A Talwar

Ultrasound-guided pneumothorax induction prior to local anaesthetic thoracoscopy

Local anaesthetic thoracoscopy (LAT) is performed by a growing number of respiratory physicians in the context of an expanding population with pleural disease. Most LATs occur in patients with moderate to large effusions where the presence of fluid allows safe access to the pleural space. Patients with little or no fluid, but other features concerning for pleural disease, are usually investigated by surgical means. Advanced LAT practitioners can also provide this service through pneumothorax induction, although there is little published data on the safety or efficacy of this technique. We present data from a series of 77 consecutive patients in whom ultrasound-guided pneumothorax induction and LAT were attempted. 67 procedures (87.0%) were successful, with the most common histopathological diagnoses being chronic pleuritis (58.2%) and mesothelioma (16.4%). No adverse events were reported secondary to the procedure. These findings demonstrate the utility of this approach and should inform future practice and guidelines.

Assessment of patient-reported outcome measures in pleural interventions

Introduction There is a lack of data evaluating the clinical effect on symptoms of pleural intervention procedures. This has led to the development of patient-reported outcome measures (PROMs) to define what constitutes patient benefit. The primary aim of this paper was to prospectively assess the effect of pleural procedures on PROMs and investigate the relationship between symptom change and clinical factors. Methods We prospectively collected data as part of routine clinical care from 158 patients with pleural effusion requiring interventions. Specific questionnaires included two patient-reported scores (a seven-point Likert scale and a 100 mm visual analogue scale (VAS) to assess symptoms). Results Excluding diagnostic aspiration, the majority of patients (108/126, 85.7%) experienced symptomatic benefit from fluid drainage (mean VAS improvement 42.6 mm, SD 24.7, 95% CI 37.9 to 47.3). There was a correlation between symptomatic benefit and volume of fluid removed post aspiration. A negative association was identified between the number of septations seen on ultrasound and improvement in dyspnoea VAS score in patients treated with intercostal chest drain. Conclusion The results of our study highlight the effect of pleural interventions from a patient’s perspective. The outcomes defined have the potential to form the basis of a clinical useful tool to appraise the effect, compare the efficiency and identify the importance of pleural interventions to the patients.

Intercostal chest drain insertion by general physicians: attitudes, experience and implications for training, service and patient safety

Background Intercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a concurrent decline in training opportunities and confidence in their procedural skills. Objectives We explored clinicians’ attitudes, experience and knowledge relating to pleural interventions and ICD insertion in order to determine what changes might be needed to maintain patient safety and quality of training. Methods Consultants and trainees delivering general medical services across five hospitals in England were invited to complete a questionnaire survey over a 5-week period in July and August 2014. Results 117 general physicians (32.4% of potential participants; comprising 31 consultants, 48 higher specialty trainees, 38 core trainees) responded. Respondents of all grades regarded ICD insertion as a core procedural skill. Respondents were asked to set a minimum requirement for achieving and maintaining independence at ICD insertion; however, only 25% of higher specialty trainees reported being able to attain this self-imposed standard. A knowledge gap was also revealed, with trainees managing clinical scenarios correctly in only 51% of cases. Conclusions Given the disparity between clinical reality and what is expected of the physician-in-training, it is unclear whether ICD insertion can remain a core procedural skill for general physicians. Consideration should be given to how healthcare providers and training programmes might address issues relating to clinical experience and knowledge given the implications for patient safety and service provision.

Thoracic involvement in IgG4-related disease in a UK-based patient cohort

IgG4-related disease (IgG4-RD) is a multi-system fibro-inflammatory disorder with classical histopathological findings, often in the context of elevated serum IgG4 levels. The thoracic manifestations of IgG4-RD are numerous and can mimic several common and better known conditions. The objective of this study was to outline the frequency and nature of thoracic involvement in a prospective cohort of IgG4-RD patients who met defined diagnostic criteria. Over 40% of IgG4-RD patients had clinicoradiological and/or histological evidence of thoracic involvement, predominantly mediastinal lymphadenopathy, the majority associated with multi-system disease outside the chest. Thoracic involvement was associated with a higher serum IgG4 level, potentially representing greater disease activity or spread. Our data highlight the diverse nature of thoracic IgG4-RD, and the importance of knowledge and recognition of the condition among respiratory physicians who are likely to encounter this disease entity on an increasing basis.

