Kassem Harris

Comparison of Moderate versus Deep Sedation for Endobronchial Ultrasound Transbronchial Needle Aspiration

RATIONALE Most bronchoscopic procedures are performed using moderate sedation achieved by combining a short-acting benzodiazepine with an opioid agent. Propofol (2.6-diisopropylphenol), a short-acting hypnotic agent, has been increasingly used to provide deep sedation in the endoscopy community with an acceptable safety profile. OBJECTIVES To compare the impact of moderate versus deep sedation on the adequacy and diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). METHODS A retrospective review of prospectively collected data was performed at two academic institutions with interventional pulmonary fellowships using two methods of sedation during EBUS (deep vs. moderate sedation). Rapid on-site cytologic evaluation was used on all procedures in both groups. EBUS-TBNA nodal sampling was considered adequate if the aspirate yielded a specific diagnosis or lymphocytes. EBUS-TBNA was considered diagnostic if a lymph node aspirate yielded a specific diagnosis or if subsequent surgical sampling or prolonged radiographic surveillance revealed no nodal pathology. MEASUREMENTS AND MAIN RESULTS No difference was observed in the indication for EBUS-TBNA between the two groups. More lymph nodes were sampled per patient in the deep sedation group (314 nodes from 163 patients; 2.2 nodes per patient) than in the moderate sedation group (181 lymph nodes from 146 patients; 1.4 nodes per patient; P < 0.01). The EBUS-TBNA diagnostic yield was higher for the deep sedation group (80% of patients) than for the moderate sedation group (66% of patients; P < 0.01). CONCLUSIONS Diagnostic yield and number of lymph nodes sampled using deep sedation is superior to moderate sedation in patients undergoing EBUS-TBNA. Prospective studies accounting for other factors including patient selection and cost are needed.

The use of convex probe endobronchial ultrasound-guided transbronchial needle aspiration in a pediatric population: A multicenter study

The presence of intrathoracic lymphadenopathy and mediastinal masses in the pediatric population often presents a diagnostic challenge. With limited minimally invasive methodologies to obtain a diagnosis, invasive sampling via mediastinoscopy or thoracotomy is often pursued. Endobronchial ultrasound transbronchial needle aspiration (EBUS‐TBNA) is a minimally invasive, outpatient procedure that has demonstrated significant success in the adult population in the evaluation of such abnormalities. Within the pediatric literature there is limited data regarding the use of EBUS‐TBNA. We report the first multicenter review of a pediatric population undergoing EBUS‐TBNA procedures identifying the feasibility, safety, utility, and outcomes of this procedure.

