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President s Lecture (18th WCBIP President)
IP-PL
Standing at the crossroads of respiratory physiology and respiratory endoscopy
Department of Respiratory and Infectious Diseases St. Marianna University School of Medicine
Teruomi Miyazawa
I will start by explaining why I became interested in
COPD. In this regard, interlobar collateral ventilation
Functional Bronchoscopy, and how I have been trying
evaluation using Chartis System is useful for the preop-
to apply it to clinical practice. It started with a knock on
erative selection of patients. In cases of heterogeneous
the door at the Second Department of Internal Medi-
emphysema without collateral ventilation,, valve place-
cine, Hiroshima University School of Medicine (Profes-
ment is most effective.
sor Yukio Nishimoto), where I enquired to become a
Functional bronchoscopy means bronchoscopy per-
member of the respiratory physiology group under the
formed by an ultrathin catheter bronchoscope equipped
supervision of Drs. Osami Nishida and Takehiko Hira-
with sensors for measuring O2, CO2, airflow, pressure,
moto. This is where I received training to become a pul-
etc. The local lung function is examined by inserting
monologist with a focus on acute!
chronic respiratory
this bronchoscope into segmental bronchi. According to
failure. I believe this was a great opportunity for me to
Dr. Lutz Freitag, an O2 sensor can be used for evaluat-
work under excellent supervisors with an emphasis on
ing segmental bronchial ventilation, and a CO2 sensor
respiratory physiology, which was very important in
can be used for evaluating the perfusion of segmental
the elucidation of symptoms and pathological conditions
lobe based on CO2 output. This catheter is used for col-
of respiratory diseases. It was at Hiroshima City Hospi-
lecting respiratory gas at a site in the vicinity of a lesion
tal where I learned about bronchology from Dr. Nori-
and VOCs (volatile organic compounds) are analyzed
tomo Seno, which was useful for diagnosing lung can-
using a breath analysis sensor such as IMS (Ion Mobil-
cer. Next, I went to Europe to learn rigid bronchoscopy
ity Spectrometry) for diagnosis. A method for rapid di-
from Dr. Hermann Tonn in Hannover, Dumon stent
agnosis by breath analyzing without performing tissue
placement from Dr. Jean"
Francois Dumon in Marseille,
biopsy is promising study for lung cancer.
Dynamic stent implantation from Dr. Lutz Freitag in
Essen, and Ultraflex stent implantation from Dr. Heinrich Becker in Heidelberg. Thereafter, I was engaged in
medical practice using Interventional bronchoscopy as
my speciality, mainly for lung cancer. It was after this
clinical practice that, I got the idea of Functional Bronchoscopy . I found myself becoming fastidious about
respiratory physiology which was a very interesting
subject for me. Interventional Pulmonology , which not
only includes laser ablation and!
or stenting but also
brochoscopic lung volume reduction with bronchial
valve for COPD and bronchial thermoplasty for bronchial asthma. Against this background, it is important
to take into account the respiratory physiological characteristics of an individual patient. For example, in the
case of airway stenosis, an appropriate stent must be
accurately placed at the flow"
limiting site (the choke
point) to obtain the best results. In this sense, pathological conditions can be evaluated in real time by measuring the airway pressure gradient between airway pressure at both sides of a stenosis using a bronchial catheter during bronchoscopy. In addition, collateral ventilation positive is problematic for brochoscopic lung volume reduction with bronchial valve placement for
105
Keynote Lecture
IP-KL1
IP-KL2
Rigid bronchoscope, essential tool for therapeutic endoscopy
Mechanical determinants of the maximum expiratory
flow. Choke point physiology
Pulmonology, Centre Hospitalo Universitaire de Marseille,
France
Jean-Francois Dumon
For Therapeutic Bronchoscopy, the Rigid Bronchoscope is
the Instrument of Choice because It is the Only Endoscope
Which Permits at the Same Time Vision, Suction and Lasing
and the Tip of the Bronchoscope Can be Used for Mechanical Debridement and Dilatation.
In a Surgical Approach the Idea is to Maintain a Clear Operating Field, Which is Impossible with a Fiberscope. the Mobile Catheter, with Its Continuous Aspiration Removes All
Secretions, Blood and Smoke. in Order to Increase the Useful
Diameter of the Barrel and Facilitate Removal of Large
Fragments or Debris as Needed, the Telescope is Not Attached at the Proximal End of the Bronchoscope, but rather
Rests and Slides Easily along the Silicone Cap. Thus, the
Lens Can be Extended for Close-Up Inspection or Retracted
to Protect It while Applying the Laser. Similarly, the Laser
Fiber or the Forceps and the Suction Catheter are Unattached so That All Three Components Can be Repositioned.
Laser Resection Consists of the Following Steps: Coagulation, Excision, Hemostasis, and Aspiration of Secretions,
Blood, and!
Or Debris. Mechanical Debridement is Often
Preferable to Laser Resection. It is Usually Carried Out Following Laser Coagulation, although Poorly Vasularized Tumors Can be Mechanically Resected without Using the Laser
for Any Other Purpose than to Coagulate the Base of the Tumor. Mechanical Resection is Carried Out under Direct Visualization. the Telescope is Retracted Well into the Bronchoscope in Order to Keep the Lens Free of Blood and Secretions. the Beveled Tip of the Rigid Bronchoscope is then
Placed against the Airway Wall and Large Fragments of Tissue are Resected by Turning the Bronchoscope in a CorkScrew Motion. the Airway Cartilage is Held as a Constant
Reference within the Airway Wall Providing Tactile Feedback to the Endoscopist. the Tumor Fragments are Removed from the Bronchoscope by Means of a Specially Designed Forceps, or Simply by Aspirating Them with the Suction Catheter. Progressive Dilatation of Airway Stenosis Can
be Achieved with Bronchoscopes of Growing Diameter. This
Method Can be Quite Effective when the Airway Stenosis is
Due to Extrinsic Compression or Loss of Cartilaginous Support. Tube Orientation is Simple in the Trachea and Slightly
Harder in the Main Stem Bronchi, Particularly the Left Main
Stem.For Stent Placement, the Rigid Bronchoscope is Use
First to Obtain a Large Dilatation. Insertion of the Stent
Need an Applicator Adapted to the Size of the Tube Used
and the Diameter of the Prosthesis.
106
Institute of Public Health, Århus, Denmark
Ole F. Pedersen
1) The maximal flow that can pass through an airway segment is determined by the following equation:
V max=A(A!
(ρCaw))0.5
where A is the cross-sectional area of the airway, ρ is the
density of the air and Caw is the compliance of the airway
(dA!
dPtm).
2) The point in the airway allowing the smallest maximal
flow is described as the choke point , which in normal subjects is situated in the transition between the intrathoracic
and the intrapulmonary airways. It moves peripherally during the expiration.
3) A number of extrincic factors like lung volume and elastic
recoil pressure are influential. This is true also for intrinsic
conditions such as unequal size, stiffness and distribution of
the bronchi.
Keynote Lecture
IP-KL3
Regenerative medicine and stem cells
Brigham and Women s Hospital, USA
Charles A. Vacanti
Advances in technology and medicine resulted in the
Mature cells have a relatively high oxygen requirement
emergence of a field in medicine referred to as Tissue
and easily die shortly after implantation as a result of a
Engineering. At the same time, reports of genetic engi-
low oxygen environment. They do not perform nor-
neering, cloning and cancer research and advances in
mally after being expanded in the incubator for signifi-
stem cell biology appear to be increasing. I believe that
cant periods of time. Alternatively, immature cells; pro-
advances in all of these fields are closely intertwined,
genitor cells and stem cells, multiply much better, and
and that coordinated research efforts will lead to com-
have a lower oxygen requirment upon initial implanta-
prehensive medical advances. I hope to present a brief
tion, and can tern into the various cell types in the spe-
review of Tissue Engineering and Stem Cell biology.
cific tissue needed. Until a few years ago, stem cells had
A painting by Fra Angelica, Healing of Justinian de-
been divided into two groups, (1) adult stem cells and (2)
picting the transplantation of a limb by Saints Damian
embryonic stem cells. With the development of induced
and Cosmas is often referred to as the first historical
pluripotent cells, the distinction became far less clear.
reference to Tissue Engineering . The science of tissue
Prior to that, adult derived stem cells were believed to
engineering, as it exists today, was born in the mid 1980
have far less potential than embryonic stem cells. This
s, first with the development of artificial skin by Iannas
limitation appears to have been overcome with the in-
and Burke, and then Tissue Engineered cartilage, de-
troduction of iPScells (1). Meanwhile, in a paper pub-
scribed by Vacanti, et. al.. The potential of Tissue Engi-
lished by Vacanti et. al. in 2001 the existence of a differ-
neering was brought to the forefront of public aware-
ent pluripotent adult stem cell, referred to as a spore-
ness in a televised report of the BBC, when they broad-
like cell (2) was reported. Its physical characteristics
cast of images of the infamous mouse with the human
are a very small size, 3-7 microns in diameter, (which is
ear . These studies were based on the premise that
smaller than a red blood cell) and the ability to with-
new, functional, replacement tissue could be grown, us-
stand hostile tissue environments, such as a low oxygen
ing living cells, seeded onto appropriately configured
environment, elevated temperature, and freeze thaw
scaffolds.
cycles (which are normally quite detrimental to cells).
Although the promise of tissue engineering has been
Numerous adult and progenitor cell reports followed
tremendous, there are relatively few clinical applica-
that report, including SKCs, VSEL cells, and MUSE
tions in use in humans. The main reason is that large
cells (3-5), which I believe are all variations of the same,
numbers of cells are needed to generate relatively
very early, immature cell type, that we have referred
small amounts of tissue. To be effective, it will be neces-
to as an adult spore-like stem cell in 2001. Based on
sary to generate large amounts of tissue, starting with
continued experiments in our laboratory, we postulated
very few cells. When mature cells are allowed to multi-
that spore-like adult stem cells, which we considered
ply in an incubator, they lose their effectiveness. Conse-
to be the body s natural repair cell, were being created
quently, scientists have started to carefully study the
via the reprogramming of mature cells upon exposure
potential of different types of cells to be used in tissue
to the harsh environments associated with the isolation
engineering.
process. When we observed high power microscopic
To be effective, cells must be easily procured or pro-
images of either tissue alone, or of normal mature cells
duced and readily available. They must then multiply
cultures , we were able to identify only small numbers
well without losing their potential to generate new
of these relatively small perfectly round, translumines-
functional tissue, not be rejected by the recipient, sur-
cent, cells containing very little cytoplasm. Since previ-
vive in the relatively low oxygen environment in which
ous reports, including our own, had all focused on the
they are placed, and not trun ito cancer.
belief that the harsh environments to which the cells
A number of different cell types have been suggested
were exposed, were destroying the mature cells, thus
for use in regenerative medicine and are discussed be-
unmasking the existence of the stem cells, the pres-
low. The cells can be autologous, allogenic or xenogenic.
ence or very few cells in the tissue or within the initial
107
Keynote Lecture
isolations of mature cells within culture dishes sug-
ski M, Ratajczak J, Ratajczak MZ. Cell Tissue Res. 2008
gested a different explanation. When we then exposed
Jan;331(1):125-34.
the cell cultures or tissues to the very harsh environ-
5. MUSE cells. Multilineage-differentiating stress-
ments to kill the mature cells, very large number of
enduring (Muse) cells are a primary source of induced
these cells were then visualized, leading us to speculate
pluripotent stem cells in human fibroblasts. Wakao S,
that the presence of these small stem cells was not sim-
Kitada M, Kuroda Y, Shigemoto T, Matsuse D, Akashi
ply unmasked , but rather were being created from
H, Tanimura Y, Tsuchiyama K, Kikuchi T, Goda M,
the mature cells. We demonstrated that mature cells
Nakahata T, Fujiyoshi Y, Dezawa M. Proc Natl Acad
could be reprogrammed to become stem cells (STAP
Sci U S A. 2011 Jun 14;108(24):9875-80
cells) without the use of vectors or addition of DNA, as
6. Stimulus-triggered fate conversion of somatic cells
reported in Nature in 2014 (6,7). These reprogrammed
into pluripotency. Obokata H, Wakayama T, Sasai Y,
cells appear to initially have a somewhat limited capac-
Kojima K, Vacanti MP, Niwa H, Yamato M, Vacanti CA.
ity for multiplying as compared to true embryonic stem
Nature. 2014 Jan 30;505(7485):641-7.
cells, and also contain some remnant markers of the
7. Bidirectional developmental potential in repro-
adult cells from which they were derived. However
grammed cells with acquired pluripotency. Obokata H,
when exposed to different chemical environments, such
Sasai Y, Niwa H, Kadota M, Andrabi M, Takata N, Tok-
as the addition of ACTH and LIF, to the nutrient pool,
oro M, Terashita Y, Yonemura S, Vacanti CA,
or of Fgf4, they lose their remnant adult cell markers,
Wakayama T. Nature. 2014 Jan 30;505(7485):676-80.
and revert to true embryonic or trophoblastic stem
cells, with the same capacity for multiplication or differentiation into any cell type as either embryonic stem
cells or placental stem cells.
The advances described above may ultimately allow
physicians and scientists to repair or replace any tissue
in the human body, of possible boost the function of a
failing organ. The potential to reverse the symptoms of
stroke and other central nervous system diseases such
as Parkinson s and Alzheimer s Disease is quite realistic. It may be possible to remove cells from diseased organs, genetically manipulate them, and return them to
the patient in a manner to cure their disease. It is conceivable that such an approach may help re-populate
specific organs such as the brain in patients with
Down s Syndrome or muscles in certain forms of Muscular Dystrophy, to result in partial recovery of function.
References:
1. iPS cells Induction of pluripotent stem cells from
mouse embryonic and adult fibroblast cultures by defined factors. Takahashi K, Yamanaka S. Cell. 2006 Aug
25;126(4):663-76. Epub 2006 Aug 10.
2. Identification of a distinct small cell population from
human bone marrow reveals its multipotency in vivo
and in vitro. Wang J, Guo X, Lui M, Chu PJ, Yoo J,
Chang M, Yen Y. PLoS One. 2014 Jan 17;9.
3. SKCs Isolation of multipotent adult stem cells from
the dermis of mammalian skin. Toma JG, Akhavan M,
Fernandes KJ, Barnabé-Heider F, Sadikot A, Kaplan
DR, Miller FD. Nat Cell Biol. 2001 Sep;3(9):778-84
4. VSELs Identification of very small embryonic like
(VSEL) stem cells in bone marrow. Kucia M, Wysoczyn108
Special Lecture
IP-SL1
Heavy problems, light solutions
Ruhrlandklinik Essen, Germany
Lutz Freitag
109
Special Lecture
IP-SL2
IP-SL2
Morphological bases of HRCT diagnosis of pulmonary
diseases
Morphological bases of HRCT diagnosis of pulmonary
diseases
Fukui University, Japan
Harumi Itoh
Pulmonary HRCT first appeared in the early 1980s in Japan. This new technique was the successful outcome of
previous radiological, anatomical and pathological correlation (RAP-C). The RAP-C has been pursued continuously to add new HRCT findings of a wide variety of diffuse and localized pulmonary diseases. The present lecture will emphasize that a greater understanding of pre-existing structures of the lung enables both clinical and
research activities of image diagnosis to add accuracy and progress further.
(1) Subpleural polygon mesh and interlobular septum The normal anatomy of visceral pleura is important to understand pleural abnormalities, like pleural tag and honeycomb lung. Three-dimensional CT of lung specimens
has demonstrated radio-opaque polygonal mesh on the pleural surface. This network corresponds to subpleural
small pulmonary veins, lymph vessels and pleuro-septal junction. The pleuro-septal junction is a V-shaped thick
portion of interstitial tissue where the interlobular septum joins the pleura. The subpleural polygon mesh develops more in the basal portion than in the upper portion of pulmonary lobe. In many cases, the subpleural polygon
mesh extends from the subpleura to the lung parenchyma 1-2 cm in depth, forming a membrane called an interlobular septum. The interlobular septa are well developed in the lung base and scarce along the interlobar surface. The septa near the anterior and inferior margins of the lung are abundant and cross the lung to connect different pleural planes.
(2) Intersegmental septum Intersegmental septum has not been described precisely due to difficulty of verifying
the septum continuously from the pleura to the hilum through serial lung slices fixed using liquid formalin. The
intersegmental septum has been visualized with serial CT images obtained from inflated lung specimens. The intersegmental septum and pulmonary veins run together and border adjacent pulmonary segments. The septum
is not always flat, particularly near the pulmonary hilum, where the lung parenchyma supplied by a small lateral
bronchus gets stuck among the roots of adjacent pulmonary segments. The intersegmental septum is connected
to interlobular septa belonging to different pulmonary segments.
(3) Pulmonary lobule The pulmonary lobule or secondary lobule of the lung is a basic lung structure to describe
abnormal patterns of diffuse pulmonary diseases. It has been pointed out that the pulmonary lobule defined by interlobular septa is quite variable in size, since the interlobular septa are not distributed evenly within the lung.
Reid and Matsumoto have proposed a different pulmonary lobule to solve this problem. This new lobule is about
10 mm in size and distributed constantly in both outer and inner portions of the lung. Lung parenchyma within
the lobule is supplied by the bronchioles with a constant branching pattern, called a millimeter pattern. In the millimeter pattern, the terminal bronchioles divide every 1-2 mm from a parent intralobular bronchiole. The lobule is
bordered by pulmonary veins, interlobular septa and thicker broncho-arterial bundles. The interlobular veins fit
into the planes that surround a lobule, being polyhedral in shape. The lobules located deep in the lung are supplied by a small lateral bronchus and pulmonary arteries divided from axial broncho-arterial pathways.
(4) Intralobular venule and pulmonary acinus The key structures dividing the pulmonary lobule into pulmonary
acini are the intralobular venules. These venules join perpendicularly to interlobular and subpleural veins at the
border of the lobule. The intralobular venules border both the pulmonary acini and the subacini. Recent micro-CT
study has proven that the pulmonary acinus and subacinus are polyhedral in shape, like the pulmonary lobule,
which enables such small lung units to be packed compactly within the lung. The pulmonary acinus and subacinus may be the key structures to explain the pathogenesis of honeycomb lung.
(5) Communications between pulmonary and bronchial circulation Previous study has shown that the bronchial
wall, peribronchial interstitial space and lymph node are equipped with a rich vascular network from bronchial
arteries. Although pulmonary veins and broncho-arterial bundles are laid alternately within lung parenchyma
and appear to be isolated structures, postmortem bronchial angiography showed vascular communications between pulmonary and bronchial circulation. Namely, the bronchial venous plexus, which surrounds the bronchoarterial bundle, is connected to the nearest pulmonary venules and furthermore to the interlobular veins. The
bronchial venous plexus also communicates with alveolar capillaries.
(6) Back-to-back arrangement of alveoli The popular 3-D schemas of peripheral lung have resulted in some confusion and misunderstanding among young residents. The gas exchange area consists of two compartments. They
are air passages (alveolar ducts and alveolar sacks) and a group of alveoli intervened by the former. The alveoli
gather to form a layer where they are arranged to face in opposite directions. Such a specially arranged structure
of the alveoli has been named back-to-back alveoli, since the dome of the alveoli is shared by the alveoli facing oppositely. Therefore, there is no space between adjacent alveolar ducts or sacks. Both the lateral wall and the dome
of the alveolar wall are equipped with rich alveolar capillaries, while the arterioles and venules are laid only along
the alveolar dome.
110
Educational Lecture
IP-EL1
IP-EL2
Roles of bronchofiberscopy for the diagnosis of interstitial lung diseases
Treatment of severe asthma: Role of bronchial thermoplasty
Clinical Research Center, National Hospital Organization
Kinki-Chuo Chest Medical Center, Japan
Yoshikazu Inoue
Interstitial lung diseases (ILDs) are lung diseases with bilateral parenchymal pulmonary infiltration with variable degrees of interstitial inflammation and!
or fibrosis. ILDs include connective tissue diseases, hypersensitivity pneumonia, and pneumoconiosis, iatrogenic lung diseases, etc. (with
known causes), and idiopathic interstitial pneumonias (IIPs),
sarcoidosis, acute!
chronic eosinophilic pneumonia, etc. (with
unknown cause). In addition, ILDs also include rare lung diseases such as pulmonary alveolar proteinosis, lymphangioleiomyomatosis, Langerhans cell histiocytosis, etc.
Diagnosis of ILDs have been described in the official guidelines, guidance, or statements from scientific societies in the
world {ATS 2012 (BALF), ATS!
ERS 2008, 2013 (IIPs), ATS!
ERS!
JRS!
ALAT 2011 (IPF), BTS (ILD), JRS 2008, 2011,
(BAL, IIPs) etc.}. In addition to clinical histories, blood
biomarkers, and pulmonary function tests, high resolution
CT, and surgical lung biopsy, bronchofiberscopy is considered to be a useful and less invasive procedure for the diagnosis of ILDs.
In this lecture, the following issues, focusing BALF, will be
presented.
(1) Compatible visual findings of ILDs.
(2) Specific or compatible microscopic, cytological or flow cytometry findings of ILDs: Bronchoalveolar lavage fluid
(BALF)
(3) Definite or compatible histologic microscopic findings:
Trans-bronchial lung biopsy ( TBLB ) , endobronchial
ultrasound-guided trans-bronchial needle aspiration (EBUSTBNA)
(4) Negative findings for differential diagnosis of ILDs: lavage
fluid, BALF, TBLB, trans-bronchial biopsy, EBUS-TBNA,
etc.
Medicine, McMaster University, Canada
Gerard Cox
A minority of patients with asthma can not achieve control
of their disease despite using moderate to high doses of inhaled medications. This subset of patients with severe
asthma need additional treatment options. Bronchial thermoplasty (BT) is a procedure delivered during bronchoscopy
that results in long-term reduction in airway smooth muscle
volume and effect (i.e. reduced bronchoconstriction). The
technique involves delivery of radio-frequency energy via a
special treatment catheter that was developed during a series of pre-clinical studies.The effect of BT on asthma was
examined in 4 clinical trials involving patients with a spectrum of asthma severity from mild to severe. The fourth of
these-Asthma Intervention Research 2 (AIR2) trial-formed
the basis of the US FDA approval of BT for the treatment of
severe asthma and provides an outline of apporpriate potential candidate patients. According to various outcomes in
these 4 trials, the more severe the asthma, the more obvious
the benefits of BT. However, adverse events were encountered after treatment-usually aggravation of airway symptoms such as dyspnea, wheeze, sputum and chest tightness.
It was obvious that adverse events were more frequent and
significant (e.g. admission to hospital) in patients with more
severe asthma. Thus, there is substantial interest in defining
the optimal patient!
optimal asthma condition to consider for
safe treatment with BT.
