Lina Zuccatosta

Bronchoscopic Treatment of Emphysema: State of the Art

In recent years, different bronchoscopic techniques have been proposed for the treatment of emphysema, with the aim of obtaining the same clinical and functional advantages of lung volume reduction surgical techniques while reducing risks and costs. Such techniques can be classified into: methods employing devices that block the airways (e.g. spigots and unidirectional valves), methods that have a direct effect on the lung parenchyma (polymeric lung volume reduction, coils and thermal vapor ablation) and procedures that facilitate the expiration of trapped air from the emphysematous lung (airway bypass). This review aimed to evaluate the indications, outcomes and safety of the different techniques, based on the evidence from the available literature. Results obtained by these methods are encouraging, but they are still based mainly on studies with small groups of patients. However, several trials are ongoing and in the near future we will acquire more knowledge which should lead to a better optimization of these procedures. Meanwhile, the bronchoscopic treatment of emphysema cannot yet be considered a standard of care and patients should be treated in the context of clinical trials or controlled registries, with well-defined programs of evaluation and follow-up.

The role of the pulmonologist in rapid on-site cytologic evaluation of transbronchial needle aspiration: a prospective study.

BACKGROUND Rapid on-site cytologic evaluation (ROSE) of cytologic specimens is a useful ancillary technique in needle aspiration procedures of pulmonary/mediastinal lesions. ROSE is not a widespread technique, however, because of a lack of time and resources. Our aim was to verify whether, in comparison with a board-certified cytopathologist, a pulmonologist could evaluate the adequacy of transbronchial needle aspiration (TBNA) specimens on-site to diagnose hilar/mediastinal adenopathies/masses after receiving training in cytopathology. Our secondary aim was to assess and compare the accuracy of ROSE as performed by both physicians. METHODS A pulmonologist and a cytopathologist, the latter deemed the gold standard, performed ROSE and classified specimens into five diagnostic categories. Agreement between clinicians was assessed through κ statistics. The accuracy of ROSE was established according to definitive cytologic assessment. RESULTS A total of 362 TBNAs were performed on 84 patients affected by hilar/mediastinal lymphadenopathies. There was an 81% overall substantial agreement between observers (κ, 0.73; 95% CI, 0.61-0.86; P , 0.001), which became excellent in cases of malignant disease (κ, 0.81; 95% CI, 0.70-0.90; P , 0.001). The accuracy of ROSE performed by the pulmonologist (80%; 95% CI, 77-90) was not statistically different from that provided by the cytopathologist (92%; 95% CI, 85-94). CONCLUSIONS Our study provides the first evidence, to our knowledge, that a trained pulmonologist can assess the adequacy of cytologic smears on-site. Training pulmonologists to have a basic knowledge of cytopathology could obviate most difficulties related to the involvement of cytopathologists in routine diagnostic activities and may reduce the costs of the procedure.

Transbronchial Needle Aspiration: A Systematic Review on Predictors of a Successful Aspirate

Background: Transbronchial needle aspiration (TBNA) is a safe and useful sampling technique for the diagnosis of mediastinal adenopathies/masses, but its accuracy seems to be influenced by selected clinical and procedural aspects. Objectives: We performed a systematic review to identify the main predictors of a successful transbronchial aspirate according to different clinical settings. Methods: We searched Medline and Embase for all studies evaluating predictors of TBNA diagnostic yield, published up to February 2012. Two authors reviewed all titles/abstracts and retrieved the full text of articles that are potentially relevant to identify studies according to predefined selection criteria. The methodological quality of studies was assessed through the revised Quality Assessment of Diagnostic Accuracy Studies tool. Evidence synthesis was graded according to overall number of studies, patients involved and methodological features. Results: Fifty-three studies, involving more than 8,000 patients and evaluating 23 potential predictive factors, were included. Major predictors in an unselected population, as well as in patients with suspected/known lung cancer, included lymph node size (short axis length ≥2 cm), presence of abnormal endoscopic findings, subcarinal and right paratracheal location, and the use of histological needle by an experienced bronchoscopist. Stage I and sampling of more than one lymph node stations were the only predictors of a successful TBNA result in patients with suspected sarcoidosis. Conclusions: The diagnostic yield of TBNA depends on selected clinical and procedural features. Knowledge of factors that predict a positive TBNA result may help optimize the diagnostic success of the procedure in different clinical settings.

Clinical predictive factors for advanced non-small cell lung cancer (NSCLC) patients receiving third-line therapy: Selecting the unselectable?

