Nicholas J. Pastis

Using Endobronchial Ultrasound Features to Predict Lymph Node Metastasis in Patients With Lung Cancer

PURPOSES Reliable staging of the mediastinum determines TNM classification and directs therapy for non-small cell lung cancer (NSCLC). Our aim was to evaluate predictors of mediastinal lymph node metastasis in patients undergoing endobronchial ultrasound (EBUS). METHODS Patients with known or suspected lung cancer undergoing EBUS for staging were included. Lymph node radiographic characteristics on chest CT/PET scan and ultrasound characteristics of size, shape, border, echogenicity, and number were correlated with rapid on-site evaluation (ROSE) and final pathology. Logistic regression (estimated with generalized estimating equations to account for correlation across nodes within patients) was used with cancer (vs normal pathology) as the outcome. ORs compare risks across groups, and testing was performed with two-sided α of 0.05. RESULTS Two hundred twenty-seven distinct lymph nodes (22.5% positive for malignancy) were evaluated in 100 patients. Lymph node size, by CT scan and EBUS measurements, and round and oval shape were predictive of mediastinal metastasis. Increasing size of lymph nodes on EBUS was associated with increasing malignancy risk (P = .0002). When adjusted for CT scan size, hypermetabolic lymph nodes on PET scan did not predict malignancy. Echogenicity and border contour on EBUS and site of biopsy were not significantly associated with cancer. In 94.8% of lymph nodes with a clear diagnosis, the ROSE of the first pass correlated with subsequent passes. CONCLUSIONS Lymph node size on CT scan and EBUS and round or oval shape by EBUS are predictors of malignancy, but no single characteristic can exclude a visualized lymph node from biopsy. Further, increasing the number of samples taken is unlikely to significantly improve sensitivity.

Understanding the Economic Impact of Introducing a New Procedure: Calculating Downstream Revenue of Endobronchial Ultrasound With Transbronchial Needle Aspiration as a Model

Over the last decade, endobronchial ultrasound (EBUS) evolved into a validated and powerful diagnostic tool. Although it is integral to medical care in some health-care systems, others struggle to justify its purchase based on diminishing reimbursement. In analyzing its value to a health-care system, looking at procedural reimbursement alone will grossly underestimate its economic impact. Downstream revenue has been defined by administrators as revenue captured after patients use one hospital service and then use others. By analyzing consecutive EBUS cases and taking downstream revenue into account,

The role of molecular analyses in the era of personalized therapy for advanced NSCLC

2.4 million in collections was attributed to 97 patients who were newly referred for this procedure.

Learning Experience of Linear Endobronchial Ultrasound Among Pulmonary Trainees

Platinum-based doublet chemotherapy is the traditional treatment of choice for advanced non-small cell lung cancer (NSCLC); however, the efficacy of these regimens has reached a plateau. Increasing evidence demonstrates that patients with sensitizing mutations in the epidermal growth factor receptor (EGFR) experience improved progression-free survival and response rates with first-line gefitinib or erlotinib therapy relative to traditional platinum-based chemotherapy, while patients with EGFR-mutation negative tumors gain greater benefit from platinum-based chemotherapy. These results highlight the importance of molecular testing prior to the initiation of first-line therapy for advanced NSCLC. Routine molecular testing of tumor samples represents an important paradigm shift in NSCLC therapy and would allow for individualized therapy in specific subsets of patients. As these and other advances in personalized treatment are integrated into everyday clinical practice, pulmonologists will play a vital role in ensuring that tumor samples of adequate quality and quantity are collected in order to perform appropriate molecular analyses to guide treatment decisions. This article provides an overview of clinical trial data supporting molecular analysis of NSCLC, describes specimen acquisition and testing methods currently in use, and discusses future directions of personalized therapy for patients with NSCLC.

Training for Linear Endobronchial Ultrasound Among US Pulmonary/Critical Care Fellowships: A Survey of Fellowship Directors

BACKGROUND Linear endobronchial ultrasound (EBUS) allows real-time guidance of transbronchial needle aspiration of thoracic structures and has become an increasingly important diagnostic tool for chest physicians. Little has been published about the learning experience of operators with this technology. The purpose of this study was to define the learning experience of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) among pulmonary trainees. METHODS This was a multicenter cohort study of fellows in pulmonary medicine over the first 2 years of their training. Prior to performing EBUS-TBNA, all participants had to complete 30 conventional bronchoscopies, an EBUS-specific didactic curriculum, and a simulation session with a plastic airway model. Each consecutive EBUS procedure was scored with a checklist that evaluated the ability to pass a bronchoscope through vocal cords, identify the appropriate node for sampling, acquire adequate ultrasound images, guide the bronchoscopy team through the technical steps of EBUS-TBNA, and obtain adequate tissue samples. RESULTS Thirteen pulmonary trainees from three training programs were enrolled in the study and were observed over a 2-year period. The majority of trainees were able to perform all essential steps of EBUS-TBNA and obtain adequate tissue after performing an average of 13 (95% CI, 7-16) procedures. CONCLUSIONS Pulmonary trainees needed an average of 13 procedures to achieve first independent successful performance of EBUS-TBNA following a training protocol that included a didactic curriculum and simulation-based practice. Our findings could guide pulmonary fellowship directors in planning EBUS training and establishing a reasonable juncture to assess EBUS skills with validated assessment tools.

