Mona Sarkiss

Complications, Consequences, and Practice Patterns of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Results of the AQuIRE Registry

BACKGROUND Few studies of endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA) have been large enough to identify risk factors for complications. The primary objective of this study was to quantify the incidence of and risk factors for complications in patients undergoing EBUS-TBNA. METHODS Data on prospectively enrolled patients undergoing EBUS-TBNA in the American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education (AQuIRE)database were extracted and analyzed for the incidence, consequences, and predictors of complications. RESULTS We enrolled 1,317 patients at six hospitals. Complications occurred in 19 patients (1.44%;95% CI, 0.87%-2.24%). Transbronchial lung biopsy (TBBx) was the only risk factor for complications,which occurred in 3.21% of patients who underwent the procedure and in 1.15% of those who did not (OR, 2.85; 95% CI, 1.07-7.59; P 5 .04). Pneumothorax occurred in seven patients(0.53%; 95% CI, 0.21%-1.09%). Escalations in level of care occurred in 14 patients (1.06%;95% CI, 0.58%-1.78%); its risk factors were age . 70 years (OR, 4.06; 95% CI, 1.36-12.12; P 5 .012),inpatient status (OR, 4.93; 95% CI, 1.30-18.74; P 5 .019), and undergoing deep sedation or general anesthesia (OR, 4.68; 95% CI, 1.02-21.61; P 5 .048). TBBx was performed in only 12.6% of patients when rapid on site cytologic evaluation (ROSE ) was used and in 19.1% when it was not used ( P 5 .006).Interhospital variation in TBBx use when ROSE was used was significant ( P , .001). CONCLUSIONS TBBx was the only risk factor for complications during EBUS-TBNA procedures.ROSE significantly reduced the use of TBBx.

Randomized Clinical Trial of Endobronchial Ultrasound Needle Biopsy With and Without Aspiration

BACKGROUND Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (EBUS-TBNA) is performed with a dedicated 22- or 21-gauge needle while suction is applied. Fine-needle sampling without suction (capillary sampling) has been studied for endoscopic ultrasound and for biopsies at various body sites and has resulted in similar diagnostic yield and fewer traumatic samples. However, the role of EBUS-guided transbronchial needle capillary sampling (EBUS-TBNCS) is still to be determined. METHODS Adults with suspicious hilar or mediastinal lymph nodes (LNs) were included in a single-blinded, prospective, randomized trial comparing EBUS-TBNA and EBUS-TBNCS. The primary end point was the concordance rate between the two techniques in terms of adequacy and diagnosis of cytologic samples. The secondary end point was the concordance rate between the two techniques in terms of quality of samples. RESULTS A total of 115 patients and 192 LNs were studied. Concordance between EBUS-TBNA and EBUS-TBNCS was high, with no significant difference in adequacy (88% vs 88%, respectively [P ± .858]; concordance rate, 83.9% [95% CI, 77.9-88.8]); diagnosis (36% vs 34%, respectively [P ± .289]; concordance rate, 95.8% [95% CI, 92-92.8]); diagnosis of malignancy (28% vs 26%, respectively [P ± .125]; concordance rate, 97.9% [95% CI, 94.8-99.4]); or sample quality (concordance rate, 83.3% [95% CI, 73.3-88.3]). Concordance between EBUS-TBNA and EBUS-TBNCS was high irrespective of LN size (≤ 1 cm vs > 1 cm). CONCLUSIONS Regardless of LN size, no differences in adequacy, diagnosis, or quality were found between samples obtained using EBUS-TBNA and those obtained using EBUS-TBNCS. There is no evidence of any benefit derived from the practice of applying suction to EBUS-guided biopsies. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00886847; URL: www.clinicaltrials.gov

Quality gaps and comparative effectiveness in lung cancer staging: The impact of test sequencing on outcomes

