Roy Semaan

Transthoracic needle biopsy of the lung

BACKGROUND Image guided transthoracic needle aspiration (TTNA) is a valuable tool used for the diagnosis of countless thoracic diseases. Computed tomography (CT) is the most common imaging modality used for guidance followed by ultrasound (US) for lesions abutting the pleural surface. Novel approaches using virtual CT guidance have recently been introduced. The objective of this review is to examine the current literature for TTNA biopsy of the lung focusing on diagnostic accuracy and safety. METHODS MEDLINE was searched from inception to October 2015 for all case series examining image guided TTNA. Articles focusing on fluoroscopic guidance as well as influence of rapid on-site evaluation (ROSE) on yield were excluded. The diagnostic accuracy, defined as the number of true positives divided by the number of biopsies done, as well as the complication rate [pneumothorax (PTX), bleeding] was examined for CT guided TTNA, US guided TTNA as well as CT guided electromagnetic navigational-TTNA (E-TTNA). Of the 490 articles recovered 75 were included in our analysis. RESULTS The overall pooled diagnostic accuracy for CT guided TTNA using 48 articles that met the inclusion and exclusion criteria was 92.1% (9,567/10,383). A similar yield was obtained examining ten articles using US guided TTNA of 88.7% (446/503). E-TTNA, being a new modality, only had one pilot study citing a diagnostic accuracy of 83% (19/23). Pooled PTX and hemorrhage rates were 20.5% and 2.8% respectively for CT guided TTNA. The PTX rate was lower in US guided TTNA at a pooled rate of 4.4%. E-TTNA showed a similar rate of PTX at 20% with no incidence of bleeding in a single pilot study available. CONCLUSIONS Image guided TTNA is a safe and accurate modality for the biopsy of lung pathology. This study found similar yield and safety profiles with the three imaging modalities examined.

Electromagnetic navigation transthoracic needle aspiration for the diagnosis of pulmonary nodules: a safety and feasibility pilot study

BACKGROUND Pulmonary nodules remain a diagnostic challenge for physicians. Minimally invasive biopsy methods include bronchoscopy and CT guided transthoracic needle aspiration (TTNA). A novel electromagnetic guidance transthoracic needle aspiration (ETTNA) procedure which can be combined with navigational bronchoscopy (NB) and endobronchial ultrasound (EBUS) in a single setting has become available. METHODS A prospective pilot study examining the safety, feasibility and diagnostic yield of ETTNA in a single procedural setting. All patients enrolled underwent EBUS for lung cancer staging followed by NB and ETTNA. Feasibility of performing ETTNA and a safety assessment by recording procedural related complications including pneumothorax or bleeding was performed. Diagnostic yield of ETTNA defined by a definitive pathologic tissue diagnosis was recorded. An additional diagnostic yield analysis was performed using a cohort analysis of combined interventions (EBUS + NB + ETTNA). All non-diagnostic biopsies were either followed with radiographic imaging or a surgical biopsy was performed. RESULTS Twenty-four subjects were enrolled. ETTNA was feasible in 96% of cases. No bleeding events occurred. There were five pneumothoraces (21%) of which only two (8%) subjects required drainage. The diagnostic yield for ETTNA alone was 83% and increased to 87% (P=0.0016) when ETTNA was combined with NB. When ETTNA and NB were performed with EBUS for complete staging, the diagnostic yield increased further to 92% (P=0.0001). CONCLUSIONS This is the first human pilot study demonstrating an acceptable safety and feasibility profile with a novel ETTNA system. Further studies are needed to investigate the increased diagnostic yield from this pilot study.

Rigid bronchoscopy and silicone stents in the management of central airway obstruction

The field of interventional pulmonology has grown significantly over the past several decades now including the diagnosis and therapeutic treatment of complex airway disease. Rigid bronchoscopy is an invaluable tool in the diagnosis and management of several malignant and non-malignant causes of central airway obstruction (CAO) and has become integral after the inception of airway stenting. The management of CAO can be a complicated endeavor with significant risks making the understanding of basic rigid bronchoscopy techniques, ablative technologies, anesthetic care and stenting of utmost importance in the care of these complex patients. This review article will focus on the history of rigid bronchoscopy, the technical aspects of performing a rigid bronchoscopy as well as the use of silicone stents their indications, complications and placement techniques.