Randomized Controlled Trials: A Systematic Review of Laparoscopic Surgery and Simulation-Based Training

BACKGROUND Endobronchial ultrasound (EBUS) has revolutionized the ability of bronchoscopists to visualize and sample structures surrounding the tracheobronchial tree. It has been shown to be safe, minimally invasive, and highly accurate in the staging and diagnosing of mediastinal diseases. A prior survey of pulmonary fellowship program directors conducted in 2004 showed that only 2% of programs offered EBUS training. METHODS Surveys were mailed to 154 pulmonary/critical care fellowship directors in the United States and Puerto Rico. Demographics of the fellowship and details of EBUS training were recorded. A comparison of EBUS volume was made between programs with and without an identifiable interventional pulmonologist (IP). RESULTS The survey response rate was 71%. EBUS equipment was available at 89% of programs. Of those without EBUS, 100% expressed the goal of obtaining equipment within the year. An identifiable IP was present in 70% of programs. This was associated with more EBUS procedures performed by trainees ( P , .01). Only 30% of programs have a formal protocol in place to evaluate EBUS competency. Conventional transbronchial needle aspiration is routinely taught in 89% of fellowship programs. CONCLUSIONS EBUS exposure has rapidly disseminated into fellowship training programs, and programs with an identifiable IP are more likely to provide fellows with more EBUS procedures. The findings of this survey point out the need to develop a standardized protocol for EBUS competency that includes current recommendations and may require training with simulation.

The effect of respiratory motion on pulmonary nodule location during electromagnetic navigation bronchoscopy.

Introduction: This systematic review was conducted to analyze the impact and describe simulation-based training and the acquisition of laparoscopic surgery skills during medical school and residency programs. Methods: This systematic review focused on the published literature that used randomized controlled trials to examine the effectiveness of simulation-based training to develop laparoscopic surgery skills. Searching PubMed from the inception of the databases to May 1, 2014 and specific hand journal searches identified the studies. This current review of the literature addresses the question of whether laparoscopic simulation translates the acquisition of surgical skills to the operating room (OR). Results: This systematic review of simulation-based training and laparoscopic surgery found that specific skills could be translatable to the OR. Twenty-one studies reported learning outcomes measured in five behavioral categories: economy of movement (8 studies); suturing (3 studies); performance time (13 studies); error rates (7 studies), and global rating (7 studies). Conclusion: Simulation-based training can lead to demonstrable benefits of surgical skills in the OR environment. This review suggests that simulation-based training is an effective way to teach laparoscopic surgery skills, increase translation of laparoscopic surgery skills to the OR, and increase patient safety; however, more research should be conducted to determine if and how simulation can become apart of surgical curriculum.

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

BACKGROUND Electromagnetic navigation has improved the diagnostic yield of peripheral bronchoscopy for pulmonary nodules. For these procedures, a thin-slice chest CT scan is performed prior to bronchoscopy at full inspiration and is used to create virtual airway reconstructions that are used as a map during bronchoscopy. Movement of the lung occurs with respiratory variation during bronchoscopy, and the location of pulmonary nodules during procedures may differ significantly from their location on the initial planning full-inspiratory chest CT scan. This study was performed to quantify pulmonary nodule movement from full inspiration to end-exhalation during tidal volume breathing in patients undergoing electromagnetic navigation procedures. METHODS A retrospective review of electromagnetic navigation procedures was performed for which two preprocedure CT scans were performed prior to bronchoscopy. One CT scan was performed at full inspiration, and a second CT scan was performed at end-exhalation during tidal volume breathing. Pulmonary lesions were identified on both CT scans, and distances between positions were recorded. RESULTS Eighty-five pulmonary lesions were identified in 46 patients. Average motion of all pulmonary lesions was 17.6 mm. Pulmonary lesions located in the lower lobes moved significantly more than upper lobe nodules. Size and distance from the pleura did not significantly impact movement. CONCLUSIONS Significant movement of pulmonary lesions occurs between full inspiration and end-exhalation during tidal volume breathing. This movement from full inspiration on planning chest CT scan to tidal volume breathing during bronchoscopy may significantly affect the diagnostic yield of electromagnetic navigation bronchoscopy procedures.

A Decade of Advances in Treatment of Early-Stage Lung Cancer

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.

Utilizing endobronchial ultrasound with fine-needle aspiration to obtain tissue for molecular analysis: a single-center experience.

Emerging from the past decade, there has been a diversification of options for the treatment of early-stage lung cancer. Video-assisted thoracoscopic surgery is now more widely performed, with oncologic outcomes equivalent to those with open thoracotomy. Although lobectomy remains the standard approach to surgical resection, lesser resections, such as segmentectomy and wedge resection, are considerations for some patients. Advances in surgical, radiation, and medical therapies continue to evolve. Future research questions will focus on comparing long-term outcomes with these modalities, including survival, as well as patient-centered endpoints, such as quality of life.