Tino Schneider

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration of an Intravascular Sarcoma Metastasis

The role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of endovascular lesions has rarely been described. We report a case of EBUS-TBNA of a solid mass in the left pulmonary artery in a patient with synovial sarcoma of the kidney, which was performed without complications and led to the diagnosis of metastatic disease. EBUS-TBNA seems to be a rapid, minimally invasive, safe and effective diagnostic procedure in selected cases of endovascular lesions.

Epidermal Growth Factor Receptor Mutation in a Patient with Squamous Cell Carcinoma of the Lung: Who Should Be Tested

We report the case of a 64-year-old ex-smoker with metastatic poorly differentiated squamous cell carcinoma (SCC) of the lung and an epidermal growth factor receptor (EGFR) mutation in exon 21 (p.L858R) who achieved prolonged clinical benefit from treatment with an EGFR tyrosine kinase inhibitor (TKI). The initial diagnosis of SCC of the lung obtained by bronchoscopic biopsy was based on immunohistochemical staining only with positivity for cytokeratin (CK) 5/6 and p63 because morphological diagnosis was not possible. Patients with non-small cell lung cancer (NSCLC), not otherwise specified (NOS) favouring SCC are usually not tested for the presence of EGFR mutations, and therefore may not receive EGFR TKI therapy. A bronchoscopic rebiopsy showed small nests of undifferentiated tumour cells with weak immunoreactivity of some tumour cells for CK5/6, p63 and no positivity of some tumour cells for thyroid transcription factor-1. These findings suggested a mixed squamous/glandular immunophenotype that has been missed at the initial biopsy. Our clinical case illustrates the problem of tumour heterogeneity encountered in small bronchoscopic biopsies and the difficulties of evaluating the histological subtype in poorly differentiated carcinomas. Initial bronchoscopy should be performed by an experienced pulmonologist who attempts to obtain sufficient material from different areas of the tumour. In the era of targeted therapy, a remote smoking history in a patient with NOS favouring SCC should also lead to EGFR mutation testing to allow highly effective therapy to be offered to mutation-positive patients.

Handheld single photon emission computed tomography (handheld SPECT) navigated video-assisted thoracoscopic surgery of computer tomography-guided radioactively marked pulmonary lesions

OBJECTIVES Radioactive marking can be a valuable extension to minimally invasive surgery. The technique has been clinically applied in procedures involving sentinel lymph nodes, parathyroidectomy as well as interventions in thoracic surgery. Improvements in equipment and techniques allow one to improve the limits. Pulmonary nodules are frequently surgically removed for diagnostic or therapeutic reasons; here video-assisted thoracoscopic surgery (VATS) is the preferred technique. VATS might be impossible with nodules that are small or located deep in the lung. In this study, we examined the clinical application and safety of employing the newly developed handheld single photon emission tomography (handheld SPECT) device in combination with CT-guided radioactive marking of pulmonary nodules. METHODS In this pilot study, 10 subjects requiring surgical resection of a pulmonary nodule were included. The technique involved CT-guided marking of the target nodule with a 20-G needle, with subsequent injection of 25-30 MBq (effective: 7-14 MBq) Tc-99m MAA (Macro Albumin Aggregate). Quality control was made with conventional SPECT-CT to confirm the correct localization and exclude possible complications related to the puncture procedure. VATS was subsequently carried out using the handheld SPECT to localize the radioactivity intraoperatively and therefore the target nodule. A 3D virtual image was superimposed on the intraoperative visual image for surgical guidance. RESULTS In 9 of the 10 subjects, the radioactive application was successfully placed directly in or in the immediate vicinity of the target nodule. The average size of the involved nodules was 9 mm (range 4-15). All successfully marked nodules were subsequently completely excised (R0) using VATS. The procedure was well tolerated. An asymptomatic clinically insignificant pneumothorax occurred in 5 subjects. Two subjects were found to have non-significant discrete haemorrhage in the infiltration canal of the needle. In a single subject, the radioactive marking was unsuccessful because the radioactivity spread into the pleural space. CONCLUSIONS In our series of 10 patients, it was demonstrated that using handheld SPECT in conjunction with VATS to remove radioactively marked pulmonary nodules is feasible. The combination of proven surgical techniques with a novel localization device (handheld SPECT) allowed successful VATS excision of pulmonary nodules which, due to their localization and small size, would typically have required thoracotomy. REGISTRATION ClinicalTrials.gov, NCT02050724, Public 01/29/214, Joachim Müller.

