have reduction in IgM concentration after resolution of infection and vaccination. Control dogs had low serum IgG and IgM concentrations, compared with the reference interval for all dogs. Lymphocyte count in blood was normal or high in 7 of 8 affected dogs. The results of this study suggest that there is a defect in immunity in Cavalier King Charles Spaniels that underlies the susceptibility of these dogs to pneumocystosis. Further studies are indicated to elucidate the mechanisms behind the defect, the prevalence within the breed, and the potential mode of inheritance of the problem.