BT has been implemented in over 350 centers in different
countries around the world. The technique remains the same
as that described in the clinical trials. BT is usually delivered
in the Endoscopy Suite as an out-patient procedure. However, it can also be administered under general anesthetic if
that is felt to be more safe.
111
Symposium
IP-SY1-i1
IP-SY1-i2
Clinical utility of medical thoracoscopy -Diagnosis of
nonspecific pleuritis-
Practical considerations in establishing an outpatient
medical thoracoscopy practice
Department of Pulmonary Medicine and Clinical Immunology,
Dokkyo Medical University School of Medicine, Japan
Yoshiki Ishii
Medical thoracoscopy under local anesthesia is a useful tool
for diagnosis and treatment of various pleural diseases. Most
frequent indications for this procedure are diagnosis of unknown etiology pleural effusion. By performing medical thoracoscopy and tharacoscopic pleural biopsy, about 70% of
cases with pleural effusion showed specific thoarcoscopic
findings or specific pathological findings, and precise diagnosis was made. Remaining 30% of cases showed non-specific
thoarcoscopic finding such as diffuse pleural thickening and
non-specific pathological findings such as fibrinous pleuritis.
In such cases, clinical information such as comorbidity, past
history and occupational history is helpful to make a precise
diagnosis. Finally, only, 6.5% of cases with pleural effusion remained to be unknown origin. Pleuritis associated with collagen vascular diseases is major cause of non-specific pleuritis.
We reviewed the thoacoscopic findings in patients with pleuritis associated with CVD such as RA, SLE, Sjogren syndrome.
112
Mayo Clinic, USA
John Joseph Mullon
Background: Although medical thoracoscopy offers a number of advantages over closed pleural biopsy and videoassisted thoracoscopic surgery in selected patient populations, only a minority of practicing pulmonologists perform
this procedure.
Discussion: This session will illustrate one center s experience in establishing a successful outpatient medical thoracoscopy practice and will use that experience as a framework to discuss practical considerations, obstacles, pitfalls,
and methods of collaboration when developing an similar
medical thoracoscopy services elsewhere.
Symposium
IP-SY1-i3
IP-SY1-i4
A hands on teaching program and clinical pathway
transforms pleural procedure outcomes in a large
teaching hospital
Medical pleuroscopy for the pulmologist
Department of Thoracic Medicine, Royal Brisbane and
Women s Hospital, Brisbane, Australia
David Fielding, Timothy Edwards, Alistair Cook,
Matthew Salamonsen, Farzad Bashirzadeh
Background: Pleural ultrasound and the performance of pleural
procedures by highly trained operators significantly improves
patient outcomes and reduces complications. In a large teaching
hospital a clinical pathway can improve the overall direction of
diagnostic tests and referrals. Also we have a duty to teach junior staff procedures rather than limit basic procedures to relatively few operators. We evaluated our outcomes from pleural
procedures pre and post 2 initiatives: a hospital wide clinical
pleural pathway and a hands-on training mannequin program
for pleurocentesis and Intercostal catheter(ICC) insertion.
Methods: Clinical pathway: derived after multidispliniary consultation, with a focus on minimising number of pleural procedures,
importance of pleural ultrasound, pre-procedure checks, seeking
supervision in procedures, and early referral for definitive testing if basic tests were non-diagnostic. Hands on Training: Simulated mannequin teaching and practice for 90 minutes after completing an on-line teaching module, followed by a tick box assessment. Audit:A retrospective analysis of all interventions performed for pleural effusions on medical patients at the Royal
Brisbane and Women s Hospital. Analysis compared patient outcomes 18 months prior to and 12 months following the instigation of pleural effusion management guidelines and hands-on
teaching.
Results: Pleural Training: 70 trainees underwent hands on training, of whom 20 ultimately performed a procedure included in
the post audit below. Six Thoracic Medicine trainees and three
consultants still performed the majority of procedures, however
all had undergone the hands-on training. Pleural procedures: Results are shown in Table 1. There were highly significant improvements in pleural ultrasound use, bedside ultrasound, and
complications.
1
Conclusions:
The instigation of the 2 service improvements vastly improved
patient outcomes while still allowing a range of doctors to perform the procedures.
Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Pyng Lee
Pleuroscopy provides the physician a window to the pleural
space while enabling biopsy of the parietal pleura under direct visual guidance for effusions of unknown etiology,
guided chest tube placement, and pleurodesis for recurrent
pleural effusions or pneumothoraces in selected patients. Although essentially falling into oblivion with the development
of anti-tuberculous drugs, the procedure enjoyed resurgence
when thoracic surgeons introduced the technique for minimally invasive surgery, also known as video-assisted thoracic
surgery (VATS). VATS is performed under general anesthesia with single lung ventilation while pleuroscopy is performed by the pulmonologist in an endoscopy suite using
non-disposable rigid or flex-rigid instruments, local anesthesia and conscious sedation. The major advance is the advent
of flex-rigid pleuroscope (model LTF-160, Olympus, Japan)
which has a 7 mm outer diameter, 22-cm rigid shaft, and 5cm flexible distal tip. It is a promising diagnostic and therapeutic instrument for physicians managing patients with
exudative pleural effusions of unclear etiology and recurrent
malignant effusions requiring pleurodesis. Pooled diagnostic
accuracy of flex-rigid pleuroscopy for exudative pleural effusions (17 studies) was 91% with 100% specificity. There were
minimal complications and no mortality reported. It has been
demonstrated that flex-rigid pleuroscopy can be safely performed as an outpatient procedure. Deficiencies commonly
cited is the size of biopsy obtained with the flexible forceps,
however smaller forceps does not necessarily imply that the
diagnostic accuracy of this technique is inferior to that of
rigid thoracoscopy in fact, investigators have found no difference in yield. To further enhance biopsy technique and diagnostic yield, investigators have incorporated electrosurgical
techniques with success and safety.
Pleuroscopy is akin to chest tube insertion however pulmonologists intent on performing flex-rigid pleuroscopy
should be knowledgeable about thoracic anatomy, and confine biopsies strictly to the parietal pleura overlying a rib.
The flex-rigid pleuroscope offers the pulmonologist a familiar
tool and a coveted view of the pleural space.
113
Symposium
IP-SY1-5
IP-SY1-6
Thoracoscopy for pleaural disorders. Egyptian experience
Withdrawn
Pulmonology, Military Medical Academy, Egypt1), Military
Respiratory Centre2), Specialized Aviation Hospital-Pulmonary
Depart.3)
Ayman A Hamid Farghaly1), Kaled Zamzam2),
Yaser El-sayed3)
Medical thoracoscopy has evolved as a mean of exploring the
darkness of the pleural space. Pleural fluid of undetermined
origin is the major indication, however others such as primary spontaneous pneumothorax can be added to the list.
Subjects & Methods: 165 patients with various pleural pathologies were evaluated over 4 years period in the Air military respiratory center in Cairo (2008-2012). Diagnostic carry
out with the proper therapeutic intervention were carried
out using semirigid thoracosocpe.
Results: Out of the 165 cases, 87 cases proved to be malignant in origin, with 51 case of tuberculous pleural effusion &
11 cases of primary spontaneous pneumothorax, in which
thoracoscopy has affected the line of management. In 16
cases, no definitive diagnosis could be reached. No mortality
was experienced, with one case of considerable bleeding, 5
cases of air leak persisited for 5 days, & 10 cases of pleural
space infection after tube fixation.
Conclusion: Beside being a useful tool for diagnosis & management of pleural effusion, medical thoracosocpy seems to a
very valuable tool in assessment of primary spontaneous
pneumothorax, if the facility is available. The safety of medical thoracoscopy is assured.
114
Symposium
IP-SY1-7
IP-SY2-i1
Closed pleural biopsy-Extinct or reborn?
EBUS TBNA-experience from India
Division of Respiratory Medicine, Department of M&G, United
Christian Hospital, Hong Kong
Alice Pik-Shan Cheung, Suet-lai Cheng,
Veronica lee Chan, Wah-shing Leung, Woon-leung Ng,
Chung-ming Chu
Chhajed Pulmonology s Lung Care and Sleep Centre, India
Prashant Chhajed
Introduction
There is ongoing debate for the most efficient and costeffective diagnostic approach for exudative pleural effusion
(PE). The limited yield in additional to fluid cytology has led
to gradual extinction of blind closed pleural biopsy (BCP) in
western countries. The situation is different in other parts of
the world including SE Asia where the prevalence of Tuberculosis(TB) is high. BCP remains the first line investigation
for exudative PE in these countries. We retrospectively reviewed the diagnostic yield and safety of BCP for exudative
PE in a regional hospital of Hong Kong where the prevalence
of TB is high.
Method
Retrospective case-note review for all patients underwent ultrasound (US) guided BCP from 1, Jan, 2010 to 30, Jun, 2013,
under the care of Division of Respiratory Medicine in United
Christian Hospital, Hong Kong.
Result
There were 55 BCP performed in the study period (43 male
and 12 female). All BCP were performed by respiratory fellows with US guidance. Pleural tissue was included in 90% of
specimens. Fifty-one percent of the cases could achieve a
definite diagnosis by BCP alone (24 TB, 4 malignant). Another 9 patients(16%) were diagnosed to have malignancy by
additional investigations [4 fluid cytology, 5 (bronchoscopy,
pleuroscopy, etc.)]. For patients with undiagnostic BCP, 12
patients(22%) did not have the recurrence of effusion in the
subsequent 6 months after the initial BCP. Three patients
(5.5%) refused further follow-up for PE and 3 patients(5.5%)
died of concurrent critical illness. Overall the sensitivity of
BCP was 76%. The diagnostic yield for TB effusion is 100% in
our series with histology showed granuloma in 23 cases
(96%) and positive ZN stain of the pleura in the remaining
case. For the complication of BCP, there was three patients
(5%) suffering a non-life-threatening pneumothorax.
Conclusion
In area where the prevalence of TB is high, blind closed pleural biopsy can still regarded as a relative safe, readily available and cost-effective first line diagnostic investigation for
exudative PE. With the increasing availability of ultrasound
which helps pulmonologist to locate pleural abnormality,
blind closed pleural biopsy may be re-introduce as an readily
available mode of investigation for malignant PE.
115
Symposium
IP-SY2-i2
IP-SY2-i3
Minimally invasive mediastinal staging, EBUS and
EUS
Real-time EBUS-TBNA in sarcoidosis and tuberculosis
Department of Pulmonology, National Cancer Center, Korea
Bin Hwangbo
Minimally invasive endoscopic methods are replacing
medastinoscopy in lung cancer staging. Endobronchial ultrasound guided-transbronchial needle aspiration (EBUSTBNA), endoscopic ultrasound guided fine needle aspiration
(EUS-FNA) or combined EBUS!
EUS is recommend over surgical staging as a best first test in invasive mediastinal staging of lung cancer (guidelines by American College of Chest
Physicians, 2013). Mediastinoscopy can access lymph nodes
at stations 1, 2, 4, and anterior parts of station 7. EBUSTBNA has a higher accessibility compared to standard mediastinoscopy. It reaches all the mediastinal nodal stations accessible by mediastinoscopy, retrotracheal nodes (3P) and
posterior parts of subcarinal nodes. An advantage of EBUSTBNA is that it also covers a large proportion of N1 lymph
nodes. Nodal stations 10, 11 and some nodes at station 12 at
lower lobes can be sampled by EBUS-TBNA. High diagnostic values of EBUS-TBNA in mediastinal staging have been
reported. According to meta-analyses, pooled sensitivities of
EBUS-TBNA were 88-93%. EBUS-TBNA has been reported
to show similar diagnostic values with mediastinoscopy. Mediastinoscopy following EBUS-TBNA may detect small metastasis missed by EBUS-TBNA, but its clinical importance
seems minimal. EUS-FNA has a lower accessibility to the
mediastinum than EBUS and has a limited ability to target
pre-tracheal lesions. According to meta-analyses, pooled sensitivities of EUS-FNA in mediastinal staging were 83-89%.
Compared to EBUS-TBNA, an advantage of EUS-FNA is
that it allows access to nodal stations 8, 9 and some lymph
nodes at station 5. EBUS-TBNA and EUS-FNA are complementary methods. Advantages of combined application of
EBUS and EUS in lung cancer staging have been reported.
By adding EUS-FNA following EBUS-TBNA, accessibility to
mediastinal nodal stations increased by approximately 6%. In
the combined approach, EBUS-first approach seems reasonable because of a higher accessibility of EBUS to the mediastinum. In a recent randomized controlled trial that compared EBUS-centered and EUS centered procedure in endoscopic mediastinal staging, additional diagnostic gain using
EUS in the EBUS-centred group was small. However, a
marked increase in diagnostic benefit was observed with the
addition of EBUS in the EUS-centred group. Considering the
requirement of EBUS following EUS, EBUS-TBNA is the
preferable primary procedure in endoscopic mediastinal
staging of lung cancer. EUS can be added following EBUSTBNA when locations that are difficult or inaccessible by
EBUS-TBNA are noticed or when bronchoscopy is difficult
due to severe cough, hypoxia and other conditions.
116
Department of Pulmonary Medicine, Izmir Dr. Suat Seren
Training and Research Hospital for Thoracic Medicine and
Surgery, Turkey
Semra Bilaceroglu
The diagnostic performance of real-time endobronchial
ultrasound-guided transbronchial needle aspiration (EBUSTBNA) in granulomatous disease has been studied mostly for
sarcoidosis and tuberculosis (TB). Its overall sensitivity, negative predictive value and accuracy in diagnosing granulomas
are 50-92%, 11-43% and 80-95%, respectively. The sensitivity
increases as the diameter of lymph node, punctured node stations or needle passes increase. The diagnostic efficacy of
EBUS-TBNA has been well established in sarcoidosis (sensitivity, negative predictive value and accuracy: 63-95%, 11-13%
and 83-95%, respectively). The sensitivity of the method is 7478% in stage I and 92-95% in stage II sarcoidosis. Its yield is
higher than those of conventional bronchoscopic methods.
EBUS-TBNA uses a 22-gauge needle whereas conventional
TBNA uses a 19-gauge needle that provides histologic samples. However, EBUS-TBNA is generally superior to conventional TBNA in sampling sarcoid mediastinal nodes. Combination of EBUS-TBNA with conventional bronchoscopic methods, particularly with transbronchial biopsy, increases the
yield from 75-90% to 91-94%. The role of EBUS-TBNA in the
diagnosis of TB has not been established as in sarcoidosis and
the related literature is limited. Its sensitivity, negative predictive value and accuracy in intrathoracic TB (lymphadenitis and pulmonary TB adjacent to airway) are 65-94%, 11-75%
and 85-90%, respectively. EBUS-TBNA can provide diagnosis
in TB by pathology in 80-86% and by microbiology in 53%
(smear: 8-27%, culture: 8-47%, TB-PCR: 54%). It can also identify drug-resistant TB cases. Combination of EBUS-TBNA
with conventional bronchoscopic techniques increases the
yield from 18% to 80% in pulmonary TB with lymphadenopathy. Although sampling by EBUS-TBNA can confirm granulomatous pathology, distinction between TB from sarcoidosis
still depends upon correlating cytologic, microbiologic, clinical
and radiological data in large series in TB endemic regions.
Cytology of EBUS-TBNA specimens can have higher sensitivity than histology alone for intrathoracic sarcoid lymphadenopathy; the sensitivity is 88% for combined cytology and
cell block examinations. The main contributions of cell blocks
are improving diagnosis of benign lesions and providing immunohistochemical staining for neoplasms. In up to 6% of thoracic malignancy, a sarcoid reaction can be found in nonmetastatic nodes. An effective communication between the
clinician and cytologist, algorithmic approach to diagnosis and
on-site adequacy criteria can markedly improve the diagnostic yield of EBUS-TBNA. Complications of EBUS-TBNA are
generally not serious. Rare significant complications are intramural hematoma and hemopneumomediastinum after aortic
puncture, cardiac tamponade after pericardial puncture, purulent pericarditis, empyema, lung abscess, mediastinal abscess and TB granuloma formation in airway via the sinus
tract of the needle.
Symposium
IP-SY2-4
IP-SY2-5
Diagnostic yield of EBUS-TBNA in sarcoidosis
Conventional TBNA and EBUS-TBNA complementarity for mediastinal staging in lung cancers
Pulmonary department, Salamanca University Hospital,
Spain1), Department of Thoracic Surgery2), Pathology Department3)
Rosa Cordovilla1), Mateo Torracchi1), Gonzalo Varela2),
Asuncion Gomez3), Jose maria Gonzalez ruiz1),
Marcelo Jimenez2), Idania De los santos1),
Miguel Barrueco1)
BACKGROUND: Transbronchial (TBBx) and endobronchial (EBBx)
biopsies are recommended as initial procedures for the diagnosis of
pulmonary sarcoidosis. Role of EBUS-TBNA in the diagnosis of indeterminate mediastinal lymph nodes with clinical suspicious of sarcoidosis remains to be studied.
AIM: We analyzed the diagnostic yield of EBUS-TBNA in the diagnosis of sarcoidosis in patients presenting with mediastinal lymphadenopathy which was eventually proven to be benign in nature. We
also studied the factors influencing this diagnostic yield.
METHODS: We retrospectively reviewed the cytopathologic reports of 50 consecutive cases of mediastinal lymphadenopathy from
benign etiologies diagnosed by EBUS-TBNA. The procedure was
performed under conscious sedation with either a 21 or a 22 G needle
with or without ROSE. We performed, neither both TBBx, EBBx nor
a bronchoalveolar lavage in any of our patients. A diagnosis of sarcoidosis was established when non-caseating epitheliod cells were present with or without the clinical suspicion of sarcoidosis. The gold
standard was the histological study of lymph nodes made by mediastinoscopy if the results of EBUS-TBNA were negative.
RESULTS: EBUS-TBNA confirmed a diagnosis of sarcoidosis in 29 of
the 50 patients (58%) by identifying non-caseating epitheliod cell
granulomas. If we use the definition of sarcoidosis as the presence of
epitheliod cells only (without well formed granulomas), the diagnostic yield improved to 64% (table 1). The remaining 21 patients were
diagnosed by mediastinoscopy, 10 patients as sarcoidosis and 11 patients as non-specific benign LN. None of these 11 patients had a high
clinical suspicion of sarcoidosis. The diagnostic yield of EBUS-TBNA
in patients with clinical suspicious of sarcoidosis was higher than in
patients without it (66,6% vs 27%). The sensitivity of EBUS-TBNA
was 74% and the diagnostic accuracy was 79%. The mean size of the
enlarged LN, as measured by EBUS, was 12.9 mm and larger in patients with sarcoidosis LN than otherwise (14.9 mm vs 12.3 mm).
ROSE didńt improve the diagnostic yield but the results were better with 21G needle than with 22G needle (80% vs 52.5%).
CONCLUSION: EBUS-TBNA is a useful tool for diagnosis of sarcoidosis and might be the first step in the diagnosis of stage I sarcoidosis. The clinical suspicious of sarcoidosis is an important influence in
the diagnostic yield of EBUS for the diagnosis of sarcoidosis. EBUSTBNA should be considered in patients who are suspected to have
sarcoidosis which may require systemic treatment.
Chest diseases and thoracic Oncology, University hospitals of
Saint Etienne France, France1), department of cytology, university hospitals of St Etienne France2)
Jean-Michel Vergnon1), Lise Thibonnier1),
Michele Cottier2)
Background: The aim of this study is to assess conventional
transbronchial needle aspiration (TBNA) and endobronchial
ultrasound guided transbronchial needle aspiration (EBUSTBNA) performances in mediastinal and hilar lymph nodes
malignant diagnosis and to propose an algorithm for the use
of these two technics according to lymph node size.
Methods: We retrospectively evaluated the performances of
TBNA and EBUS-TBNA for enlarged and!
or positron emission tomography positive mediastinal and hilar lymph nodes
diagnosis in 138 patients from January 2009 to November
2011.
Results: Among 148 procedures, 139 lymph nodes were sampled by TBNA (mean size 23.2 mm 10.5; 3.1 aspirations 1.2)
and 100 lymph nodes by EBUS-TBNA (mean size 13.2 mm
5.5 mm; 3.0 aspirations 1.1). The most sampled lymph nodes
were 4R, 7 and 11 R. The sensitivity, specificity, accuracy,
positive predictive value and predictive negative value were
respectively 85%, 100%, 87%, 100%, and 50% for TBNA and
84%, 100%, 88%, 100%, and 65% for EBUS-TBNA. For EBUSTBNA, 12 procedures were necessary to achieve sensitivity
and accuracy higher than 90%. Sensitivity and accuracy of
EBUS-TBNA were higher than those of TBNA in lymph
nodes smaller than 15 mm (p<0.003 and p<0.03 respectively).
There was no difference for lymph nodes ranging from 15 to
20 mm and superior to 20 mm.
Conclusion: TBNA and EBUS-TBNA are safe and complementary in the diagnosis of hilar and mediastinal lymph
nodes. TBNA should be proposed as first-line procedure for
lymph nodes 4R, 4L, 7, 11R and 11L higher than 15 mm.
117
Symposium
IP-SY2-6
IP-SY3-i1
A prospective study of EBUS-TBNA compared with
mediastinoscopy for mediastinal nodal staging of
NSCLC
Endobronchial ultrasonography with a guide-sheath
for pulmonary peripheral lesions
Department of Medicine, Samsung Medical Center, Korea1),
Department of Biostatistics and Bioinformatics, Duke University School of Medicine, USA2), Department of Pathology, Samsung Medical Center, Korea3), Department of Thoracic and
Cardiovascular Surgery, Samsung Medical Center, Korea4)
Sang-Won Um1), Sin-ho Jung2), Joungho Han3),
Kyung jong Lee2), Hye yun Park3), Yong soo Choi4),
Young mog Shim4), Jhingook Kim4), Hong kwan Kim4),
Hojoong Kim1)
Background:
Correct mediastinal staging is critical for determination of the
most appropriate management strategy in patients with non-small
cell lung cancer (NSCLC). Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was directly compared
with mediastinoscopy to determine its role in staging. The objective of this study was to compare the diagnostic performance of
EBUS-TBNA with that of mediastinoscopy used to identify N2!N3
metastasis in patients with potentially resectable NSCLC.
Methods:
A prospective, nonrandomized, single-center trial was conducted
in a tertiary referral center in South Korea between March 2010
and May 2012. Each patient underwent EBUS-TBNA followed by
mediastinoscopy. Mediastinoscopy was not performed if the presence of contralateral hilar metastases was confirmed by EBUSTBNA. Surgical resection and complete lymph node dissection
were conducted in patients for whom no evidence of mediastinal
metastasis was apparent following mediastinoscopy. The primary
endpoint was the diagnostic sensitivity. Secondary endpoints were
diagnostic specificity, accuracy, and positive (PPV), and negative
predictive (NPV) values.