CCL19-producing fibroblastic stromal cells restrain lung carcinoma growth by promoting local antitumor T-cell responses

Background A particular characteristic of non–small cell lung cancer is the composition of the tumor microenvironment with a very high proportion of fibroblastic stromal cells (FSCs). Objective Lapses in our basic knowledge of fibroblast phenotype and function in the tumor microenvironment make it difficult to define whether FSC subsets exist that exhibit either tumor‐promoting or tumor‐suppressive properties. Methods We used gene expression profiling of lung versus tumor FSCs from patients with non–small cell lung cancer. Moreover, CCL19‐expressing FSCs were studied in transgenic mouse models by using a lung cancer metastasis model. Results CCL19 mRNA expression in human tumor FSCs correlates with immune cell infiltration and intratumoral accumulation of CD8+ T cells. Mechanistic dissection in murine lung carcinoma models revealed that CCL19‐expressing FSCs form perivascular niches to promote accumulation of CD8+ T cells in the tumor. Targeted ablation of CCL19‐expressing tumor FSCs reduced immune cell recruitment and resulted in unleashed tumor growth. Conclusion These data suggest that a distinct population of CCL19‐producing FSCs fosters the development of an immune‐stimulating intratumoral niche for immune cells to control cancer growth. Graphical abstract Figure. No Caption available.

Treatment of COPD Exacerbation in Switzerland: Results and Recommendations of the European COPD Audit

Background: The European COPD Audit initiated by the European Respiratory Society (ERS) evaluated the management of hospital admissions due to exacerbation of chronic obstructive pulmonary disease (COPD) in several European countries. Data on the treatment of severe acute exacerbations of COPD (AECOPDs) in Switzerland are scarce. Objectives: In light of the GOLD 2010 guidelines, this work aims to examine the quality of care for AECOPD and to provide specific recommendations for the management of severe AECOPD in Switzerland. Methods: A total of 295 patients requiring hospital admission to 19 Swiss hospitals due to exacerbation of COPD during a predefined 60 days in 2011 were included in the study. We compared the Swiss data to the official GOLD 2010 recommendations and to the results of the other European countries. Results: Approximately 43% of the Swiss patients with severe AECOPD were current smokers at hospital admission, compared to 33% of the patients in other European countries (p < 0.001). In Switzerland and in Europe, spirometry data were not available for most patients at hospital admission (65 and 60%, respectively; p = 0.08). In comparison to other European countries, antibiotics were prescribed 14% less often in Switzerland (p < 0.001). Only 79% of the patients in the Swiss cohort received treatment with a short-acting bronchodilator at admission. Conclusions: Considering the overall high standard of health care in Switzerland, in light of the GOLD 2010 guidelines we are able to make 7 recommendations to improve and standardize the management of severe AECOPD for patients treated in Switzerland.

A chest wall mass after breast carcinoma surgery: a simple diagnosis?

Tuberculosis affects pulmonary and extra‐pulmonary sites with a multitude of differing presentations. The involvement of thoracic wall is a rare entity. We report the case of a patient who had a tumefaction on the right chest wall 6 months after a right breast mastectomy. After an initial radiological suspicion of malignancy, we detected intraoperatively an abscess in which histologic examination revealed granulomas with multinucleated giant cells.

First experience with a biodegradable endobronchial stent in a case of bronchomalcia

Introduction: Stents are widely used to preserve airways from obstruction. Complications include migration, formation of granuloma and obstruction due to trapped secretions. In this context the use of biodegradable stents might be an alternative. Methods: A 72 years old patient suffering from dyspnea especially on exercise was refered to our Department. The patient9s history included a liver-transplantation related to a cryptogenic cirrhosis in 1994, an oropharyngial carcinoma in 2003 treated with radiation (cervical & supraclavicular) followed by laryngectomy. The patient also suffered from normofrequent atrial fibrillation. Endoscopically there was a breath dependent subtotal stenosis of the left main bronchus (under conscious sedation & awake). The right main bronchus showed a small narrowing. The FEV1 was 0.94 l (37%) and VC 2.17 l (67%). Results: The patient had a history of granulomas in the area of larynectomie. He also had a tracheostomy, therefore a silicon stent was difficult to implant. As a consequence, in this case of benign stenosis we decided to implant a 14 x 30 mm biodegradable polydioxanone stent. The wall tension seemed to be less than with silicon or nitinol stent. In situ the stent did not expand fully and was longer than calculated spaning from the main carina to the partially open ostium of the left upper lob. Fifty days later, the stent was partially bioabsorbed and the in- and expiratory functionality the left main bronchus was open. There were no problem of mucus. The lung functions improved regarding FEV1 1.40 l (55%) and VC 2.79 l (87%). Conclusion: Biodegradable stents are a promising alternative option for the maintainance of the endobronchial lumen.

ARDS nach akzidentieller Aspiration von Petroleum bei einem Erwachsenen

Petroleum aspiration as a reason for lipid pneumonia is a rare complication. Mostly children are affected and mortality rates are low. In most case series, virtually every subject survived.We describe here the case of a patient who developed ARDS and pneumatoceles with a fatal outcome. Due to the undulant nature of the disease, multipe thoracic CT were performed, enabling us to describe the precise radiologic course of the disease.