R Breen

Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: a multicentre study

Background Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as an important tool for the diagnosis and staging of lung cancer but its role in the diagnosis of tuberculous intrathoracic lymphadenopathy has not been established. The aim of this study was to describe the diagnostic utility of EBUS-TBNA in patients with intrathoracic lymphadenopathy due to tuberculosis (TB). Methods 156 consecutive patients with isolated intrathoracic TB lymphadenitis were studied across four centres over a 2-year period. Only patients with a confirmed diagnosis or unequivocal clinical and radiological response to antituberculous treatment during follow-up for a minimum of 6 months were included. All patients underwent routine clinical assessment and a CT scan prior to EBUS-TBNA. Demographic data, HIV status, pathological findings and microbiological results were recorded. Results EBUS-TBNA was diagnostic of TB in 146 patients (94%; 95% CI 88% to 97%). Pathological findings were consistent with TB in 134 patients (86%). Microbiological investigations yielded a positive culture of TB in 74 patients (47%) with a median time to positive culture of 16 days (range 3–84) and identified eight drug-resistant cases (5%). Ten patients (6%) did not have a specific diagnosis following EBUS; four underwent mediastinoscopy which confirmed the diagnosis of TB while six responded to empirical antituberculous therapy. There was one complication requiring an inpatient admission. Conclusions EBUS-TBNA is a safe and effective first-line investigation in patients with tuberculous intrathoracic lymphadenopathy.

Screening for EGFR and KRAS mutations in endobronchial ultrasound derived transbronchial needle aspirates in non-small cell lung cancer using COLD-PCR.

EGFR mutations correlate with improved clinical outcome whereas KRAS mutations are associated with lack of response to tyrosine kinase inhibitors in patients with non-small cell lung cancer (NSCLC). Endobronchial ultrasound (EBUS)-transbronchial needle aspiration (TBNA) is being increasingly used in the management of NSCLC. Co-amplification at lower denaturation temperature (COLD)–polymerase chain reaction (PCR) (COLD-PCR) is a sensitive assay for the detection of genetic mutations in solid tumours. This study assessed the feasibility of using COLD-PCR to screen for EGFR and KRAS mutations in cytology samples obtained by EBUS-TBNA in routine clinical practice. Samples obtained from NSCLC patients undergoing EBUS-TBNA were evaluated according to our standard clinical protocols. DNA extracted from these samples was subjected to COLD-PCR to amplify exons 18–21 of EGFR and exons two and three of KRAS followed by direct sequencing. Mutation analysis was performed in 131 of 132 (99.3%) NSCLC patients (70F/62M) with confirmed lymph node metastases (94/132 (71.2%) adenocarcinoma; 17/132 (12.8%) squamous cell; 2/132 (0.15%) large cell neuroendocrine; 1/132 (0.07%) large cell carcinoma; 18/132 (13.6%) NSCL-not otherwise specified (NOS)). Molecular analysis of all EGFR and KRAS target sequences was achieved in 126 of 132 (95.5%) and 130 of 132 (98.4%) of cases respectively. EGFR mutations were identified in 13 (10.5%) of fully evaluated cases (11 in adenocarcinoma and two in NSCLC-NOS) including two novel mutations. KRAS mutations were identified in 23 (17.5%) of fully analysed patient samples (18 adenocarcinoma and five NSCLC-NOS). We conclude that EBUS-TBNA of lymph nodes infiltrated by NSCLC can provide sufficient tumour material for EGFR and KRAS mutation analysis in most patients, and that COLD-PCR and sequencing is a robust screening assay for EGFR and KRAS mutation analysis in this clinical context.