Ovarian vein thrombosis in the nonpregnant woman: an overlooked diagnosis

Ovarian vein thrombosis (OVT) is a rare condition occurring in 1/600 to 1/2000 pregnancies [Dunnihoo et al. 1991; Ortin et al. 2005] mainly in the postpartum setting. It is also known to be associated with other conditions such as malignancy, pelvic inflammatory disease, inflammatory bowel disease, sepsis and recent pelvic or abdominal surgery [Andre et al. 2004; Heavrin and Wrenn, 2008; Jacoby et al. 1990; Klima and Snyder, 2008; Marcovici and Goldberg, 2000; Salomon et al. 1999; Simons et al. 1993]. It is extremely rare to find OVT without identified etiology and, hence, idiopathic OVT is only described as case reports throughout the literature. Here, we report a unique case of idiopathic isolated OVT that presented with right flank pain and an abdominal mass. Although four similar cases of idiopathic isolated OVT have been reported in the literature [Heavrin and Wrenn, 2008; Murphy and Parsa, 2006; Stafford et al. 2010; Yildirim et al. 2005], none of these patients presented with an abdominal mass. The diagnosis of isolated OVT requires a high index of suspicion. If misdiagnosed, OVT can lead to potentially fatal complications such as sepsis and pulmonary embolism. [Benfayed et al. 2003; Kominiarek and Hibbard, 2006; Maldjian and Zurlow, 1997; Wysokinska et al. 2006]. A 53-year-old postmenopausal woman with a past medical history of hypertension presented to the medical clinic complaining of 1-week history of aching right flank pain that was not associated with fever, dysuria, hematuria, nausea, vomiting, diarrhea or vaginal discharge. The patient denied any other constitutional symptoms. She is a nonsmoker with no family history of hematologic disorders. On physical examination, she was afebrile, normotensive, without tachycardia. Pelvic exam revealed a nontender, normal size uterus and adnexa. However, a 3 cm tender mass was palpated in the right lower quadrant. Laboratory data revealed a white blood cell count of 4400-cells/mm3 and hemoglobin level 11.9 g/dl. Renal function and electrolytes were within normal limits. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast showed right ovarian vein thrombus without extension to the inferior vena cava (IVC) (Figure 1). Figure 1. CT scan at presentation. Further work up for hypercoagulability was negative. Age- and sex-appropriate cancer screenings were all negative. Moreover, screening for ovarian pathology, with pelvic ultrasound and CA-125, was also normal. Shortly after the diagnosis of isolated OVT, the patient was placed on oral anticoagulation. It was elected not to administer antibiotics. Warfarin was continued for 5 months with the International Normalized Ratio (INR) maintained between 2 and 3. A follow-up CT scan of the abdomen and pelvis performed 5 months later showed persistence of the thrombus with no further extension beyond the ovarian vein (see Figure 2). Anticoagulation was discontinued at this point with close clinical follow up. Figure 2. CT scan after 5 months of anticoagulation therapy. Ovarian vein thrombosis was first described by Austin in 1956 [Austin, 1956]. It occurs in the right side in 70–90% of cases, and bilaterally in 11–14% [Baran and Frisch, 1987; Prieto-Nieto et al. 2004]. The most widely accepted hypothesis for the higher incidence on the right is that the right ovarian vein is longer than the left, and lacks competent valves. The typical presentation is the triad of pelvic pain, fever, and a right-sided abdominal mass [Dessole et al. 2003; Dunnihoo et al. 1991; Klima and Snyder, 2008; Prieto-Nieto et al. 2004]. Fever is present in 80% and right iliac fossa pain in 55% of the patients [Prieto-Nieto et al. 2004]. Given the nonspecific presenting symptoms, prompt diagnosis of OVT requires a high index of suspicion. The differential diagnosis includes most conditions that affect the abdominal lower quadrant such as acute appendicitis and inflammatory bowel diseases. Therefore, imaging studies are essential to establish the diagnosis of OVT. Magnetic resonance angiography (MRA) has the highest sensitivity and specificity that approaches 100%. CT scan with intravenous contrast enhancement has a sensitivity of 77.8% and specificity of 62.5%. Color Doppler ultrasound has the lowest sensitivity of 55.6% and a specificity of 41.5% among other imaging modalities [Kubik-Huch et al. 1999]. A delay in the diagnosis and treatment of OVT can lead to potentially life-threatening complications, such as thrombus extension into the IVC or ileofemoral vessels and eventually the evolution of pulmonary arterial embolization. The incidence of pulmonary embolism is approximately 25% in patients with untreated OVT and the mortality in these patients can reach about 4% [Benfayed et al. 2003; Dunnihoo et al. 1991; Kominiarek and Hibbard, 2006]. Other serious complications include septic thrombophlebitis and, rarely, infectious emboli [Dessole et al. 2003; Heavrin and Wrenn, 2008]. Ovarian vein thrombosis can resolve spontaneously but considering the potential catastrophic consequences, anticoagulation is usually recommended [Wysokinska et al. 2006]. There is no definite guideline regarding the duration of anticoagulation therapy. Wysokinska and colleagues studied the incidence and the recurrence of OVT compared with lower extremity deep venous thrombosis (DVT) [Wysokinska et al. 2006]. None of the 35 patients in the OVT group was idiopathic and the recurrence rate was comparable to patients diagnosed with lower extremity DVT (3 per 100 patient years of follow up). The average treatment with warfarin was 5.3 and 6.9 months for OVT and lower extremity DVT, respectively. Based on these findings, the authors suggested the application of lower extremity guidelines for the treatment of OVT. Antibiotics can also be administered for approximately 7 days especially in cases of postpartum OVT [Brown and Munsick, 1971; Dessole et al. 2003; Maldjian and Zurlow, 1997; Wysokinska et al. 2006]. In patients with hypercoagulable disorders, anticoagulation may need to be lifelong therapy [Wysokinska et al. 2006]. In rare cases of persistent OVTs, an IVC filter or surgical intervention to ligate the ovarian vein can be considered [Carr and Tefera, 2006; Clarke and Harlin, 1999]. Our patient was diagnosed with an idiopathic OVT since none of the above predisposing factors for OVT were found. The patient’s abdominal pain subsided few days after starting anticoagulation and she did not develop any worrisome signs such as fever, dyspnea, or chest pain. Five years later, the patient remains asymptomatic while off anticoagulation, without any further thrombotic conditions. To date, four cases of idiopathic OVT were described [Heavrin and Wrenn, 2008; Murphy and Parsa, 2006; Stafford et al. 2010; Yildirim et al. 2005]. None of these cases had abdominal or pelvic palpable masses at presentation. Therefore, our report describes a unique case of idiopathic OVT presenting with one symptom and one sign of the typical triad. The palpable mass in the right iliac fossa was only described in cases of OVT that occur in the postpartum period as well as in other inflammatory and hypercoagulable conditions. OVT is a rare condition with potential life-threatening complications. In female patients presenting with lower quadrant pain, with or without fever or palpable abdominal or pelvic mass, OVT should be considered in the differential diagnosis after ruling out other common conditions. MRA and CT scan with intravenous contrast are the most useful imaging modalities to diagnose this condition. Overlooking this diagnosis can lead to life-threatening conditions, such as pulmonary embolism, sepsis, and even death. Hence, prompt diagnosis of OVT requires a high index of suspicion in order to prevent these outcomes.