P2 Incorporation of an in-depth thoracic ultrasound assessment into routine pre-procedural evaluation of patients with pleural effusions

Background Pleural disease affects 1 in 300 people annually; furthermore, the incidence of malignant pleural effusion (MPE) is increasing with over 40,000 cases each year in the UK alone. A significant minority of patients will have non-expandable lung (NEL) secondary to underlying disease. At present, there is no way of pre-emptively identifying these individuals; with current strategies such as pleural manometry requiring invasive intervention. Early recognition of patients with NEL would streamline care and allow them to be offered appropriate treatment; i.e., indwelling pleural catheter insertion rather than chemical pleurodesis. Recent research1 has described the novel use of thoracic ultrasound (TUS) to identify NEL by assessing mobility and compliance of the atelectatic lung within an effusion. However, this work has not been replicated and was delivered by researchers with expertise and facilities not used by or available to most practitioners. Method We incorporated an in-depth TUS protocol into the pre-procedural assessment of patients undergoing intervention for suspected MPE, where ≥500 mL of fluid was expected to be drained. TUS images were acquired by two chest physicians with RCR level 1 competence or above. Data recorded included size and characteristics of the effusion; presence of pleural thickening; behaviour of the lung and diaphragm; and M-mode displacement with cardiac impulse of the atelectatic lung during breath hold manoeuvres. NEL was determined using post-drainage imaging (chest X-ray and/or CT) and clinical notes. Results 34 patients underwent in-depth TUS evaluation (Table 1). Image acquisition and measurements took no more than five minutes in any patient. Poor M-mode displacement (<0.8 mm) was only seen with NEL, whilst good movement (>1.2 mm) was highly predictive of free lung. The presence of visceral thickening on TUS may also predict NEL, although there was only limited data to support this finding. Conclusion In-depth TUS assessment can be delivered and interpreted quickly in the day-case setting using widely available portable ultrasound equipment, with potential implications for patient care and non-invasive diagnosis of NEL. Further research is needed to evaluate the ability of M-mode and other TUS parameters to predict NEL and symptom response prior to invasive intervention. Reference Salamonsen MR, et al. Novel use of pleural ultrasound can identify malignant entrapped lung prior to effusion drainage. Chest 2014;146(5):1286–93. Abstract P2 Table 1 In-depth thoracic ultrasound (TUS) findings in 34 patients undergoing pleural drainage for suspected malignant disease POST-DRAINAGE LUNG CHARACTERISATION Free(n = 23) Indeterminate (n = 5) Non-expandable (n = 6) Static TUS features Effusion side Right 11/23 5/5 5/6 Left 12/23 0/5 1/6 Effusion size Moderate 10/23 2/5 4/6 Large 13/23 3/5 2/6 Septations evident 2/23 2/5 4/6 Parietal pleural thickening evident 0/23 0/5 1/6 Visceral pleural thickening evident 0/23 0/5 3/6 Distinct pleural nodularity evident 5/23 4/5 2/6 Dynamic TUS features Paradoxical motion of diaphragm evident 9/23 2/5 3/6 Free movement of atelectatic lung evident 22/23 3/5 2/6 Clear inspiratory expansion of atelectatic lung evident 7/23 0/5 0/6 M-mode motion of atelectatic lung(inspiratory hold, near or approaching TLC) <0.8 mm; n (%) 0/23 0/5 5/6 0.8–1.2 mm; n (%) 7/23 3/5 1/6 >1.2 mm; n (%) 16/23 2/5 0/6 M-mode motion of atelectatic lung(expiratory hold, near or approaching RV) <0.8 mm; n (%) 0/23 0/5 3/6 0.8–1.2 mm; n (%) 2/23 1/5 3/6 >1.2 mm; n (%) 21/23 4/5 0/6

The role of computed tomography in assessing pleural malignancy prior to thoracoscopy.

Purpose of review Computed tomography (CT) scanning is part of the routine diagnostic work up of patients with suspected pleural malignancy but has a wide variation in the reported sensitivity and specificity. This review was to appraise the recent literature on the utility of CT scanning. Recent findings When investigating patients for suspected pleural malignancy, the sensitivity of a malignant CT report may be higher than previously reported (68%), but the specificity seems significantly lower (78%). The predictive value of CT scanning (on all patients with pleural effusions) may be increased using a CT scoring system. Recent meta-analyses of the utility of PET give differing opinions on the value of this imaging modality. Further work needs to be done to define its place in the diagnostic pathway. Summary CT scoring systems may allow further risk stratification. However, a low negative predictive value of a ‘negative’ CT scan could lead to false reassurance and missed malignancy. PET/CT does not currently appear to add additional diagnostic value. Pulmonary emboli should be considered in all patients being investigated for clinically suspected malignant pleural disease. Respiratory physicians should be mindful of rare or unusual presentations.

