António Bugalho

Superior vena cava syndrome in thoracic malignancies.

The superior vena cava syndrome (SVCS) comprises various symptoms due to occlusion of the SVC, which can be easily obstructed by pathological conditions (eg, lung cancer, due to the low internal venous pressure within rigid structures of the thorax [trachea, right bronchus, aorta]). The resulting increased venous pressure in the upper body may cause edema of the head, neck, and upper extremities, often associated with cyanosis, plethora, and distended subcutaneous vessels. Despite the often striking clinical presentation, SVCS itself is usually not a life-threatening condition. Currently, randomized controlled trials on many clinically important aspects of SVCS are lacking. This review gives an interdisciplinary overview of the pathophysiology, etiology, clinical manifestations, diagnosis, and treatment of malignant SVCS.

Endobronchial ultrasound-guided cryobiopsies in peripheral pulmonary lesions: a feasibility study

Peripheral lung lesions are sometimes difficult to reach even with endobronchial ultrasound (EBUS) and insufficient material is often obtained by transbronchial forceps biopsy. Cryoprobes can be used for performing tissue biopsies. We evaluated the safety and feasibility of the cryoprobe in combination with EBUS for the diagnosis of peripheral lung lesion. Patients with peripheral lung lesions of up to 4 cm were enrolled. After identifying the lung lesion by radial EBUS, forceps biopsies and cryobiopsies were performed in a randomised order. We evaluated safety and feasibility, and compared diagnostic yield and sample size. 39 patients were randomised and the peripheral lung lesion was reached in 31. The overall diagnostic yield was 60.5% and, in the lesions reached by EBUS, it was 74.2%. In 19 cases, the diagnosis was made with forceps as well as cryobiopsy and, in four cases, only with cryobiopsy. Cryobiopsies were significantly larger than forceps biopsies (11.17 mm2 versus 4.69 mm2, p<0.001). We observed one case of moderate bleeding. Transbronchial cryobiopsy with EBUS guidance is safe and useful to obtain histological samples. Larger tissue samples can be obtained by cryoprobe. Transbronchial cryobiopsy with EBUS-guidance is safe and useful to obtain samples from peripheral lesions http://ow.ly/pPry9

Diagnostic value of endobronchial and endoscopic ultrasound-guided fine needle aspiration for accessible lung cancer lesions after non-diagnostic conventional techniques: a prospective study

BackgroundLung cancer diagnosis is usually achieved through a set of bronchoscopic techniques or computed tomography guided-transthoracic needle aspiration (CT-TTNA). However these procedures have a variable diagnostic yield and some patients remain without a definite diagnosis despite being submitted to an extensive workup. The aim of this study was to evaluate the efficacy and cost of linear endobronchial (EBUS) and endoscopic ultrasound (EUS) guided fine needle aspiration (FNA), performed with one echoendoscope, for the diagnosis of suspicious lung cancer lesions after failure of conventional procedures.MethodsOne hundred and twenty three patients with an undiagnosed but suspected malignant lung lesion (paratracheal, parabronchial, paraesophageal) or with a peripheral lesion and positron emission tomography positive mediastinal lymph nodes who had undergone at least one diagnostic flexible bronchoscopy or CT-TTNA attempt were submitted to EBUS and EUS-FNA. Patients with endobronchial lesions were excluded.ResultsOf the 123 patients, 88 had a pulmonary nodule/mass and 35 were selected based on mediastinal PET positive lymph nodes. Two patients were excluded because an endobronchial mass was detected at the time of the procedure. The target lesion could be visualized in 121 cases and FNA was performed in 118 cases. A definitive diagnosis was obtained in 106 cases (87.6%). Eighty-eight patients (72.7%) had non-small cell lung cancer, 15 (12.4%) had small cell lung cancer and metastatic disease was found in 3 patients (2.5%). The remaining 15 negative cases were subsequently diagnosed by surgical procedures. Twelve patients (9.9%) had a malignant tumor and in 3 (2.5%) a benign lesion was found. The overall sensitivity, specificity, positive and negative predictive values of EBUS and EUS-FNA to diagnose malignancy were 89.8%, 100%, 100% and 20.0% respectively. The diagnostic accuracy was 90.1% in a population with 97.5% prevalence of cancer. The ultrasonographic approach avoided expensive surgical procedures and significantly reduced costs (p < 0.001).ConclusionsLinear EBUS and EUS-FNA are able to improve the diagnostic yield of suspicious lung cancer lesions after non-diagnostic conventional techniques. These techniques, performed with one scope, can be offered to patients with accessible lesions as an intermediate step for diagnosis since they may avoid more invasive procedures and hence reduce costs.

