Phan Nguyen

High specificity of combined narrow band imaging and autofluorescence mucosal assessment of patients with head and neck cancer

The purpose of this study was to evaluate combined autofluorescence (AF) and narrow band imaging (NBI) for detection of mucosal lesions additional to known primary head and neck cancers and to determine impact on management.

Optical Differentiation Between Malignant and Benign Lymphadenopathy by Grey Scale Texture Analysis of Endobronchial Ultrasound Convex Probe Images

BACKGROUND Morphologic and sonographic features of endobronchial ultrasound (EBUS) convex probe images are helpful in predicting metastatic lymph nodes. Grey scale texture analysis is a well-established methodology that has been applied to ultrasound images in other fields of medicine. The aim of this study was to determine if this methodology could differentiate between benign and malignant lymphadenopathy of EBUS images. METHODS Lymph nodes from digital images of EBUS procedures were manually mapped to obtain a region of interest and were analyzed in a prediction set. The regions of interest were analyzed for the following grey scale texture features in MATLAB (version 7.8.0.347 [R2009a]): mean pixel value, difference between maximal and minimal pixel value, SEM pixel value, entropy, correlation, energy, and homogeneity. Significant grey scale texture features were used to assess a validation set compared with fluoro-D-glucose (FDG)-PET-CT scan findings where available. RESULTS Fifty-two malignant nodes and 48 benign nodes were in the prediction set. Malignant nodes had a greater difference in the maximal and minimal pixel values, SEM pixel value, entropy, and correlation, and a lower energy (P < .0001 for all values). Fifty-one lymph nodes were in the validation set; 44 of 51 (86.3%) were classified correctly. Eighteen of these lymph nodes also had FDG-PET-CT scan assessment, which correctly classified 14 of 18 nodes (77.8%), compared with grey scale texture analysis, which correctly classified 16 of 18 nodes (88.9%). CONCLUSIONS Grey scale texture analysis of EBUS convex probe images can be used to differentiate malignant and benign lymphadenopathy. Preliminary results are comparable to FDG-PET-CT scan.

Prospective randomised trial of endobronchial ultrasound-guide sheath versus computed tomography-guided percutaneous core biopsies for peripheral lung lesions

Aim:  To determine diagnostic rate, complications and patient tolerability of endobronchial ultrasound‐guide sheath (EBUS‐GS) and computed tomography (CT)‐guided percutaneous core biopsy for peripheral lung lesions.

Utility of EBUS-TBNA for diagnosis of mediastinal tuberculous lymphadenitis: a multicentre Australian experience

BACKGROUND Endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA) is an important diagnostic procedure for the interrogation of mediastinal lymph nodes. There is limited data describing the accuracy & safety of this technique for the diagnosis of tuberculous mediastinal lymphadenitis. METHODS A multi-centre retrospective study of all EBUS-guided TBNA procedures that referred samples for mycobacteriology was performed. Results were correlated with post-procedural diagnoses after a period of surveillance and cross-checked against relevant statewide tuberculosis (TB) registries, and sensitivity and specificity was calculated. In addition, nucleic acid amplification techniques (NAAT) were assessed, and sensitivity and specificity calculated using positive mycobacterial culture as the reference gold standard. RESULTS One hundred and fifty-nine patients underwent EBUS-TBNA and had tissue referred for mycobacterial culture, of which 158 were included in the final analysis. Thirty-nine were ultimately diagnosed with TB (25%). Sensitivity of EBUS-TBNA for microbiologically confirmed tuberculous mediastinal lymphadenitis was 62% (24/39 cases). Specificity was 100%. Negative predictive value (NPV) and diagnostic accuracy for microbiologic diagnosis was 89% [95% confidence intervals (CI), 82-93%] and 91% (95% CI, 84-94%) respectively. For a composite clinicopathologic diagnosis of TB NPV and accuracy were 98% (95% CI, 93-99%) and 98% (95% CI, 95-99%) respectively. Sensitivity for NAAT was 38% (95% CI, 18-65%). CONCLUSIONS EBUS-TBNA is a safe and well tolerated procedure in the assessment of patients with suspected isolated mediastinal lymphadenitis and demonstrates good sensitivity for a microbiologic diagnosis of isolated mediastinal lymphadenitis. When culture and histological results are combined with high clinical suspicion, EBUS-TBNA demonstrates excellent diagnostic accuracy and NPV for the diagnosis of mediastinal TB lymphadenitis. We suggest EBUS-TBNA should be considered the procedure of choice for patients in whom TB is suspected.

Protocol of the Australasian Malignant Pleural Effusion-2 (AMPLE-2) trial: a multicentre randomised study of aggressive versus symptom-guided drainage via indwelling pleural catheters