S101 A comparison of the imaging features of early stage primary lung cancer in patients treated with surgery, sabr and microwave ablation

Introduction Stereotactic Ablative Radiotherapy (SABR) and percutaneous microwave ablation (PMWA) are now being performed in patients deemed “medically inoperable” with non-small cell lung cancer (NSCLC). The majority of these patients are treated without ground truth histology, relying on imaging to establish the diagnosis. The purpose of this study was to investigate whether there were differences in the visible imaging features including CT Texture Analysis (CTTA) between patients referred for surgery, SABR and PMWA, which might suggest differences in underlying diagnosis. Methods 92 patients with one pulmonary nodule (PN) suspected as T1N0M0 to T2AN0M0 NSCLC on imaging were treated either with SABR (22 patients), PMWA (25) or Video-assisted thorascopic surgery (45) of which 23 had NSCLC (SURG M) and 22 had benign disease (SURG B). Patient characteristics, CT nodule morphology, presence of emphysema and percentage emphysema score, FDG avidity and CT textural features were compared. Twenty texture features (previously used in combination to create a nodule probability of malignancy score between 0–1) were extracted from each automatic contoured region surrounding the PN. The Kruskal-Wallis test was used to compare texture features between the 4 patient groups (SABR, PMWA, SURG M and SURG B). Results There was no significant difference in nodule morphology, volume at presentation (p=0.280) or volume doubling times (p=0.149), and presence of emphysema (p=0.348) or emphysema score (p=0.367) between the 4 groups. There was no statistical difference in CTTA malignancy prediction score between the SABR, PMWA and SURG M groups (p≥0.05). The probability of malignancy score was significantly lower (p-value<0.01) for SURG B (0.58 mean ±0.19 sd) vs. SABR (0.79±0.15) treatment groups (figure 1). Conclusion This is the first study to our knowledge to evaluate the radiological differences between patient groups referred for surgical and non-surgical treatments for NSCLC. On this small study, the Results support the hypothesis that the non-operative patient groups comprise the same proportion of benign and malignant as those in the operative group. The Results also demonstrate the potential clinical utility of CTTA in patient selection when histology is not obtainable. CTTA does not require volumetry detectable growth to detect change, and therefore may be a useful biomarker of malignancy at first diagnosis. Abstract S101 Figure 1 Summary statistics for probability of malignancy scores.

S15 Improving the risk stratification for malignancy in small pulmonary nodules from an unselected patient population

Introduction Distinguishing between benign and malignant small pulmonary nodules (PNs) detected on CT scanning is a significant challenge. Such nodules are commonly detected in clinical practice as incidental findings or in patients with a history of prior malignancy. CT texture analysis (CTTA) has been proposed as a potential imaging biomarker in tumour characterisation. Image texture refers to the statistical analysis of spatial intensity variations of the pixels within an image to produce a CT texture score. This score is then mapped onto a probability of malignancy from 0–1. Aims and Objectives To create a registry of patients with small solid PNs from an unselected population of patients. Patient demographic data were combined with information acquired from CT derived parameters such as shape, size, and texture analysis (CTTA) to develop and validate a generalised linear model to determine the probability of malignancy of PNs. A parallel prospective interventional cohort study was also conducted to assess whether CTTA repeatability was comparable to automatic volumetric measurements when a patient is scanned twice on the same day. Methods Between January 2012 to September 2014, 1008 patients presenting with small solid PNs were identified. The gold standard diagnosis of the nodules was established by histology or nodule stability at 2 years of CT follow-up. Results The prevalence of malignant PNs was 31.6% (319/1008). Significant independent predictors of malignancy included prior history of malignancy within 5 years (OR=117.4,(95% confidence interval(CI)):67.1 to 272.8, p<0.001); larger nodule diameter (OR=9.7, CI: 4.1 to 17.6, p<0.001); nodule count (OR=1.6, CI:1.3 to 1.8, p<0.001) and nodule spiculation (OR=118.4, CI:61.9 to 772.3, p<0.001). The models’ performance using the area under the ROC curve (AUC) was 0.969. When CTTA was used alone the AUC was 0.800 (figure 1). CTTA displayed ULR and LLR below ±17.8%, comparable to volume using Bland-Altman and also had high repeatability {CCC (0.84≤CCC≤0.99)}. Conclusion This study has highlighted the potential clinical utility of CTTA in the risk stratification of PNs. It has also shown that CTTA is a highly repeatable imaging biomarker of malignancy, akin to volume measurements but with the advantage of not requiring imaging follow-up. Abstract S15 Figure 1 (A) Patient demographics and nodule characteristics, (B) Performance of clinical models (AUC is area under the ROC curve), and (C) Bland-altman plot to show variability in texture feature scores and volumetry for 40 Pulmonary nodules.

