Noriaki Kurimoto

Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions

The usefulness of endobronchial ultrasonography (EBUS) with guide-sheath (GS) as a guide for transbronchial biopsy (TBB) for diagnosing peripheral pulmonary lesions (PPL)s and for improving diagnostic accuracy was evaluated in this study. EBUS-GS-guided TBB was performed in 24 patients with 24 PPLs of ≤30u2005mm in diameter (average diameter=18.4u2005mm). A 20-MHz radial-type ultrasound probe, covered with GS was inserted via a working bronchoscope channel and advanced to the PPL in order to produce an EBUS image. The probe with the GS was confirmed to reach the lesion by EBUS imaging and X-ray fluoroscopy. When the lesion was not identified on the EBUS image, the probe was removed and a curette was used to lead the GS to the lesion. After localising the lesion, the probe was removed, and TBB and bronchial brushing were performed via the GS. Nineteen peripheral lesions (79.2%) were visualised by EBUS. All patients whose PPLs were visible on EBUS images subsequently underwent an EBUS-GS-guided diagnostic procedure. A total of 14 lesions (58.3%) were diagnosed. Even when restricted to PPLs <20u2005mm in diameter, the diagnostic sensitivity was 53%. In conclusion, endobronchial ultrasonography with guide sheath-guided transbronchial biopsy was feasible and effective for diagnosing peripheral pulmonary lesions.

Endobronchial ultrasound morphology of expiratory central airway collapse.

Abstract:u2003 Differences in central airway wall structure in patients with various forms of expiratory central airway collapse can be identified by endobronchial ultrasound using a 20u2003MHz radial probe. In tracheobronchomalacia due to relapsing polychondritis, the cartilage is thick and irregular while the membranous portion is normal. In malacia due to chronic inflammation after tracheotomy, the cartilage is thick and irregular and the membranous portion is also thick. In excessive dynamic airway collapse associated with COPD, on the contrary, the cartilage is normal and the posterior membrane is thin when compared to the normal airway wall structures identified in a patient with physiological dynamic airway collapse. These findings may support the hypothesis that various clinical forms of expiratory central airway collapse are not only different morphologically, physiologically and aetiologically, but also structurally.

Close association of IASLC/ATS/ERS lung adenocarcinoma subtypes with glucose-uptake in positron emission tomography

OBJECTIVESnCorrelations between maximum standardized uptake value (SUVmax) in fluorodeoxyglucose positron emission tomography (FDG-PET) and IASLC/ATS/ERS histopathologic subtypes of lung adenocarcinoma remain unclear. Therefore, the aim of this study was to retrospectively clarify associations between SUVmax and adenocarcinoma subtypes with postoperative outcomes.nnnMATERIALS AND METHODSnAssociations of SUVmax measured in preoperative FDG-PET/CT and histologic subtypes of lung adenocarcinoma resected in our hospital were analyzed retrospectively. Overall and disease-free survival rates after surgery were calculated by the Kaplan-Meier method, and survival differences between patient groups were tested by the log-rank test. Multivariate analysis for survival was performed using the Cox regression model.nnnRESULTSnA total of 255 patients (130 men and 125 women; mean age, 69 years; range, 22-88 years) were included in the study. Clinical stages included IA in 151 patients, IB in 79, IIA in 9, IIB in 10, and IIIA in 6. SUVmax was closely associated with histologic subtype in resected specimens (p<0.0001). Values were highest in micropapillary predominant invasive adenocarcinoma (MPA) followed by solid predominant (SPA), invasive mucinous (IMA), acinar predominant (APA), papillary predominant (PPA), lepidic predominant (LPA), minimally invasive adenocarcinoma (MIA), and adenocarcinoma in situ (AIS). When the subtypes were classified into three subgroups [group A, AIS+MIA+LPA (low risk); group B, APA+PPA+IMA (intermediate risk); and group C, SPA+MPP (high risk)] by expected postoperative prognoses, there were significant differences in SUVmax among the subgroups corresponding to recurrence risk (p=0.0001).nnnCONCLUSIONnPreoperative SUVmax was closely associated with both adenocarcinoma subtype and aggregated subgroups, reflecting malignant grade of the tumor and prognosis.

Association of IASLC/ATS/ERS Histologic Subtypes of Lung Adenocarcinoma With Epidermal Growth Factor Receptor Mutations in 320 Resected Cases.