Introduction Malignant pleural effusions (MPEs) can complicate most cancers, causing dyspnoea and impairing quality of life (QoL). Indwelling pleural catheters (IPCs) are a novel management approach allowing ambulatory fluid drainage and are increasingly used as an alternative to pleurodesis. IPC drainage approaches vary greatly between centres. Some advocate aggressive (usually daily) removal of fluid to provide best symptom control and chance of spontaneous pleurodesis. Daily drainages however demand considerably more resources and may increase risks of complications. Others believe that MPE care is palliative and drainage should be performed only when patients become symptomatic (often weekly to monthly). Identifying the best drainage approach will optimise patient care and healthcare resource utilisation. Methods and analysis A multicentre, open-label randomised trial. Patients with MPE will be randomised 1:1 to daily or symptom-guided drainage regimes after IPC insertion. Patient allocation to groups will be stratified for the cancer type (mesothelioma vs others), performance status (Eastern Cooperative Oncology Group status 0–1 vs ≥2), presence of trapped lung (vs not) and prior pleurodesis (vs not). The primary outcome is the mean daily dyspnoea score, measured by a 100 mm visual analogue scale (VAS) over the first 60 days. Secondary outcomes include benefits on physical activity levels, rate of spontaneous pleurodesis, complications, hospital admission days, healthcare costs and QoL measures. Enrolment of 86 participants will detect a mean difference of VAS score of 14 mm between the treatment arms (5% significance, 90% power) assuming a common between-group SD of 18.9 mm and a 10% lost to follow-up rate. Ethics and dissemination The Sir Charles Gairdner Group Human Research Ethics Committee has approved the study (number 2015-043). Results will be published in peer-reviewed journals and presented at scientific meetings. Trial registration number ACTRN12615000963527; Pre-results.

Improved surgical margin definition by narrow band imaging for resection of oral squamous cell carcinoma: A prospective gene expression profiling study

Incomplete primary tumor excision contributes to localized postsurgical recurrence of oral squamous cell carcinoma (OSCC). The purpose of this study was to provide molecular evidence that surgical margin definition using narrow band imaging (NBI) resulted in more complete OSCC excision than conventional white light (WL) panendoscopy.

Comparison of objective criteria and expert visual interpretation to classify benign and malignant hilar and mediastinal nodes on 18-F FDG PET/CT

There is widespread adoption of FDG‐PET/CT in staging of lung cancer, but no universally accepted criteria for classifying thoracic nodes as malignant. Previous studies show high negative predictive values, but reporting criteria and positive predictive values varies. Using Endobronchial ultrasound transbronchial needle aspiration (EBUS‐TBNA) results as gold standard, we evaluated objective FDG‐PET/CT criteria for interpreting mediastinal and hilar nodes and compared this to expert visual interpretation (EVI).

Thoracic ultrasound recognition of competence: A position paper of the Thoracic Society of Australia and New Zealand

The ability to perform bedside thoracic ultrasound is increasingly recognized as an essential skill for thoracic clinicians, extending the clinical examination and aiding diagnostic and therapeutic procedures. Thoracic ultrasound reduces complications and increases success rates when used prior to thoracentesis or intercostal chest tube insertion. It is increasingly difficult to defend performing these procedures without real or near‐real time image guidance. To assist thoracic physicians and others achieve and demonstrate thoracic ultrasound competence, the Interventional Pulmonology Special Interest Group (IP‐SIG) of the Thoracic Society of Australia and New Zealand (TSANZ) has developed a new pathway with four components: (i) completion of an approved thoracic ultrasound theory and hands‐on teaching course. (ii) A log of at least 40 relevant scans. (iii) Two formative assessments (following 5–10 scans and again after 20 scans) using the Ultrasound‐Guided Thoracentesis Skills and Tasks Assessment Tool (UG‐STAT). (iv) A barrier assessment (UG‐STAT, pass score of 90%) by an accredited assessor not directly involved in the candidates training. Upon completion of these requirements a candidate may apply to the TSANZ for recognition of competence. This pathway is intended to provide a regional standard for thoracic ultrasound training.

[Review of the role of EBUS-TBNA for the pulmonologist, including lung cancer staging].

This review focuses on the role of endobronchial ultrasound‐guided transbronchial needle aspiration in day‐to‐day pulmonology practice. Case examples are given of the common indications for endobronchial ultrasound‐guided transbronchial needle aspiration which are: (i) lung cancer staging; (ii) confirming a diagnosis of malignancy in thoracic lymph nodes; (iii) diagnosing central pulmonary masses; (iv) sarcoidosis; and (v) inflammatory/benign thoracic lymph nodes. The technique is widely used, and after appropriate training by experienced bronchoscopists can be easily integrated into a bronchoscopy service.

Combining autofluorescence and narrow band imaging with image analysis in the evaluation of preneoplastic lesions in the bronchus and larynx

Background and ObjectivesAutofluorescence (AF) techniques improve the diagnostic yield of white light inspection for preneoplastic lesions in the bronchus and head and neck region. Although highly sensitive, AF has poor specificity, particularly in situations where there have been earlier biopsies or treatments such as radiotherapy. Narrow band imaging (NBI) is a newer imaging technique that enhances the early abnormal angiogenesis seen in preneoplastic lesions. NBI has higher specificity when compared with AF. We aimed to combine these imaging modalities, using AF as an effective screening tool and NBI to confirm AF findings. We also used computer-assisted image analysis techniques to give objective confirmation to our visual inspection. MethodsThree patients were selected for image analysis of their NBI images using the L*a*b* color scale in manually drawn regions of interest of biopsy-confirmed areas. Each case compared pathology with a different benign condition: normal tissue, postbiopsy effect, and postradiation therapy change. Patients had white light followed by AF inspection. Abnormal areas of AF were cross-examined with NBI. ResultsNBI clearly showed dysplasia and carcinoma in situ. It also confirmed abnormal fluorescence because of earlier biopsies and radiation therapy. Analysis of the L*a*b* color space scale in each case showed segmentation between pathology and the benign tissue. ConclusionsThere may be additive and discriminatory benefits of NBI after AF inspection. Further study with computer-assisted color segmentation techniques and image analysis is required before optical diagnosis can become a reality in bronchoscopic techniques in the future.