S94 Biological markers of favourable prognosis and successful pleurodesis for malignant pleural effusion

Introduction and objectives Malignant pleural effusion (MPE) is a rapidly rising healthcare burden and critically hampers the patients’ survival and quality of life. Current treatments aim to symptoms’ palliation and talc pleurodesis remains a standard therapeutic modality. There is relatively little high quality research data in prediction of patients’ survival and successful pleurodesis. Therefore prognostic and therapeutic biomarkers are desperately needed. Aim To identify and validate novel prognostic and therapeutic biomarkers in MPE. Methods Clinical data and pleural fluids from MPE patients, prior to treatment have been prospectively collected for TIME2 trial. According to the trial database patients have been classified in two different groups: survival cohort (poor, n = 20/good, n = 14) and treatment outcome cohort (success, n = 15/failure, n = 11). Pleural fluids on enrolment were assessed with mass spectrometry profiling after depletion of the 12 most abundant proteins. Full protein profile analysed with R software and ELISA technique was performed for the validation of the results. Pathway analysis on samples performed with Ingenuity Pathway Analysis software. Results With the use of mass spectrometry we identified 1,154 proteins in the pleural fluid, 167 of which were statistical significant (two tailed T-Test, p < 0.05) between survival groups and 97 of which were statistically significant (two tailed T-Test, p < 0.05) between the pleurodesis groups. Analysis of the data (cross validated by 3 independent core bioinformatic groups) identified 10 survival and 3 pleurodesis biomarkers that were differentially expressed in the favourable prognosis and treatment success group respectively. Exploration of the mass spectrometry data identified pathways that were upregulated on patients with favourable survival that could be used for targeted therapies. Conclusions Based on unique database survival and therapeutic biomarkers were identified that can potentially stratify patients’ management. The results are currently validated on a different retrospective dataset (TIME1 trial) and with a prospective clinical trial (SIMPLE study).

P4 A prospective assessment of the clinical utility of intercostal artery identification in pleural intervention

Background Respiratory Specialists perform an increasing number of complex pleural procedures. With this comes a greater focus on patient safety and risk reduction. There is strong evidence that ultrasound guidance in procedure site selection for pleural effusion reduces organ puncture and pneumothorax, but it remains important to choose intervention sites to avoid the intercostal arteries (ICA). Previous data suggest that the ICA can follow a tortuous course especially in the elderly. The use of colour Doppler to identify intercostal and collateral arteries has been shown to be accurate in research studies and may assist in selecting a safe intervention site. This study aimed to prospectively assess identification of the ICA in routine practice and the effect on procedure site selection. Methods Data on identification of the ICA was prospectively collected as part of routine clinical care and documented in the pleural procedure records in a tertiary centre between July 2015 and July 2016. Successful identification of the ICA and its influence in choosing the procedure site was recorded. Results 404 procedures were carried out over the study period. The mean age of the patients was 69.3 years (sd 14.2). Identification of the ICA was attempted in 386 (95.5%) procedures and the ICA was identified within the intercostal space in 192 (49.7%) of cases. The site of the procedure was altered after ICA detection in 56/192 (29.2%) of procedures and in 16/32 (50.0%) of image guided pleural biopsies. In 7/192 (3.6%) procedures the ICA was identified in all rib spaces at potential intervention sites, leading to the procedure not being attempted. No complications related to post procedure haemorrhage were reported. A more detailed analysis of the identification of the ICA and its influence on practice by procedure type is shown in Table 1. Conclusion Screening for the ICA in routine clinical practice influences procedural site selection. In some cases identification can result in abandoning a procedure, which may have led to intercostal bleeding. Patient position and potential rib crowding may explain differences in the rates of successful identification between procedures. If these findings are replicated in larger prospective studies, identification of the ICA may become routine practice to maximise safety. Abstract P4 Table 1