Results:
One hundred and thirty-eight patients underwent EBUS-TBNA,
but eight dropped out after the procedure. Contralateral hilar metastases were confirmed by EBUS-TBNA in three patients and
they did not undergo mediastinoscopy. The remaining 127 patients completed both EBUS-TBNA and mediastinoscopy. N2!N3
disease was confirmed in 59% of study subjects. The diagnostic
sensitivity, specificity, accuracy, PPV, and NPV of EBUS-TBNA
were 88% (95% confidence interval [CI] 81-95%), 100% (95% CI 100100%), 93% (95% CI 89-97%), 100% (95% CI 100-100%), and 85% (95%
CI 76-94%), respectively. The diagnostic sensitivity, specificity, accuracy, PPV, and NPV of mediastinoscopy were 81% (95% CI 7390%), 100% (95% CI 100-100%), 89% (95% CI 84-94%), 100% (95% CI
100-100%), and 79% (95% CI 69-89%), respectively. Significant differences in sensitivity, accuracy, and NPV were evident between
EBUS-TBNA and mediastinoscopy (all P values <0.01).
Conclusions:
EBUS-TBNA was superior to mediastinoscopy in terms of its diagnostic performance for mediastinal staging of NSCLC. Because
EBUS-TBNA is both less invasive and affords superior diagnostic
sensitivity, it should be the first-line procedure performed in patients with potentially resectable NSCLC.
Disclousure of funding source: This study was supported by the
Samsung Medical Center Clinical Research Development Program
(CRS-110-19-1 and CRS-110-49-2).
118
First Department of Medicine, Hokkaido University, School of
Medicine, Japan1), Respiratory Department, National Hospital
Organization Hokkaido Cancer Center, Sapporo, Japan2)
Naofumi Shinagawa1), Noriaki Sukoh2),
Noriyuki Yamada1), Kosuke Nakano2),
Yasuyuki Ikezawa1), Eiki Kikuchi1), Satoshi Oizumi1),
Masaharu Nishimura1)
Small-caliber radial-type ultrasound probes can be used for
the clinical application of ultrasonography to examine
tracheal-bronchial lesions in a decade. Endobronchial ultrasonography (EBUS) has been used for imaging guidance for
transbronchial biopsy (TBB) of pulmonary peripheral lesions
(PPLs). We showed high diagnostic yield for small (<3.0cm in
diameter) PPLs by TBB using endobronchial ultrasonography with a guide sheath (EBUS-GS) with virtual bronchoscopic navigation system in V-NINJA study.
In ACCP guideline, for patients suspected of having lung
cancer, who have a peripheral lung nodule, radial EBUS is
recommended as an adjunct imaging modality (Grade 1C).
However, the TBB method using Guide-sheath does not
spread out in the world.
The benefits of EBUS-GS for TBB and bronchial brushing
are as follows: 1) to confirm the precise location of PPLs by
EBUS imaging even when such lesions are not visible on Xray fluoroscopy; 2) to facilitate obtaining biopsy and brushing
specimens repeatedly by leaving the GS in the PPLs; 3) to obtain biopsy specimens from PPLs that are accessible only
through the use of a curette via the GS; 4) to decrease bleeding resulting from trapping the GS in the bronchus; and 5) to
assess the internal structure of PPLs.
We believe EBUS-GS is one of the most promising methods
for diagnosing PPLs.
Symposium
IP-SY3-i2
IP-SY3-i3
EBUS-GS technical issue
Analysis of internal structures using EBUS for peripheral pulmonary lesions
Department of Chest Surgery, Iwakuni Minami Hospital, Japan1), Department of Chest Surgery, St Marianna University,
Japan2), Nomura Clinic, Suo Oshima, Japan3), Department of
Pulmonary Medicine, Iwakuni Minami Hospital, Japan4)
Katsuhiko Morita1), Seishi Nosaka1), Masaki Murayama1),
Noriaki Kurimoto2), Haruhiko Nakamura2),
Hisakazu Nomura3), Yuka Imoto4)
Several tips can facilitate introducing a GS-probe to the intended branch and obtaining sufficient samples. An expected bronchial image indicating the directly involved bronchus should be drawn by hand prior to bronchoscopy from a
thorough assessment of findings from computed tomography. In addition, use of a navigation edit system could improve the accuracy of the so-called handwritten roadmap to
the peripheral pulmonary lesion (PPL). After reaching the insertion limit of the scope due to the size of its tip during
bronchoscopy, better visibility can be achieved by advising
the awake patient to breathe deeply to prevent airway collapse. In cases limited to a lesion including solid part, another
solution to poor visibility is to insert the GS-probe after filling
the airway with a small amount of saline through the instrumental channel. Sputum pushed from the channel by the
probe is unlikely to stick to the scope tip, so the GS-probe can
be inserted under good observation. When the probe is introduced around the nodule under fluoroscopy, we should begin
to delineate the PPL using EBUS. The desirable position of
the probe is within rather than adjacent to the lesion. A
probe in the latter position should be withdrawn and inserted while using an up or down angle to bring the probe
closer to the lesion under EBUS, then the probe can be introduced to the preferred within position. EBUS can describe
not only the nodule, but also the peripheral pulmonary artery accompanying the involved bronchus before the nodule.
The location of the accompanying artery could offer good information just before reaching the lesion, and might suggest
both the direction to go and the rough distance to the lesion.
Once the probe has been introduced within the lesion, paying attention to the longitudinal position of the lesion is important. When a vessel is apparent around the introduced
bronchus, a safer site should be selected while avoiding the
vessel. If detailed estimation of the nodule under EBUS cannot propose a safe site, an up-or-down angle should be mandated to keep the probe away from vessels and prevent postbiopsy hemorrhage. Once EBUS-GS for PPL suspected as
representing malignancy has been started in your institute,
the diagnostic yield will easily improve to 80%. If a higher diagnostic yield than this is warranted, a fully planned strategy on a case-by-case basis is needed. The harmonious combination of devices, patients and examiners could produce
good results.
Department of Chest Surgery, St. Marianna University, Japan1), Department of pulmonary and infectious diseases, St.
marianna University2), Deapartment of Surgery, Iwakuni Minami Hospital3)
Noriaki Kurimoto1), Hiromi Muraoka2), Mariko Okamoto2),
Ayano Usuba2), Teppei Inoue2), Miwa Fujiwara2),
Naoki Furuya2), Kei Morikawa2), Hirotaka Kida2),
Hiroshi Handa2), Hiroki Nishine2), Atsuko Ishida2),
Takeo Inoue2), Seiichi Nobuyama2),
Masamichi Mineshita2), Katsuhiko Morita3),
Seishi Nosaka3), Masaki Murayama3),
Haruhiko Nakamura1), Teruomi Miyazawa2)
I. Analysis of EBUS images for peripheral pulmonary lesions
EBUS uses high-frequency ultrasound to create detailed images
of the internal structure of peripheral pulmonary lesions. We reported the internal structure of peripheral pulmonary lesions
by EBUS, correlate these findings with the histopathologic findings of the surgical specimen, and classified peripheral pulmonary lesions into three classes and six subclasses by EBUS images. The lesions were typed based on the internal echoes
(whether homogenous or heterogenous), vascular patency, and
the morphology of the hyperechoic areas (reflecting the presence of air and the state of the bronchi). Factors indicating malignancy were heterogenous internal echo, obstructive vessels,
and obstructive bronchi. A homogenous pattern (Type I) was
overwhelmingly benign (92%), whereas hyperechoic dots or a
heterogenous pattern (Type II and III, respectively) portended
malignancy in 98 of 99 cases (99%). EBUS permits visualization
of the internal structure of peripheral pulmonary lesions and
this information suggest the histology of the lesion.
Histogram-based quantitative evaluation of EBUS images of peripheral pulmonary lesion. EBUS images were obtained as still
images and analyzed using Image J software.Six histogram features were used for analysis: height (the number of maximum
pixels), width (the gray value at maximum pixels minus gray
value at maximum pixels), height!width ratio (the number of
maximum pixels!the gray value at maximum pixels minus
gray value at maximum pixels), standard deviation of histogram, kurtosis, and skewness. Of the 6 histogram parameters,
height, width, height!width ratio and standard deviation were
significantly different between malignant and benign lesions using statistical analysis.
II. EBUS-GS for peripheral lung cancer with ground-glass opacity.
Forty eight patients with a confirmed diagnosis of lung cancer
underwent either surgery or GS. Subjects were then categorized by the ratio of solid area and GGO (longest diameter of tumor with mediastinal window!longest diameter of tumor with
lung window 100) on CT as pure GGO or mixed GGO (<25%,
25-50%, >50%). The total diagnostic yield of GS in patients with
GGO was 77.1%. Cytological diagnosis was 54.2%, and tissue diagnosis was 70.8%. The diagnostic accuracy when the EBUS
was invisible was 0%, adjacent to the lesion was 71.4%, and
within the lesion was 83.9%. Increasing the solid part in the lesion, the population of typeIIb, within, and diagnostic yield increased.
119
Symposium
IP-SY3-4
IP-SY3-5
EBUS-GS for malignant peripheral pulmonary nodules
Diagnosis of pulmonary nodules using radial-EBUS. A
single french center experience in 345 patients
Respiratory Endoscopy, National Cancer Center Hospital, Tokyo, Japan
Christine Laoang Chavez, Shinji Sasada,
Takehiro Izumo, Junko Watanabe, Masahiro Katsurada,
Takaaki Tsuchida
Background. Radial endobronchial ultrasound (R-EBUS) is a diagnostic modality recommended for peripheral pulmonary nodules (PPNs). Improvements in
accuracy came about with the use of a guide sheath (GS) and efforts are underway to increase this further. This study aims to determine what factors other
than those already known could affect diagnostic yield of EBUS-GS for peripheral pulmonary nodules.
Methods. This is a retrospective study involving malignant peripheral pulmonary lesions measuring <30mm that underwent diagnostic bronchoscopy from
April 2012 to March 2013 at the National Cancer Center Hospital, Tokyo.
Those without a definitive diagnosis after more than 6 months of follow-up
were excluded.
All procedures of transbronchial sampling (biopsy, brush, washing) utilized
fluoroscopy and EBUS with two sizes of guide sheaths and their corresponding sampling devices.
The diagnostic yield was computed and study variables pertaining to both the
characteristics of the PPN and the EBUS-GS procedure were described and
analyzed using logistic regression.
Results. Our study included 204 malignant PPNs with a mean diameter of 21
5 mm in the major axis. Majority were solid nodules (56%) while 44% had
ground glass opacity. Overall diagnostic yield was 71 percent. In logistic regression analysis, factors that significantly increased this yield further were
shorter procedure time, EBUS-probe within, and central location of the PPN
(Table 1). In a sub-group analysis, use of a larger size GS kit had a high diagnostic yield regardless of the location of the PPN while use of a smaller size GS kit
had a significantly lower yield when the PPN was located adjacent to the
pleura (57% vs. 81%, p<0.05).
Conclusion. EBUS-GS is an acceptable procedure for malignant PPNs with a
diagnostic yield of 71 percent. Aside from EBUS-probe within, other factors
that increase this yield are shorter procedure time and central location of the
lesion.
120
Pneumology, Rouen University Hospital, France1), Department
of Pathology & Cytology, Rouen University Hospital, France2)
Samy Lachkar1), Berengere Obstoy1), Mathieu Salaun1),
Suzanna Bota1), Francis Roussel2), Luc Thiberville1)
Background: Radial-EBUS allows the observation and sample of peripheral lung nodules that cannot be imaged with
conventional bronchoscopy.
Aim: To assess the diagnostic yield of radial-EBUS for the diagnosis of peripheral lung nodules.
Methods: 345 patients underwent radial-EBUS at the Rouen
University Hospital between May 2008 and May 2013 for the
diagnosis of peripheral lung nodules. Before each procedure,
the nodule location was mapped using a virtual bronchoscopy software (iLogic System). EBUS procedure was performed using a 4.0mm bronchoscope and a 17S Olympus
radial-EBUS probe.
Results: 310!
345 procedures were performed under local anesthesia. No adverse event was reported. The nodules median diameter was 25mm [min-max=5-32mm]. The median
nodule-to-pleura distance was 15mm [min-max=0-91mm].
Radial-EBUS provided the diagnosis in 210 of the 281 diagnosed nodules, including 199!
245 malignant lesions, and 11!
36 benign lesions (2 actinomycosis, 1 aspergillosis, 2 sarcoidosis and 6 others). EBUS-guided brushing and biopsies were
both contributive in 36% of the procedures, the brushing
alone in 23%, and the biopsy alone in 13%. The sheath washing was contributive in 66 patients but was contributive
alone (negative brushing and biopsy) for only one patient.
The diagnostic accuracy was higher in malignant lesions
(199!
245 vs. 11!
36, p<0.001, Fisher test), when the lesion was
visualized with the radial probe (205!
295 vs. 5!
14, p=0.0153,
Fisher test), and when the lesion was >2cm (147!
220 vs. 62!
120, p=0.073, Fisher test). The diagnostic yield did not
change between 2008 and 2013 but the nodules were smaller
in 2013 than in 2008 (median=25.5 vs.19.5mm, p=0.01, MannWhitney test).
Conclusion: Radial-EBUS guided with a virtual bronchoscopy
software is an easy and safe new endoscopic technique that
allows the visualization and the diagnosis of peripheral lung
nodules.
Symposium
IP-SY3-6
IP-SY4-i1
Absence of interbronchoscopist variability in the diagnosis of peripheral lung cancer by TBB with EBUS-GS
Present and future of the TNM classification of lung
cancer and its implications in thoracoscopic surgery
Division of Respiratory Medicine and Clinical Allergy, Department of Internal Medicine, Fujita Health University, Japan
Department of Thoracic Surgery, Mutua Terrassa University
Hospital, Spain
Kazuyoshi Imaizumi, Takuya Okamura,
Tomoyuki Minezawa, Sayako Morikawa,
Mariko Morishita, Teppei Yamaguchi, Yoshikazu Niwa,
Tomoko Takeyama, Yuki Mieno, Tami Hoshino,
Sakurako Uozu, Masamichi Hayashi, Sumito Isogai,
Toru Nakanishi, Okazawa Mitsushi
Ramon Rami-Porta
Background
Previous reports have demonstrated that the diagnostic
yield of bronchoscopy for lung cancer is dependent on both
the type of bronchial lesions present and the bronchoscopist.
However, little is known about the interbronchoscopist variability in diagnostic yield of trans-bronchial biopsy (TBB) using endobronchial ultrasonography with a guide sheath
(EBUS-GS).
Methods
We retrospectively reviewed 79 consecutive patients who
underwent TBB with EBUS-GS for primary or metastatic
lung cancer presenting as a peripheral lesion between April
2012 and March 2013 in our institute. All studied patients
were pathologically confirmed as having lung cancer by
bronchoscopy or other diagnostic modalities (CT guided needle biopsy or surgical biopsy). We compared the diagnostic
yield of bronchoscopy according to operator or years of operator s experience.
Results
The total diagnostic yield in this study was 78%. Although
the diagnostic yield of each bronchoscopist ranged 66.7% to
100%, inter-operator variability was not significant. In addition, no significant difference for the diagnostic yield was observed among three groups of operator categorized according to the experienced years as a bronchoscopist (more than
10 years, 6-9 years and 3-5years) (Figure).
Conclusion
Our results suggested EBUS-GS might reduce the interbronchoscopist difference in diagnostic yield of bronchoscopy for
peripheral lung cancer.
The 7th edition of the tumour, node and metastasis (TNM)
classification of lung cancer included the changes recommended by the International Association for the Study of
Lung Cancer (IASLC). The changes derived from the analyses of more than 80,000 patients from all over the world studied by the IASLC Staging and Prognostic Factors Committee and Cancer Research And Biostatistics (CRAB). With this
edition, an era of data-based revisions of the TNM classification was opened to validate, revise and update the present
classifications of lung cancer, mesothelioma, thymic tumours
and oesophageal cancer. The analyses of retrospective databases are now being followed by analyses of new retrospective and prospective databases to overcome the limitations
of the retrospective ones. Databases of 80,000 new patients
with lung cancer, over 3,000 patients with mesothelioma,
over 10,000 cases of thymic tumours, and around 10,000
cases of oesophageal cancer collected by the Worldwide
Esophageal Cancer Collaboration are being analysed to inform the 8th edition of the TNM classification due to be published in 2016.
Thoracoscopic surgery is key to diagnosis and staging of
lung cancer and mesothelioma. Its most common indication
is the evaluation of lung cancer with pleural effusion. However, advances in technology now allow the surgeons to assess ipsilateral and contralateral additional nodules and obtain histopathological confirmation of their nature, either by
simple biopsy or by removal with a wedge resection, which
allows proper staging. Thoracoscopic surgery also allows the
exploration of the pericardium and the confirmation of tumour involvement or the involvement of the heart. Mediastinal biopsies and assessment of mediastinal lymph nodes are
also possible. Thoracoscopic surgery is quickly evolving. Animal and clinical research is being conducted to explore other
approaches to reach the pleural cavity avoiding the
intercostal route. Thoracoscopy through the mediastinum
(mediastino-thoracoscopy) was first described by Delauriers
in 1976, but it has been revitalized with the use of videothoracoscopes. It allows the exploration of both pleural cavities from the cervical incision used for mediastinoscopy, completing mediastinal and pleural staging in a single operation.
This is especially indicated in patients with lung cancer and
concomitant mediastinal disease and pleural effusion or ipsilateral or contralateral peripheral additional nodules. The
transcervical approach allows reaching both pleural cavities,
explore them and take biopsies or remove lung nodules. The
subxiphoid approach is also gaining adepts, as it allows bilateral thoracoscopic surgery and the introduction of the hand
into the pleural cavity avoiding the intercostal space.
121
Symposium
IP-SY4-i2
IP-SY4-3
Thoracoscopic lobectomy with lymphnode dissection Advanced technique including bronchoplasty-
Clinical feasibility and efficacy of video-assisted mediastinoscopic lymphadenectomy for non-small cell
lung cancer
Department of Thoracic Surgery, Toranomon Hospital, Japan
Tadasu Kohno, Sakashi Fujimori, Takashi Harano,
Soichiro Suzuki, Takahiro Iida, Emi Sakai
Objective: Thoracoscopic lobectomy with systematic mediastinal lymph node dissection for lung cancer is still controversial. Particularly advanced procedure such as bronchoplasty has not been reported often. We are going to present the technique of our 3-port thoracoscopic procedures.
Methods: Between 2004 and 2013, 1335 thoracoscopic lobectomies were performed among 1833 total lung cancer resection. All the procedures were done completely thoracoscopicaly. Our methods were done through 3 incisions with the
length of 7mm, 10mm and up to 30mm. Systematic lymph
node dissection is not only removing the lymph node but removing entire tissue in the area. The technique is then dissecting the surrounding organ. Sleeve lobectomy technique
is done by usual vascular control followed by manual separation of the bronchus. In anastomosing the bronchial stump, 3
to 4 running sutures completed the telescope type anastomosis. In order to obtain a better surgical view, an endoscopic
peanut was inserted through one of the three incisions used
for lobectomy.
Results: In all the procedure, 3-port thoracoscopic lobectomies with mediastinal lymph node dissection was safely performed.
Conclusions: The technique of three-port thoracoscopic complete mediastinal lymph node dissection for lung cancer is
shown. This technique can be one of the option in thoracoscopic lung cancer surgery. In well trained team, thoracoscopic sleeve lobectomy can be performed safely.
122
Department of Thoracic Surgery, Uji Tokushu-kai Hospital,
Japan1), Department of Pulmonology, Uji Tokushu-kai hospital2)
Hideki Itano1), Takayuki Takeda2), Masahiko Saitou2)
Objectives The objective of this study was to analyze the
clinical feasibility and efficacy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) in the staging and treatment of resectable non-small cell lung cancer (NSCLC).
Methods Between October 2009 and December 2013, consecutive 52 patients underwent mediastinoscopic lymphnode
biopsy!
dissection for preoperative staging of resectable
NSCLC. 30 patients (58%) had VAMLA and 22 (42%) had
standard video-mediastinoscopy. The patients who had negative VAMLA!
mediastinoscopy results underwent VATS
anatomical pulmonary resection and systematic lymphnode
dissection.
Results Both groups had no complication. The operation time
and numbers of dissected lymphnode station had no significant difference between groups. The total numbers of dissected lymphnodes per VAMLA!
mediastinoscopy procedure in VAMLA group (51.6 20.7) were significantly higher
than those in mediastinoscopy group (25.4 12.6) (P<0.0001).
There was no significant difference in the total numbers of
dissected lymphnodes in VATS pulmonary resection between VAMLA group (46.1 18.5) and mediastinoscopy
group (45.3 17.7). The total numbers of dissected
lymphnodes of both VAMLA!
mediastinoscopy and VATS in
VAMLA group (98.5 29.9) were significantly higher than
those in mediastinoscopy group (70.4 24.9) (P=0.0019)
(MEAN SD). Both accuracy and negative predictive value in
VAMLA group (93.3, 93.1) were higher than mediastinoscopy
group (86.4, 85.7).
Conclusion VAMLA is a safe and clinically feasible procedure for more accurate mediastinal staging and radical mediastinal dissection for NSCLC. It can be a substitution of, or
compare favorably with the lymphnode dissection in VATS
anatomical pulmonary resection, especially in left-sided diseases.
Symposium
IP-SY4-4
IP-SY4-5
Preoperative CT-guided bronchial metallic coil marking for non-palpable small peripheral lung tumors
Endo-finger palpation to detect small pulmonary
ground glass nodules during thoracoscopic surgery
Department of Thoraci,Endocrine Surgery and Oncology, Institute of Health Biosciences, The University of Tokushima
Graduate School, Japan
Koichiro Kajiura, Shoji Sakiyama, Hiroaki Toba,
Saki Nagase, Atsushi Morishita, Mitsuhiro Tsuboi,
Yasushi Nakagawa, Yukikiyo Kawakami,
Mitsuteru Yoshida, Hiromitsu Takizawa, Kazuya Kondo,
Akira Tangou
【background】It is difficult to recognize the location of small
peripheral lung tumors. Some preoperative marking methods were tried for these tumors. Hookwire method has the
risk of bleeding, pneumothorax and rarely air emboli. Air
emboli may be fetal complication. Preoperative marking
method of our institute is CT-guided bronchial metallic coil
marking. We assessed this method in utility and safety.
【method】We studied CT-guided bronchial metallic coil
marking for small peripheral lung tumor from June.2003 to
November.2013. Indication criteria of metallic coil marking
are (a) tumor size less than 2cm and more than 5mm distance from pleura.