Photodynamic Therapy of Non–Small Cell Lung Cancer. Narrative Review and Future Directions

Photodynamic therapy (PDT) is an established treatment modality for non-small cell lung cancer. Phototoxicity, the primary adverse event, is expected to be minimized with the introduction of new photosensitizers that have shown promising results in phase I and II clinical studies. Early-stage and superficial endobronchial lesions less than 1 cm in thickness can be effectively treated with external light sources. Thicker lesions and peripheral lesions may be amenable to interstitial PDT, where the light is delivered intratumorally. The addition of PDT to standard-of-care surgery and chemotherapy can improve survival and outcomes in patients with pleural disease. Intraoperative PDT has shown promise in the treatment of non-small cell lung cancer with pleural spread. Recent preclinical and clinical data suggest that PDT can increase antitumor immunity. Crosslinking of signal transducer and activator of transcription-3 molecules is a reliable biomarker to quantify the photoreaction induced by PDT. Randomized studies are required to test the prognosis value of this biomarker, obtain approval for the new photosensitizers, and test the potential efficacy of interstitial and intraoperative PDT in the treatment of patients with non-small cell lung cancer.

Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review

Abstract The bronchoscopic procedures have seen a remarkable increase in both numbers and complexity. Although many anesthesia providers have kept pace with the challenge, the practice is varied and frequently suboptimal. Shared airway during bronchoscopy poses unique challenges. The available reviews have tried to address this lacuna; however, these have frequently dealt with the technical aspects of bronchoscopy than anesthetic challenges. The present review provides evidence-based management insights into anesthesia for bronchoscopy—both flexible and rigid. A systematic approach toward pre-procedural evaluation and risk stratification is presented. The possible anatomical and physiological factors that can influence the outcomes are discussed. Pharmacological principles guiding sedation levels and appropriate selection of sedatives form the crux of safe anesthetic management. The newer and safer drugs that can have potential role in anesthesia for bronchoscopy in the near future are discussed. Ventilatory strategies during bronchoscopy for prevention of hypoxia and hypercarbia are emphasized.

Leiomyosarcoma of the pulmonary artery diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration

Leiomyosarcoma of the pulmonary vasculature is an extremely rare condition that has not been previously diagnosed by endobronchial ultrasound (EBUS) bronchoscopy. We present the case of a 43-year-old white male with a history of leiomyosarcoma who was diagnosed with pulmonary embolism 2 years ago. As the filling defects on follow-up chest computed tomography continued to worsen despite anticoagulation, EBUS-guided transbronchial needle aspiration (EBUS-TBNA) of the right pulmonary artery lesion was safely and successfully performed. Cytopathological examination revealed the “thrombus” to be metastatic leiomyosarcoma. In experienced hands, and carefully selected cases, EBUS-TBNA seems to be a safe and effective in diagnosing thoracic endovascular lesions.

