Helen Doran

EBUS-TBNA in Elderly Patients with Lung Cancer: Safety and Performance Outcomes

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) enables minimally invasive lymph node sampling during bronchoscopy under conscious sedation. The primary purpose of this study was to investigate the safety profile of EBUS-TBNA in an elderly population. The secondary aim was to assess the efficacy of EBUS-TBNA for nodal staging and pathological diagnosis in elderly patients with primary lung cancer. Methods: This was a prospective cohort study of patients undergoing EBUS-TBNA, between March 2010 and August 2012, at a single U.K. hospital site. Procedure and outcome data including 6-month follow-up were collected prospectively. Patients were divided into less than 70 (<70yrs) or 70 and older (≥70yrs) age categories for analysis. Results: Four hundred and fifty-one patients underwent EBUS-TBNA during the study period. Mean age of the patients was 66.9 ± 11.9 years, 43.9% (n=198) of them were aged ≥70yrs. Older patients (≥70yrs) had a worse performance status (p=0.0001) and required significantly lower levels of sedation (p<0.000001) but had similar overall complication rates (<70yrs 8.7% versus ≥70yrs 5.1%; p=0.13) and tolerated the procedure better than younger patients (p=0.036). Sensitivity (92.9% versus 86.4%; p=0.12) was equivalent, but negative predictive value (91.8% versus 73.9%; p=0.001) and diagnostic accuracy (96.0% versus 90.2%; p=0.02) of nodal sampling in patients with confirmed or suspected lung cancer (n=273) was higher in the ≥70yrs cohort (n=131, 48.0%). However, the prevalence of nodal malignancy was significantly different between the two groups as was the proportion of patients subject to surgical lymph node sampling after negative EBUS-TBNA. EBUS-TBNA samples produced low non–small-cell lung cancer–not otherwise specified rates (6.9%) and high levels of successful epidermal growth factor receptor mutation analysis (97.5%) irrespective of age category. Conclusion: EBUS is a safe and well-tolerated procedure in elderly patients, which facilitates accurate pathological diagnosis and minimally invasive staging in patients with lung cancer.

Olanzapine-induced eosinophilic pleuritis

An elderly patient, with a history of depression with psychosis, presented with breathlessness, a right exudative pleural effusion and a peripheral eosinophilia. The pleural fluid was eosinophil-rich (10% of leucocytes). Olanzapine therapy had been commenced 12 months previously. There was a family history of TB and the patient was of African origin. A full diagnostic work-up ensued including computed tomography of the thorax and local anaesthetic thoracoscopy. The pleura was unremarkable on CT and displayed bland smooth thickening at visual inspection during thoracoscopy. Pleural biopsies demonstrated chronic inflammation with eosinophils but no evidence of granulomatous inflammation or malignancy. Pleural tissue culture did not yield mycobacteria. A diagnosis of olanzapine-induced eosinophilic pleuritis was suspected and the pleural disease resolved with withdrawal of olanzapine. Eosinophilic pleural fluid is not a marker of non-malignant aetiology and eosinophilic pleural effusions require a careful and systematic diagnostic work-up. This is the second case report to identify olanzapine as a causative agent in eosinophilic pleural effusion.

EBUS-guided mediastinal lung cancer staging: monitoring of quality standards improves performance

This audit examined key performance indices related to endobronchial ultrasound (EBUS)-guided mediastinal lung cancer staging before and after the introduction of defined quality standards, at four independent EBUS centres in one cancer network. Data from 642 procedures were prospectively collected and analysed. The introduction of standards was associated with a significant increase (p<0.001) in sampling of key mediastinal lymph node stations (4R, 4L and 7) and a reduction in the variability of staging sensitivity between centres. These data reinforce the requirement for an appropriate regulatory framework for EBUS-transbronchial needle aspiration provision that includes quality assurance and performance monitoring.