Use of Electromagnetic Navigational Transthoracic Needle Aspiration (E-TTNA) for Sampling of Lung Nodules

Lung nodule evaluation represents a clinical challenge especially in patients with intermediate risk for malignancy. Multiple technologies are presently available to sample nodules for pathological diagnosis. Those technologies can be divided into bronchoscopic and non-bronchoscopic interventions. Electromagnetic navigational bronchoscopy is being extensively used for the endobronchial approach to peripheral lung nodules but has been hindered by anatomic challenges resulting in a 70% diagnostic yield. Electromagnetic navigational guided transthoracic needle lung biopsy is novel non-bronchoscopic method that uses a percutaneous electromagnetic tip tracked needle to obtain core biopsy specimens. Electromagnetic navigational transthoracic needle aspiration complements bronchoscopic techniques potentially allowing the provider to maximize the diagnostic yield during one single procedure. This article describes a novel integrated diagnostic approach to pulmonary lung nodules. We propose the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) for mediastinal staging; radial EBUS, navigational bronchoscopy and E-TTNA during one single procedure to maximize diagnostic yield and minimize the number of invasive procedures needed to obtain a diagnosis. This manuscript describes in detail how the navigation transthoracic procedure is performed. Additional clinical studies are needed to determine the clinical utility of this novel technology.

Tridimensional Medical Thoracoscopy

A 26-year-old man with a history of HIV presented with a recurrent right side lymphocytic exudative pleural effusion. A medical thoracoscopy was performed using a novel tridimensional (3D) articulating (Endoeye 3D, Flex LTF 19010-3D; Olympus Medical System, Tokyo, Japan). High-resolution 3D images and articulating scope properties allowed a realistic appreciation of the anatomy, depth perception, and spatial relationship, and a complete chest cavity inspection.

Pleuropulmonary Kaposi Sarcoma in the Setting of Immune Reactivation

We present a case of a 26 year with history of HIV/AIDS who presented with a pleural effusion. Serial radiography, pleural fluid analysis as well as clinical symptoms revealed development of Kaposi Sarcoma related immune reconstitution inflammatory syndrome (KS-IRIS) in the setting of initiation of effective anti- retroviral therapy.

A randomized controlled trial evaluating airway inspection effectiveness during endobronchial ultrasound bronchoscopy.

BACKGROUND Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) has revolutionized the evaluation of patients with mediastinal and hilar adenopathy. Limitations of conventional endobronchial ultrasound (C-EBUS) bronchoscopes include the inability to perform a complete airway inspection, low definition optics, and limited maneuverability. These limitations require the use of a standard bronchoscope to perform an airway examination prior to the EBUS procedure. Recently, a hybrid endobronchial ultrasound (H-EBUS) bronchoscope with high definition optics and increased maneuverability has been introduced. Our objective was to assess the ability of H-EBUS to perform a full airway inspection and TBNA. METHODS Patients referred for EBUS-TBNA were prospectively randomized to either form of EBUS from November 2013 to January 2014. The primary outcome was the airway segment visualization in each lobe using an EBUS bronchoscope. Secondary outcomes included the number of bronchoscopes used per procedure, procedure length, diagnostic yield and specimen adequacy. RESULTS Sixty-two consecutive patients undergoing EBUS-TBNA were randomized to H-EBUS (n=30) or C-EBUS (n=32). In cases in which EBUS-TBNA was the only procedure performed (n=32), use of a second bronchoscope to perform an adequate airway inspection was significantly higher in C-EBUS compared to H-EBUS (5 vs. 0, P=0.046). There was better segmental visualization achieved in multiple lobes when using H-EBUS (P<0.01). No differences in TBNA sample diagnostic yield, specimen adequacy or procedure time were noted when comparing bronchoscopes (P= NS). CONCLUSIONS Use of an H-EBUS may improve the ability to perform an adequate airway inspection potentially obviating the need for a conventional bronchoscope.