(b) deeply located nodules measuring less than 30mm from
the pleural surface. (c) Ground-grass opacity (GGO) lesions
without pleural changes. Exclusion criteria are (a) Lesion
with pleural change. (b) Deeply located nodules measuring
more than 30mm from the pleural surface. (c) Lesion that are
palpable by using forceps at surgery. The procedure of coil
marking: 1) CT scan in IVR-CT room. 2) observance bronchus by usual bronchial fiber. 3) changing to ultrathin bronchial fiber and insert objective bronchus. 4) conforming the
location of sheath edge near to lesion by X-ray and put on
the metallic coil. 5) Surgery with X-ray had done. 55!
94 cases
had done with VBN.
【result】Total case are 94 cases, 100 lesion. Tumor size is
12.4 5.5mm (5-29mm). The distance from pleura is 7.45 6.9
mm (0-33mm). Frequency of CT is 3.2 1.2. The tumor-coil
distance is 6.5 5.9mm. The lesion: lepidic type adenocarcinoma 63 cases, adenocarcinoma 12cases, squamouse cell carcinoma 2cases, AAH 5cases, metastatic tumor 10cases, benign 6cases and cartinoid 1case. Operative procedure are
lobectomy 15cases, segmentectomy 13cases, partial resection 72cases. The days after putting on metallic coil is 4.8 2.4
days. The complication are mild pneumothorax without
drainage(1%) and intraoperative migration(1%).
【conclusion】It is very useful for detecting tumor location of
small peripheral lung tumor, because the distance of tumorcoil is about 6.5mm and accessible in all part of the lung. The
tumor-coil distance is measured by CT. It gets shorter in operation, because of lung collapsed at that time. It is the merit
that the metallic coil don t influence tumor cell in postoperative histological examination. The rate of these complication
(midl pneumothorax and coil migration) are further less than
percutaneous methods. There are no fetal complication in
the bronchoscopic coil marking.
Respiratory Surgery, National Hospital Organization Yokohama Medical Center, Japan1), Respiratory Medicine, National
Hospital Organization Yokohama Medical Center2), Department of Surgery, Yokohama City University3)
Kazuhiro Sakamoto1), Daisuke Noma1), Kohei Ando1),
Shigeto Sudo2), Hideto Goto2), Yasushi Yamakawa2),
Motofumi Tsubakihara2), Munetaka Masuda3)
Introduction
Various preoperative marking techniques have been described for the localization of pure ground glass nodules
(GGNs) in the lung but potential complications may occur,
such as pneumothorax, hemorrhage, and serious air embolism. Moreover, they requires a lot of time. In this study, we
evaluated the localization of small pure GGNs in thoracoscopic surgery using the endo-finger palpation.
Materials and Methods
Patients with peripheral pure GGNs that were 20 mm and
less in diameter were eligible for this study. Preoperatively,
no marking technique was performed. Thoracoscopy was
performed in the lateral position under single lung anesthesia. Thoracoports were placed near the GGNs based on the
CT findings. One finger was inserted through the port into
the pleural cavity to palpate the lung to localize the GGNs
(the endo-finger technique). After the GGNs were detected,
they were resected by endostaplers with adequate safety
margin.
Result
Thirty-four GGNs of twenty patients were resected from
January 2005 to May 2013. The number of the GGNs that had
diameter of 5 mm or less, 6-10 mm, 11-15 mm and 16-20 mm
was 8, 14, 9 and 3, respectively. The depth of the lesions from
the visceral pleura ranged from 0-14 mm. The main reasons
for the resection were a need for another ipsilateral simultaneous operation in six cases, the patients requests in five
cases, tumor size (>10 mm) in six cases and enlargement of
the GGNs during the follow-up period in three cases. All but
one GGN could be detected using the endo-finger technique
with two or three thoracoports, and were resected. Some of
the GGNs adjacent to the visceral pleura were visualized by
thoracoscopy as color changes in the visceral pleura. There
was one conversion to thoracotomy in one patient who had a
severe pleural adhesion due to a previous ipsilateral lobectomy of the lung. No complications occurred in association
with this procedure. The pathological diagnoses of the GGNs
were bronchioloalveolar carcinoma in 23 nodules, atypical
adenomatous hyperplasia in nine, hyperplasia of the alveolar
epithelium in one and an inflammatory lesion in one. The surgical margins of all of the resected specimens were pathologically negative.
Conclusion
The endo-finger technique is safe and useful for the localization and resection of peripheral GGNs during thoracoscopic
surgery. We suggest that the preoperative marking to detect GGNs can be replaced by the endo-finger technique in
some cases.
123
Symposium
IP-SY4-i6
IP-SY5-i1
Thoracoscopic surgery for non-small cell lung cancer
Rationale for effectiveness and safety in interventional
bronchoscopy
Department of General Thoracic, Breast and pediatric Surgery, Fukuoka University Faculty of Medicine, Japan
Shin-ichi Yamashita
Background: Video-assisted thoracic surgery (VATS) is considered for early-stage non-small cell lung cancer (NSCLC)
surgeries. In the annual report of the Japanese Association
for Thoracic Surgery 2011, more than half of lung cancer surgeries (19,534 out of 32,801 cases) were performed under
VATS. It appears recommendable for VATS lobectomy to
be considered and applied to patients with clinical stage I
NSCLC. VATS showed better or at least equivalent outcomes regarding intra- or postoperative complications compared with thoracotomy, with less invasiveness. Additionally, long-term survival by VATS lobectomy was suggested
to be at least equivalent. This lecture shows the technical aspects of thoracoscopic surgery by video and equivalent oncological outcome to thoracotomy for more advanced lung
cancer, in addition to thoracoscopic segmentectomy and
lobectomy for early stage NSCLC.
Methods: Our surgical technique via thoracoscopy was five
ports (one 12mm, two 10mm, and two 5mm ports) methods
without minithoracotomy. All procedures are performed by
visualization through a television monitor, so-called complete
VATS or total thoracoscopy. 1) 214 patients with stage IA
NSCLC underwent thoracoscopic segmentectomy or lobectomy and were compared regarding with short and long
term outcome. 2) Additionally, forty-seven patients underwent thoracoscopic surgery and 32 patients standard thoracotomy for patients with clinical N0-N2 and pathological N2
disease were compared regarding with perioperative and oncological outcomes between two procedures.
Results: 1)The perioperative outcome, including operative
time, blood loss, duration of chest tube drainage, and length
of hospital stay, was not significantly different between segementectomy and lobectomy. Morbidity and mortality were
not significantly different between two procedures. Diseasefree and overall survivals showed no differences between
two procedures in stage IA.
2) There were no significant differences between the two
groups regarding dissected number of lymph nodes, operative time, morbidity, and mortality. However, blood loss in
thoracoscopy group was significantly less than in open
group. Five-year overall survival in thoracoscopy group
(32%) was better than in open group (16%, p=0.013). Multivariate Cox regression analysis showed that thoracoscopic
approach was significantly better prognostic factor in overall
survivals (HR=0.37; 95%CI=[0.18-0.75]; p=0.006).
Conclusions: There is growing evidence that thoracoscopic
segmentectomy is associated with minimal invasiveness and
an outcome equivalent to that of thoracoscopic lobectomy in
stage I NSCLC. Furthermore, thoracoscopic surgery for nonbulky N2 disease was feasible and not inferior to standard
thoracotomy in terms of oncological outcome. Thoracoscopic
resection may be the treatment of choice for non-bulky N2
disease.
124
Department of Pulmonary Medicine, Izmir Dr. Suat Seren
Training and Research Hospital for Thoracic Medicine and
Surgery, Turkey
Semra Bilaceroglu
Interventional bronchoscopy (IB) involves minimally invasive diagnostic and therapeutic procedures for pulmonary,
airway and mediastinal disorders. Therapeutic procedures
may be palliative for central airway obstruction, hemoptysis,
stridor, cough in malignant and benign disease, or curative
for early lung cancer or benign disease. Interventional bronchoscopist should know and perform IB according to appropriate and suitable indications. A life threatening obstruction
should always be managed using rigid bronchoscope, and the
IB treatment should be selected according to the type of airway obstruction. A detailed and thorough historical, physical,
laboratory and radiologic evaluation is required as well as
consideration of all factors related to possible problems and
complications before IB procedures. Detailed risk evaluation
regarding pulmonary, cardiac and general condition is critical. Pulmonary, airway and mediastinal anatomy and their
relationships with each other should be very well known and
assessed. The type of bronchoscope and anesthesia should
be suitable to and consistent with the clinical condition of the
patient and with the type of the lesion to be treated. Efficacy
and limitations of the IB procedure, experience of the bronchoscopist, equipment, procedure, safety measures, sedation,
anesthetic care, technical facilities of hospital, logistic factors
and contraindications are critical factors to that will affect
the efficacy and safety of IB procedures. Malignancy, tracheal lesions, diabetes mellitus and COPD have been found
to be related to high morbidity and mortality within 30 days
after IB procedures. Being ready for all possible complications as an IB team with sufficient equipment and technique,
experience in endotracheal intubation and rigid bronchoscopy, being moderate in IB procedures, combining techniques (e.g. coagulation and mechanical debulking) will decrease related morbidity and mortality. IB treatment success
should be evaluated bronchoscopically, using pulmonary
function tests and regarding quality of life and impact on survival. Repeat bronchoscopy 4-6 weeks later and further clinical follow-up are important to see if additional IB treatment
is necessary or if there is any complication. An IB method
should be combined with others (e.g. electrocautery and
stenting) or with radiotherapy, chemotherapy and!
or surgery when feasible. Thus, a multidisciplinary approach in IB
with a close collaboration of interventional pulmonologist, experienced thoracic surgeon, anesthesiologist, radiologist, radiation oncologist and medical oncologist is necessary. Optimal IB approach for each patient should be tailored, selective, multimodality, costeffective and targeted to increase
quality of life. Finally but importantly, there should be a formal and structured training and accreditation in IB to accomplish the above-mentioned rationale.
Symposium
IP-SY5-i2
IP-SY5-i3
Safety of interventional pulmonology-complication review at a cancer center
Airway problem in tuberculosis
Division of Pulmonary and Critical Care Medicine, Sun YatSen Cancer Center, Taipei, Taiwan, Taiwan1), Division of Thoracic Surgery, Sun Yat-Sen Cancer Center, Taipei, Taiwan2),
Department of Pathology, Sun Yat-Sen Cancer Center, Taipei,
Taiwan3), Division of Cardiology, Sun Yat-Sen Cancer Center,
Taipei, Taiwan4), Department of Research, Sun Yat-Sen Cancer Center, Taipei, Taiwan5)
Li-han Hsu1), Chia-chuan Liu2), Jen-sheng Ko3),
Chao-chun Chen4), An-chen Feng5)
The complication of bronchoscopy is rare, with reported rate from
0.08 to 1.08%. As bronchoscopy extends the spectrum of diagnostic
and therapeutic capabilities, which, in turn, makes procedure more
complicated and protracted, complication rates may be expected to
rise. No large-scale survey of complications associated with new
techniques has been performed until 2010. The Japan Society for
Respiratory Endoscopy conducted a community-based survey with
a reported complication rate by lesions ranging from 0.51% to
2.06% and by procedure ranging from 0.17% to 1.93%.
The availability and usage of current armamentarium of interventional pulmonology varies significantly between institutes. We conducted a longitudinal evaluation of the same operator s performance at a cancer center through detailed record review of bronchoscopy between January 1997 and March 2013 and intrapleural
urokinase (IPUK) therapy for loculated malignant pleural effusion
or lung entrapment between January 2000 and December 2012.
Among the 1,358 diagnostic bronchoscopies, there were nine major
complications requiring premature termination and three pneumothoraces on follow-up (0.88%). Escalation in level of care was required for 4 patients with massive bleeding, asthma, sedation intoxication and myocardial ischemia respectively. Six cases occurred after brushing and five cases before any sampling procedure. The complication rate was highest for peripheral lesions.
In addition to technical problems encountered and those attributed
to progressive underlying malignancy, neither immediate nor longterm major patient-specific complications occurred among the 108
therapeutic bronchoscopies except for excessive granulation formation following metallic stenting in the only patient with benign
tracheal stenosis. Among the 156 patients that underwent IPUK
therapy, 93 patients achieved lysis of the loculation and ipsilateral
lung re-expansion. Sixty-two of 80 assessable patients (77.5%)
achieved successful pleurodesis. IPUK induced massive hemothorax in two patients and one had empyema during the process of
lung re-expansion.
The results were more reflective of everyday practice encountered at a community hospital adhered to the principles of costeffectiveness and minimal cancer staging guidelines. The complication rate of bronchoscopy was comparable to historical control in
the literature, and their occurrence appeared to be sporadic, not
relevant to patient characteristic and mostly related to bronchoscopy itself rather than the introduction of new techniques. Bronchoscopy remains safe along with technical innovations. IPUK therapy is also a safe treatment modality for malignant pleural effusion.
However, risk recognition and effective prevention is essential.
Utilizing a nationwide survey and registries with uniform definition of complication followed by identification of risk factors and
guideline establishment is essential.
Pulmonology and Respiratory Medicine, Faculty of Medicine
University of Indonesia, Indonesia
Faisal Yunus, Wahyu Widyaningsih, Ginanjar Arum
Background
Pulmonary tuberculosis is one of the leading causes of infectious disease-related mortality. According to WHO, the estimated worldwide incidence was 9.4 million new cases in 2009
and Asia has the highest proporton (55%). Tuberculosis have
some form of airway manifestations, such as endobronchial
tuberculosis (EBTB) and hemoptysis, which require some
tools for diagnosis and therapy in the field of interventional
pulmonology.
Endobronchial Tuberculosis
Endobronchial tuberculosis (EBTB) is tuberculous infection
of tracheobronchial tree, with microbial and histopathological evidence. EBTB is present in 10-40% of patients with active tuberculosis and causes some degree of bronchial stenosis in more than 90% of the patients. The pathogenesis of
EBTB is not yet fully established. However, sources of EBTB
may include direct implantation of tubercle bacilli into the
bronchus from an adjacent pulmonary parenchymal lesion,
direct airway infiltration from an adjacent tuberculous mediastinal lymph node, erosion and protrusion of an intrathoracic tuberculous lymph node into the bronchus, hematogenous spread, and extension to the peribronchial region by
lymphatic drainage.
The clinical features depend on the site and the extent of involvement. The disease may occur in the absence of recognized symptoms. A barking cough is the most common
symptom. Systemic symptoms may not be prominent in
EBTB. Fever is observed in 50-87%, night sweats in 55% and
weight loss in 71% of patients. Bronchoscopic examination
with microbiological and histopathological evidence is the
key to diagnosis.
Complications of EBTB include obstruction, atelectasis (with
or without secondary infections), bronchiectasis and tracheal
or bronchial fibrostenosis which become the most frequent.
Hemoptysis
Hemoptysis is expectorated blood or sputum containing
blood that derived from the airway below the vocal cords. A
study in India for 6 years (1996-2002) stated that pulmonary
tuberculosis was the leading cause of hemoptysis (79.2%). Research at Persahabatan Hospital Indonesia in 2010 get a percentage of hemoptysis due to tuberculosis for about 51,3%.
Bronchoscopy plays an important role to localize the
anatomic site of bleeding, isolate the involved airway, control
of hemorrhage and treatment of the underlying cause of hemoptysis in case of visible endoluminal lesions.9 Treatment
strategies used in clinical practice are: cold-saline lavage,
topical vasoconstrictive agents, tranexamic acid, balloon tamponade, endobronchial stent tamponade, endobronchial airway blochade, laser photocoagulation, argon plasma coagulation, electrocautery, and bronchial artery embolization.
125
Symposium
IP-SY5-4
IP-SY5-5
Results of endoscopic dilatation for the treatment of
acquired subglottic stenosis in infants and children
A randomized controlled trial of EBUS under general
anesthesia versus moderate sedation
Dept. Cardiopneumology, Division of Thoracic Surgery, InCor
(Heart Institute)-HCFMUSP, University of Sao Paulo School of
Medicine, Brazil
Paulo F.G. Cardoso, Nilza Abe, Helio Minamoto,
Fernanda s. Alfinito, Ascedio j. Rodrigues,
Mauro f. l. Tamagno, Jose p. Otoch, Ricardo m. Terra,
Paulo m. p. Fernandes, Viviane r. Figueiredo
Background: Acquired subglottic stenosis (SS) is a common
cause of airway obstruction in both adults and children. It
usually derives from local trauma to the subglottis following
intubation. Its management in the pediatric patients is both
challenging and controversial and includes bronchoscopic
dilatation. This study focuses on the results of endoscopic
dilatation as a primary treatment for SS in chlidren and newborns in a tertiary academic hospital. Methods: Retrospective analysis of pediatric patients submitted to endoscopic dilation for SS between January 2006 and December 2009. The
SS was classified according to the Meyer-Cotton grading system. Dilation was carried out using rigid bronchoscopy under genereal anesthesia in all patients. Results: Seventy-four
patients between 30 days and 7 years of age (median 2
years), 37,5% f the patients were below 2 years of age. There
were 38 males and 36 females were included and all had a
grade II and II SS. Overall, 40,5% of the patients with grade
II and III SS achieved clinical improvement with endoscopic
dilation. Fifty patients (64%) had a tracheostomy. Among patients without a tracheostomy, a stable clinical improvement
was achieved in 23 after 3-4 dilatation procedures and 1 patient required a Montgomery T tube. Among the patients
with a tracheostomy, only 7 (14%) were successfully decannulated and 11 of the remaining 43 patients required Montgomery T tube. Six patients developed grade IV SS regardless of the endoscopic dilation sessions and all had a previous
tracheostomy. Conclusions: We conclude that endoscopic
dilatation as primary treatment results in clinical improvement of dyspnea in almost half the infants and children with
acquired SS. Previous tracheostomy in our patient population was related to a poor prognosis in the resolution of SS.
126
Pulmonary Medicine, Baylor College of Medicine, USA1), Pulmonary Medicine, Baylor College of Medicine, United States2),
Thoracic Surgery, Baylor College of Medicine, United States3),
Anesthesia, The University of Texas M.D. Anderson Cancer
Center, United States4), Pulmonary Medicine, The University
of Texas M.D. Anderson Cancer Center, United States5), Anesthesia, Baylor College of Medicine, United States6)
Roberto Fernando Casal1), Donald Lazarus2),
Sarah Perusich2), Lorraine Cornwell3), Mona Sarkiss4),
Carlos Jimenez5), David Ost5), George Eapen5),
Rodolfo Morice5), Sheila Austria6), Farrah Kheradmand2)
Background: Data about the influence of anesthesia type on
yield, complications, and tolerance of EBUS-TBNA is mostly
based on retrospective studies and it is largely inconsistent.
These are preliminary results from our prospective randomized trial.
Methods: Adults with an indication for EBUS-TBNA of mediastinal or hilar lymph nodes were randomized (1:1) to undergo the procedure under general anesthesia (GA) versus
moderate sedation (MS). Cytologists were blinded to randomization arm. The main objectives were diagnostic yield
and sensitivity. The study was self-funded.
Results: A total of 57 patients were performed under GA and
52 under MS. The median age was 65 years (range 46 to 77)
and 66 years (range 43 to 84) in the GA and MS group, respectively. There were no significant differences in baseline
comorbidities and ASA score. There were no differences in
the indications for EBUS-TBNA: diagnosis (GA 32%, MS
31%), staging (GA 26%, MS 25%), both diagnosis and staging
(GA 33%, MS 34%), or re-staging (GA 9%, MS 10%). Per patient, an average of 3.03＋!
-1.8 lymph nodes (LN) were sampled in the GA group vs. 2.55＋!
-1.6 in the MS group (p=NS).
The average LN size was 11mm＋!
-6mm (standard deviation) in the GA group, vs. 12＋!
-7mm in the MS group (p=
NS). Procedure time (first scope in!
last scope out) was 25＋!
15 min in the GA group and 21＋!
-9 min in the MS group. In
the MS group, the average does of Midazolam was 4 mg, and
the average dose of Fentanyl was 100 mcg. Samples were
adequate in 100% of LN in the GA group vs. 99.8% of LN in
the MS group. A specific diagnosis was found in 72% of patients in the GA group vs. 67% in the MS group (p=NS). Sensitivity was 98% in the GA group and 94% in the MS group
(p=NS). Malignancy was found in 61% of GA group and 51%
of MS group. There were no EBUS-related complications in
either group. Sedation!
anesthesia related complications
were only minor, and more common in the MS group (25%
vs. 7%) (p<0.05). Patients tolerance was assessed postprocedure with a Likert scale questionnaire, showing no significant difference.
Conclusions: Anesthesia type seems to have no influence on
EBUS-TBNA diagnostic yield, but a greater rate of minor
sedation-related complications was detected in the MS
group. Final results will be available at the meeting.
Symposium
IP-SY5-6
IP-SY6-i1
CP-EBUS TBNA & conscious sedation
Virtual bronchoscopic navigation (VBN)
Interventional thoracic surgery, Toronto General Hospital,
Canada
Department of Pulmonary Medicine, Gifu Prefectural General
Medical Center, Japan
Amir M Khan, AG Gundogdu, K Yasufuku
Fumihiro Asano
Introduction:
Adequate moderate sedation can be provided for flexible
bronchoscopic procedures, however it is debated if moderate
versus deep sedation is the optimal method for CP-EBUS
TBNA. Proponents of moderate sedation argue quick recovery times and low costs (no OR usage, anesthesia expertise,
equipment usage etc), whereas advocates of deep sedation
argue this against higher yields and increase safety profile
during bronchoscopic procedures.
The literature is sparse in terms of post-procedural recovery
times and actual door to door (arrival & discharge) times following moderate or deep sedation for bronchoscopy but to
date there is no data for EBUS TBNA. The choice of anesthesia, post procedural recovery and discharge times may
have significant cost bearings especially since reimbursement for bronchoscopic procedures has been on the
decline. We report our experience of conscious sedation, to
date this is the first study to report door to door, procedural
& recovery times in CP-EBUS TBNA.
Methods:
A retrospective review of prospectively collected data of 406
consecutive cases of CP-EBUS TBNA for one year with conscious sedation in our institution. All procedures were performed in the interventional thoracic surgery suite (ITSS)
with pre assessment and post procedural recovery in the endoscopy outpatient department (OPD). All data was independently collected by OPD nursing staff. Age & gender,
amount of sedation, total time in ITSS, procedural, post recovery & discharge (door to door) times, nadir (lowest) oxygen (02) saturation during the procedure, average total no. of
lymph nodes biopsied, discharge score (total of 10 with each
score of 0-2, and includes vitals, pain score, consciousness,
bleeding, nausea!
vomiting) was recorded.