BACKGROUNDnThe relationships between the subtypes defined by the new international histologic classificationxa0ofxa0lung adenocarcinoma (IASLC/ATS/ERS) and epidermal growth factor receptor (EGFR) mutations were studied.nnnPATIENTS AND METHODSnWe retrospectively reviewed 320 patients with lung adenocarcinoma (162 women,xa0158 men; mean age, 69 years) who had undergone complete resection, focusing on the new histologic subtypes and EGFR mutations. The clinical stage was IA in 196 patients, IB in 95, IIA in 10, IIB in 10, IIIA in 6, and IVxa0inxa03.nnnRESULTSnThe most prevalent subtype was papillary (35.0%), followed by acinar (29.4%), lepidic (13.1%),xa0solid (7.2%), adenocarcinoma in situ (6.6%), minimally invasive adenocarcinoma (6.3%), micropapillary (1.6%), and invasive mucinous adenocarcinoma (1.0%). These subtypes were predictive for both postoperativexa0disease-free and overall survival. EGFR mutations, detected in 40.6% of all cases, were most frequent in acinarxa0(48.4%), followed by minimally invasive adenocarcinoma (45.0%) and papillary (43.8%). They were least frequent in the solid subtype (17.4%). EGFR mutation status did not affect postoperative disease-free or overall survival.nnnCONCLUSIONnThe outcome after complete resection for lung adenocarcinoma was predicted by the proposed subtype classification. Because EGFR mutations were found in all subtypes, mutation analyses are essential to identify patients with postoperative relapse who would benefit from EGFR-tyrosine kinase inhibitor therapy.

Assessment of central airway obstruction using impulse oscillometry before and after interventional bronchoscopy

BACKGROUND: Spirometry is used to physiologically assess patients with central airway obstruction (CAO) before and after interventional bronchoscopy, but is not always feasible in these patients, does not localize the anatomic site of obstruction, and may not correlate with the patients functional impairment. Impulse oscillometry may overcome these limitations. We assessed the correlations between impulse oscillometry measurements, symptoms, and type of airway narrowing, before and after interventional bronchoscopy, and whether impulse oscillometry parameters can discriminate between fixed and dynamic CAO. METHODS: Twenty consecutive patients with CAO underwent spirometry, impulse oscillometry, computed tomography, dyspnea assessment, and bronchoscopy, before and after interventional bronchoscopy. The collapsibility index (the percent difference in airway lumen diameter during expiration versus during inspiration) was calculated using morphometric bronchoscopic images during quiet breathing. Variable CAO was defined as a collapsibility index of > 50%. Fixed CAO was defined as a collapsibility index of < 50%. The degree of obstruction was analyzed with computed tomography measurements. RESULTS: After interventional bronchoscopy, all impulse oscillometry measurements significantly improved, especially resistance at 5 Hz, which decreased from 0.67 ± 0.29kPa/L/s to 0.38 ± 0.17kPa/L/s (P < .001), and reactance at 20 Hz, which increased from –0.09 ± 0.11 to 0.03 ± 0.08 (P < .001). Changes in dyspnea score correlated with resistance at 5 Hz, the difference between the resistance at 5 Hz and the resistance at 20 Hz, and the reactance at 5 Hz, but not with spirometry measurements. The type of obstruction also correlated with dyspnea score, and showed distinct impulse oscillometry measurements. CONCLUSIONS: Impulse oscillometry measurements correlate with symptom improvements after interventional bronchoscopy. Impulse oscillometry might be useful to discriminate variable from fixed central airway obstruction. (University Hospital Medical Information Network, http://www.umin.ac.jp/english, ID000005322).

Novel Multimodality Imaging and Physiologic Assessments Clarify Choke-Point Physiology and Airway Wall Structure in Expiratory Central Airway Collapse

Choke points and airway wall structure in expiratory central airway collapse are poorly defined. Computed tomography, white light bronchoscopy, endobronchial ultrasound, vibration response imaging, spirometry, impulse oscillometry, negative expiratory pressure, and intraluminal catheter airway pressure measurements were used in a patient with cough, dyspnea, and recurrent pulmonary infections. Computed tomography and white light bronchoscopy identified dynamic collapse of the trachea and mainstem bronchi, consistent with severe crescent tracheobronchomalacia. Spirometry showed severe obstruction. Endobronchial ultrasound revealed collapse of the airway cartilage, and vibration response imaging revealed fluttering at both lung zones. Impulse oscillometry and negative expiratory pressure suggested tidal expiratory flow limitation in the intrathoracic airways. Intraluminal catheter airway pressure measurements identified the choke point in the lower trachea. After Y-stent insertion, the choke point migrated distally. Imaging studies revealed improved airway dynamics, airway patency, and ventilatory function. Novel imaging and physiologic assessments could be used to localize choke points and airway wall structure in tracheobronchomalacia.