BACKGROUND Evidence-based guidelines recommend mediastinal sampling as the first invasive test in patients with suspected lung cancer and mediastinal adenopathy. The goal of this study was to assess practice patterns and outcomes of diagnostic strategies in this patient population. METHODS We conducted a retrospective analysis of all patients in 2009 who had mediastinal adenopathy without distant metastatic disease to determine whether guideline-consistent care was delivered. Guideline-consistent care was defined as mediastinal lymph node sampling being performed as part of the first invasive procedure. RESULTS One hundred thirty-seven patients were included. Guideline-consistent care was provided in 30 cases (22%). Patients receiving guideline-consistent care had fewer invasive tests than patients with guideline-inconsistent care (1.3 ± 0.5 tests/patient vs 2.3 ± 0.5 tests/patient, respectively; P < .0001) and fewer complications (0 of 30, 0% vs 18 of 108, 17%; P = .01). Most of the complications (16 of 18) were related to CT image-guided needle biopsy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was sufficient to guide treatment decisions without any other invasive tests in 88 patients (64%). Although not all the complications and costs due to CT image-guided biopsies could have been avoided, roughly two-thirds could have been eliminated by just changing the testing sequence. CONCLUSION Quality gaps in lung cancer staging in patients with mediastinal adenopathy are common and lead to unnecessary testing and increased complications. In patients with suspected lung cancer without distant metastatic disease with mediastinal adenopathy, EBUS-TBNA should be the first test.

Respiratory Infections Increase the Risk of Granulation Tissue Formation Following Airway Stenting in Patients With Malignant Airway Obstruction

BACKGROUND The most serious complications of airway stenting are long term, including infection and granulation tissue formation. However, to our knowledge, no studies have quantified the incidence rate of long-term complications for different stents. METHODS To compare the incidence of complications of different airway stents, we conducted a retrospective cohort study of all patients at our institution who had airway stenting for malignant airway obstruction from January 2005 to August 2010. Patients were excluded if more than one type of stent was in place at the same time. Complications recorded were lower respiratory tract infections, stent migration, granulation tissue, mucus plugging requiring intervention, tumor overgrowth, and stent fracture. RESULTS One hundred seventy-two patients with 195 stent procedures were included. Aero stents were associated with an increased risk of infection (hazard ratio [HR] = 1.98; 95% CI, 1.03-3.81; P = .041). Dumon silicone tube stents had an increased risk of migration (HR = 3.52; 95% CI, 1.41-8.82; P = .007). Silicone stents (HR = 3.32; 95% CI, 1.59-6.93; P = .001) and lower respiratory tract infections (HR = 5.69; 95% CI, 2.60-12.42; P < .001) increased the risk of granulation tissue. Lower respiratory tract infections were associated with decreased survival (HR = 1.57; 95% CI, 1.11-2.21; P = .011). CONCLUSIONS Significant differences exist among airway stents in terms of infection, migration, and granulation tissue formation. These complications, in turn, are associated with significant morbidity and mortality. Granulation tissue formation develops because of repetitive motion trauma and infection.

Management of malignant pleural effusions

Malignant pleural effusions are a common clinical problem in patients with primary thoracic malignancy and metastatic malignancy to the thorax. Symptoms can be debilitating and can impair tolerance of anticancer therapy. This article presents a comprehensive review of pharmaceutical and nonpharmaceutical approaches to the management of malignant pleural effusion, and a novel algorithm for management based on patients’ performance status.

Infected Mediastinal Bronchogenic Cyst Successfully Treated by Endobronchial Ultrasound-Guided Fine-Needle Aspiration

Bronchogenic cysts are one of the most common bronchopulmonary congenital malformations found in adults. Most authors agree that symptomatic or infected cysts should be surgically removed. We report our experience in which we treated an infected mediastinal bronchogenic cyst with a combination of antibiotics and drainage by endobronchial ultrasound-guided fine-needle aspiration, with resolution of symptoms and no evidence of recurrence after an 18-month follow-up.