A not negligible proportion of NSCLC patients may be considered eligible for a third-line therapy with a palliative intent. Unfortunately, it is not uncommon to observe toxic side-effects with lack of efficacy. Aim of our study was to analyse clinical factors potentially influencing the global outcome of advanced NSCLC patients receiving third-line therapy. Patients with histologically proven inoperable (IIIB) or metastatic (IV) NSCLC, who received a second- and third-line treatment (either with EGFR-TKIs or chemotherapy), were eligible for our analysis. 143 patients received a second-line treatment after failing a first line cisplatin-based chemotherapy. 52 patients from this series were offered a third-line treatment. In the third-line setting, a better overall survival (months) was related to sex and to response to second-line. Globally, our findings seem to indicate that an improved overall survival in third-line is more strictly dependent on response to second-line, thus suggesting that when planning a third-line treatment, response to second-line should be considered as a relevant factor for the decision making process.

An Unusual Iatrogenic Foreign Body (Surgical Gauze) in the Trachea

We report the case of a 60-year-old male with history of surgery for tracheal stenosis 21 years prior to the onset of difficult asthma-like symptoms. Upon exploring the tracheobronchial tree using the fiberoptic bronchoscope, a surgical gauze was found. The foreign body migrated transluminally from the mediastinum into the trachea and its removal was possible with rigid bronchoscopy leading to a rapid recovery of his symptoms.

Silver nitrate through flexible bronchoscope in the treatment of bronchopleural fistulae

OBJECTIVE Bronchopleural fistula is a severe complication after pneumonectomy or lobectomy. Local application of silver nitrate to seal bronchopleural fistulae was reported once 25 years ago with considerable success but was never repeated. We aimed to develop and evaluate a concrete technique of applying silver nitrate through a flexible bronchoscope to treat bronchopleural fistulae in central airways. METHODS Consecutive patients with small (<or=5 mm) bronchopleural fistulae in proximal airways were included in the study. After measurement of bronchopleural fistula size through a flexible videobronchoscopy, a standard bronchoscopic cytology brush covered with silver nitrate was passed through the working channel of the scope and was rubbed against the fistulas orifice producing blanching and edema on the mucosa. This procedure was repeated until closure of the fistulas orifice (treatment success) or absence of any tissue response after 2 bronchoscopic sessions (treatment failure). RESULTS Of 16 patients referred, 5 were excluded from treatment because of large (>5 mm) fistulae. Among the 11 treated patients (median fistula diameter 3 mm, range 2-5 mm), treatment failure was observed in 2 patients in whom treatment was attempted early (15 days postsurgery). In the remaining 9 patients, treatment success was achieved (81.8% success rate) after a median of 2.5 (range 1-10) applications of silver nitrate. After 11 (0.5-24) months of follow-up, no relapse was observed among successfully treated fistulae. CONCLUSION The local application of silver nitrate through a flexible bronchoscopic brush produced a burn and healing process on the mucosa of small bronchopleural fistulae of the central airways, leading to effective and lasting treatment in most cases.

A PHASE II STUDY OF MITOMYCIN C, VINDESINE AND CISPLATIN COMBINED WITH ALPHA INTERFERON IN ADVANCED NON-SMALL CELL LUNG CANCER

Aims and background MVP chemotherapy (mitomycin C, vindesine or vinblastine, cisplatin) is one of the most commonly used regimens for advanced non-small cell lung cancer (NSCLC). Experimental data suggest a synergistic cytotoxic activity of alpha-interferon (α-IFN) when combined with cisplatin, mitomycin C, and vinca alkaloids. In an effort to improve MVP chemotherapy activity, we have combined this regimen with α-IFN. Patients and methods Thirty-five patients with advanced NSCLC (19 stage IV) were treated with the MVP regimen (mitomycin C, 8 mg/m2; vindesine, 3 mg/m2; cisplatin, 75 mg/m2, all on day 1) plus α-2a-IFN, 3×106 U im from day 1 to 7. The cycles were repeated every 28 days. Results There were no complete responses and 18 partial responses, for an overall response rate of 51%. Median time to treatment failure was 6 months (range, 1-18), and median survival was 9.5 months (range, 1-32). WHO grade 3 toxicity was recorded in up to 8% of patients, flu-like syndrome was a common complaint; one toxic death occurred. Conclusions The combination yielded a level of response comparable to that of other cisplatin-based regimens. Larger randomized trials are needed to assess the role of α-IFN combined with chemotherapy in advanced NSCLC.

Pilot feasibility study of transbronchial needle forceps: a new tool for obtaining histology samples from mediastinal subcarinal lymph nodes.