Introduction of Endobronchial Ultrasonography (EBUS) in Bronchoscopy Clearly Reduces Fluoroscopy Time: Comparison of 147 Cases in Groups Before and After EBUS Introduction

BACKGROUNDnEndobronchial ultrasonography (EBUS) has been used in diagnosing peripheral lung cancer and has allowed for higher rates of peripheral lung cancer diagnosis. However, no studies have reported that fluoroscopy time is shortened by the use of endobronchial ultrasonography. We aimed to investigate whether fluoroscopy time is shortened using endobronchial ultrasonography.nnnMETHODSnWe retrospectively researched fluoroscopy time in terms of the rate of diagnosis, lesion size, age, gender, histologic type and lesion site in 147 cases of malignant lesions from January 2006 to September 2007 at the Tokai University Hospital. The location of the bronchial brush or biopsy forceps was confirmed by fluoroscopy without endobronchial ultrasonography with guide-sheath group in 96 of the 147 cases, while fluoroscopy with endobronchial ultrasonography guide sheath group was confirmed in 51 cases.nnnRESULTSnThe result was that fluoroscopy time was significantly shortened in the endobronchial ultrasonography guide-sheath group (4.08 ± 3.27 min) compared with the non-endobronchial ultrasonography guide-sheath group (7.06 ± 3.99 min), but there was no significant difference between either groups in terms of bronchoscopic diagnosis, lesion size, age, gender, histologic type and lesion site.nnnCONCLUSIONnThe use of endobronchial ultrasonography guide sheath allows a reduction in fluoroscopy time and may reduce the adverse effects of radiation exposure on patients and staff.

Malignant pleural mesothelioma presenting as a spontaneous pneumothorax.

Malignant pleural mesothelioma (MPM) is thought to arise from the mesothelial cells that line the pleural cavities. Most patients initially experience the insidious onset of chest pain or shortness of breath and have a history of asbestos exposure. MPM rarely presents as spontaneous pneumothorax. We report two male patients who presented with a spontaneous hydropneumothorax. One was exposed to asbestos and the other was not. Computed tomography showed tiny nodules with pleural thickness. They both underwent pleural effusion cytology and/or pleural biopsy. Therefore, the pathological diagnosis of MPM was obtained in both cases. We also reviewed 16 Japanese MPM cases with pneumothorax including our two patients. More than half of the patients suffered from pneumothorax repeatedly. We emphasize the need to obtain a pathological diagnosis of pleural effusion cytology and/or pleural biopsy in older patients presenting with a spontaneous hydropneumothorax.

Impact of intraoperative blood loss on long-term survival after lung cancer resection.

PURPOSEnThe purpose of this study was to clarify relationships between intraoperative blood loss (IBL) and long-term postsurgical survival in lung cancer patients.nnnMETHODSnWe retrospectively analyzed 1336 patients undergoing surgery: lobectomy in 1016, sublobar resection in 174, pneumonectomy in 106, and combined resection with adjacent organs in 40. The lobectomy group was stratified further by pathologic stages; overall survival difference was examined according to amount of IBL.nnnRESULTSnVolume of IBL differed significantly according to surgical procedure when all patients were included. Within the lobectomy group, IBL differed significantly between gender, pathologic stage, histologic type (adenocarcinoma vs. non-adenocarcinoma), and year of operation (1983 to 2002 vs. 2003 to 2012). After stratification by pathologic stage, survival differed with IBL for stages IB to IIIB. Multivariate analysis identified gender, patients age (<69 vs. ≥69), pathologic stage (IA to IIB vs. IIIA to IV), year of operation, histologic type, and IBL as significant predictors of survival.nnnCONCLUSIONnSince degree of IBL is an independent predictor of overall survival after lung cancer resection, IBL should be minimized carefully during surgery.

Standardized Uptake Values in the Primary Lesions of Non-Small-Cell Lung Cancer in FDG-PET/CT Can Predict Regional Lymph Node Metastases

PurposeMaximum standardized uptake values (SUVmax) at the primary lesions of non-small-cell lung cancer in 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT), and the microscopic local extension of tumors were examined to develop reliable criteria to determine candidates for sublobar resection.MethodsWe retrospectively analyzed 209 patients who underwent lobectomy, bilobectomy, or pneumonectomy with systematic lymph node dissection. Preoperative SUVmax at the primary lesion, microscopic lymphatic, venous, and pleural invasion in addition to lymph node metastases in the resected specimens were examined. Receiver operating characteristic analyses were used to predict an optimal cutoff for lymph node metastases.ResultsWith receiver operating characteristic analysis, the areas under the curve for SUVmax and tumor size were 0.693 and 0.545, respectively, suggesting SUVmax superiority for prediction of lymph node metastases with a cutoff of 2.9. When a tumor was ≤2.0xa0cm (nxa0=xa041, 19.6xa0%), the percentages of microscopic lymphatic invasion, venous invasion, pleural invasion, and lymph node metastases were 12.2, 7.3, 4.9, and 17.1xa0%, respectively. When SUVmax was <3.0 (nxa0=xa091, 43.5xa0%), these percentages were 15.4, 3.3, 7.7, and 8.8xa0%, showing that SUVmax could efficiently exclude nodal metastases in more cases than tumor size. The postoperative 5-year survival rate was 86.6xa0% in patients with SUVmaxxa0<xa03.0 and 58.1xa0% in patients with SUVmaxxa0≥xa03.0 (pxa0<xa00.001).Conclusions18F-FDG uptake value was more useful than tumor size for selecting patients with non-small-cell lung cancer suitable for intentional sublobar resection.