The diagnostic value of transthoracic ultrasonographic features in predicting malignancy in undiagnosed pleural effusions: a prospective observational study.

Background: Transthoracic ultrasound (US) is an important instrument to identify pleural effusions and safely conduct invasive procedures. It also allows systematic scanning of the pleural surface, though its value remains uncertain for differentiation between malignant (MPE) and nonmalignant pleural effusion (non-MPE) in routine clinical practice. Objectives: To evaluate the utility of US features to predict malignancy in undiagnosed pleural effusions in a real-life clinical setting. Methods: The US features of 154 consecutive patients with a pleural effusion were prospectively assessed. Anonymous images were recorded by an operator blinded to the clinical and radiological results. The US findings were classified by independent reviewers and compared to the final diagnosis. Results: A total of 133 patients were included (age 67 ± 16 years; BMI 25.1 ± 4.6; 54.1% females). The final diagnosis was MPE in 66 cases and non-MPE in 67 cases. US had an overall sensitivity of 80.3%, a specificity of 83.6%, and positive and negative predictive values of 82.8 and 81.2%, respectively, for the detection of malignancy. US accuracy was 81.9%. The presence of pleural/diaphragmatic nodules, pleural/diaphragmatic thickness >10 mm, and a swirling sign was significantly different between both groups (p < 0.001). Lung air bronchogram sign and a septated US pattern were more common in non-MPE patients (p < 0.01). The existence of nodularity and the absence of air bronchograms were more likely to indicate malignancy (OR 29.0, 95% CI 7.65-110.08 and OR 10.4, 95% CI 1.65-65.752, respectively). Conclusions: In the presence of an undiagnosed pleural effusion, US morphological characteristics can aid in differentiating MPE from non-MPE. Pleural/diaphragmatic nodularity was the most relevant feature although no finding was pathognomonic of MPE.

Cytokeratin 19, Carcinoembryonic Antigen, and Epithelial Cell Adhesion Molecule Detect Lung Cancer Lymph Node Metastasis in Endobronchial Ultrasound-Guided Transbronchial Aspiration Samples

INTRODUCTION Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) holds promise for accurate examination of mediastinal lymph nodes in NSCLC patients. However, it is not always possible to achieve a definitive diagnosis or subtype all cases. We aimed to evaluate the role of EBUS-TBNA combined with quantitative reverse transcription polymerase chain reaction (qRT-PCR) and flow cytometry (FCM) to assess tumor-associated antigens and immune responses to identify metastases and pathological patterns in lymph node aspirates. PATIENTS AND METHODS EBUS-TBNA samples from patients with NSCLC (n = 33) and nonmalignant diseases (n = 17) were prospectively collected. Cytokeratin 19 (CK-19), carcinoembryonic antigen (CEA), epithelial cell adhesion molecule (EPCAM), sialyl-Lewis(x), CD44, and the immune compartment were analyzed using qRT-PCR and FCM. RESULTS In the NSCLC patients, the epithelial cell compartment was significantly increased (30.8% vs. 12% CD45⁻ CK-19⁺ cells) and showed brighter CK-19 staining than controls (P = .039) using FCM. Carcinoembryonic antigen was exclusively expressed by the NSCLC epithelial compartment (35% of the cases) and absent in controls. The NSCLC immune compartment showed an increased monocyte population (P = .04), and decreased lymphocyte subpopulations, anticipating a disruption in the distribution of myeloid and lymphoid immune cells. Quantitative reverse transcription polymerase chain reaction showed that CK-19, CEA, and EPCAM transcripts were significantly higher in NSCLC. A positive correlation between the primary tumor lesion size and EPCAM (ρ = 0.476; P = .005), CK-19 (ρ = 0.594; P = .001), and CEA (ρ = 0.394; P = .023) was also found. CONCLUSION The identification of CK-19, CEA, and EPCAM in EBUS-TBNA samples using FCM and qRT-PCR is feasible and might further aid in the detection of NSCLC lymph node metastasis.