Diagnosis of invasive aspergillus tracheobronchitis facilitated by endobronchial ultrasound-guided transbronchial needle aspiration: a case report

IntroductionInvasive pulmonary aspergillosis is the most common form of infection by Aspergillus species among immunocompromised patients. Although this infection frequently involves the lung parenchyma, it is unusual to find it limited to the tracheobronchial tree, a condition known as invasive aspergillus tracheobronchitis.Case presentationA 65 year-old Hispanic man from Bolivia with a history of chronic lymphocytic leukemia developed cough and malaise eight months after having an allogenic stem cell transplant. A computed tomography of the chest revealed an area of diffuse soft tissue thickening around the left main stem bronchus, which was intensely fluorodeoxyglucose-avid on positron emission tomography scanning. An initial bronchoscopic exam revealed circumferential narrowing of the entire left main stem bronchus with necrotic and friable material on the medial wall. Neither aspirates from this necrotic area nor bronchial washing were diagnostic. A second bronchoscopy with endobronchial ultrasound evidenced a soft tissue thickening on the medial aspect of the left main stem bronchus underlying the area of necrosis visible endoluminally. Endobronchial ultrasound-guided transbronchial needle aspiration performed in this area revealed multiple fungal elements suggestive of Aspergillus species.ConclusionWe describe the first case of invasive aspergillus tracheobronchitis in which the diagnosis was facilitated by the use of endobronchial ultrasound guided trans-bronchial needle aspiration. To the best of our knowledge, we are also presenting the first positron emission tomography scan images of this condition in the literature. We cautiously suggest that endobronchial ultrasound imaging may be a useful tool to evaluate the degree of invasion and the involvement of vascular structures in these patients prior to bronchoscopic manipulation of the affected areas in an effort to avoid potentially fatal hemorrhage.

Stents Are Associated With Increased Risk of Respiratory Infections in Patients Undergoing Airway Interventions for Malignant Airways Disease

BACKGROUND Long-term complications of therapeutic bronchoscopy include infections and airway restenosis due to tumor. No studies have compared the incidence rates of infection in patients with stents with those without stents. We hypothesized that patients with stents would have a higher incidence of lower respiratory tract infections than would patients without stents. METHODS We conducted a retrospective cohort study, covering the period September 2009 to August 2011, of patients who had therapeutic bronchoscopy for malignant airways disease. Outcomes recorded were lower respiratory tract infection and airway restenosis by tumor. RESULTS Seventy-two patients had therapeutic bronchoscopy for malignant airways disease. Twenty-four of these patients had one or more stents placed. Twenty-three of the 72 patients (32%) developed lower respiratory tract infections. Stents were associated with an increased risk of infection (hazard ratio [HR], 3.76; 95% CI, 1.57-8.99; P = .003). The incidence rate of lower respiratory tract infection was 0.0057 infections per person-day in patients with stents vs 0.0011 infections per person-day in patients without stents. The incidence rate difference, 0.0046 infections per person-day, was significant (95% CI, 0.0012-0.0081; P = .0002). Restenosis due to tumor overgrowth was associated with more severe obstruction at baseline (obstruction ≥ 50% vs < 50% preprocedure; HR, 13.71; 95% CI, 1.75-107.55; P = .013). CONCLUSION Therapeutic bronchoscopy with stent placement is associated with a higher risk of infection than is therapeutic bronchoscopy alone. If ablative techniques reopen the airway and there is a good chance that the tumor may respond to chemotherapy and/or radiation, a strategy of initially holding off on stenting may be warranted.

Complete mediastinal and hilar lymph node staging of primary lung cancer by endobronchial ultrasound: Moderate sedation or general anesthesia?

