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.     

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.     

Endobronchial ultrasound-facilitated video-assisted lobectomy with wedge bronchoplasty for typical carcinoid tumor of the right middle lobe

A 19-year-old man presented with pneumonia, cough, and occasional dyspnea. Chest CT scan and bronchoscopy with biopsy revealed a typical carcinoid tumor obstructing the orifice of the right middle lobe, leading to lobar collapse. Preoperative surgical planning included radial endobronchial ultrasound, which confirmed that the tumor was not invasive into the bronchus intermedius. With that information, a video-assisted right middle lobectomy was performed with a wedge bronchoplasty in order to preserve the right lower lobe. The operation was performed completely thoracoscopically with three 1.2-cm ports and one 3.5-cm utility incision. With the intralobar pulmonary artery retracted, the bronchus was divided with a scalpel in wedge fashion to obtain a margin on the endobronchial tumor, and the defect was closed with absorbable suture. The patient recovered without complication and was doing well at 8-month follow-up, without evidence of recurrent disease.     

Automatic objective diagnosis of lymph nodal disease by B-mode images from convex-type echobronchoscopy

BACKGROUND: We investigated whether artificial neural networks (ANNs) could diagnose pathology of lymph nodes by feeding B-mode images from convex-type echobronchoscopy to ANNs. METHODS: Subjects comprised 91 patients who had undergone endobronchial ultrasonography transbronchial needle aspiration at our hospital between April 2005 and March 2007. Diagnosis was lymph node metastasis from lung cancer in 66 patients, and sarcoidosis in 25 patients. Layered ANNs consisting of input, middle layers, and output layers were prepared. Back-propagation was chosen as a learning algorithm. For the malignant findings, images obtained from six patients with lymph node metastasis of lung cancer (ie, adenocarcinoma, two patients; squamous cell carcinoma, two patients; small cell carcinoma, two patients) were used. As benign findings, typical images obtained from three patients with sarcoidosis were used. For each image used for supervised training, 5, 10, or 15 regions of interest were randomly selected. Repeated learning comprised either 500,000 or 1,000,000 repetitions. A total of five thoracic surgeons were asked to diagnose the pathology base on the same images. Accuracies were compared between ANNs and thoracic surgeons. RESULTS: The diagnostic accuracy of the surgeon with 5 years of experience and that of the surgeon with 1 year of experience were 78% and 51%, respectively, compared to 91% for the ANNs. CONCLUSION: Assessment of B-mode images by ANNs may offer a useful basis for automatic diagnostic methods.     

Monitoring recovery from diaphragm paralysis with ultrasound

BACKGROUND: Diaphragmatic paralysis is an uncommon, yet underdiagnosed cause of dyspnea. Data regarding the time course and potential for recovery has come from a few small case series. The methods that have been traditionally employed to diagnose diaphragmatic weakness or paralysis are either invasive or limited in sensitivity and specificity. A new technique utilizing two-dimensional, B-mode ultrasound (US) measurements of diaphragm muscle thickening during inspiration (Deltatdi%) has been validated in the diagnosis of diaphragm paralysis (DP). The purpose of this study was to assess whether serial US evaluation might be utilized to monitor the potential recovery of diaphragm function. METHODS: Twenty-one consecutive patients with clinically suspected DP were referred to the pulmonary physiology laboratory. Sixteen patients were found to have DP by US (unilateral, 10 patients; bilateral, 6 patients). Subjects were followed up for up to 60 months. On initial and subsequent visits, Deltatdi% was measured by US. Additional measurements included upright and supine vital capacity (VC), maximal inspiratory pressure (Pimax), and maximal expiratory pressure. RESULTS: Eleven of 16 patients functionally recovered from DP. The mean (+/- SD) recovery time was 14.9 +/- 6.1 months. No diaphragm thickening was noted in those patients who did not recover. Positive correlations were found between improvement in Deltatdi% and interval changes in VC, Pimax, and end-expiratory measurements of diaphragm thickness. CONCLUSIONS: US may be used to assess for potential functional recovery from diaphragm weakness or DP. As in previous series, recovery occurs in a substantial number of individuals, but recovery time may be prolonged.     

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.     

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.     

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.     