Diagnosis and Subtyping of De Novo and Relapsed Mediastinal Lymphomas by Endobronchial Ultrasound Needle Aspiration

RATIONALE The current management of lymphoma requires accurate diagnosis and subtyping of de novo lymphoma and of relapsed or refractory lymphoma in known cases. The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the clinical management of lymphomas is unclear. OBJECTIVES To investigate the use of EBUS-TBNA in the diagnosis of de novo and relapsed mediastinal lymphomas. METHODS A total of 2,256 consecutive patients who underwent EBUS-TBNA in a tertiary center between February 2008 and April 2013 were prospectively evaluated. The diagnostic accuracy and clinical use of EBUS-TBNA in 100 cases of de novo or suspected relapsed mediastinal lymphoma was investigated by comparing EBUS-TBNA diagnosis with the final diagnosis. MEASUREMENTS AND MAIN RESULTS De novo mediastinal lymphoma was correctly diagnosed by EBUS-TBNA in 45 (88%) of 51 and relapsed lymphoma in 15 (100%) of 15 lymphoma cases. EBUS-TBNA accurately established a diagnosis other than lymphoma in 32 (97%) of 33 patients with suspected lymphoma relapse. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EBUS-TBNA in the diagnosis of mediastinal lymphoma were 89%, 97%, 98%, 83%, and 91%, respectively. Sensitivity of EBUS-TBNA in subtyping lymphomas into high-grade non-Hodgkin lymphoma, low-grade non-Hodgkin lymphoma, and Hodgkin lymphoma was 90%, 100%, and 79%, respectively. EBUS-TBNA diagnosis was adequate for clinical management in 84 (84%) of 100 cases. CONCLUSIONS Multimodality evaluation of EBUS-TBNA can be successful in the diagnosis of de novo mediastinal lymphomas and is ideally suited in distinguishing lymphoma relapse from alternative pathologies; it is least sensitive in subtyping Hodgkin lymphoma.

ALK rearrangements in EBUS-derived transbronchial needle aspiration cytology in lung cancer.

Patients with non‐small cell lung cancer (NSCLC) positive for anaplastic lymphoma kinase (ALK) gene rearrangements may be treated successfully with the ALK inhibitor crizotinib. ALK copy‐number abnormalities have also been described. In this study, we evaluated the suitability of fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) to determine ALK status in endobronchial ultrasound (EBUS)‐derived cytology samples.

A 380-gene meta-signature of active tuberculosis compared with healthy controls

Mycobacterium tuberculosis is estimated to have infected one third of the worlds population and continues to be a significant cause of mortality and morbidity [1]. There is a need for new and improved diagnostics or treatment-monitoring tools and blood-based mRNA diagnostics are a potential solution [2]. Gene expression microarray analysis of human blood has been widely used to profile the host transcriptional response in active tuberculosis (TB) to identify potential biomarkers and better understand the host immune response [2]. So far, there has been a relative lack of concordance in the actual genes being identified from the published studies [2, 3], although there has been agreement in some of the pathways identified. Interferon (IFN) signalling has been identified as a dominant signature in many of the individual studies [2, 4]; however, when significant gene lists were combined from eight publicly available TB datasets, TREM1 (triggering receptor expressed on myeloid cells 1) signalling became the most significant pathway [5]. Modular and meta-profiling identify a common transcriptional response of patients with TB versus healthy controls http://ow.ly/YvEP7

Diagnosis and subclassification of thymoma by minimally invasive fine needle aspiration directed by endobronchial ultrasound: a review and discussion of four cases

M.T. Moonim, R. Breen, B. Gill‐Barman and G. Santis

Respiratory papillomatosis of lung and F-18 FDG PET-CT

Abstract: Recurrent respiratory papillomatosis (RRP) is the most common benign tumor of the larynx in children. Papillomas in RRP are usually benign and are localized to the larynx. Lung involvement is rare. The papillomas in the laryngotracheal and bronchioloalveolar region may undergo malignant degeneration to squamous cell carcinoma and are reported to have a poor prognosis. A 28-year-old woman presented with hemoptysis. She had known RRP in the trachea but no previous lung involvement. A chest radiograph and CT scan revealed multiple nodules, some of which were cavitating and some were with a predominantly cystic appearance. PET/CT showed increased F-18 FDG uptake in these nodules and guided biopsy.