Results:
Of the total 406 cases of EBUS-TBNA, 265 men and 141
women had an average age of 65 years. All patients received
topical anesthesia. Average total of 121 mcg of fentanyl, 3.5
mg of midazolam, 17 ml of topical 2% lidocaine was used during the procedure. The average total time in ITSS room was
50 mts:04 secs with average procedural time of 35 mts:54
secs, average nadir 02 sat was 92%. Average total no. of
Lymphnode biopsied was 3.1. The average total recovery
time was 58 mts:34 secs. Total average discharge score was
9.9!
10. The average door to door discharge times were 2 hrs:
46 mts:29 secs.
Conclusion:
We conclude that EBUS TBNA can be performed efficiently
with the use of combination of benzodiazepines and opiates
as conscious sedation aided with topical sedation in OPD settings.
Transbronchial biopsy has few complications and is less invasive. However, the diagnostic yield of bronchoscopy for peripheral pulmonary lesions is unsatisfactory. The 2013 Guidelines of the American College of Chest Physicians (ACCP)
showed a diagnostic yield of 34% for lesions<2 cm in diameter. A major problem with this method is difficulty in the
guidance of the bronchoscope and biopsy tools. Presently,
many bronchoscopists mentally reconstruct the 3D bronchial arrangement based on 2D planar axial slices of CT performed before bronchoscopy, and select a bronchial path.
However, since this method is inaccurate, the diagnostic
yield depends on the operator s experience and skill.
Virtual bronchoscopic navigation (VBN) is a method in which
images from virtual bronchoscopy (VB) of the bronchial path
to a peripheral lesion are produced and used as a guide for
the navigation of a bronchoscope. Since the bronchial
branching pattern on VB images is similar to that on real
bronchoscopic images, the bronchoscope can be advanced
close to the target lesion according to the bronchial path to
the lesion displayed on VB images.
VBN has been used concomitantly with CT-guided ultrathin
bronchoscopy and endobronchial ultrasonography with a
guide-sheath (EBUS-GS), and satisfactory results have been
reported. The diagnostic yield was 65.4-86.1% by VBN with
CT-guided ultrathin bronchoscopy, 63.3-84.4% by VBN with
EBUS-GS, 62.5-78.7% by VBN with fluoroscopy, 80.0% by
VBN without fluoroscopy, and 73.2% by VBN with all techniques combined.
The first randomized study that we performed has shown
that the use of VBN under EBUS-GS improves the diagnostic
yield and shortens the time until the arrival of the bronchoscope to the target, and thus the total examination time. The
second randomized study hasn t shown that the use of VBN
combined with ultrathin bronchoscopy under x-ray fluoroscopy statistically. However, the method improves the diagnostic yield for lesions in the subcategories (right upper lobe,
invisible, peripheral third) in the study.
VBN is a safe method in which the bronchoscope is guided
by looking at both the real image and virtual one, and no
complications of VBN itself have been reported. In addition,
since VBN requires no special apparatus except software,
the cost is generally not prohibitive. Its wider use is thus anticipated.
127
Symposium
IP-SY6-i2
IP-SY6-3
Electromagnetic navigation
Advanced diagnostic bronchoscopic techniques
among lung transplant recipients with pulmonary nodules
Pulmonary Medicine, Respiratory Institute, Cleveland Clinic,
United States
Mehta C Atul
EMN is an image-guided localization device which assists in
placing endobronchial accessories in target areas of the lung.
It operates on principles of electromagnetism. EM Location
Board placed under cephalic end of the bronchoscopy table
produces low frequency waves to create EM field over patient s chest. A micro-sensor placed within the field, its position in x-y-z axes and in-motion (roll,pitch,yaw) is captured by
the system and displayed on the monitor in real-time, superimposed upon previously acquired CT. Locator guide allows
its distal end to be steered in 360 degrees; it is placed
through the working channel of the bronchoscope via extended working channel to reach the peripheral lesions.
Schwarz performed the first trial to determine its accuracy
and safety in locating peripheral lesions (PLL) in a swine
model. Becker in his pilot study obtained biopsies of PLL using EMN in 30 adults with 69%. Schwarz performed a study
on difficult to reach PLL achieving identical yield. A prospective, single center, study on 60 patients to sample PLL and
mediastinal lymph nodes proved diagnostic yield of 74% &
100% respectively; 80.3% irrespective of size and location of
lesion. Prospectively Makris and Eberhardt determined the
yield for PLL without fluoroscopic guidance to be 67% and
62.5% respectively. Combination of EBUS and EMN improves the diagnostic yield of FB for PLL (88%) without compromising safety. In pts with PLL, EMN in combination with
ROSE and prior PET-CT yields diagnosis in 77%.
We believe that major obstacle to the wide spread use of the
EMN is its cost and the need for expensive disposable accessories.
EMN is a promising technology not only in diagnosing the
PLL and mediastinal lymphnodes, but also may provide a
means for therapeutic interventions for the treatment of
lung cancer especially in the area of interstitial brachytherapy, minimally invasive robot-assisted (MIRA) lung
brachytherapy, and Sterotactic radiosurgery (Cyberknife).
Electromagnetic navigation is a novel tool which aids diagnostic yield of flexible bronchoscopy for the PLL and mediastinal lymph nodes. The procedure is safe, effective, and
easy and can be performed with or without the use of fluoroscopy. It plays a complementary role with endobronchial
ultrasound. It has a potential to be a helpful tool in improving
outcomes from interstitial brachytherapy and cyberknife
therapy. Its upfront cost and that associated with the accessories could hinder its popularity. Emerging radiological
tools, such as Lung Mapping may pose a challenge to the
technology of EMN.
128
Respiratory Institute, Cleveland Clinic Foundation, USA1), Pulmonary, Allergy and Critical Care Medicine, Cleveland Clinic
Foundation, Cleveland, Ohio, USA.2), Spectrum Health Medical
Group, Grand Rapids MI.3)
Abdul Hamid Alraiyes1,2), Thomas r Gildea2),
Gustavo Cumbo-nacheli3), Michael S Machuzak2),
Marie Budev2), Atul C Mehta2)
Background: To assess usefulness of Endobronchial Ultrasound (EBUS) and Electromagnetic Navigation (EMN) among lung transplant patients with pulmonary nodules.
Methods: We identified lung transplant recipients who presented with a new lung nodule from January 2009 to October 2013. We included patients in which EMN and!or
EBUS were used in order to establish the etiology of each lung nodule. We describe the
diagnostic yield of these advanced diagnostic modalities, pathology and compare results with autopsy information, when available.
Results: Twenty-three patients (Age: 52 15 years, Females: 12) presented with new
lung nodules after Lung transplantation. These nodules were evident after a mean (
SD) of 17 ( 7) months. Twelve lung transplants were bilateral. Eighteen nodules were
visualized on chest tomogram; seventeen of these were identified in transplanted lung,
whereas two in the native lungs. Eight patients had mediastinal lymphadenopathy at
the time of diagnosis. In our opinion, conventional bronchoscopic or percutaneous diagnostic procedures were of high-risk benefit ratio in these patients. Bronchoscopy with
linear EBUS was used in eight patients, radial EBUS in eighteen patients and EMN in 7
with peripheral lesions. Combined, these modalities accurately detected etiologies in 4!
24 (83%) patients (7 focal pneumonias, and 7 neoplasms). These techniques were not
able to define an etiology for nodules due to post-transplant lymphoproliferative disorder (PTLD) on 3 patients; the diagnosis was established at the time of autopsy.
Conclusions: Advanced bronchoscopic techniques appear to aid in the diagnosis of lung
nodules, although the true value of such approach remains uncertain. We failed to diagnose condition of PTLD using advanced bronchoscopic techniques. Further work in
this patient population is encouraged in order to elucidate improved diagnostic approaches.
Symposium
IP-SY6-4
IP-SY6-5
Conebeam CT (CBCT) as a new tool in interventional
chest medicine for multimodality navigational access
Virtual bronchoscopy clinical applications and new
developments
II Medical Clinic, Coburg Clinic aff. University of Wuerzburg,
Germany1), Pulmonary Department, G Papanikolaou, General
Hospital, Aristotle University of Thessaloniki, Thessaloniki,
Greece2), Institute for Diagnostic and Interventional Radiology,
Johann Wolfgang Goethe-University Frankfurt a. M., Germany3)
Wolfgang Hohenforst-Schmidt , Paul Zarogoulidis ,
Thomas Vogl3), Johannes Brachmann1)
1)
2)
Purpose: First time report on a 3 years experience on a
Conebeam CT(CBCT) for interventional chest medicine in
more than 100 cases with incidental solitary pulmonary nodules (iSPN).
Results: We published in 2012 an abstract of the first time
use of CBCT for endobronchial realtime navigation in a series of 50 iSPNs (2010-2012) (AJRCCM Vol 185, 2012). In the
whole group overall diagnostic yield (y.) differed with 70%
expected from navigational y. with 91%, overall sensitivity
for malignancy was 77%. In a subgroup-analysis the sensitivity for malignancy was 82% for the invisible iSPNs (diameter
(d) 15+3mm) and 76% for partly invisible iSPNs (d 19+5mm).
As in clinical decision making the question wether a benign
biopsy is truely representing the histology of an iSPN we
looked at the specifity of the biopsies in regards to the position of the forceps in the 3D-volume (3DV) of an iSPN and set
up the concept of differentiating between biopsies of the inner 2!
3 of a 3DV (3D-centered (3Dc)) in comparison to the biopsies in the outer 1!
3 of a 3DV (3D-inside (3Di)). The analysis showed a statistical significant (p=0,0375) difference in the
whole group although both positions were evaluated as navigational positive: Specifity for 3Dc biopsies was 0,9 versus for
3Di only 0,3. Since 2012 we did 53 cases in which we have
used this concept in order to reduce the in general higher
complication rate of a pure radiological approach (ap.) which
e.g. typically shows higher diagnostic y. than any endobronchial, flouroscopy based ap.. In our combined one-stop-shop
ap. we applied additional transthoracical CBCT navigation
(iguide) only in endobronchial negative and 3Di navigations
at the same time and on the same table. Navigational y. in
purely endobronchially navigated cases was 89% but diagnostic y. was only 55%, the complication rate was 3%. Using
the combined one-stop-shop-approach the diagnostical and
navigational y. was 100% accompanied with an increase of
the complication rate up to 6%. Furthermore we applied
CBCT for endobronchial pernasal abscess drainage, tattooing of iSPN before surgery and modifying y-stents in tracheal stenosis. We started applying CBCT-vascular ap. for
specific embolisation purposes and -transcutaneous ap. for
microwave ablation. Radiation exposure of CBCT navigation
towards an iSPN after the 8th segmentation in the right upper lobe has a comparable low value of 1,15mSv measured
with the Aldo-Randerson-Phantom (under review).
Conclusion: CBCT covers successfully different navigational
needs in interventional chest medicine.
Radiology, Seka State Hospital, Turkey1), BASAKSEHIR
STATE HOSPITAL ISTANBUL TURKEY2), UZUNMEHMET CHEST DISSEASSE HOSPITAL ZONGULDAK
TURKEY3)
Bora Kalaycioglu1), Alev Ketenci2), Murat Altuntas3)
Virtual bronchoscopy (VB) is a term that describes a variety
of software-based three-dimensional visualizations created
from medical imaging methods such as CT or MRI scans,
with the goal of creating results similar to minimally invasive
bronchoscopy procedures of the trachea and upper airways.
This technique offers a detailed, noninvasive view of the airways, with reduced risk of infection or perforation, and facilitates preoperative planning for airway interventions that
would otherwise not be possible. It is no possible that VB will
replace fiberoptic bronchoscopy; however, as VB techniques
become more sophisticated and as sufficient computing and
imaging power become more readily available, noninvasive
visualization of the airways will play an important and useful
role in the evaluation of airway diseases in well defined clinical situations. VB can be used for planning and assisting
minimal invasive bronchoscopic airway interventions.
129
Symposium
IP-SY6-6
IP-SY6-7
Diagnosis of middle-third peribronchial pulmonary lesion by conventional TBNA with virtual bronchoscopic
navigation
Relationship of preoperative radiological findings and
diagnostic yield of transbronchial biopsy using VBN
and EBUS-GS
1st Department of Internal Medicine, Shinshu University
School of Medicine, Japan1), Department of Radiology, Shinshu
University School of Medicine, Japan2), Second Department of
Surgery, Shinshu University School of Medicine, Japan3)
Yasuo Masanori1), Takashi Kobayashi1), Mineyuki Hama1),
Takashi Ichiyama1), Kazunari Tateishi1),
Atsuhito Ushiki1), Kazuhisa Urushihata1),
Hiroshi Yamamoto1), Satoshi Kawakami2),
Kazuo Yoshida3), Masayuki Hanaoka1)
Background: Recent advancement of computed tomography (CT) imaging and diagnostic technology in bronchoscopy such as endobronchial
ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) or
endobronchial ultrasound-guide sheath (EBUS-GS) have remarkably
changed the existing approach for undiagnosed lesions. However, when
the small pulmonary lesion is located too far (peripheral) for EBUSTBNA and too close (proximal) for EBUS-GS, physicians will not be able
to use these modalities.
Objective: Based on chest CT findings, we have named from the second
to the fourth or fifth of bronchial generation levels, the middle third
pulmonary area (Figure). Peribronchial middle-third lesions which are
not associated bronchus, have been considered difficult to diagnose by
bronchoscopy. Neither EBUS-TBNA nor EBUS-GS can easily unveil the
lesions. To overcome this issue, we tried to perform conventional
TBNA with virtual bronchoscopic navigation (VBN).
Methods: We retrospectively analyzed eleven serial cases of conventional TBNA with VBN. These procedures were performed from January 2012 to June 2013. The bronchoscope used was a BF TYPE P260F
(Olympus), and the VBN used was a LungPoint (Broncus Technologies,
Inc.). The lesions were traced in the VBN system, then the virtual bronchoscopy was performed using the VBN image mirroring the actual
bronchoscopy. The TBNA site was determined by VBN, and then the
samples were obtained by the conventional TBNA procedure under Xray fluoroscopy guidance. The study was approved by the Shinshu University Ethical Committee.
Results: Definitive diagnosis was made in seven cases. We could not obtain adequate sampling in three cases. In the remaining case, the diagnosis after surgical biopsy was lymphatic inflammation, and we could
obtain adequate samples, however we did not reach a definitive diagnosis by bronchoscopy. We could diagnose not only primary lung cancer
but metastatic lung cancer and pulmonary carcinoid. No adverse effect
has been experienced except for an acceptable amount of bleeding.
Conclusions: Conventional TBNA with VBN was safe and useful for the
diagnosis of middle-third peribronchial pulmonary lesions.
130
First department of Internal Medicine, University of Toyama,
Japan
Kenta Kambara, Ryuuji Hayasi, Koutarou Tokui,
Seisuke Okazawa, Minehiko Inomata, Kensuke Suzuki,
Tohoru Yamada, Toshirou Miwa, Shouko Matui,
Kazuyuki Tobe
Background and objective:
The bronchoscopy s diagnostic yield for lung peripheral malignancy was not enough to therapy for lung cancer. There
are several reports about improvement of the diagnostic
yield of transbronchial biopsy using virtual bronchoscopic
navigation (VBN) and endobronchial ultrasonography with a
guide sheath (EBUS-GS). Factors related to diagnostic yield
of transbronchial biopsy using conventional bronchoscopy
without VBN nor EBUS-GS were suggested in several reports. However, there were no reports about preoperative
radiological finding related to diagnostic yield of transbronchial biopsy using VBN and EBUS-GS.
This study evaluates the preoperative radiological finding
related to diagnostic yield of transbronchial biopsy using
VBN and EBUS-GS on historogical diagnostic yield for peripheral malignancy.
Methods:
This was a retrospective study. Between Apr.2010 and
Dec.2012, 288 patients who underwent lung peripheral biopsy were enrolled. All patients were histologically diagnosed as having pulmonary malignancy.
Results:
The histological diagnostic yield was 72.4%. The diagnostic
yield is higher in obviously detectable lesions in preoperative
chest radiograph than in unclear lesions(80.8% vs 53.0%; p<
0.001). Concerning CT findings, CT sign is related to diagnostic yield (positive vs negative; 76.4% vs 42.3%; p<0.001). Lesion s size influence diagnostic yield (larger size (>20.0mm)
vs smaller size (<20.0mm); 78.2% vs 61.3%; p<0.01). In the
multivariate analysis, obviously detectable lesion in preoperative chest radiograph and CT sign in preoperative CT influence diagnostic yield individually.
Conclusions:
Preoperative factors related to diagnostic yield of transbronchial biopsy using VBN and EBUS-GS were not only lesion s
size but also obviously detectable lesion in preoperative
chest radiograph and CT sign in preoperative CT.
Symposium
IP-SY7-i1
IP-SY7-i2
Bronchoplasty: From the viewpoint of technical education
Current status of bronchoplasty for lung cancer
Division of Thoracic Surgery, Kyorin University School of
Medicine, Japan
Haruhiko Kondo, Hidefumi Takei, Yasushi Nagashima,
Ryota Tanaka, Yoko Nakazato, Shin Karita,
Riken Kawachi, Keisei Tachibana, Rie Matsuwaki,
Tomoyuki Goya
Recently, annual screening program, prevalence of computed tomography, and the decrease of smoking populations
have led to an increasing proportion of small sized peripheral
lung cancer and a decreasing proportion of centrally located
squamous cell lung cancer in Japan. With this trend, the proportion of lung cancer surgery with bronchoplasty (BP) has
been decreasing year by year. The proportion of BP was
3.4% in 1998 which was only 1.2% in 2011. How to learn the
technique of BP is an important issue for the young surgeon
now. We have introduced Hands-on-Seminars (HOS) utilizing
swine thracheo-broncho-pulmonary specimens. Although
swine tracheobronchial anatomy is different from human, all
trainees can experience the BP techniques of suturing and
adjusting the caliber difference effectively. The issues about
BP and how to educate the BP technique in the HOS will be
presented.
Department of Surgery, Nagasaki University Graduate School
of Biomedical Sciences, Japan
Takeshi Nagayasu, Naoya Yamasaki, Tomoshi Tsuchiya,
Keitaro Matsumoto, Takuro Miyazaki, Ryoichiro Doi,
Ryusuke Machino
Bronchoplasty has become widely accepted as a reliable and
safe lung-saving procedure for lung cancer. To evaluate the
current status of bronchoplasty for lung cancer, the data
from an annual survey of the Japanese Association for Thoracic Surgery (JATS) and the original data in Nagasaki University Hospital were analyzed.
Though the annual number of operations for lung cancers in
Japan has increased drastically in the last decade, from
17,296 cases in 1999 to 33,878 cases in 2011, the annual numbers of bronchoplasties, including sleeve lobectomy and
sleeve pneumonectomy, have been stable, ranging from 400
to 512.
In the data from a JATS survey from 2005 to 2011, lung cancers were resected in 201,598 cases, including 3053 (1.5%)
with sleeve lobectomy, 4235 (2.1%) with pneumonectomy,
and 119 (0.1%) with sleeve pneumonectomy. The 30-day mortality rates for all operations, sleeve lobectomy, pneumonectomy and sleeve pneumonectomy were 0.4%, 1.2%, 2.6% and
5.0%, respectively. The hospital mortality rates for all operations were 0.9%, 2.1%, 4.3% and 10.1%, respectively.
In the 2416 patients who underwent lung resections for lung
cancer at Nagasaki University Hospital from 1980 to 2010,
there were 222 bronchoplastic procedures. After excluding
patients who underwent carinoplasty as well as those with
small cell carcinoma, 213 patients (159 bronchoplasty and 54
broncho-angioplasty) were included.
The 5-year survival for all patients was 47.8%. The 5-year
survival was 67.6% (n=50) in the 2000s, 47.9% (n=81) in the
1990s, and 39.0% (n=82) in the 1980s (p=0.0013). Comparing
bronchoplasty and broncho-angioplasty, the 5-year survival
was 56.0% and 46.8% in the post 1990s group, and 42.9% and
30.8% in the 1980s group, respectively (p=0.0215).
Using multivariate analysis to identify potential prognostic
factors, the type of operation, histological type, and pN status
were significant factors affecting survival in the 1980s, but
the risk factors changed to histological type and pT status after the 1990s.
These results suggest that progress in the perioperative
staging system and medical management has been contributing to current improvements in patients undergoing bronchoplasty and broncho-angioplasty. However, since sleeve
pneumonectomy has a high hospital mortality rate, its indications should be considered carefully.
131
Symposium
IP-SY7-i3
IP-SY7-i4
Tracheal surgery for benign condition
Experimental study of two-staged tracheal reconstruction with temporary bioabsorbable tracheal scaffold
grafting
Thoracic Surgery, Respiratory Disease Center, Seirei Mikatahara General Hospital, Japan
Hiroshi Niwa, Masayuki Tanahashi, Haruhiro Yukiue,
Eriko Suzuki, Hiroshi Haneda, Naoko Yoshii
Benign airway obstruction is uncommon, resulting in limited clinical experience for most thoracic surgeons and pulmonary physicians, even at
tertiary centers. We like to present our experience of tracheal surgery
for benign condition. Tracheal benign lesions include trauma, post intubation stenosis, tuberculosis and other causes of inflammation like sarcoidosis and Wedgener granulomatosis, tracheoesophageal fistula, fistula between the trachea and brachiocephalic artery, and tracheomalacia. Separation between the larynx and the trachea is definitive treatment for intractable life-threatening aspiration. Most popular benign
condition is tracheal stenosis and obstruction. Dilation and laser resection have been used for the management of the benign tracheobronchial
stenosis. Tracheobronchial stents have been used to palliate the effects
of large air way obstruction caused by extrinsic compression, intraluminal disease, or loss of cartilaginous support. It is important to differentiate between simple web like stenosis and complex stenosis. Simple
stenosis is ideal for endoscopic treatment because the tracheal wall is
normal. Complex stenosis, which involves destruction of the cartilaginous support, may be idiopathic or occur after prolonged intubation or
tracheostomy and require operative repair as definitive management.
Stent placement should be reserved for patients who cannot undergo
surgery or as a means for achieving immediate symptom relief until
surgery can be performed. Any tight stricture should be dilated before
resection. As a rule, any tracheal stenosis of less than 6mm in diameter
should be dilated immediately after induction of anesthesia to avoid retention of secretions, difficult ventilation, and progressive hypercapnia.
There are some special techniques for tracheal surgery. Circumferential resection is popular technique for limited stenosis. If long segmental
resection required, suprahyoid release described by Montgomery may
be employed. Esophageal tracheoplasty described by Niwa will be
achieved for longitudinal defect of membranous portion. Laryngotracheal anastomosis following resection of cricoid cartilage may be required for subglottic stenosis. Tracheaoesophageal diversion is ideal to
avoid recurrent aspiration pneumonia. We will discuss ultimate treatment for benign tracheal condition.
