Ross Morgan

Comparison of Suction Catheter versus Forceps Biopsy for Sampling of Solitary Pulmonary Nodules Guided by Electromagnetic Navigational Bronchoscopy

Background: Electromagnetic navigation has been approved for use as an adjunct to standard bronchoscopy. The diagnostic yield varies depending on the size of the lesion and successful navigation to the lesion. Objectives: The performance of two different biopsy tools, i.e. catheter aspiration and forceps biopsy, in the diagnosis of small pulmonary nodules (SPN) guided by electromagnetic navigational bronchoscopy (ENB) was examined. Methods: 54 patients referred for suspected lung cancer underwent ENB and 55 SPN (<3 cm) were sampled using both techniques. Endobronchial ultrasound (EBUS) was used to verify the accuracy of target lesion localization by ENB. Primary end points of the study were successful navigation to the lesion and a positive diagnosis. Patients were followed until a definitive diagnosis was obtained. Results: All 55 lesions were accessed. Two lesions were excluded from data analysis as the patients were lost to follow-up and their diagnoses could not be confirmed. Of the remaining 53 lesions, 40 samples (75.5%) were diagnostic. Compared to forceps biopsy, catheter aspiration was positively correlated with the success rate (36/40 vs. 22/40; p = 0.035). The diagnostic yield was 93% when EBUS verified the lesion location after navigation and only 48% when lesion location was not confirmed. There were no significant complications. Conclusions: ENB is a useful tool in the evaluation of SPN <3 cm in diameter. For malignant lesions, sampling by catheter aspiration is associated with a higher diagnostic yield than sampling by forceps biopsy alone, in particular when EBUS could not confirm lesion location prior to sampling.

Endobronchial Ultrasound-Guided Miniforceps Biopsy in the Biopsy of Subcarinal Masses in Patients with Low Likelihood of Non-Small Cell Lung Cancer

BACKGROUND Transbronchial needle aspiration (TBNA) is used to sample mediastinal masses, but the value may be limited by the small specimen size obtained. In benign diseases and hematologic malignancies, the sample size from TBNA is often considered insufficient for diagnosis. We evaluated the safety and efficacy of obtaining histologic specimens from subcarinal masses using a 1.15-mm miniforceps under endobronchial ultrasound (EBUS) guidance and compared the diagnostic yield with TBNA alone. METHODS Patients being evaluated for subcarinal lesions exceeding 2.5 cm (short axis) and without known or suspected non-small cell lung cancer were included. Bronchoscopy was performed, and EBUS-guided BNA of the lesion was performed first with a 22-gauge needle, followed by the 19-gauge needle. The miniforceps was then passed through the airway into the lesion (three to five passes) under real-time EBUS guidance. Three biopsy specimens were obtained. RESULTS The study enrolled 75 patients (41 men; mean age, 51.5 years). Specimens were acquired from each patient using the three techniques and processed separately. A specific diagnosis was made in 36% of patients with the 22-gauge needle, 49% with the 19-gauge needle, and in 88% with the miniforceps. The increase in diagnostic yield with miniforceps was most significant in patients with sarcoidosis (88% vs 36% for TBNA, p = 0.001) or lymphoma (81% vs 35%, p = 0.038). No complications occurred. CONCLUSIONS Miniforceps biopsy, performed under real-time EBUS guidance, can be used to obtain tissue specimens from subcarinal masses adjacent to the airway. The diagnostic yield for lymphoma and sarcoidosis is superior to TBNA alone, and the procedure appears safe.

Interventional chest procedures in pregnancy.

Interventional pulmonology encompasses diagnostic and therapeutic bronchoscopic procedures, and pleural interventions. In the last 10 years older techniques have been refined and exciting new technologies have extended the reach and application of the instruments used. The main areas within pulmonary medicine for which these interventions have a role are malignant and nonmalignant airway disease, pleural effusion, pneumothorax, and artificial airways. There are no data from well-designed prospective trials to guide recommendations for interventional pulmonary procedures in pregnancy. The recommendations provided in this article are based on critical review of reported case series, opinion from recognized experts, and personal observations.

