Conventional transbronchial needle aspiration decreases the rate of surgical sampling of intrathoracic lymphadenopathy

BACKGROUND: Previous studies have suggested a decreased need for the surgical biopsy of intrathoracic lymph nodes (LNs) due to improved diagnostic rates utilizing transbronchial needle aspiration (TBNA) with endobronchial ultrasound and endoscopic ultrasound. The goal of this study was to determine whether conventional TBNA using combined cytologic and histologic analysis of tissue specimens impacted the rates of surgical diagnostic biopsies of patients with intrathoracic lymphadenopathy. METHODS: Retrospective review at a single academic center. All mediastinal and hilar tissue samples submitted for pathologic analysis over an 8.4-year period were analyzed. Patients were categorized into a "before" group and an "after" group based on two different time periods. The before group underwent only cytologic analysis of Wang needle (19-gauge or 21-gauge) aspirates. The after group had cytologic analysis of aspirates as well as histologic analysis of needle "core" (19 gauge) biopsy specimens. The groups were compared for the rate of intrathoracic LNs sampled by surgical means vs TBNA and the number of times that TBNA averted the need for a surgical diagnostic procedure. RESULTS: The success of TBNA increased significantly in the after group compared to that in the before group. The yield for the successful sampling of mediastinal and hilar LNs increased from 53 to 91% (p < 0.001) in the before group vs the after group. TBNA averted a surgical biopsy in 35% of the before cases compared to 66% of the after cases (p < 0.001). CONCLUSIONS: Conventional TBNA using large-bore needles with both cytology and surgical pathology evaluation decreases the need for surgical sampling of the mediastinum to diagnose thoracic lymphadenopathy.     

Exclusive diagnostic contribution of the histology specimens obtained by 19-gauge transbronchial aspiration needle in suspected malignant intrathoracic lymphadenopathy

BACKGROUND: Transbronchial needle aspiration (TBNA) performed with a 19-gauge needle provides both cytologic and histologic specimens. However, the diagnostic yield for malignancy gained by histologic examination is unclear. Moreover, this kind of needle is often reserved only for selected cases, in part due to fear for complications. The primary aim of this study was to investigate the diagnostic contribution for malignancy added by histologic to the cytologic specimen examination. The secondary aim was to evaluate the safety of using a 19-gauge needle routinely in all patients. METHODS: Consecutive patients presenting with mediastinal and/or hilar lymph node enlargement of > or = 1 cm, in whom suspicion for malignancy was raised, underwent TBNA with a 19-gauge needle. Patients with negative aspirate test results underwent surgical investigation. RESULTS: Among 77 patients who were examined, 66 had malignant intrathoracic lymphadenopathy. TBNA proved malignancy in 58 patients, whereas it missed the diagnosis in 8 patients (sensitivity, 87.9%; negative predictive value, 57.9%). TBNA established the diagnosis in 94% of patients with small cell lung cancer (SCLC), and in 88% of patients with non-SCLC (p = 0.7). Exclusive diagnosis was obtained in 36.4% of patients by histology (compared with 18.2% of patients by cytology [p = 0.06]), representing an increase of 35.3% in the diagnostic yield of TBNA over sole cytology examination. No major complication occurred. CONCLUSIONS: Histology specimens obtained exclusively with a 19-gauge TBNA needle enabled diagnosis in about 36% of patients with malignant intrathoracic lymphadenopathy. The routine use of a 19-gauge needle is safe.     

Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomography-normal mediastinum in patients with lung cancer

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can reliably sample enlarged mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC), and in practice is mostly used to sample nodes visible on CT or positron emission tomography (PET). Few data are available on the use of endoscopic procedures to stage the mediastinum in clinical stage 1 lung cancer. The aim of the present study was to determine the results of EBUS-TBNA in sampling mediastinal lymph nodes in patients with lung cancer and a radiographically normal mediastinum and no PET activity. From January 2004 to May 2007, patients highly suspicious for NSCLC with CT scans showing no enlarged lymph nodes (no node > 1 cm) and a negative PET finding of the mediastinum underwent EBUS-TBNA. Identifiable lymph nodes at locations 2r, 2L, 4r, 4L, 7, 10r, 10L, 11r, and 11L were aspirated. All patients underwent subsequent surgical staging. Diagnoses based on aspiration results were compared with those based on surgical results. One hundred patients (mean age, 52.4 years; 59 men) were included. After surgery, 97 patients (mean age, 52.9 years; 57 men) had NSCLC confirmed and were included in the analysis. In this group, 156 lymph nodes ranging 5 to 10 mm in size were detected and sampled. Malignancy was detected in nine patients but missed in one patient. Mean diameter of the punctured lymph nodes was 7.9 mm. The sensitivity of EBUS-TBNA for detecting malignancy was 89%, specificity was 100%, and the negative predictive value was 98.9%. No complications occurred. In conclusion, EBUS-TBNA can be used to accurately sample and stage patients with clinical stage 1 lung cancer and no evidence of mediastinal involvement on CT and PET. Potentially operable patients with no signs of mediastinal involvement may benefit from presurgical staging with EBUS-TBNA.     