132
General Thoracic Surgery, St. Elizabeth s Medical Center,
USA1), Reliant Medical Group, Worcester, MA2)
Hisashi Tsukada1), Armin Ernst2)
INTRODUCTION: Marked native tracheal axial shifting
phenomenon without tracheal cartilage ring regeneration
was observed in our previous studies which sheep trachea
was replacement with a fresh aortic allograft or bioabsorbable scaffold. This phenomenon may allow for safe two-stage
end-to-end tracheal reconstruction of large tracheal defect.
AIM: To confirm tracheal axial shifting phenomenon in mature animal model and to test surgical feasibilityof two-stage
end-to-end tracheal reconstruction.
METHODS: Five canines (19kg to21kg) underwent cervical
tracheal replacement (5cm) using copolymer of L-lactide
andε-caprolactone sponge tube (Gunze Ltd, Kyoto, Japan). A
silicone stent (7cm) was placed to prevent graft collapse.
Postoperative bronchoscopy and CT scans were planned
checking tracheal approximation. Native tracehal end-to-end
reconstruction surgery was planned at 9 month when the
original grafted area shortening more than 50% (length less
than 25mm).
RESULTS: One canine developed a silicone stent related
granulation tissue in the airway which was dropped followup at 6 month. The rest of four animals were no postoperative complications. CT imaging in the grafted area length of
four animals were ranging between 19mm and 23mm at 9
month after surgery. Those four animals were received a
second tracheal reconstruction surgery. The second surgery
was consisted with resection of the original grafted area and
end-to-end native tracheal re-anastomosis without endotracheal stent placement. The original tracheal scaffold was
completely absorbed. There were no procedural deaths and
postoperative complications after the second surgery up to 2
month after surgery without any airway symptoms.
CONCLUSION: Tracheal axial shifting phenomenon was observed in mature animal model. Two-staged end- to- end tracheal reconstruction with temporary grafting technique is
feasible. It may applicable for selected case of large tracheal
defect reconstruction surgery.
Symposium
IP-SY7-5
IP-SY8-i1
Bronchoscopic findings of post wedge bronchoplastic
lobectomy
Interventional bronchoscopy combined with surgery
for the treatment of lung cancer
Respiratory disease center, Showa University Northern Yokohama Hospital, Japan
Akihiko Kitami, Takashi Suzuki, Humitoshi Sano,
Shinichi Ohashi, Shoko Hayashi, Kosuke Suzuki,
Shugo Uematsu, Yoshito Kamio
Background: It is speculated that the advantage of wedge resection lies in the ability to maintain bronchial perfusion and
to obtain good results. On the other hand, wedge lobectomy
can result in kinking at the anastomosis site and anastomotic
stricture.
Material and methods: From 2004 to 2012, 9 patients (All
male; mean age 64) underwent wedge bronchoplastic lobectomy for non-small cell lung carcinoma. We evaluate comparatively operative findings and bronchoscopic findings following wedge lobectomy. As concerns operative findings, we
evaluated the angles of the wedge and distance of the preserving parts in the cut line of the bronchus (so called bronchial bridge). The bronchial anastomosis was routinely
checked with a bronchoscopy in the operating room following conclusion of the operation, and 8 days post-operatively.
Results: The pathological diagnosis was squamous cell carcinoma in all nine patients. Five patients underwent induction
therapy (chemotherapy in three patients and chemoradiotherapy in two patients). There were 6 right upper
lobectomies, two middle and lower lobectomies, and one left
lower lobectomy. Pathologic staging classified one patient
into stage I, three patients into stage II, and five patients into
stage IIIA. In bronchoscopic findings, five patients who were
all undergone right upper lobectomy showed the bulging
into the bronchial lumen (high grade in two cases and low
grade in three cases). There were no anastomotic strictures.
In operative finding in these patients, bronchial bridge
tended to be relatively long and!
or the angle of the wedge
resection tended to be relatively wide.
Conclusion: To prevent bulging into the bronchial lumen after right upper wedge lobectomy, bronchial wedge excisions
ought to be shaped in order to reduce the bronchial bridge to
shorter length (about 5-10mm).
Department of Thoraic Surgery, Tokyo Medical University,
Ibaraki Medical Center, Japan1), Tokyo Medical University, Japan2)
Kinya Furukawa1), Hiroaki Kataba1), Takefumi Oikawa1),
Hideyuki Furumoto1), Remi Yoneyama1), Makoto Saito1),
Norihiko Ikeda2)
Background: The report of patients with NSCLC who could receive surgery after interventional bronchoscopy (IVB) or IVB
for complication after surgery is relatively rare. Also, the influence of IVB on surgical procedure is virtually unknown. Objectives: To assess the usefulness and clinical issue of IVB combined with surgery. Methods: We experienced a total of 8 patients treated by IVB combined with surgery, 4 of them were
performed IVB first. Because of improvement of severe dyspnea
and!or general condition after IVB, we could perform surgery in
4 patients. A patient with severe cicatricial stenosis caused by
photodynamic therapy was performed right middle and lower
lobectomy after Dumon stent placement in the right main bronchus. Two patients were performed left lower lobectomy. One
was after snaring and APC of the polypoid tumor which located
in left main bronchus originated from B6 followed by induction
chemotherapy, and another was after endobronchial Watanabe
spigots (EWS) occlusion to stop bleeding from peripheral lung
cancer. We experienced 3 patients with lung cancer involving
the carina. One of 3 patients was treated by a Dumon-Y stent
placement followed by carinoplasty, and the remaining 2 patients were performed stenting for the anastomotic complication
after carinoplasty. Results: Dumon stents or custom-made stents
were placed for the bronchial stenosis or anastomosis complication in 5 patients. EWSs were used to occlude the bronchi for the
purpose of stopping aspiration of blood in 2 patients. In a patient,
electorocautery alone using snaring and APC was performed for
reduction of the tumor extent. The findings of patients who
were performed surgery showed severe adhesion and hypertrophic scar surrounding the treated bronchial wall and lymphoid hyperplastic change in the hilar and mediastinum lymph
nodes. These inflammatory reactions make the surgical procedure difficult. In a case of EWS occlusion followed by surgery,
swelling of the lung by congestion made difficult to manipulate
the hilar of the lung. We lost the patient of Dumon-Y stent placement followed by carinaplasty caused by anastomotic failure
due to infection. Conclusion: We need careful manipulation and
management on surgery after IVB because of severe inflammatory reaction, infection due to biofilm or congestion. However,
we should realize that there are some patients who can be
treated by surgery after IVB because of improvements of their
conditions. Also, IVB is useful for the management of anastomotic complication after surgery.
133
Symposium
IP-SY8-i2
IP-SY8-i3
Chinese airway covered metallic stents and its clinical
usage
New trends on tracheobronchial stents
Department of Pulmonary Medicine, Beijing Tiantan Hospital,
Capital Medical University, China
Jie Zhang
Due to no silicone and other non-metal airway stent in China,
we have to apply the self-expandable metallic stents (EMS)
for the treatment of airway stenosis. We mainly use metallic
stents for malignant airway diseases, as for benign airway
stenosis, we usually choose the covered metallic stents in order to remove it from the airway afterwards. In China today
there are two main types of the self-expandable metallic
stents: Nickel-titanium Memory Alloy Stents (covered or not
covered) and Z-type Stainless Steel Wire Stent (all covered).
The greatest advantage of the Chinese stents is that: the
stents can be customized into cylinder, cone, L, Y, and other
special shapes and different size according to the actual situation of the pathological airway and are available in 3-5 days,
which is a unique feature of the Chinese stents. Deployment
devices of these two metallic stents are different, but both of
them can be performed under local anesthesia.The insertion
of the pusher for Z-type Stainless Steel Wire Stent is a little
bit more difficult. It is recommended to use rigid bronchoscope for the placement of special shapes stent such as Y
stents under general anesthesia. Metallic stents are usually
applied to treat malignant airway stenosis, but covered metallic stents can be used for the treatment of benign airway
stenosis and more easily placed with flexible bronchoscope
under local anesthesia compared with Dumon stents. It also
can be safely removed from the airway within half a year.
Moreover covered metallic stents are more widely applied in
the treatment of airway-esophageal fistula and airwaypleural fistula because it can be made into various shapes.
134
Pulmonology, Hospital Universitari de Bellvitge, Spain1), Microbiology, Hospital Universitari de Bellvitge-IDIBELL, Barcelona2), Microbiology, Hospital Universitari de Bellvitge, Barcelona3), Microbiology-CIBERES-IDIBELL, Hospital Universitari
de Bellvitge, Barcelona4), Grup de Ingenieria de Materiales
(GEMAT); Institut Quimic de Sarria, Universitat Ramon Llull;
Barcelona5), Laboratori de Pneumologia Experimental, Hospital de Bellvitge, IDIBELL; Barcelona6), Servei de Pneumologia,
Hospital Universitari de Bellvitge-IDIBELL; Barcelona7),
Servei de Pneumologia, Hospital Universitari de BellvitgeIDIBELL-CIBERES; Barcelona8)
Antoni Rosell1), Sara Marti2), Laura Calatayud3),
Fina Linares4), Gilabert Joan5), Borros Salvador5),
Huamani Carlos6), Montes Ana6), Rosa Lopez-Lisbona7),
Noelia Cubero8), Jordi Dorca8)
Although airway stenting is an important strategy for managing
various types of tracheobronchial obstruction. there has been no
change in their design over the last two decades. There are two
types of stents, depending on the material they are manufactured
from: silicone stents and metal auto-expandable stents, both of
which may be straight or in a Y shape. The principal function of
all stents is to stabilize the airway lumen, by providing an outward radial force. All stents are susceptible to the same complications, including bacterial colonization, migration, granulation tissue formation and mucus plugging. Developments in other procedural specialties like cardiology, have shown many of these limitations, constraints and complications can be overcome by widening the functionality of stents, either by introducing new biomaterials or by applying new tooling and manufacturing techniques. A
second generation of tracheobronchial stents would see the incorporation of drug-eluting materials in their manufacture. Candidate drugs include silver, cisplatine, paclitaxel or mitomycine.
Silver-coated endotracheal tubes reduce ventilator-related pneumonia (Rello, 2010). This same principle could be applied to avoid
bacterial colonization of a stent, one of the most common complications. In vitro studies show that silver deposited on silicone at a
concentration of 1 μg!mm2 can prevent colonization when exposed to Pseudomonas aeruginosa and Staphylococcus aureus up
to 1.5x106 CFU!ml (Rosell, 2014). Mitomycine C has been shown
to achieve a continuous release for 80 days in an animal model
(Zhu, 2011), and could be used to inhibit the upregulated fibroblasts in post-inflamatory tracheal stenosis, with an intent to cure
this recurrent disease. A third tracheobronchial stent generation
would include biodegradable and!or customized stents, with or
without drug elution. Biodegradable stents are based on polymeric (polyglycolic or poly-L-lactic acid (PLLA) or their copolymers) or metallic (Magnesium with rare earth metals) materials.
While widely used in cardiology, there are only a few case series
in respiratory endoscopy, mainly in children (Vondrys, 2011).
Rapid prototyping and tooling of custom-made tracheobronchial
stents through 3D printing is also possible. However, this can t be
achieved with silicone and would require new biocompatible materials. This manufacturing technique would allow stent design to
be tailored to an individual s complex anatomy. In conclusion, advances in nanomedicine and biomaterials, along with new manufacturing techniques, promise to bring us closer to the everelusive goal of producing the ideal tracheobronchial stent
Symposium
IP-SY8-4
IP-SY8-5
Multidisciplinary management of benign pseudoglottic
tracheal stenosis: A retrospective study of 60 patients
Withdrawn
Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Departement, North University Hospital, France1),
Department of Pulmonary Medicine, Christian Medical College, Vellore, India2)
Herve Dutau1), Jerome Plojoux1), Sophie Laroumagne1),
Dj Christopher2), Philippe Astoul1)
Background:
Benign tracheal stenosis (BTS) complicates tracheal intubation
or tracheostomy in 1 to 8%. Surgical sleeve resection of trachea
is the reference treatment. Endoscopic treatment is used for inoperable patients with success in 17 to 69%. Pseudoglottic tracheal stenosis (PGTS) is a type of BTS which results in a dynamic stenosis due to anterior fracture of one cartilage ring,
frequently associated with posterior, focal tracheomalacia. We
report the results of our multidisciplinary management (MM).
Method and Patients:
Sixty patients with PGTS stenosis were included. Management
decision was made during initial bronchoscopy, considering
symptoms and contraindication to surgery. Patients suitable
for surgery were referred to surgeons. Posterior localized tracheomalacia was treated with YAP Laser. Tracheal stents
were placed in case of persistent stenosis after laser, as sole
treatment or as a bridge to surgery.
Straight silicone stents (TD), stenotic silicone stents (ST), Ttube or a fully covered self-expandable metallic stent (SEMS)
placement was based on operator s judgment. After 12-18
months, stents were removed. In case of persistent stenosis,
surgery was reconsidered or!and the stent replaced. In case of
satisfactory result, patients were followed and a stent was replaced if recurrence occurred. Stable patients after surgery or
endoscopic treatment without long-term tracheal device were
considered as success, requirement of long-term tracheostomy
or T tube as failure and long-term tracheal stent as partial success.
Results:
All patients had developed PGTS after tracheostomy. Thirtythree (55%) patients had posterior tracheomalacia on the first
evaluation. In 13 (21.6%) patients, mild stenosis only required
surveillance. Two (3.3%) patients were directly referred for
surgery. Endoscopic management was first line therapy in 45
(75%) patients and was successful in 23 (51%) patients, partially
successful in 10 (22%) and failed in 12(27%). Three of the endoscopic treatment failures were operated. Five patients with
successful outcomes had required only laser therapy. In all 70
stents were placed in 35 patients: 41(59%) TD, 14 (20%) ST and
14 (20%) SEMS and migration rates were 31%, 43% and14% respectively. Overall success of MM was in 38(63%).
Conclusion:
PGTS multidisciplinary management was successful in 63%.
Stent migration was frequent, mainly due to the dynamic component of the lesions, but seemed to be least with SEMS which
had larger mean diameter and better adapted to the shape of
the stenosis. Posterior localized tracheomalacia could be successfully treated in carefully selected cases, thus avoiding stent
placement.
135
Symposium
IP-SY8-6
IP-SY9-i1
A series of 810 therapeutic rigid bronchoscopy procedures in 555 cases with central airway diseases
Confocal bronchoscopy in the diagnosis of lung cancer
Department of Respiratory Medicine and Medical Oncology,
Meitan General Hospital, China
Wang Hongwu, Dongmei Li, Zhang Nan, Zou Hang,
Zhou Yunzhi, Li Jing, Sujuan Liang
Objective: To explore the indications and clinical applications of rigid bronchoscopy for the treatment of central airway diseases.
Materials and Methods: We retrospectively reviewed the
data of rigid bronchoscopy procedures performed in 810
cases with central airway diseases under general anaesthesia.The age ranges from 6 to 92 years old.
Results: There were 506 out of 810 procedures were successfully performed. Among all, 610 procedures were performed in 383 malignant noeplasmas, and 200 procedures in
123 benign disorders. The most common foci were located at
the trachea. The complications were less common, including
incubation failure in 4 (0.5%) patients with post-tracheotomy
cicatricial stenosis, anterior teeth lost in 4 (0.5%) patients,
slight injury of upper trachea in 5 (0.6%) patients, and larynx
edema in 5(0.6%) patients. There was no death caused by
procedures.
Conclusion: Rigid bronchoscopy is feasible for the treatment
of complex or difficult airway diseases, owing to the safe and
rapid procedure.
136
The Ohio State University, USA
Shaheen Islam
Confocal Bronchoscopy uses technology to obtain images
from a single cellular plane. It is being been used in GI to diagnose Barrett s esophagus. A commercially available system (Cellvisio, MKT, Paris, France) uses fluorescence based
laser endomicrosocpy at different at wavelengths of 488nm
or 660nm excitation to image cellular structures. It can be
used with with or without fluorescein based dyes such as
methylene blue or acriflavine to aid in the identification of
cellular morphology and tissue matrix. Recently it has been
used to characterize endobronchial malignant lesions. Diagnosis of peripheral lung nodules may be difficult with existing technology. The confocal probe used in combination with
navigation bronchoscopy is able to confirm abnormal areas
before it can be biopsied. Presence of certain features on confocal system such as distorted architecture, easy friability of
alveolar wall, presence of large cellular structures suggest
malignant lesions. Specific findings will be discussed during
the session. In the future, development of specific fluorescein
dyes tagged to specific antibodies targeted towards cancer
biomarkers may be able to diagnose subtypes of primary or
metastatic lung cancer.
Symposium
IP-SY9-i2
IP-SY9-i3
An endo-cytoscopy system combined with white light
imaging (WLI) and narrow band imaging (NBI)
In vivo molecular and vascular microscopic imaging of
the airways
Department of Chest Surgery, Matsudo City Hospital, Japan1),
Department of Respirology, Matsudo City Hospital, Japan2),
Department of Pathology, Matsudo City Hospital, Japan3)
Clinique Pneumologique, Rouen University Hospital, France1),
QuantiF laboratory, Rouen University, France2)
Kiyoshi Shibuya , Nao Okada , Hidemitsu Funabashi ,
Hiromasa Kohno1), Naomichi Iwai1), Masahiro Noro3),
Bunshiro Akikusa3)
1)
1)
2)
Objectives: An Endo-Cytoscopy System (ECS; Olympus Optical Corp. Tokyo, Japan) has been enabled real-time in vivo
surface cellular and vascular imaging during endoscopy. The
ECS uses a new optical imaging technique that employs light
contact microscopy after application of methylene blue to
the mucosal surface. We investigated the ability of ECS combined with white light imaging (WLI) and narrow band imaging (NBI) to detect bronchial mucosal change in squamous
cell carcinoma (SCC), as well as (angiogenic) squamous dysplasia (ASD).
Methods: The integrated-type ECS for the bronchoscope has
a built-in two imaging system with a conventional mode and
a high-power endocytoscopic mode. ECS has a high magnification of 570 X. The abnormal area of interest were stained
with 0.5% methylene blue and examined with white light imaging (WLI) and narrow band imaging (NBI).
Results: Cellular imaging: In dysplastic lesions, superficial
cells with rounded nuclei and abundant cytoplasm were arranged with minimal irregularity. The nuclei were darkly
stained, and cytoplasma had a light blue tone. The N!
C ratio
had a mild variation, and the morphologic pattern was nearly
homogeneous. In squamous cell carcinoma, polymorphic tumor cells showed increased cellular densities. The N!
C ratio
was high and irregular. The nuclei were stained dark blue.
Vascular imaging: Some dotted vessels, in addition to increased vessel growth and complex networks, in ASD; several dotted vessels and spiral or screw type tumor vessels, in
SCC were clearly found using the ECS with NBI.
Conclusion: An endo-cytoscopy system combined with white
light imaging (WLI) and narrow band imaging (NBI) were
useful in detecting bronchial mucosal cellular and vascular
change in SCC, as well as squamous dysplasia. This novel
technology has an excellent potential to provide in vivo diagnosis during bronchoscopic examinations.
Luc Thiberville1), Mathieu Salaun1), Helene Morisse1),
Florian Guisier1), Maxime Patout1), Samy Lachkar1),
Pierre Bohn2)
In vivo confocal microendoscopy (Cell-vizio) is a minimally invasive technique that allows microstructural imaging of the
human airways, in vivo and in situ. The technique uses the
principles of fluorescence confocal imaging, with the lung
structures being excited at 488 or 660 nm using a laser beam.
The light is injected through a 1mm large, 3m long flexible fiber bundle or miniprobe , containing up to 30000 microfibres. Each microfibre acts as a pinhole that both excites the
tissue and collects back the fluorescence emitted by the tissue in contact with the miniprobe tip. The resulting signal is
recorded and visualized in real time as a video signal at 9-12
frames!
second. The miniprobe can enter the working the 2
mm working channel of any fiber optic bronchoscope, and is
therefore able to reach the lung structures, from the proximal bronchus down to the more distal acinar parts of the
lungs.
The technique can be applied to the in vivo microstructure
analysis of the distal lung is several pathological conditions,
such as diffuse intertitial lung diseases, peripheral lung nodules, lung emphysema.
We have conducted the first trial using this technique for the
exploration of both proximal airways and alveoli, and found
that the main signal that forms the image at 488 nm excitation comes from the elastin network of the basement membrane, the axial elastic network of the alveolar ducts and entrances, as well as the elastic sheeth that surround the acinar
extraalveolar microvessels.
We found that, in addition to the autofluorescent signal, the
technique could be coupled with the use of exogenous fluorophores such as methylen blue for the imaging of the epithelial cells of the proximal bronchi and peirpheral lung nodules.
Here, we will present new data on in vivo imaging of the alveolar capillary network using fluorescein and show that the
technique can assess the loss of capillary in the alveolar wall
of emphysema patients. We will also present original experimental data using smart fluorescent probes targetting distal
lung invasive aspergillosis, EGFR mutated tumors, and in
vivo assessment of early apoptosis of cancer cells after exposure to Cisplatin or Gefitinib.
In vivo confocal microendoscopy appears a promising
method for the exploration of a large variety of lung diseases.
137
Symposium
IP-SY9-4
IP-SY9-5
HD bronchoscopy exploratory study of diagnostic
value compared to standard white light and autofluorescence bronchoscopy
Comparison of probe-based confocal laser endomicroscopic images with light microscopy in lung cancer
Pulmonary Diseases, Radboud University Medical Center,
Netherlands
Erik H.F.M. Van Der Heijden, Olga Schuurbiers,
Wouter Hoefsloot
Rationale
Bronchoscopy is an essential procedure for the diagnosis of lung
cancer and other pulmonary diseases. It renders important anatomical information and subtle changes in the epithelium or vascular patterns of the bronchial tree are clues to guide the endoscopist in this procedure, especially in case of centrally located
lung cancer. These subtle changes may influence the choice of
treatment, site of biopsy and surgical approach of centrally located lung cancers. Earlier studies have shown diagnostic superiority of video-autofluorescence bronchoscopy (AFB) over routine
white light bronchoscopy (WLB).
In this study we aimed to investigate the diagnostic performance
of high-definition (HD-) bronchoscopy with or without additional
filtering techniques (surface enhancement and tone enhancement
(iScan)) in comparison to standard WLB and AFB for detecting
abnormalities of the tracheobronchial tree.
Study design:
In patients with known or suspected lung cancer or head and
neck cancer and an indication for a planned procedure under general anesthesia a bronchoscopy was performed using a laryngeal
mask under general anesthesia. Bronchoscopy was performed in
a standardized order using five different imaging modes. The order of the different modes will be randomized and videos of the
entire procedures were made. The five imaging modes used in
this study are:
1. Standard white light videobronchoscopy (WLB-Pentax EB1570)
2. High Definition (HD)-bronchoscopy (Pentax EB1990i)
3. HD-bronchoscopy+surface enhancement (iSCAN1).
4. HD-bronchoscopy+tone enhancement (iSCAN2)
5. Auto Fluorescence Bronchoscopy in dual video mode (AFB,
Pentax SAFE3000 and EB1970A).