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   

Radial artery pulse pressure variation correlates with brachial artery peak velocity variation in ventilated subjects when measured by internal medicine residents using hand-carried ultrasound devices

BACKGROUND: Rapid prediction of the effect of volume expansion is crucial in unstable patients receiving mechanical ventilation. Both radial artery pulse pressure variation (DeltaPP) and change of aortic blood flow peak velocity are accurate predictors but may be impractical point-of-care tools. PURPOSES: We sought to determine whether respiratory changes in the brachial artery blood flow velocity (DeltaVpeak-BA) as measured by internal medicine residents using a hand-carried ultrasound (HCU) device could provide an accurate corollary to DeltaPP in patients receiving mechanical ventilation. METHODS: Thirty patients passively receiving volume-control ventilation with preexisting radial artery catheters were enrolled. The brachial artery Doppler signal was recorded and analyzed by blinded internal medicine residents using a HCU device. Simultaneous radial artery pulse wave and central venous pressure recordings (when available) were analyzed by a blinded critical care physician. RESULTS: A Doppler signal was obtained in all 30 subjects. The DeltaVpeak-BA correlated well with DeltaPP (r = 0.84) with excellent agreement (weighted kappa, 0.82) and limited intraobserver variability (2.8 +/- 2.8%) [mean +/- SD]. A DeltaVpeak-BA cutoff of 16% was highly predictive of DeltaPP > or = 13% (sensitivity, 91%; specificity, 95%). A poor correlation existed between the CVP and both DeltaVpeak-BA (r = - 0.21) and DeltaPP (r = - 0.16). CONCLUSIONS: The HCU Doppler assessment of the DeltaVpeak-BA as performed by internal medicine residents is a rapid, noninvasive bedside correlate to DeltaPP, and a DeltaVpeak-BA cutoff of 16% may prove useful as a point-of-care tool for the prediction of volume responsiveness in patients receiving mechanical ventilation.     

Variation in training for interventional pulmonary procedures among US pulmonary/critical care fellowships: a survey of fellowship directors

STUDY OBJECTIVES: The American College of Chest Physicians has published guidelines recommending minimum competency requirements for 17 interventional pulmonary procedures. Our aim was to assess what procedures are offered to fellows in US pulmonary/critical care fellowships and to determine whether the recommended competency numbers are being met. METHODS: Surveys were mailed to 122 pulmonary/critical care fellowship directors in the United States, and fellowship demographics, the types of procedures offered, and the average number of procedures performed were recorded. The presence of a dedicated interventional pulmonologist (IP) was ascertained, and procedural offerings and volume were compared with programs that did not have an IP. RESULTS: The response rate of the survey was 77%. There was wide variation in the procedures offered by different programs. The presence of an IP was associated with an increased likelihood of advanced procedural training in brachytherapy (p < 0.05), electrocautery/argon plasma coagulation (p < 0.001), stents (p < 0.001), laser therapy (p < 0.01), rigid bronchoscopy (p < 0.001), and cryotherapy (p < 0.05). For only 3 of the 17 procedures did > 50% of the programs reach the targeted numbers to obtain competency. CONCLUSIONS: There is a large variation in the spectrum of pulmonary procedures offered to trainees. Programs with a dedicated IP are more likely to offer training in advanced therapeutic procedures. When interventional procedures are offered by fellowships, < 30% of programs meet the competency recommendations. These findings have implications for training, delivery of care, and research. An extra year of fellowship in interventional pulmonology might be desirable if one is to reach the desired competency numbers. An alternative to reaching the recommended numbers for select procedures would be to consider regionalizing care at centers that perform many procedures. Finally, to provide justification for the current competency recommendations, clinical outcomes should be correlated with physicians' procedural volume, as has been done in other subspecialties.     

Factors related to diagnostic sensitivity using an ultrathin bronchoscope under CT guidance

BACKGROUND: We investigated factors related to the diagnostic sensitivity of CT-guided transbronchial biopsy (TBB) using an ultrathin bronchoscope and virtual bronchoscopy (VB) navigation for small peripheral pulmonary lesions. METHOD: We have performed this procedure on 83 patients with 85 small peripheral pulmonary lesions (< 20 mm in diameter). We analyzed the relationship between the diagnostic sensitivity and the location of the lesions, the bronchial generation to which an ultrathin bronchoscope was inserted, and the lesion-bronchial and lesion-pulmonary arterial relationships on high-resolution CT. RESULTS: Fifty-six of the 85 lesions (66%) were diagnosed following CT-guided TBB using an ultrathin bronchoscope with VB navigation. The lesions located in the left superior segment of the lower lobe (S6) had a significantly low diagnostic sensitivity compared to other locations (p < 0.01). When an ultrathin bronchoscope could be inserted to the fifth or greater bronchial generation, the yield was above the average diagnostic sensitivity of 66%. Moreover, not only the patients with the presence of a bronchus leading directly to a lesion (CT-bronchus sign), but also the patients with the presence of a pulmonary artery leading to a lesion (CT-artery sign), had high diagnostic sensitivity (p < 0.01). Multivariate analysis revealed that the location of lesion was an independent predictor of diagnostic sensitivity (p < 0.05). CONCLUSIONS: The location of the lesion, the bronchial generation to which an ultrathin bronchoscope was inserted, and the presence of a bronchus as well as a pulmonary artery leading to the lesion were valuable for predicting successful CT-guided TBB using an ultrathin bronchoscope with VB navigation.