Reducing the toll of inflammatory lung disease

Toll-like receptors (TLRs) are pivotal in human response to microbial stimuli. Their activation and signaling underpin much of the observed epidemiologic data generated by the hygiene hypothesis, and their contribution to infectious exacerbations of airways disease is likely to be highly important. Our growing knowledge in this field will have a significant impact on the understanding of the pathogenesis of inflammatory diseases, and TLR-based therapies are already in early clinical trials to modify atopic disease severity.     

Surfactant in airway disease

Beta(2)-adrenergic agonists cause a release of pulmonary surfactant into lung airways. The surfactant phospholipids maintain the patency of the conducting airways, but this function is inhibited by plasma proteins entering an inflamed airway. The physical behavior of the surfactant can be studied with a pulsating bubble surfactometer and a capillary surfactometer. Calf lung surfactant extract was found to be inhibited by plasma proteins and by a lowering of temperature. Severe breathing difficulties and malfunctioning surfactant developed in BALB/c mice inhaling ozone or infected with respiratory syncytial virus, mainly as a result of proteins invading the airways. Patients with asthma were challenged with allergens in an area of one lung. BAL fluid (BALF) from such an area contained a surfactant that functioned poorly (ie, an inability to maintain airway openness) compared with BALF from the other lung or from the lungs of healthy volunteers. When proteins in the BALF were removed, surfactant performance clearly improved. Eosinophils, so prominent in asthmatic patients, synthesize the enzyme lysophospholipase, which, together with the enzyme phospholipase A(2), catalyzes the hydrolysis of the main component of the surfactant, phosphatidylcholine. Such hydrolysis incapacitates the ability of the surfactant to maintain airway patency. The treatment of asthma with beta(2)-adrenergic agonists and steroids will have a valuable effect on the surfactant system. It will cause a release of fresh surfactant into terminal airways. Surfactant can also be nebulized and inhaled, which has been shown to be an effective treatment.     

Endobronchial ultrasound

During flexible fiberoptic bronchoscopy (FB), a solitary pulmonary nodule (SPN) is sampled by means of transbronchial needle aspiration (TBNA), brush, or transbronchial lung biopsy under fluoroscopy; and mediastinal lymph nodes are sampled using "blind" TBNA. Endobronchial ultrasound (EBUS) was developed to help visualize the lesion at the time of biopsy in order to improve the diagnostic yield. METHODS: There are two types of EBUS techniques: using a radial probe (RP) with a rotating transducer at the distal tip, which produces a 360 degrees image to the long axis of the bronchoscope; and using an EBUS bronchoscope with a linear transducer at its distal tip, producing a 50 degrees image parallel to its long axis. RESULTS: In biopsies of SPNs < 2 cm using an RP, EBUS demonstrates a higher diagnostic yield than conventional FB techniques. With mediastinal and hilar nodal stations, except for the subcarina, EBUS shows a higher yield over blind TBNA. The current procedural terminology code for EBUS is 31620, a "ZZZ" code submitted in addition to other performed procedures (31622-31638). In 2007, an estimate of physician Medicare reimbursement for EBUS is $70.49. Reimbursement is locality dependent and based on economic-exchange conversion factors. Incorporating an ultrasound image into the report substantiates the use of this technique. Limitations: The physician must learn ultrasound image interpretation and the EBUS technique, and be skilled in TBNA. Maintaining competency requires frequent performance of EBUS. CONCLUSION: EBUS-directed biopsy improves the yield over conventional FB for SPNs < 2 cm and for most mediastinal or hilar nodal stations. This reduces the need to conduct additional diagnostic procedures.     

Can Mediastinal Nodal Mobility Explain the Low Yield Rates for Transbronchial Needle Aspiration Without Real-Time Imaging?