The video s are reviewed by two experienced physicians (OS and
WH) in random order and blinded for patient information and
date. The video s are scored using a predefined system to describe epithelial surface, vascular patterns and tumors.
Results:
A full data-set has been obtained in 25 patients with known or
suspected lung cancer and the images are currently being analysed. The final data will be available for presentation at the conference. The data collection in 25 patients with head and neck
cancer is ongoing and we expect to have the final results in this
group available as well. Preliminary interpretation of the images
by the unblinded physician collecting the data (EH) suggests that
the diagnostic performance HD bronchoscopy in combination
with iSCAN2 filtering technique is the optimal imaging modality
and seems superior compared to standard WLB and AFB for determining epithelial changes, changes in vascular patterns and tumor margins.
STUDY IDENTIFICATION: www.ClinicalTrials.gov-Identifier
NCT01676012
138
Interventional Pulmonary Program, Louisiana State University Health Sciences Center, USA
Adam Wellikoff, Robert Holladay, Catherine s. Chaudoir,
Luis Brandi, Elba A. Turbat-herrera
Introduction: Light microscopic examination of ex vivo tissue is the gold standard
for diagnosing lung cancer. This requires the removal of tissue and processing of
specimens resulting in a time-delay between tissue acquisition and diagnosis. Probebased confocal laser endomicroscopy (pCLE) is a novel technology that allows microscopic tissue examination in vivo during bronchoscopy. This FDA-approved
technology has shown that different types of tissue can be demonstrated accounting for the spectrum of pulmonary diseases. Normal elastin!collagen airway and alveolar appearance with pCLE has been previously described in several reports. Although validated criteria for interpretation of pCLE images is forthcoming, little has
been published comparing traditional light microscopy to pCLE images. The aim of
this work is to describe the histologic findings with pCLE images in lung cancer.
Methods: Following IRB approval, cases of lung cancer diagnosed from July 2012 to
January 2013 obtained via bronchoscopy with pCLE images were identified. Diagnoses were made from sampling endobronchial or transbronchial lesions. In order to
assure that images obtained by pCLE and samples were taken from the same area,
electromagnetic navigation and fluoroscopy were employed for the transbronchial
cases while direct visualization was used for the endobronchial cases. Tissue was
then obtained and the pathology slides compared to the pCLE images retrospectively.
Results: Twenty-five cases were identified that meet criteria (11 adenocarcinoma, 8
squamous cell carcinoma, 1 small cell carcinoma [SCLC] and 5 either poorly differentiated carcinomas or metastatic lesions). The case of SCLC was diagnosed via transbronchial needle aspiration into an extrinsically compressed airway with edematous
bronchial mucosa. The other cases all showed varying degrees of disorganization
and friability of the underlying elastin!collagen consistent with the destructive!desmoplastic reactions seen in malignancy. To summarize, a ragged appearance can be
observed along with disorganization of the elastin!collagen network within the
bronchus!alveoli where tumor is present. Disarray!friability increases with more
poorly differentiated tumors. Areas with malignant cell groups appear as black
holes giving the tissue a moth-eaten appearance. Tumors with lepidic pattern are
suspected by pCLE when a studded appearance is noted.
Discussion: These cases demonstrate that traditional histopathology does correlate
with images obtained from pCLE during bronchoscopy. This suggests that pCLE
appears to be a useful adjunct in guiding biopsies to increase yield. It also suggests
that pCLE may be helpful in the future for in vivo diagnosis of lung cancer. Further
study is needed to confirm these findings and correlate them with molecular
changes.
Symposium
IP-SY10-i1
IP-SY10-i2
Airway intervention in post-tuberculosis stenosis
Multimodality treatment of large airway obstruction in
benign diseases
Division of Pulmonary & Critical Care Medicine, Department
of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
Hojoong Kim
Szent Gyorgy University Teaching Hospital of Fejer County,
Hungary
Zsolt Papai-Szekely
Airway tuberculosis (TB) is a unique feature of Mycobacterium tuberculosis infection involving tracheobronchial tree.
After the infection, healing process of TB would result in tracheobronchial fibrosis causing airway stenosis in 11-42% of
patients. In Korea, where pulmonary TB is still prevalent,
airway TB is the most common cause of benign tracheobronchial stenosis. Post-TB tracheobronchial stenosis (PTTS)
may cause progressive dyspnea and often represents lifethreatening respiratory insufficiency. Surgical resection and
reconstruction after the eradication of Mycobacterium tuberculosis has been the preferred treatment for most patients with PTTS. However, most of PTTS occurs in young
female patients, who usually refuse surgery. In addition, active TB infection would provoke many problems during and
after surgical management.
Bronchoscopic intervention has been developed to deal with
airway stenosis and to avoid the potential morbidities of surgery. We had experienced repeated ballooning in PTTS patients. However, the overall success rate was less than 10%,
needing new modality of intervention. Multiple techniques,
including ballooning, laser resection, bougienation and silicone stenting were applied to PTTS patients at one stage
under rigid bronchoscopy. Almost all patients experienced
immediate relief of symptom. Silicone stenting had a key role
for intervention, and stents could be removed successfully in
about 2!
3 of patients at a median 1.5 years after the insertion. After the stent was removed, patients maintained good
airway patency and pulmonary function. Acute complications developed in less than 10% of patients without mortality. Subgroup analysis showed that successful removal of
stent was significantly associated with male sex, young age,
good baseline lung function and less use of bougienation.
In conclusion, bronchoscopic intervention could be applied to
PTTS patients with acceptable efficacy and tolerable safety.
139
Symposium
IP-SY10-3
IP-SY10-4
Survival after covered Y-shaped stents in malignant
lesions of the carina
Evolution of patients treated by dumon Y prothesis in
case of cancer invading the tracheobronchial tree
Department of Pneumology, Grenoble University Hospital,
France1), Ear, Nose and Throat Division, Grenoble University
Hospital, France2), Radiology Division, Grenoble University
Hospital, France3), Pharmacy Division, Grenoble University
Hospital, France4)
Louis-Marie Galerneau1), Ihab Atallah2),
Amandine Briault1), Adrien Jankowski3),
Caroline Vincent4), Gilbert Ferretti3),
Wahju Aniwidyaningsih1), Emile Reyt2),
Christian Righini2), Christophe Pison1)
We evaluated the effects of Y-stenting in malignant carina lesions on respiratory failure treatments and survival. Moreover we post-hoc analysed which patients benefited the most
of these palliative care. Thiry-two consecutive patients, 61.0
8.4 yrs. old, 26 men were treated with Y-stent (Microtec,
China), inserted between II-09 to X-13, under general anaesthesia with rigid bronchoscopy under brilliancy amplifier.
Lung cancers were 62.5%, oesophageal cancers 37.5%, stage I
7%, II 10%, III 50% and IV 33%. Median follow-up was 106
days (m-M: 3-673). No deaths were related to the procedure.
Survival according to Kaplan Meier analysis were 64%, 45%,
34% and 8% at 1, 2, 3 month and 1 year respectively in 32
cases; median survival was 49 days. Ventilation and oxygen
therapy in pre procedure were used in 3 and 10 respectively
and 1 and 10 after stent insertion, p: 0.12 for oxygen therapy.
A multivariate Cox related to survival showed no effects of
age, gender, BMI or lung versus oesophageal cancers. Subjective improvement in symptoms, the main goal of these
procedures has not been adequately measured which was
the main limitation of our series. As compared to previous series, n=86, 45% deaths at 90 days in Dutau et al. Chest 2004;
126:951-8, n=12 median 94 days in Oki et al. ERJ 2012;40:
1483-8, our median survival seemed to be shorter, and as others we were unable to unravel prognosis factors suggesting
that carina localisation has a very poor prognosis per se independently of co-variables as stage, BMI, age and gender.
Performance status (0-5)<or=3 and!
or a MRC dyspnoea
scale (1-5)<or=4 were associated to a better survival in a retrospective analysis of 50 consecutive patients receiving 72
stents with malignant central airway obstruction (Razi et al.
Ann Thorac Surg 2010;90;1088-93). We conclude that covered
Y-shaped stents in malignant carina lesions could be safely
inserted. We were unable to find any prognostic factors on
survival, resulting in persistent issue to select patients that
will benefit the most. An assessment of quality of life is mandatory to support these palliative procedures and to better
anticipate survival benefits probably in intermediate performance group.
140
thoracic surgery, Bordeaux University School of Medecine,
France
Matthieu Thumerel, Benjamin Chevalier,
Arnaud Rodriguez, Arnaud Germain,
Jean-francois Velly, Jacques Jougon
Background: The use of Dumon Y covered stent is indicated
in tracheal-bronchial neoplastic stenosis responsible of disabling symptoms which could lead to suffocation.
Method: This 6-year retrospective study deals with the evolution (complications and survival) of 41 patients who were
offered this treatment.
Results: On 41 patients, there are few complications imputable to the stent: one migration and two obstructions. The
survival analysis shows a global survival of 54% at three
months, 29% at six months and of 17% at one year. Several
reasons minoring the survival have been found like the setting of a neoadjuvant carcinogenic therapy (p=0.0338), the
absence of any adjuvant carcinogenic therapy (p=0.003), the
tracheal-bronchial affection rather than the separate tracheal or separate bronchial affection and at last, the fact that
the patient was admitted already intubated (p=0.049).
Conclusion: The short delay of the endoscopic realization in
case of neoplastic tracheobronchial stenosis patients and the
incentive to set an adjuvant carcinogical therapy seem both
to be survival profits.
Symposium
IP-SY10-5
IP-SY10-6
Changing indications for bronchoscopic electrocautery therapy for central airway obstruction
Is a stent required after the initial resection of an obstructive lung cancer? The answers following SPOC
trial
Centre for Respiratory Diseases, Jaipur Golden Hospital, India
Rajiv Goyal, Pratibha Gogia, Vaibhav Chachra
Objectives-We present a retrospective analysis of patients
with central airway obstruction (CAO) due to different
causes where Bronchoscopic Electrocautery therapy (BECT)
was used not only for palliation, but also for cure or to facilitate subsequent cancer treatment.
Methods-Patients who presented with CAO due to different
etiologies where BECT was performed were selected from
the year 2009 till 2011. Patients with tumors more than 4cm
in size and!
or where the distal extent of the obstructed segment was not visible were excluded. Monopolar cautery was
used and applied through an insulated probe, snare or knife
passed through the channel of the fibreoptic bronchoscope.
Outcome measures were visual assessment of deobstruction
by bronchoscopist, improvement in symptoms assessed by
visual analogue scale, complications, and recurrence of obstruction on follow up.
Results-There were 55 patients between 17 to 75 years of
age. There were 40 males and 15 females. BECT was performed with curative intent in 22 patients. Of these 11 patients had benign tumors including 6 typical carcinoids, 10
patients had benign stenosis and 1 patient had a post bronchotomy granuloma. Palliative BECT was done in 17 cases
with CAO due to advanced primary lung or metastatic malignancies to give symptomatic relief to the patients. BECT
was also done in 16 cases for malignant obstruction to facilitate subsequent treatment with surgery, radiation or chemotherapy thereby prolonging survival. More than 75% deobstruction as assessed by the bronchoscopist could be
achieved in 47 patients (85%) and between 50-75% in 6 patients (10%).Unsatisfactory deobstruction ie. <50% was seen
in only 2 patients (3%). Satisfactory improvement in symptoms was reported by 48 patients (87%). Three patients had
significant bleeding, 2 patients had migration of the cut tumor to the normal lung, two patients had septicemic shock
after the procedure, and one patient had pneumothorax. On
follow up 4 patients had recurrence of benign stenosis, and 1
patient recurrence of carcinoid tumor.
Conclusions-In properly selected cases BECT is an excellent
modality for CAO with immediate results and minimal complications. It is very effective for palliation, in selected case it
can be used for cure and may also be indicated for facilitating subsequent treatment surgery where it can be used upfront before definitive treatment. This is an important
change in indications for BECT for CAO.
Chest diseases and thoracic Oncology, University Hospitals of
Saint Etienne France, France1), Department of chest diseases,
university hospitals of Marseille France2), department of chest
diseases, St Antoine Hospital, University hospitals of Paris,
France3), department of chest diseases, University hospitals of
Nantes, France4), department of chest diseases, University hospitals of Toulouse, France5), department of chest diseases, University hospitals of Reims, France6)
Jean-Michel Vergnon1), Herve Dutau2), Yoann Thibout1),
Michel Febvre3), Laurent Cellerin4),
Christophe Hermant5), Herve Vallerand6),
Fabrice Di palma1)
Therapeutic bronchoscopy (TB) with a rigid bronchoscope is
fruitful in patients with symptomatic obstructive lung cancer involving central airways. But the usefulness of adding a
silicone stent to prevent local tumoral restenosis (barrier effect) remains to be proven. To answer this question, we have
conducted in 9 university hospitals in France the randomized prospective protocol SPOC with a grant of the French
National Cancer Institute. For this trial, Novatech SA company provides stents free.
Patients with inoperable symptomatic obstructive cancers
were included after successful therapeutic bronchoscopy. A
randomization was done and a silicone stent from Novatech
company was inserted or not. Borg scale and EORTC QOL
questionnaires were assessed before and after the resection,
then 3, 6 and 12 months after treatment. The randomization
was done in 3 groups according to the parallel treatment. In
group 1, a first line chemo-radiotherapy was used after TB.
In group 2, a first line chemotherapy with Platinum doublets
was used after TB. In group 3, other treatments (other line,
irradiation alone, palliation) were used. The main endpoint
was the survival without local tumoral restenosis>50%,
judged at one year. Quality of life, local restenosis, survival
and tolerance of stents were the secondary endpoints. In
case of local restenosis, a new therapeutic bronchoscopy
could be done and stent could be inserted.
78 patients were included in 3 years, 23 were in group 1, 20
in group 2 and 35 in group 3. 40 patients were randomized in
the stent arm and 38 in the no stent arm. The 2 arms were
similar on each point.
We have observed in both arms an initial dramatic improvement in dyspnoea after TB (6.6 to 2.5 on Borg analogic scale)
and in quality of life without significant difference at one
year. Mean survival is similar in both arms (5 months).
Thanks to the TB, only 7.5% of deaths are related to bronchial obstruction. The mean survival free of stenosis was 4.4
months in stent arm and 2.5 in no stent arm. A decrease of
29% in the risk of local re-stenosis or death was observed in
the stent arm. The impact of stenting on the local tumoral
stenosis risk is highly significant but only seen in group 3.
This prospective study confirms the barrier effect of stenting in patients where a first line treatment cannot be proposed in parallel.
141
Symposium
IP-SY10-7
IP-SY11-i1
Clinical utility of CT-guided bronchoscopy radiofrequency ablation as a novel intervention therapy for
lung cancer
Management of malignant pleural effusions: State-ofthe-art
Departent of Comprehensive Cancer Therapy, Shinshu University School of Medicine, Japan1), 1st Department of Internal
Medicine, Shinshu University School of Medicine, Japan2), Department of Respiratory Medicine, Chiba University School of
Medicine, Japan3)
Tomonobu Koizumi1), Tsuyoshi Tanabe2),
Kenji Tsushima3), Toshihiko Agatsuma2), Michiko Itou2),
Takashi Kobayashi1), Masanori Yasuo2)
Background; Radiofrequency ablation (RFA) is an alternative
therapeutic tool in medically inoperable patients with early
stage of non-small cell lung cancer (NSCLC). However, since
RFA therapy for lung cancer has been more widely used by
percutaneous imaging-guided therapy, the complications
from this method include pain, pneumothorax, hemothorax,
and pleural effusion. We have developed a new internal
cooled electrode for RFA (Japan Application No. 2006-88228)
suitable for forceps channel bronchoscopy. We had previously demonstrated that the increased necrotic area by RFA
was obtained by with the improvement of RFA catheter tips
and prolongation of ablation time in animal and human study
(Eur Respir J 29;1193,2007, Chest 137; 8990, 2010). Now, we
have advanced this method for a clinical application for patients with NSCLC.
Methods and Subjects; This study was undertaken with the
approval of our institutional human studies committee, and
written informed consent was obtained from patients. Patients with pathologically diagnosed with NSCLC, who had
no lymph node involvement and distant metastases (T1-2N0
M0), but not indication for surgery because of other complications for example; synchronous multiple nodules, advanced
age, cardiovascular diseases, poor pulmonary function et al,
were enrolled in the present study. RFA output power in the
generator and temperature were setted to be 20-30 W and
60-70℃, respectively. A peristaltic pump was used to infuse
cold water (4℃) into the internal lumen of the catheter electrode at 50ml!
minute. Computed tomography (CT) guided
bronchoscopy-guided cooled RFA were performed in these
patients and followed CT.
Results; 21 patients, mean age of 74.4 (46-87) yrs were enrolled and total 31 RFA were performed. Almost targeted lesions ablated by RFA were changed to be scarred or decreased after bronchoscopy-guided cooled RFA. During follow up (median 44 months, 5-92 months) after bronchoscopyguided cooled RFA, local progression occurred in 7 patients
and RFA was repeated in 4 of them. The other lesions maintained stable after RFA. Six patients died because of the progressive disease in three and other causes in three, respectively. There were no adverse events and complications in
the present study.
Conclusion; Bronchoscopy-guided internal cooled-RFA was
safe and feasible procedure that could become a potential
therapeutic tool in local control in medically inoperable patients with stage I non-small cell lung cancer.
142
Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology Hôpital Nord-Marseille-France
Philippe Astoul
Malignant pleural effusion (MPE) is a frequent feature of disseminated or advanced cancer. Thirty percent of lung cancer in particular result in MPE. Consequences of MPE, such
as dyspnea and cough, experienced by patients in the last
months of live deteriorate the quality of life and palliation,
aiming alleviation of breathlessness, is one of the major goals
of therapy. Among mechanisms proposed to explain the development of MPE, one of the commonest is the inability of
the parietal pleura to reabsorb pleural fluid because of involvement of mediastinal lymph nodes. The other possible
causes include direct tumor invasion and hematogenous
spread to the parietal pleura. Beside this former view of
MPE development, recent studies have shown another pathway to MPE formation involving a loop of interactions between pleural-based tumor cells and the host vasculature
and immune system resulting in increased fluid production
via enhanced plasma extravasation into the pleural space.
Consequently several therapeutic options can be proposed
based on these MPE mechanisms.
Current therapeutic options include removal of the pleural
fluid by iterative thoracentesis or pleural drainage. Recently
the use of long-term indwelling pleural catheter have shown
to be a cost-efficient procedure allowing outpatient or minimal hospital stay improving patients quality of life. In the future, pleural-bladder shunt should be a new option in this
field. The other current method for the treatment of MPE
aims to obliterate the pleural cavity. Talc is the goldstandard for a chemical pleurodesis through a chest tube
( talc slurry ) or better by insufflations during a thoracoscopy
procedure. Since several studies have shown the safety of
calibrated, asbestos-free dedicated talc, the question of the
safety of talc is not longer relevant and talc is not dirty .
However all these standard palliative methods are suboptimal with few drawbacks leading to consider the role of excessive plasma leakage through hyperpermeable pleural network as critical mechanism for MPE formation. Inflammatory mesothelial and endothelial cell in the pleural environment interact with tumor cells leading to MPE formation.
The new targets for the treatment of MPE in the future will
be several mediators enrolled in this biological cascade.
This lecture through a systematic review of the practices
will describe all the treatments for the management of MPE
and the quest of an ideal management in 2014 and for the
next future.
Symposium
IP-SY11-i2
IP-SY11-i3
Thoracoscopy in malignant pleural mesothelioma;
First step for diagnosis
Full-thickness pleural biopsy technique using an
insulated-tip diathermic knife 2 during flex-rigid pleuroscopy
Department of Respiratory Medicine, Hyogo College of Medicine!Japan, Japan
Takashi Nakano, Taiichiro Otsuki, Kozo Kuribayashi
The most common clinical presentation of early-stage malignant pleural mesothelioma(MPM) is asymptomatic unilateral
pleural effusion, therefore fluid examination is the first and
minimally invasive diagnostic method. Almost all adenocarcinomas are usually diagnosed with cytology, but it is not recommended to make a diagnosis of mesothelioma based on cytology alone because of high-risk error. Malignant mesothelioma cells can be indistinguishable from benign and reactive
mesothelial cells. Frequently, cytologic samples, even when
patients already have mesothelioma, show negative or only
subtle abnormalities. ERS!
ESTS (Eur Respir J, 2010) and
IMIG Guidelines(Arch Pathol Lab Med, 2013) recommend
that a cytological suspicion of mesothelioma should be followed by tissue confirmation. Blind fine needle biopsy of the
pleura is usually not diagnostic for early stage MPM because
of small inadequate samples. Thoracoscopy, either medical
or VATS, is the preferred method to obtain sufficient materials in suspected MPM, because it allows multiple, deep and
large biopsies and complete visual examination in the thoracic cavity. In some cases of early-stage MPM with asymptomatic pleural effusion, mesothelioma cells are demonstrated in the fluids, but no tumors of the pleura are seen
with thoracoscopy, whose biopsied materials show stromal
invasion of malignant cells. There is no doubt that so-called
in-situ mesothelioma exists, but we have no consensus on
pathological and clinical definition of in-situ mesothelioma. In
the initial stage of MPM, some small tumors are limited to
the parietal pleura with no involvement of visceral pleura(T1
a), then tumor deposits on the visceral pleural surface(T1b).
T1 stage tumors are usually associated with a free pleural
space and a large pleural effusion. Thoracoscopy with a narrow band imaging and autofluorescence imaging system is
useful in detecting small pleural tumors of MPM. With tumor
growth, CT scan shows a typical finding of confluent growth
of the pleural tumor including interlobar fissure(T2). And, tumor usually extends to the underlying lung parenchyma and
diaphragmatic muscle. Surgical treatment with pleurectomy!
decortication cannot rid the patient of all macroscopic
tumors at this clinical stage, but extrapleural pneumonectomy can do it.
MPM is a highly lethal and particular refractory tumor for
which multimodal treatments have been far from satisfactory in achieving survival benefit. The majority of patients
have clinical Stage 1b or more locally advanced disease at diagnosis. These patients do not benefit from surgery, and rapidly succumb to their disease. Early detection and early accurate diagnosis can positively affect mesothelioma prognosis when patients will be effectively treated.