Procedural Learning Perspectives of Pulmonary Fellows and Practitioners

Background: Procedural learning requires both didactic knowledge and motor skills. Optimal teaching styles and techniques remain to be defined for pulmonary procedural learning. We investigated the preferences of learners at 2 different points in a pulmonary career; as pulmonary fellows and as clinical practitioners. Methods: A perception survey was conducted among pulmonary fellows and practitioners from multiple institutions throughout the United States. Fellows and practitioners were immediately surveyed on procedural learning factors after completing a procedural learning course using low/high-fidelity and/or cadaver simulators. Survey questions consisting of biographical information and multiple choice, Likert style, and qualitative questions regarding learning preferences were collected. Results: Seventy-five physicians (44 pulmonary fellows, 31 practitioners) from 35 centers completed the survey. Pulmonary practitioners preferred an academic expert, whereas fellows preferred familiar faculty as lecturers for procedural learning (P=0.03). There were no statistical differences between fellows/practitioners value of the use of simulators, didactics, or handouts. Both groups preferred animal/cadaver and high-fidelity simulators to low-fidelity simulators. Both groups also preferred a traditional course structure to problem-based learning/flipped classroom. The most common answer to barriers for learning a new procedure was “time” for training followed by “opportunities” to learn. Conclusions: Pulmonary fellows and practitioners we surveyed preferred a traditional course structure with cadaver/animal models and high-fidelity simulation training as compared with a flipped classroom model and low-fidelity simulators, but whether this holds true for the wider population is unknown. Larger studies are needed to validate learning perception with outcomes.

Stylet Use Does Not Improve Diagnostic Outcomes in Endobronchial Ultrasonographic Transbronchial Needle Aspiration: A Randomized Clinical Trial

BACKGROUND: Endobronchial ultrasonographically guided transbronchial needle aspiration (EBUS‐TBNA) of thoracic structures is a commonly performed tissue sampling technique. The use of an inner‐stylet in the EBUS needle has never been rigorously evaluated and may be unnecessary. METHODS: In a prospective randomized single‐blind controlled clinical trial, patients with a clinical indication for EBUS‐TBNA underwent lymph node sampling using both with‐stylet and without‐stylet techniques. Sample adequacy, diagnostic yield, and various cytologic quality measures were compared. RESULTS: One hundred twenty‐one patients were enrolled, with 194 lymph nodes sampled, each using both with‐stylet and without‐stylet techniques. There was no significant difference in sample adequacy or diagnostic yield between techniques. The without‐stylet technique resulted in adequate samples in 87% of the 194 study lymph nodes, which was no different from the with‐stylet adequacy rate (82%; P = .371). The with‐stylet technique resulted in a diagnosis in 50 of 194 samples (25.7%), which was similar to the without‐stylet group (49 of 194 [25.2%]; P = .740). There was a high degree of concordance in the determination of adequacy (84.0%; 95% CI, 78.1–88.9) and diagnostic sample generation (95.4%; 95% CI, 91.2–97.9) between the two techniques. A similar qualitative number of lymphocytes, malignant cells, and bronchial respiratory epithelia were recovered using each technique. CONCLUSIONS: Omitting stylet use during EBUS‐TBNA does not affect diagnostic outcomes and reduces procedural complexity. TRIAL REGISTRY: ClinicalTrials.Gov: No. NCT 02201654; URL:www.clinicaltrials.gov.

Academic Productivity of Interventional Pulmonology Training Programs

RATIONALE The Hirsch index (h-index) has been validated as a measure of academic productivity and may be an appropriate tool to assess the scholarly activity of interventional pulmonology (IP). OBJECTIVES This study aimed to elucidate the factors associated with increasing h-index scores among IP training programs. METHODS A cross-sectional study was conducted of IP training programs across the United States and Canada. Data, including their respective h-index, number of publications, academic rank, geographic location, and possession of an advanced degree, were collected on IP faculty and fellows from 23 teaching institutions. MEASUREMENTS AND MAIN RESULTS Ninety-three IP physicians (48 faculty, 45 fellows) in all were included in the study from 23 institutions with a total of 101 data points. The faculty h-index mean was 3.88. The proportion of faculty with an h-index greater than the mean value was increased significantly with higher academic rank (P < 0.0001). In addition, physicians holding an advanced degree beyond an M.D./D.O. had a significantly higher h-index than did those without (P = 0.0062). CONCLUSIONS For academic interventional pulmonologists, the h-index rises with increasing academic rank and possession of an advanced degree. The h-index for IP is roughly comparable to that for other surgical and procedural-based specialties.