BACKGROUND: The diagnostic yields with transbronchial needle aspiration (TBNA) for mediastinal nodes are highly variable. Nodal positions, as assessed on a breath-hold conventional CT scan, do not account for nodal motion. We studied nodal motion on four-dimensional (4D) CT scans. METHODS: A total of 47 mediastinal nodes were identified on 4D CT scans performed for radiotherapy planning in 25 patients with lung cancer. Nodes were mainly located at stations 4R, 4L, 7, and 2R, and each identified node was contoured in all 10 phases of the 4D CT scan. Nodal motion was correlated with changes in carina position. RESULTS: The mean (+/- SD) nodal diameter was 10.2 +/- 4.0 mm; and the mean nodal volume was 1.8 +/- 2.3 mL. Movement was maximal in the craniocaudal axis (mean length, 4.7 +/- 2.3 mm), and the corresponding mean mediolateral and ventrodorsal movements were 2.8 +/- 1.9 mm and 2.4 +/- 1.8 mm, respectively. The mean three-dimensional displacement of the nodal center was 6.2 +/- 2.9 mm, and it exceeded 10 mm in five nodes. The nodal mass was constantly present in only 25 +/- 14% of the region encompassing all nodal positions. The mean variation in craniocaudal distance between all nodes and the carina position during respiration was 5.3 +/- 2.1 mm (range, 2.2 to 10.5 mm). CONCLUSIONS: Both nodal motion and the varying distance between the carina and nodal position may explain the lower diagnostic yields for TBNA procedures performed without real-time guidance.     

Impaired objective daytime vigilance in obesity-hypoventilation syndrome: impact of noninvasive ventilation

BACKGROUND: Obesity-hypoventilation syndrome (OHS) is efficiently treated by noninvasive ventilation (NIV). Sleep respiratory disturbances, reduced ventilatory drive, and excessive daytime sleepiness (EDS) are commonly reported, but their relationships remain unclear. OBJECTIVES: To characterize sleep breathing disorders encountered in patients with OHS, to compare low and normal CO(2) responders in terms of sleep abnormalities, subjective and objective measures of EDS, and to measure the changes induced by NIV on these parameters. METHODS: At baseline and after 5 nights of NIV, 15 consecutive patients (mean [+/- SD] age, 55 +/- 9 years; mean body mass index, 38.7 +/- 6.1 kg/m(2); Paco(2), 47.3 +/- 2.3 mm Hg) prospectively underwent polysomnography, CO(2) ventilatory response testing, Epworth sleepiness scale scoring, and the Oxford Sleep Resistance (OSLER) test, which is an objective vigilance test. RESULTS: OHS patients exhibited obstructive sleep apnea syndrome (mean apnea-hypopnea index, 62 +/- 32 events per hour) and rapid eye movement (REM) sleep hypoventilation (mean REM sleep time, 35 +/- 33%). Baseline CO(2) sensitivity was significantly related to the proportion of hypoventilation during REM sleep (r = 0.54; p = 0.037). Six patients showed abnormal sleep latencies during the OSLER test (71% of the low CO(2) responders vs 14% of the normal CO(2) responders). Low CO(2) responders exhibited significantly shorter sleep latencies during the OSLER test (23 +/- 14 vs 37 +/- 8 min, respectively; p = 0.05). Using NIV, diurnal blood gas levels were improved and REM sleep hypoventilation were suppressed. Objective sleepiness was improved in low CO(2) responders (p = 0.04). CONCLUSION: In OHS patients, the lower the daytime CO(2) response, the higher the proportion of REM sleep hypoventilation and daytime sleepiness. Short-term therapy with NIV improves all of these parameters.     

Histopathologic pattern and clinical features of rheumatoid arthritis-associated interstitial lung disease

STUDY OBJECTIVES: To investigate the histopathologic pattern and clinical features of patients with rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) according to the American Thoracic Society (ATS)/European Respiratory Society consensus classification of idiopathic interstitial pneumonia. DESIGN: Retrospective review. SETTING: Two thousand-bed, university-affiliated, tertiary referral center. PATIENTS: Eighteen patients with RA who underwent surgical lung biopsy (SLBx) for suspected ILD. METHOD: SLBx specimens were reviewed and reclassified by three lung pathologists according to the ATS/European Respiratory Society classification. Clinical features and follow-up courses for the usual interstitial pneumonia (UIP) pattern and the nonspecific interstitial pneumonia (NSIP) pattern were compared. RESULTS: The histopathologic patterns were diverse: 10 patients with the UIP pattern, 6 patients with the NSIP pattern, and 2 patients with inflammatory airway disease with the organizing pneumonia pattern. RA preceded ILD in the majority of patients (n = 12). In three patients, ILD preceded RA; in three patients, both conditions were diagnosed simultaneously. The majority (n = 13) of patients had a restrictive defect with or without low diffusion capacity of the lung for carbon monoxide (D(LCO)) on pulmonary function testing; 2 patients had only low (D(LCO)). The UIP and NSIP groups were significantly different in their male/female ratios (8/2 vs 0/6, respectively; p = 0.007) and smoking history (current/former or nonsmokers, 8/2 vs 0/6; p = 0.007). Many of the patients with the UIP pattern had typical high-resolution CT features of UIP. Five patients with the UIP pattern died, whereas no deaths occurred among patients with the NSIP pattern during median follow-up durations of 4.2 years and 3.7 years, respectively. CONCLUSIONS: The histopathologic type of RA-ILD was diverse; in our study population, the UIP pattern seemed to be more prevalent than the NSIP pattern.     