We are responding to the concerns raised by Rice and colleagues regarding the Lung Cancer Guidelines1 related to the treatment for patients with potentially resectable stage IIIA lung cancer, in which N2 nodal metastases were histologically proven prior to surgery, our stage IIIA3. Our recommendations were based primarily on the randomized trials listed in Table 6.1 The two largest and most recent multicenter trials2,3 provided the most convincing data. In the European Organisation for Research and Treatment of Cancer (EORTC) 08941 trial,2 patients with histologically proven stage IIIA-N2 non-small cell lung cancer were administered induction chemotherapy. Only responders were randomized to either surgical resection with or without postoperative radiotherapy vs sequential radiotherapy without surgery. Rice et al note the fact that this trial accrued patients with “unresectable N2 disease” and question whether results would be applicable to patients with resectable stage IIIA. In the “Methods” section of their publication,2 the EORTC definition of “unresectable” was as follows: “(1) any N2 involvement by a nonsquamous carcinoma; (2) in the case of squamous cell carcinoma any N2 involvement exceeding level 4R in a right-sided tumor and level 5 and 6 for a left sidedtumor.” Essentially the EORTC considered unresectable all stage IIIA-N2 patients with single or multistation N2 metastases, which is exactly the focus of the stage IIIA chapter. The progression-free survival and the overall survival of the chemotherapy/surgery and chemoradiotherapy groups were not statistically different. The conclusion of the EORTC was “in view of its low morbidity and mortality, radiotherapy should be considered the preferred locoregional treatment for these [Stage IIIA-N2] patients.”2 The other large randomized, multicenter trial3 was Intergroup 0139, in which stage IIIA-N2 patients received induction chemoradiotherapy. Responders were randomized to surgical resection followed by chemotherapy vs completion of radiotherapy plus more chemotherapy. In this trial,3 the 30-day operative mortality was high overall at 7.9% and especially elevated in pneumonectomy patients (25.9%). Although the progression-free survival favored the surgical arm (median survival, 12.8 months in the surgical arm vs 10.5 months in the chemoradiotherapy arm, p 0.017), overall survival rates at 2 years and 5 years were not significantly different in the two treatment groups. Unfortunately, full data from this study have not been published, so we are unable comment on questions raised about any post hoc subgroup analysis. Of the earlier two small induction therapy studies in Table 6, the trial by Taylor et al4 was indeed retrospective and was included in error. The final study was the earlier, small Radiation Therapy Oncology Group 89-01, a randomized phase III trial5 of stage IIIA patients with histologically proven N2 disease. After induction chemotherapy, patients were randomized to surgery vs sequential radiotherapy followed by additional chemotherapy. There was no significant difference between the two treatment groups in progression-free survival or overall survival. Unfortunately, this study closed prematurely due to poor patient accrual, making the results inconclusive. Intuitively, surgical resection of the cancer seems ideal, particularly to thoracic surgeons (including one of the authors, L.A.R.). The occasional patient with complete N2 node clearing from induction chemotherapy (occurring in perhaps 20% of patients) may truly benefit from surgical resection, although it is likely concurrent radiotherapy in this subgroup would have an equally effective role. This may be the reason that the randomized trials show no superior survival benefit with surgery. After an exhaustive discussion of this controversial subset of stage IIIA reviewing primarily the two large randomized induction therapy trials,3,4 the Lung Cancer Guidelines Panel concluded that employing surgery for locoregional control did not provide a superior survival advantage. Therefore, the less morbid modality of radiotherapy added to chemotherapy delivered concurrently, when possible, is the preferred treatment regimen for stage IIIA.

Diagnostic performance of endobronchial ultrasound-guided mediastinal lymph node sampling in early stage non-small cell lung cancer: A prospective study

Standard nodal staging of lung cancer consists of positron emission tomography/computed tomography (PET/CT), followed by endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) if PET/CT shows mediastinal lymphadenopathy. Sensitivity of EBUS‐TBNA in patients with N0/N1 disease by PET/CT is unclear and largely based on retrospective studies. We assessed the sensitivity of EBUS‐TBNA in this setting.