Sonali Sethi

Endobronchial Ultrasound-guided Transvascular Needle Aspiration: A Single-Center Experience.

Background:Endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) is well established for the staging and diagnosis of lung cancer and mediastinal lymphadenopathy. Central mediastinal vascular structures may preclude EBUS-TBNA access to lymph nodes in the aortopulmonary window and certain centrally located parenchymal lesions. Thus, a transvascular approach is necessitated. Few such reports exist in the literature. Methods:We retrospectively analyzed the results of endobronchial ultrasound–guided transvascular needle aspiration (EBUS-TVNA) performed over 1 year to sample mediastinal lymph nodes (stations: 5) and lung lesions inaccessible by standard bronchoscopy or EBUS-TBNA. Data regarding the indication, location, size, and relationship to adjacent blood vessels, the number of transvascular passes, EBUS-TVNA diagnosis, the final diagnosis, procedural images, and complications were collected. Patients’ charts were reviewed for 6 months after the procedure for evidence of late complications, including mediastinitis or mediastinal hemorrhage. Results:Of 865 EBUS-TBNA procedures, 10 were performed by traversing the pulmonary artery or its branches. Nine were for left-sided lesions, 3 for hilar parenchymal nodules, 6 for hilar or mediastinal LN, and the remainder for a right-sided mass. Rapid-onsite evaluation was either diagnostic or positive for lymphoid cells in 9 patients and the final cytopathology was diagnostic in 9 patients: 5 non–small cell lung cancer, 1 small cell cancer, 1 metastatic colon cancer, and 2 normal lymphoid tissue. One patient had necrosis and required video assisted thoracoscopic surgery to diagnose histoplasmosis. Bleeding was insignificant, with no short-term/long-term complications. Conclusions:From our single-center experience, we conclude that in experienced hands, EBUS-TVNA is feasible, with a high yield, but without complications. Larger prospective trials are warranted to explore its diagnostic potential.

A Prediction Model to Help with the Assessment of Adenopathy in Lung Cancer (HAL).

Rationale: Estimating the probability of finding N2 or N3 (prN2/3) malignant nodal disease on endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) in patients with non‐small cell lung cancer (NSCLC) can facilitate the selection of subsequent management strategies. Objectives: To develop a clinical prediction model for estimating the prN2/3. Methods: We used the AQuIRE (American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education) registry to identify patients with NSCLC with clinical radiographic stage T1‐3, N0‐3, M0 disease that had EBUS‐TBNA for staging. The dependent variable was the presence of N2 or N3 disease (vs. N0 or N1) as assessed by EBUS‐TBNA. Univariate followed by multivariable logistic regression analysis was used to develop a parsimonious clinical prediction model to estimate prN2/3. External validation was performed using data from three other hospitals. Measurements and Main Results: The model derivation cohort (n = 633) had a 25% prevalence of malignant N2 or N3 disease. Younger age, central location, adenocarcinoma histology, and higher positron emission tomography‐computed tomography N stage were associated with a higher prN2/3. Area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.82‐0.89), model fit was acceptable (Hosmer‐Lemeshow, P = 0.62; Brier score, 0.125). We externally validated the model in 722 patients. Area under the receiver operating characteristic curve was 0.88 (95% confidence interval, 0.85‐0.90). Calibration using the general calibration model method resulted in acceptable goodness of fit (Hosmer‐Lemeshow test, P = 0.54; Brier score, 0.132). Conclusions: Our prediction rule can be used to estimate prN2/3 in patients with NSCLC. The model has the potential to facilitate clinical decision making in the staging of NSCLC.

Airway Involvement in Granulomatosis with Polyangiitis

The evaluation and diagnosis of a patient with suspected tracheobronchial granulomatosis with polyangiitis (GPA), formerly called Wegener’s granulomatosis, requires a combination of clinical assessment, serologic testing, sinus and chest imaging, pulmonary function tests, bronchoscopy, and tissue biopsy. The diagnosis is established when serologic and histopathologic evidence of vasculitis and granulomatous inflammation is present in a patient with a compatible clinical presentation. In contrast to surgical lung biopsy, bronchoscopic tissue sampling of tracheobronchial luminal abnormalities only reveals histologic features of GPA in a minority of cases. The general principles of medical therapy for GPA also apply to patients who have tracheobronchial involvement. For those patients who remain symptomatic despite appropriate medical management, endoscopic management is an option.

Rapid On-Site Evaluation in Detection of Granulomas in the Mediastinal Lymph Nodes

RATIONALE Rapid On-Site Evaluation (ROSE) of specimens collected by endobronchial ultrasound (EBUS)-guided-transbronchial needle aspiration (TBNA) ensures sample adequacy and triages subsequent biopsy procedures. EBUS-TBNA allows sampling of lymph nodes in granulomatous diseases; however, the ability of ROSE to predict the final diagnosis in this setting has not been well characterized. OBJECTIVES We performed a retrospective evaluation to study the utility of ROSE in the diagnosis of granulomatous diseases as well as to establish the procedure characteristics that would optimize the concordance between ROSE and final diagnosis. METHODS Charts of patients with a cytological diagnosis of granuloma by EBUS-TBNA between June 2008 and May 2013 were reviewed. Preliminary ROSE findings and final cytological diagnosis were compared. Patient demographics and procedure variables were assessed using mean (±SD). The variables collected were considered in a logistic regression analysis using concordance as the outcome. MEASUREMENTS AND MAIN RESULTS In our study, 255 procedures were performed to sample 625 lymph nodes that contained granulomas. An average of 2.4 (±1.2) lymph nodes were biopsied per procedure, with a mean size of 14.4 (±7.9) mm. The concordance between ROSE and the final diagnosis was 81.6%. The concordance rate was not impacted by needle size, lymph nodes size or station, number of stations biopsied, or passes per lymph node. The concordance did improve with the experience of the bronchoscopist (P < 0001). CONCLUSIONS In this single-center study, there was a high concordance between ROSE and the final cytological diagnosis for mediastinal lymph nodes containing granulomas that were sampled by EBUS-TBNA. ROSE may serve to reduce procedure time, enhance sample triaging, and obviate the need for further invasive testing. The only variable associated with increased concordance was the experience of the operator.

EBUS-TBNA Bronchoscopy

Endobronchial ultrasound (EBUS) is an evolving technology that has been used successfully to visualize structures adjacent to central airways that cannot be seen during bronchoscopy. EBUS-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to be a well tolerated, minimally invasive, cost-effective, and accurate procedure in the sampling of mediastinal and hilar lymph nodes. Its major indications include diagnosis and staging of lung cancer, restaging after chemotherapy and/or radiation, diagnosis of metastasis from extrathoracic malignancy, diagnosis of sarcoidosis, tubercular mediastinal lymphadenitis, and other etiologies of mediastinal lymphadenopathy. In this chapter we discuss the technique, specimen handling, anesthesia issues, and diagnostic yield of EBUS-TBNA in various disease processes and compare its diagnostic yield with other methods of sampling lymph nodes. Complications and limitations of EBUS-TBNA are also discussed.

A remedy for hoarseness in a patient with granulomatosis with polyangiitis.

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