Diagnostic value of endobronchial ultrasonography with a guide sheath for peripheral pulmonary lesions without X-ray fluoroscopy

STUDY OBJECTIVES: We evaluated the feasibility and efficacy of transbronchial biopsy (TBB) and bronchial brushing by endobronchial ultrasonography (EBUS) with a guide sheath (GS) as a guide for diagnosing peripheral pulmonary lesions (PPLs) without radiographic fluoroscopy. PATIENTS: One hundred twenty-one patients with 123 PPLs (mean diameter, 31.0 mm) whose bronchoscopic findings were normal. METHODS: An EBUS-GS was inserted and advanced to the PPL without fluoroscopy. Once we obtained the EBUS image, the probe was withdrawn and the GS was left in place. TBB and/or bronchial brushing were performed via the GS. When an EBUS image could not be obtained, we changed to the bronchoscopic examination under fluoroscopy. RESULTS: Seventy-six of 123 PPLs (61.8%) were diagnosed by EBUS-GS guidance without fluoroscopy. The diagnostic yield for PPLs > 20 mm in diameter (75.6%) was significantly higher than that for those 相似文献   

Transbronchial needle aspirates: comparison of two preparation methods

STUDY OBJECTIVES: Transbronchial needle aspiration has evolved as a key bronchoscopic sampling method. Specimen handling and preparation are underrated yet crucial aspects of the technique. This study was designed to identify which of two widely practiced sample preparation methods has a higher yield. DESIGN: Prospective comparison of two diagnostic methods. SETTING: Tertiary academic hospital. PATIENTS: Consecutive patients undergoing transbronchial needle aspiration. INTERVENTIONS: Transbronchial aspirates were obtained pairwise. One specimen was placed directly onto a slide and smears were prepared on site (ie, the direct technique), and the other specimen was deposited into a vial containing 95% alcohol and further prepared in the laboratory (ie, the fluid technique). In total, 282 pairs of samples were aspirated from 145 target sites (paratracheal, 10 sites; tracheobronchial, 101 sites; hilar, 17 sites; endobronchial or peripheral, 17 sites). MEASUREMENTS AND RESULTS: The measured outcome was the presence of diagnostic material at the final laboratory assessment. At least one diagnostic aspirate was obtained in 66% of 86 investigated patients (small cell lung cancer, 18 patients; non-small cell lung cancer, 47 patients; other diagnoses, 21 patients). The direct technique had a better yield overall than the fluid technique (positive aspirates, 36.2% vs 12.4%, respectively; p < 0.01), as well as after stratification for tumor type and for anatomic site. CONCLUSION: The direct technique is superior to the fluid technique for the preparation of transbronchial needle aspirates.     

Automatic titration and calculation by predictive equations for the determination of therapeutic continuous positive airway pressure for obstructive sleep apnea

BACKGROUND: It is unknown to what extent therapeutic continuous positive airway pressure (CPAP) levels obtained by various methods for the treatment of obstructive sleep apnea syndrome (OSAS) differ. This study aimed to explore the relationships among pressures titrated by an automatic CPAP (APAP) device and those calculated using different predictive equations, and to compare different ranges of calculated pressures with pressure values titrated by APAP. METHODS: In 140 OSAS patients, the 95th percentile pressure delivered by an APAP device (AutoSet T; ResMed; Sydney, NSW, Australia) during polysomnography, and pressures calculated by three equations (equation 1, Hoffstein and Miljetig [1994]; equation 2, Sériès et al [2000]; and equation 3, Stradling et al [2004]) were compared. RESULTS: Titrated and calculated pressures were weakly correlated. Significant differences were found between the mean (+/- SD) pressures (11.1 +/- 1.6, 8.3 +/- 1.8, 10.5 +/- 1.6, and 10.3 +/- 1.3 cm H(2)O, respectively) for 95th percentile APAP, and pressures calculated by equations 1, 2, and 3, except between values calculated by equations 2and 3. Differences between the calculated and APAP-derived pressures were negative for the low calculated values, and were progressively attenuated, or became positive, for the high values. The differences were smallest for calculated pressures from 11 to > 13 cm H(2)O, which were represented to a greater extent among the values calculated by equations 2 and 3 than by those calculated by equation 1. CONCLUSIONS: Considerably different therapeutic CPAP levels may be determined using various methods. The differences between the calculated and APAP-derived pressures are largest for calculated values of < 9 or > 15 cm H(2)O. The clinical consequences of these findings deserve further evaluation. Caution is still required before treating OSAS patients with calculated pressures.