Proteomic analysis of bronchoalveolar lavage fluid (BALF) from lung cancer patients using label-free mass spectrometry

Background Lung cancer is the leading cause of cancer-related mortality in both men and women throughout the world. The need to detect lung cancer at an early, potentially curable stage, is essential and may reduce mortality by 20%. The aim of this study was to identify distinct proteomic profiles in bronchoalveolar fluid (BALF) and plasma that are able to discriminate individuals with benign disease from those with non-small cell lung cancer (NSCLC). Methods Using label-free mass spectrometry analysis of BALF during discovery-phase analysis, a significant number of proteins were found to have different abundance levels when comparing control to adenocarcinoma (AD) or squamous cell lung carcinoma (SqCC). Validation of candidate biomarkers identified in BALF was performed in a larger cohort of plasma samples by detection with enzyme-linked immunoassay. Results Four proteins (Cystatin-C, TIMP-1, Lipocalin-2 and HSP70/HSPA1A) were selected as a representative group from discovery phase mass spectrometry BALF analysis. Plasma levels of TIMP-1, Lipocalin-2 and Cystatin-C were found to be significantly elevated in AD and SqCC compared to control. Conclusion The results presented in this study indicate that BALF is an important proximal biofluid for the discovery and identification of candidate lung cancer biomarkers. General significance There is good correlation between the trend of protein abundance levels in BALF and that of plasma which validates this approach to develop a blood biomarker to aid lung cancer diagnosis, particularly in the era of lung cancer screening. The protein signatures identified also provide insight into the molecular mechanisms associated with lung malignancy.

Bronchial dentures as a cause of airway actinomycosis.

A 65-year-old man was referred to the respiratory clinic with recurrent chest infections on a background of stage 3 chronic obstructive pulmonary disease. On examination, there was wheeze bilaterally more marked on the left lower lobe. Subsequent imaging revealed an obstruction of the left main bronchus that was concerning for malignancy. Initially, on flexible bronchoscopy, a hard mass was found and multiple biopsies were positive for actinomycosis. Subsequent rigid bronchoscopy was undertaken and a set of dentures were removed from the airway.

Brief Report on the Detection of the EGFR T790M Mutation in Exhaled Breath Condensate from Lung Cancer Patients

ABSTRACT The EGFR T790M somatic mutation is the most common mechanism of resistance to tyrosine kinase inhibitors in NSCLC. Patients with advanced disease are not always amenable to repeat biopsy for further molecular analysis. Developing noninvasive methods to detect T790M in cell‐free DNA in the absence of tissue is being actively investigated. Unfortunately, the low sensitivity of plasma for detection of T790M has limited its clinical use. Exhaled breath condensate (EBC) is an easily collected sample that is known to harbor cell‐free DNA, including lung cancer mutations. This report details the potential utility of exhaled breath condensate in the detection of the EGFR T790M mutation.

Physiology of Fixed Airway Obstruction

Upper airway obstruction frequently presents to the interventional bronchoscopist, and common causes include malignant disease of the trachea and post-intubation airway stenosis. The physiological changes that occur with upper airway obstruction are a consequence of increasing turbulence of airflow at the site of stenosis and a consequent increase in airway resistance which leads to an increased work of breathing, hypoventilation and exercise limitation. Upper airway obstruction is associated with distinct changes on pulmonary function testing. Careful inspection of the inspiratory and expiratory limbs of a well-performed flow-volume loop demonstrates three identifiable patterns of variable intrathoracic, variable extrathoracic and fixed airway obstruction in which there is flow limitation throughout the respiratory cycle. A number of quantitative criteria obtained from spirometry have also been found to have value in recognition of upper airway obstruction, in particular in differentiating this from chronic obstructive conditions such as COPD and asthma which affect the smaller airways but may coexist. Studies have found that patterns on lung function tests suggestive of upper airway obstruction can be found in as many as 7 % of consecutive tests. While abnormalities on spirometry and flow-volume loops are often the first indicator of airway obstruction and are cheap and widely available, they lack sufficient sensitivity for diagnosis and when suspected airway inspection by bronchoscopy and airway imaging, usually by computerised tomography, are required.