The Transcriptional Signature of Active Tuberculosis Reflects Symptom Status in Extra-Pulmonary and Pulmonary Tuberculosis.

Background Mycobacterium tuberculosis infection is a leading cause of infectious death worldwide. Gene-expression microarray studies profiling the blood transcriptional response of tuberculosis (TB) patients have been undertaken in order to better understand the host immune response as well as to identify potential biomarkers of disease. To date most of these studies have focused on pulmonary TB patients with gene-expression profiles of extra-pulmonary TB patients yet to be compared to those of patients with pulmonary TB or sarcoidosis. Methods A novel cohort of patients with extra-pulmonary TB and sarcoidosis was recruited and the transcriptional response of these patients compared to those with pulmonary TB using a variety of transcriptomic approaches including testing a previously defined 380 gene meta-signature of active TB. Results The 380 meta-signature broadly differentiated active TB from healthy controls in this new dataset consisting of pulmonary and extra-pulmonary TB. The top 15 genes from this meta-signature had a lower sensitivity for differentiating extra-pulmonary TB from healthy controls as compared to pulmonary TB. We found the blood transcriptional responses in pulmonary and extra-pulmonary TB to be heterogeneous and to reflect the extent of symptoms of disease. Conclusions The transcriptional signature in extra-pulmonary TB demonstrated heterogeneity of gene expression reflective of symptom status, while the signature of pulmonary TB was distinct, based on a higher proportion of symptomatic individuals. These findings are of importance for the rational design and implementation of mRNA based TB diagnostics.

Gene expression profiling of endobronchial ultrasound (EBUS)-derived cytological fine needle aspirates from hilar and mediastinal lymph nodes in non-small cell lung cancer.

R. Lee, D. J. Cousins, E. Ortiz‐Zapater, R. Breen, E. McLean and G. Santis 
Gene expression profiling of endobronchial ultrasound (EBUS)‐derived cytological fine needle aspirates from hilar and mediastinal lymph nodes in non‐small cell lung cancer

P222 Pleural TB: a common cause of pleural effusion in South London

Background Pleural tuberculosis (TB) is one of the most common forms of extrapulmonary TB, reported to account for up to 25% of TB infected adults, and 30% of exudative pleural effusions in developing countries. Despite this, little information has been reported on its incidence within London. Aims and methods A retrospective observational study was performed at a London tertiary referral centre. The aim was to identify the contribution of pleural TB to the overall burden of both pleural and TB disease, and assess diagnostic yields of investigation techniques and outcomes of treatment. Results 28 patients were diagnosed with pleural TB between Jan 1st 2010- 31st Dec 2012. This represented 6.2% of the total number of TB cases, and 4% of the total number of investigated pleural disease cases. The mean age of the patients was 33 ± 10 (range 17–62); 79% were male; 46% were Black African, 29% Asian, 21% Caucasian and 4% Black Caribbean. There was a range of symptoms at presentation, with 96% of patients complaining of at least one symptom (Figure 1). Diagnostic yields were as follows; sputum smear 3% and culture 18%; pleural fluid smear 0 and culture 36%; pleural biopsy smear 11% and culture 54%; pleural biopsy histology 93%. Culture yield for pleural fluid and biopsy was 61%, and overall culture yield for sputum, pleural fluid and biopsy was 68%. All patients’ received quadruple TB therapy, with 82% of patients being given the standard six-month therapy. 92% showed an excellent radiological response, with the x-ray being normal, or with only minor residual abnormalities. To the present date, there has been no diagnosed recurrence of TB. Conclusions Pleural TB contributes significantly to the overall burden of pleural disease in this London hospital. TB should be considered in patients presenting with pleural disease, especially young patients from ethnic minority backgrounds. To improve the diagnosis and treatment of pleural TB, culture yields need improvement. Abstract P222 Figure 1. Percentage of patients presenting with various symptoms.