Endobronchial ultrasound-guided transbronchial needle aspiration of pulmonary artery tumors: A systematic review (with video).

Convex probe endobronchial ultrasound (CP-EBUS) was originally introduced as a diagnostic and staging tool for lung cancer and subsequently utilized for diagnosis of other malignant and benign mediastinal diseases such as melanoma, lymphoma, and sarcoidosis. More recently, CP-EBUS has been successfully used for the visualization and diagnosis of pulmonary emboli and other vascular lesions including primary and metastatic pulmonary artery (PA) tumors. In this review, we will underline the role of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of pulmonary arterial tumors such as sarcomas and tumor emboli. We will concisely discuss the clinical applications of EBUS-TBNA and the types of pulmonary arterial tumors and their different diagnostic modalities. We searched the Cochrane Library and PubMed from 2004 to 2014 to provide the most comprehensive review. Only 10 cases of EBUS-TBNA for intravascular lesions were identified in the literature. Although many cases of EBUS and EUS-guided transvascular tumor biopsies were described in the literature, there were no reported cases of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for intravascular tumor biopsies. Except for one paper, all cases were published as case reports.

Recent Advances in Bronchoscopic Treatment of Peripheral Lung Cancers

The detection of peripheral lung nodules is increasing because of the expanded use of CT imaging and implementation of lung cancer screening recommendations. Although surgical resection of malignant nodules remains the treatment modality of choice at present, many patients are not surgical candidates, thus prompting the need for other therapeutic options. Stereotactic body radiotherapy (SBRT) and percutaneous thermal ablation are emerging as viable alternatives to surgical resection. For safety, efficacy, and cost-effectiveness purposes, however, alternative bronchoscopic methods for treatment of peripheral lung cancer are currently under active exploration. We searched the Cochrane Library and MEDLINE from 1990 to 2015 to provide the most comprehensive review of bronchoscopic treatment of malignant lung nodules. We used the following search terms: bronchoscopy, lung nodule, peripheral lung lesion, and bronchoscopic treatment. We focused on peripheral pulmonary nodules that are confirmed or highly likely to be malignant. Seventy-one articles were included in this narrative review. We have provided an overview of advanced bronchoscopic modalities that have been used or are under active investigation for definitive treatment of malignant pulmonary nodules. We have concisely discussed the use of direct intratumoral chemotherapy or gene therapies, transbronchial brachytherapy, bronchoscopy-guided radiofrequency ablation (RFA), placement of markers to guide real time-radiation and surgery, cryotherapy, and photodynamic therapy. We have also briefly reported on emerging technologies such as vapor ablation of lung parenchyma for lung cancers. Advances in bronchoscopic therapy will bring additional treatment options to patients with peripheral lung malignancies, with putative advantages over other minimally invasive modalities.

Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis

BACKGROUND: The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions. METHODS: We conducted a systematic review and meta‐analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study. RESULTS: Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%‐65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%‐24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%‐4.7%); loculation, 2.0% (95% CI, 0.0%‐4.7%); dislodgement, 1.3% (95% CI, 0.0%‐3.7%); leakage, 1.3% (95% CI, 0.0%‐3.5%); and pneumothorax, 1.2% (95% CI, 0.0%‐4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%‐4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%‐3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%‐4.0%); and other, 2.5% (95% CI, 0.0%‐5.2%). One death was directly related to IPC use. CONCLUSIONS: IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high‐quality studies such as randomized controlled trials are needed.

Original Research: Pulmonary ProceduresManagement of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis

BACKGROUND: The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions. METHODS: We conducted a systematic review and meta‐analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study. RESULTS: Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%‐65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%‐24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%‐4.7%); loculation, 2.0% (95% CI, 0.0%‐4.7%); dislodgement, 1.3% (95% CI, 0.0%‐3.7%); leakage, 1.3% (95% CI, 0.0%‐3.5%); and pneumothorax, 1.2% (95% CI, 0.0%‐4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%‐4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%‐3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%‐4.0%); and other, 2.5% (95% CI, 0.0%‐5.2%). One death was directly related to IPC use. CONCLUSIONS: IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high‐quality studies such as randomized controlled trials are needed.