Ecoendoscopia brônquica: Aspectos práticos e aplicabilidade clínica

Resumo A ecoendoscopia bronquica constitui, na area da broncologia, um dos maiores avancos tecnologicos dos ultimos anos. Existe, no presente momento, evidencia cientifica que confirma a sua utilidade nao so no diagnostico e estadiamento do cancro do pulmao, como tambem noutras patologias. E fundamental que o broncologista execute e interprete este metodo de imagem correctamente, de forma a optimizar o diagnostico e o tratamento dos seus doentes. O presente artigo faculta uma revisao de cariz eminentemente pratico dos dois sistemas de ecoendoscopia actualmente disponiveis, abordando, igualmente, as suas principais indicacoes clinicas. Rev Port Pneumol 2008; XIV (1): 55-88

Immature myeloid cells and tolerogenic cytokine profile in lung adenocarcinoma metastatic lymph nodes assessed by endobronchial ultrasound

In lung cancer, the immune cell compartment of tumor-draining lymph nodes (TDLNs) dictate the response against tumors. This response is predominantly triggered by myeloid antigen-presenting cells (mAPCs) that capture antigens and, if matured, prime anti-tumor-specific T cell populations. However, the clinical role of mAPCs infiltrated in TDLN from lung cancer patients is poorly understood. The purpose of this study was to study mAPCs in TDLN from lung adenocarcinoma patients, in comparison to individuals with non-malignant diseases, using minimally invasive sampling methods. Mediastinal lymph nodes were assessed by endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). mAPCs were characterized by flow cytometry and cytokine expression by quantitative polymerase chain reaction. The association with tumor burden, overall survival, and response to treatment was assessed. TDLN from lung adenocarcinoma patients (n = 24) showed a reduced immune cell compartment, but a higher level of infiltrating mAPCs, when compared with control lymph nodes (n = 17). A decreased expression of co-stimulatory molecules CD80/CD86 by TDLN and blood mAPC was observed. TDLN showed lower levels of TNF-α and IL-12 and increased levels of immunosuppressive cytokines TGF-β and IL-10. The IL-12 expression was inversely correlated with the percentage of infiltrated tumor cells, while IL-10 was directly correlated. Patients with lower expression of IL-12 in TDLN or lower expression of CD80/86 in blood mAPCs had worse overall survival and response to therapy. mAPCs of lung adenocarcinoma patients express less co-stimulatory molecules, and within TDLN, the cytokine profile is biased towards a tolerance-inducing phenotype. Patients with enhanced immune parameters have better survival and response to treatment. EBUS-TBNA allows the collection of viable specimens from TDLN that may provide further insight on relevant immunological mechanisms.

Árgon-plasma no tratamento de leiomioma benigno metastizante pulmonar, um caso clínico

Benign metastasizing leiomyomas of the lung are rare smooth muscle cells tumours. We report the case of a 48 year-old female who was evaluated due to persistent cough, progressive dyspnoea and constitutional symptoms. Chest computed tomography revealed a left endobronchial mass, multiple parenchyma nodules and a pleural effusion. Bronchial biopsy histological features were consistent with benign metastasizing leiomyoma. The patient was successfully treated with argon-plasma and mechanical debulking. There was no disease relapse in the last four years.

Semi-invasive aspergillosis in an immunocompetent patient with Swyer-James-MacLeod Syndrome: a case report

IntroductionInvasive and semi-invasive pulmonary aspergillosis usually occurs in immunocompromised patients. It has been described occasionally in patients with normal immunity and previous lung disease such as chronic obstructive pulmonary disease.Swyer-James-MacLeod Syndrome is a rare condition characterized by hyperlucency of one lung, lobe or part of a lobe due to decreased vascularity and air trapping.Case presentationWe report a case of semi-invasive pulmonary aspergillosis in a 38-year-old Portuguese, Caucasian man who is immunocompetent, with a pre-existing Swyer-James-McLeod Syndrome, a structural lung disease.ConclusionsTo the best of our knowledge, this is the first reported case in the literature on the relationship between these two diseases. Although rare, aspergillosis can occur in immunocompetent adults with a pre-existing lung disease other than chronic obstructive pulmonary disorder.

Endobronchial ultrasound: Practical aspects and clinical applications

Endobronchial ultrasound (EBUS) has become a major advance in bronchoscopy. Substantial scientific evidence has confirmed its usefulness in lung cancer diagnosis and staging, as well as in other clinical settings. It is of growing importance that endoscopists perform and interpret this imaging method accurately, in order to optimize diagnosis and treatment of their patients. The present article provides a practical and comprehensible review of the two EBUS systems currently available and its main clinical indications.