BackgroundCutting transbronchial histology needles to obtain tissue cores from hilar/mediastinal lymph nodes or masses adjacent to the tracheobronchial tree are able to provide adequate histology tissue samples in only 38% to 78% of cases. The aim of this pilot study was to evaluate the efficacy and safety of a new instrument developed to obtain a fragment of a tissue for histologic diagnosis of enlarged subcarinal lymph nodes. MethodsThe transbronchial needle forceps (TBNF) is a sampling instrument that combines the characteristics of a needle (beveled tip for penetrating through the bronchial wall) with that of a forceps (2 serrated jaws for grasping the biopsy). The external diameter of the needle forceps is 1.5 mm. ResultsFourteen patients (11 male, 3 female; mean age: 51 y) with subcarinal lymph node enlargement greater than 2 cm in short axis were included in this pilot study. TBNF provided tissue for histologic diagnosis in 8 patients (57.1%). In 4 patients (28.5%) TBNF could not be inserted through the bronchial wall. For patients in whom it was possible to insert the TBNF, a tissue core adequate for histologic examination was obtained in 9 (90%) and a diagnosis in 8 (80%) (non-small-cell lung cancer in 3, sarcoidosis in 2, small cell lung cancer in 1, tuberculosis in 1, and Hodgkin lymphoma in 1). No clinically significant procedure-related complications were encountered. ConclusionsThis study demonstrates that, when insertion through the bronchial wall is possible, TBNF safely provides diagnostic histologic specimens of subcarinal lymphadenopathy in a large percentage of cases.

Prognostic Factors in Early Stage Non-Small Cell Lung Cancer: TheImportance of Number of Resected Lymph Nodes and Vascular Invasion

Background: Despite an appropriate surgical treatment, half of early-stage non-small cell lung cancer patients will die due to lung cancer. The number of resected lymph-nodes and vascular invasion has proved to be a prognostic factor in other solid tumors, as well as breast and colorectal cancer. Here we evaluate their prognostic impact in the largest mono-centric series of resected non-small cell lung cancer patients. Methods: Clinical and pathological characteristics and prognostic outcomes of four hundred thirty-nine consecutive patients undergoing radical surgical resection for non-small cell lung cancer at our Institution were evaluated. Results: The multivariate analysis showed that number of resected lymph nodes, vascular invasion and sex had a prognostic impact on overall survival. The optimal cut-off number of lymph nodes with the highest sensitivity and specificity for estimating the outcome was set at ten after Receiver Operating Characteristics curve analysis. Removing ten lymph nodes in our study represents a cut-off with a significant prognostic impact particularly in resected stage II non-small cell lung cancer. Conclusions: Similarly to other cancer types (for example colorectal cancer), our results suggest that an adequate classification of non-small cell lung cancer should always include an adequate lymph nodes clearance, particularly in stage II non-small cell lung cancer. Again vascular invasion resulted independent prognostic factors for overall survival. Therefore the number of resected lymph nodes, together with vascular invasion, may also drive the selection of nonsmall cell lung cancer patients for adjuvant treatment. Lung cancer is one of more aggressive tumor. Lung tumor surgery with loco-regional lymphadenectomy represents the only way for the eradication of neoplastic disease. In particular, an adequate lymph nodes clearance, especially in stage II non-small cell lung cancer may modify prognosis.

Conventional versus Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Hilar/Mediastinal Lymph Adenopathies: A Randomized Controlled Trial

Background: Conventional transbronchial needle aspiration (c-TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are both valuable diagnostic techniques for the diagnosis of hilar/mediastinal lesions. Although a superiority of EBUS-TBNA over c-TBNA may be expected, evidence-based data on a direct comparison between these 2 procedures are still lacking. Objectives: We aimed to test the superiority of EBUS-TBNA over c-TBNA in a randomized trial and to evaluate the cost-effectiveness profile of a staged strategy, including c-TBNA as initial test followed by EBUS-TBNA, in case of inconclusive results at rapid on-site evaluation. Methods: Eligible patients were randomized 1:1 to either the EBUS-TBNA or c-TBNA group. The primary endpoint was to test the superiority of EBUS-TBNA sensitivity over c-TBNA. The secondary endpoints included the sensitivity of the staged strategy, as well as costs and safety related to each procedure and to their sequential combination. Results: A total of 253 patients were randomized to either EBUS-TBNA (n = 127) or c-TBNA (n = 126), and 31 patients of the c-TBNA group subsequently underwent EBUS-TBNA. The sensitivity of EBUS-TBNA was higher, but not significantly superior to that of c-TBNA (respectively. 92% [95% CI 87-97] and 82% [95% CI 75-90], p > 0.05). The sensitivity of the staged strategy was 94% (95% CI 89-98). No major adverse events occurred. Conclusions: EBUS-TBNA was the single best diagnostic tool, although not significantly superior to c-TBNA. Due to the favorable cost-effectiveness profile of their sequential combination, in selected scenarios with a high probability of success from the standard procedure, these should not be necessarily intended as competitive and the staged strategy could be considered in clinical practice.