A case of pulmonary cryptococcoma due to Cryptococcus gattii in the United Kingdom

We report a case of Cryptococcus gattii infection in the UK in a 76-year-old woman on biologic therapy for intra-abdominal non-Hodgkin lymphoma. An incidental nodular lung lesion was found on a chest imaging and histology, culture and molecular mycology studies of the lobectomy specimen revealed the presence of C. gattii.

Pathological Non-rejection Findings in the Endomyocardial Biopsy

Heart transplant patients undergo regular endomyocardial biopsies to assess rejection, but a range of other histological findings need to be recognised and distinguished from cellular and antibody-mediated rejection. Some of these findings will require treatment in their own right; others need to be identified to avoid unnecessary treatment. Some changes in the early postoperative period should not be over-interpreted as early rejection. ‘Quilty’ effect is due to immunosuppressive therapy and resembles cellular rejection without the same clinical outcome. Later differentials include complications associated with transplantation such as infection, ischaemia due to cardiac allograft vasculopathy and lymphoproliferative disorders. Viral infection may produce a lymphocytic infiltrate difficult or even impossible to distinguish from cellular rejection. The primary disease may recur. Repeated biopsies themselves cause changes in the endomyocardium of the right ventricle; other structures such as valves, epicardium or liver fragments may be sampled. Pathologists should be aware of all these possibilities.

Referral patterns for mediastinal staging with EBUS across a UK Lung Cancer Network: A report from the Manchester Cancer EBUS sub-group.

Manchester Cancer is a large Cancer Network in the North West f England, consisting of ten National Health Service (NHS) Trusts. n 2012, 2302 patients were diagnosed with lung cancer across this etwork. In the same year the number of centres providing Endoronchial Ultrasound (EBUS) within the Network increased from ne to four. This led the commissioners to introduce a service specfication for all EBUS centres that mandated the collection of data n relation to referral pathways, indication and performance, and rompted the formation of an EBUS sub-group. Therefore, for the calendar year 2012 the EBUS sub-group has ata for all EBUS referrals from each of the ten NHS trusts in our Netork (from the EBUS database) as well as the number of lung cancer atients diagnosed at each trust (from the National Lung Cancer udit Report 2013). From this data we could calculate the proortion of lung cancer patients from each trust that were referred or mediastinal staging with EBUS. We postulated there may be elationship between a trust’s EBUS referral rate and the surgical esection rate for non-small cell lung cancer (NSCLC) at that trust. pearman correlation was used to ascertain if such a relationship ay exist. The 2013 National Lung Cancer Audit Report confirms that 2302 atients were diagnosed with lung cancer in this Network in the calndar year of 2012. In the same period, 302 patients were referred or EBUS-TBNA, 193 patients for the purpose of mediastinal stagng. Therefore, only 8.4% of all lung cancer patients underwent ediastinal staging with EBUS across the Network. The proporion of lung cancer patients referred for mediastinal staging with BUS varied significantly across the ten trusts ranging from 3.4% o 30.2% (p < 0.0001, Table 1). The spearman co-efficient was 0.60 p = 0.07) suggesting a possible relationship between the proporion of patients referred for EBUS and surgical resection (Fig. 1). owever, this may be due to a very high rate of staging EBUS at ne trust, which if excluded yields a spearman co-efficient of 0.45 p = 0.22). It is highly concerning that only 8% of lung cancer patients nderwent EBUS nodal staging in our network, given the results f two recent UK population based studies in lung cancer. Both tudies, totalling nearly 100,000 patients, reported that 52% of UK

42 Endobronchial ultrasound (EBUS)-guided transbronchial biopsy/brush of peripheral pulmonary nodules: an initial cancer centre experience

42 Endobronchial ultrasound (EBUS)-guided transbronchial biopsy/brush of peripheral pulmonary nodules: an initial cancer centre experience L. Brown1, A. Chaturvedi2, H. Doran2, L. Joseph2, P. Bishop2, P.V. Barber1, R. Booton1. 1North West Lung Centre, University Hospital of South Manchester, UK, School of Translational Medicine, University of Manchester, United Kingdom, 2Department of Pathology, University Hospital of South Manchester, United Kingdom