Department of Endoscopy, Respiratory Endoscopy Division,
National Cancer Center Hospital, Japan
Shinji Sasada, Takehiro Izumo, Yuji Matsumoto,
Yukio Watanabe, Christine Chavez, Takaaki Tsuchida
Introduction: The biopsy size obtained with standard flexible
forceps (SFF) during flex-rigid pleuroscopy is often insufficient
for pathological examination especially in malignant pleural
mesothelioma. An insulated-tip diathermic knife 2 (IT knife 2;
IT-2) appears to be safe for resection of a larger lesion in gastrointestinal endoscopy. We validated an electrocautery pleural biopsy technique using the IT-2 during flex-rigid pleuroscopy.
Methods: Seventeen patients with pleural thickening were eligible for biopsy using the electrocautery. After subpleural injection of lidocaine and epinephrine, the pleural lesion was electrically incised circumferentially and removed in its fullthickness by manipulating the IT-2. Pathological findings of the
specimens obtained by the IT-2 were compared to those by
SFF, and the pleuroscopic parameters such as complications,
procedure time, and diameter of the specimens were reviewed.
Results: Diagnostic yields from specimens obtained with the
IT-2 and SFF were 94.1% (16!17) and 29.4% (5!17), respectively
(p-value 0.0026, McNemar s Chi-Square Test). The IT- 2 biopsy
was superior to SFF in 11 of 17 patients (malignant pleural
mesothelioma in 5, lung adenocarcinoma in 3, metastatic breast
cancer in 1, chronic inflammation in 1, and fibrous pleuritis in
1). These pleural lesions revealed thickened, smooth abnormal
appearances. The combination of IT-2 and SFF were diagnostic in 16 of 17 cases except for one with sarcomatous mesothelioma. The mean time of the procedure was 66.4 13.5 minutes
and mean diameter of specimens was10.3 2.64 mm. There
were no severe complications during the procedure.
Conclusions: Full-thickness pleural biopsy using the IT-2 during flex-rigid pleuroscopy has great potential for diagnosing
smooth abnormal pleura that is difficult to biopsy with SFF.
143
Symposium
IP-SY11-4
IP-SY11-5
Talc poudrage using a catheter technique through
pleuroscopy
Pleural manometry: A forgotten tool in need of resurrection
Division of Respiratory and Infectious Diseases, Department
of Internal Medicine, St. Marianna University School of Medicine, Japan
Atsuko Ishida, Hirotaka Kida, Takeo Inoue,
Masamichi Mineshita, Teruomi Miyazawa
Background: For pleurodesis, talc administered by poudrage
is usually insufflated visually from the second port, or blindly
from a single port of entry with assistance of rigid thoracoscope. In order to visually perform talc poudrage from a
single port, we introduced a catheter technique through
pleuroscopy to assess the safety and efficacy of this method.
Methods: Patients with uncontrolled and symptomatic pleural effusion, and those with intractable pneumothorax were
eligible for this study. Pleuroscopy was performed under local anesthesia using a pleuroscope (LTF-240!
260; Olympus,
Tokyo, Japan). A catheter (SG-201C; Olympus) with 2.55-mm
outer diameter and 2.1-mm inner diameter was connected to
a talc atomizer (Wolf Company, Knittlingen, Germany) and
inserted through the working channel of the pleuroscope.
Under direct visualization, 4 g of sterile talc was insufflated
into the pleural cavity for pleural effusion cases, and 2 g of
sterile talc for pneumothorax cases.
Results: Sixteen procedures were performed on 15 patients,
including 10 pleural effusions and 5 pneumothorax cases.
Four patients were>75 years old, and 4 were Karnofsky Performance Status 50 or less. Propofol was used in 3 pleural effusion cases and the other patients were not sedated. The
mean operative time was 29.6 minutes for all pleural effusion
cases, 22.1 minutes for non-sedative pleural effusion cases,
and 12.4 minutes for pneumothorax cases. All procedures
were performed easily under clear visualization without major complications or catheter obstructions. Of 11 pleurodesis
for pleural effusion, 9 cases were effective and showed no recurrence at 1-month follow-up, and 2 cases required pleural
effusion drainage within 1 month of talc pleurodesis. Of 5
pleurodesis for pneumothorax cases, 2 were effective, 2 cases
required endobronchial occlusion with EWS as an additional
procedure before successful drainage tube removal, and 1
case eventually underwent operation.
Conclusion: This novel technique was well tolerated and feasible for patients with uncontrolled pleural effusion and intractable pneumothorax. We consider this technique useful
even for difficult cases, such as elderly patients or those with
relatively low performance status.
144
Pulmonary, Christiana Care Health System, USA
Tuhina Raman
PURPOSE: A 65 year old female presented with non-bilious
emesis, epigastric pain and dyspnea and was found to have a
large right pleural effusion. A chest CT confirmed this finding with passive atelectasis of right middle and lower lobes
with no pleural thickening, pneumothorax, parenchymal lesions or mediastinal adenopathy. Her medical history included metabolic syndrome, hypothyroidism, bipolar disease
and endometriosis. Basic labs including TFTs, Connective
tissue disease panel and echocardiogram was normal.
METHODS: A CT guided thoracentesis was done with removal of 1300 cc of fluid with partial expansion of the right
lower lobe and an ex vacuo pneumothorax was identified on
chest x-ray post procedure. Patient reported an improvement of her dyspnea. Subsequent chest x-rays showed a recurrence of the effusion.
RESULTS: A right thoracentesis with manometry was performed. The opening pressure was minus 2 cm of water.
Pleural fluid was removed in 50 mL aliquots to a total of 800
mL at which point, the pleural pressure fell dramatically to
minus 25. The elastance was calculated at 27, consistent with
a trapped lung. Labs revealed a lymphocyte predominant
transudate culture negative with no malignant cells and no
evidence of an atypical lymphoid population. Chest x-ray
showed a persistent elevation of the right hemi diaphragm
with minimal fluid. Follow up chest rays five months out
have shown a persistent small right effusion. Patient remains
asymptomatic.
CONCLUSIONS:
At our hospital a multidisciplinary team built a simple, manmade water manometer out of readily available items that allows for measuring pleural elastance while performing a thoracentesis (Modeled after the pneumothorax machine used
in 1911 to surgically treat tuberculosis). For over six years
we have kept staff educated on its correct use and maintenance.
CLINICAL IMPLICATIONS:
Measuring the pleural elastance provides invaluable information that streamlines a patient s care. Determining
whether a patient has a trapped or entrapped lung allows us
to save them from treatments of no benefit (pleurodesis!
decortication).
Symposium
IP-SY12-i1
IP-SY12-i2
Hybrid VATS segmentectomy
Sublobar resection for early-stage NSCLC <Current
clinical trials>
Department of Surgical Oncology, Hiroshima University
School of Medicine, Japan
Yoshihiro Miyata, Takahiro Mimae, Tomoharu Yoshiya,
Shinsuke Sasada, Norihumi Tsubokawa, Morihito Okada
Aim: Anatomic segmentectomy for small-sized pulmonary
malignancies is a useful procedure both for preservation of
pulmonary function and oncologic radicality. However, due
to its technical and anatomical difficulty, thoracoscopic segmentectomy is still controversial. In this study, we evaluated
our technique that improves the identification of the intersegmental borders for segmentectomy via hybrid VATS,
consisting of mini-thoracotomy with television monitoring
and direct visualization.
Methods: We perform segmentectomy with hilar and mediastinal lymph node dissection for patients with c-stage IA
lung cancer, even in good-risk patients. When lymph node
metastasis is evident by frozen-section analysis or the resection margin is not sufficient, the surgical procedure must be
converted to a lobectomy. A 1-cm camera port and musclesparing thoracotomy (4-6 cm) without rib spreading were
made. Selective jet ventilation was applied to the burdened
bronchus to explore an anatomic plane between the inflated
segment to be resected and the deflated area to be preserved. Inter-segmental plane was dissected by electrocautery but not by staple, resulted in safe surgical margins and
full expansion of the preserved segments.
Results: From June 2007 to December 2012, 73 consecutive
patients with c-stage IA lung cancer underwent hybrid
VATS segmentectomy with curative intent. The operation
was performed to 32 women and 41 men with a median age
of 67 (32-89). The Median tumor size, GGO ratio (%) and SUVmax on PET were 14 mm (8-28.6), 30% (0-30) and 1.3 (0-4.9)
respectively. The median operative time, bleeding during
the operation, drainage periods and Hospital stay were 170
minutes (81-311) and 47.5 g (0-480), 2 days (1-13) and 7 days (418), respectively. There were no treatment related mortality
within 90 days after surgery. The 5 year overall and recurrent free survival were 96.0% and 89.7%. respectively.
Conclusion: Hybrid VATS segmentectomy is a safe and feasible procedure. This method can be performed not only in
high risk patients, but also in patients who would tolerate
lobectomy. The exact identification of anatomical intersegmental plane followed by dissection using electrocautery is
critical from oncological and functional perspectives.
General thoracic surgery, Osaka City General Hospital, Japan
Ryu Nakajima, Keiko Thei, Takuma Tsukioka,
Makoto Takahama, Ryoji Yamamoto, Hirohito Tada
Recent advances in high-resolution CT and CT screening
program enhanced the detection of small peripheral lung
cancers and the number of patient diagnosed with stage IA
disease were increasing. Japanese lung cancer registry
study (JLCRS) in 2004 reported 54% of surgically resected
case was Stage IA, and JLCRS reported that 5-year overall
survival rates of resected patients with stage IA disease was
more than 70% and outcomes are even better for patients
with tumors sized less than or equal to 2 cm (T1a).
The standard of care for early stage non-small cell lung cancer (NSCLC) has been lobectomy with lymph node dissection
since 1980s. However, results from observational studies and
a recent evaluation of the Surveillance, Epidemiology and
End Results (SEER)-Medicare registry suggests that limited
resection may be an adequate alternative for stage I NSCLC
patients with T1a, particularly among the elderly. In cases
where oncologic results are equivalent, potential benefits of
limited resection include preserving vital lung tissue and
providing the chance for further resection.
Three phase III randomized trials were on going at North
America (CALGB140503), China (NCT0170788) and Japan
(JCOG0802), to evaluate lobectomy versus sublobar resection
for patient with <2cm peripheral, node negative NSCLC.
CALGB140503 has been started since June 2007 and the target accrual is 908 randomized patients. Primary endpoint is
non inferiority of disease free survival (DFS) after sublobar
resection (wide wedge resection or segmentectomy).. NTC
0170788 has been started since October 2012 and the target
accrual is 1100 randomized patients. Primary endpoint is non
inferiority of 5 year overall survival after sublobar resection
(wide wedge resection or segmentectomy).. JCOG0802 has
been started since June 2009. Primary end point is non inferiority of 5 year overall survival after segmentectomy (wide
wedge resection is not allowed). Secondary end points include DFS, pulmonary function six months and 1 year after
surgery. The target accrual is 1100 randomized patients. To
date, 995 patients have been enrolled.
We will discuss about these ongoing trials (mainly JCOG
0802) and the factors for consideration in selecting patients
for limited resection including tumor size, radiographic characteristics, tumor cell type.
145
Symposium
IP-SY12-i3
IP-SY12-i4
Intraoperative guided segmentectomy using indocyanine green injection
Virtual segmentectomy: Preoperative simulation of
segmentectomy using 3D-MDCT reconstraction software
Department of Thoracic Surgery, Juntendo University School
of medicine, Japan
Shiaki Oh, Kenji Suzuki, Kazuya Takamochi,
Kota Imashimizu, Takamitsu Banno, Takashi Matsunaga
[Objectives] Segmentectomy could be one of the mainstay
for the treatment for resectable lung cancer. One of the most
difficult points in a complete segmentectomy is to detect the
intersegmental plane. Especially right upper or lower segmentectomy, which we have to make more than one intersegmental planes, is very difficult. We devised a method
to detect an intersegmental plane using indocyanine green
injection to the bronchus.
[Method]
We show two movies. One is right segment 1 segmentectomy using ICG method. Another is left segment 9 and 10
segmentectomy using that method.
Operative Procedures:
1) Expose the pulmonary artery (PA), vein (PV) and bronchus (Br).
2) Ligate a segmental Br following the division of PA &PV.
3) Then inject ICG into the segment through Br.
4) The segment turns green following the injection.
The border of an intersegmental plane is easily detected not
only pleural surface but also pulmonary parenchyma.
[Result] In the resected segment inflation method, we can detected the intersegmental plane of pleural surface. But we
can t find out the intersegmental plane into the pulmonary
parenchyma. Using this method, we can recognize the intersegmental plane in not only pleural surface but also pulmonary parenchyma.
We didn t have complications of injecting indocyanine green.
[Conclusion] Even though the segmentectomy needed more
than one intersegmental planes is difficult, we can perform
the segmentectomy safely and usefully by this method.
146
Department of Chest Surgery, St. Marianna University School
of Medicine, Japan1), Thoracic Surgery, Tokoyo Medical University, Japan2)
Hisashi Saji1), Ikeda Norihiko2), Nakamura Haruhiko1)
OBJECTIVES: The aim of this study was to demonstrate the
feasibility and efficacy of a novel simulation software called,
virtual segmentectomy.
METHOD: We developed the segmentectomy simulation
system, which was programmed to analyse the detailed 3D
bronchovascular structure and to predict the appropriate
segmental surface and surgical margin, based on lung modelling from CT images.
RESULTS: We have attempted this novel technique for 6
cases of early lung cancer and 3 cases of pulmonary metastases. For validation, the predicted resection margin was compared with the actual resected specimen. The surgical surface, as estimated by the simulation, was compared with the
surface of the specimen and a surgical video. To test its feasibility, the operation time, blood loss, durations of chest tube
placement and hospitalization as well as pathological findings
were assessed.
CONCLUSIONS: Preoperative simulation and intraoperative
guidance by virtual segmentectomy could contribute significantly to determining the most appropriate anatomical segmentectomy and curative resection. In this session, we present a video of virtual segmentecotmy and its segemtectomy
of typical case.
Symposium
IP-SY12-i5
IP-SY13-i1
Long-term oncologic outcomes of segmentectomy for
c-Stage IA, T1a NSCLC based on the modern indication
Excessive dynamic airway collapse: Pathophysiology
and treatment
Department of Thoracic Surgery, Yao Municipal Hospital, Japan1), Department of Thoracic Surgery Osaka Medical Center
for Cancer and Cardiovascular Diseases, Japan2), Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan3)
Ken Kodama1), Masahiko Higashiyama2), Jiro Okami2),
Toshiteru Tokunaga2), Tomio Nakayama3)
Objectives: The oncologic outcome of segmentectomy for lung cancer should be validated by comparing anatomical lobectomy after long-term follow-up to take late recurrence into consideration. We retrospectively compared the oncologic outcome after
segmentectomy versus lobectomy based on the modern indication in patients with
clinical (c-) stage IA, T1aN0M0 non-small cell lung cancer (NSCLC).
Methods: From 1997 to 2010, 676 patients with c-T1aN0M0 NSCLC were determined to
require a surgical approach categorized as lobectomy, segmentectomy, or wide wedge
resection (WWR), based on the modern indication incorporating the lesion size, location,
ground-glass opacity (GGO) percentage on thin section computed tomography (TSCT),
and intraoperative lavage cytology of the resection margin. Of the 676 patients, those
with pure GGO-type lesions, multiple lung cancer, active other-organ cancer, WWR,
and!or a poor cardiopulmonary function were excluded. Consequently, 314 patients
were enrolled in this study. Oncologic outcomes were compared between 81 patients
who received segmentectomy and 233 patients who underwent standard lobectomy.
This was a single institution study.
Results: There was no operation-related mortality. Video-assisted thoracic surgery
(VATS) was employed in 30 (37%) of the 81 segmentectomies and 79 (34%) of 233 lobectomies. The median follow-up time was 74 months. The 3, 5, and 10-year cancer-specific
survival rates of the 81 patients with segmentectomy were 98.7, 98.7, and 90.7%, respectively, compared with 94.7, 92.2, and 87.6%, respectively, for the 233 patients who underwent lobectomy (p=0.083) (Figure 1). Local-regional recurrence as the first relapse site
was found in 4 (4.9%) of the 81 segmentectomies and 14 (6.3%) of the 233 lobectomies.
The 4 local-regional recurrences after segmentectomy occurred in the mediastinum,
and not in the resection margin. Intraoperative conversion of the procedure from segmentectomy to lobectomy was performed in 8 patients because of a macroscopically insufficient margin, being resection margin cytology-positive, or showing a grade IV
stamp cytology. These 8 patients are all alive without disease. There was no localregional recurrence in patients with part-solid GGO nodules showing GGG>50%, regardless of the surgical procedure.
Conclusion: Our results suggest that the oncologic outcomes of patients undergoing
segmentectomy or lobectomy are similar. Although the non-inferiority of segmentectomy to lobectomy should be confirmed in randomized trials, the selection of candidates for segmentectomy based on the modern indication may be acceptable among
patients with c-stage IA, T1a NSCLC.
Pulmonary and Critical Care Medicine, University of Chicago,
USA
Septimiu Dan Murgu
A physiologic approach to treatment of expiratory central
airway collapse is warranted given the confounding entity of
excessive dynamic airway collapse (EDAC), which may coexist or mimic tracheobronchomalacia (TBM). EDAC is often
caused by peripheral airway disease or obesity and may not
represent a true central airway disorder. In general, if the
collapsing central airway is deemed responsible for symptoms, then either intermittent non-invasive positive pressure
ventilation, airway stents or open surgical interventions can
be offered to improve dyspnea, lung function and quality of
life. This lecture will present the evidence supporting the
morphologic and pathophysiologic differences between
EDAC and TBM and how these differences impact treatment decisions.
147
Symposium
IP-SY13-i2
IP-SY13-i3
Abnormalities of impulse oscillometry in patients with
dynamic expiratory collapse of the large airways
Airway management in relapsing polychondritis
Department of Thoracic Medicine, Royal Brisbane and
Womens Hospital, Australia1), Department of Thoracic Medicine Royal Brisbane and Women s Hospital, Australia2), School
Of Public Health, University of Queensland, St Lucia Australia3)
David Fielding1), Justin Travers2), Mark David2),
Phan Nguyen2), Michael g Brown2), Stephen Morrison2),
Robert Ware3)
Aims: Expiratory dynamic airways collapse (EDAC) is most
commonly seen accompanying COPD, however it can be a
primary phenomenon with significant symptoms. A non invasive way to detect it could be useful, particularly as it is ultimately diagnosed by bronchoscopy or dynamic CT. Because Impulse Oscillometry (IOS) can detect subtle changes
of both large and small airway obstruction, we sought to
characterise IOS features of expiratory dynamic airway collapse (EDAC) in patients with normal conventional spirometry.
Methods: EDAC was identified at bronchoscopy as 75%100% expiratory closure at the carina or bilateral main bronchi. Four patient groups were compared: Group A with
EDAC and normal lung function, Group B with EDAC and
small airways obstruction, Group C with no EDAC but small
airways obstruction and Group D with no EDAC and normal
lung function.
Results: Patient numbers in Groups A through D were 15,8,7,
and 9. Mean FEV1 and FEV1!
FVC ratio were Group A (91%,
83%), Group B(72%, 61%), Group C (73%,56%) and Group D
(105%, 79%) respectively. In Group A compared to controls
there were significant elevations in Resistance at 5Hz (R5)
(0.52 vs 0.32 p<0.05), Resonance frequency (Fres) (19.4 vs 11.3
p<0.01) and Area under reactance curve (AX) (1.43 vs 0.31
p=0.03). The magnitude of change was similar for Group A
and Group B. Group A also showed significant differences in
expiratory versus inspiratory data for R5, Reactance at 5Hz
(X5), Fres and AX. Conclusions: EDAC patients can be identified by IOS, even when spirometry and flow volume loops
are normal. This simple non-invasive test could then be followed up with bronchoscopy to characterise the degree of
abnormality and plan treatment. IOS features resembled
those of small airway obstruction rather than large airway
obstruction.
148
Division of Respiratory and Infectious Diseases, Department
of Internal Medicine, St. Marianna University School of Medicine, Japan
Hiroshi Handa, Masamichi Mineshita,
Teruomi Miyazawa
Background: Airway involvement in relapsing polychondritis (RP) is characterized by chondritis of the larynx and tracheobronchial tree. RP often causes tracheobronchomalacia
(TBM), which can lead to dynamic airway collapse. TBM can
be debilitating and life threatening, and pulmonary intervention is often required.
Objective: The purpose of this study is to establish a decision
making protocol for the placement of stents in RP patients
with airway involvement.
Methods: This is a retrospective study of 44 RP patients
treated at our department from January 2004 to November
2013. Thirty-six of 44 RP patients developed airway involvements such as subglottic stenosis, airway wall calcification,
airway stenosis and TBM. The McAdam s or Damiani and
Levine diagnostic criteria were used to diagnose RP in patients.
Results: Twenty-two RP patients were confirmed with TBM
by chest CT and!
or bronchoscopy. First, medication therapy
such as combined systemic steroids and immunosuppressive
agent was administrated; however, medication alone could
not stabilize subglottic stenosis and TBM. Twenty-three RP
patients developed subglottic stenosis and tracheostomy
was performed in 16 RP patients. NIPPV was then performed to prevent expiratory airway collapse in 14 RP patients with TBM. In 9RP patients, medication and NIPPV
were able to prevent airway collapse. Eleven RP patients required stenting. In 10 RP patients, silicone stents were unable to be placed. Therefore, 33 ultraflex stents were implanted in 10 patients. We also replaced a silicone stent in 1
patient. After stenting, all patients maintained airway
patency regardless of NIPPV.
Conclusions: The use of ultraflex stents is suitable for implantation of the central airway in TBM by RP. Implantation of
stents at the choke point in TBM is important since incorrect
positioning of the stent can migrate to the weaker bronchi
making stent implantation difficult.
Symposium
IP-SY13-4
IP-SY13-5
Withdrawn
Endoscopical management of tracheomalacia using
electrocautery
Department of Interventional Pneumology and Thoracic Surgery, RESPIREMOS SAS Unit of Respiratory EndoscopyClinica Comfamiliar-Clinica Saludcoop Pereira, Colombia1),
Respiremos SAS Unit of Interventional Pulmonology-Clinica
Comfamiliar-Clinica Saludcoop, Colombia2)
Mauricio Cespedes Roncancio31,2), Mauricio Gonzalez1,2),
Alberto Franco1,2), Manuel Pacheco1,2)
Background: tracheobronchomalacia is a central airway disease characterized by narrowing of airway lumen secondary
to weakness of the tracheal and bronchial walls, which collapse during the different respiratory phases, producing
varying degrees of obstruction. Cough, expectoration, dyspnea, recurrent respiratory tract infections, thorax oppression
and hypoventilation are common chronic symptoms. This pathology is associated with hypoxemia, hypercapnia and alveolar hypoventilation, which may lead to severe chronic
respiratory failure and death. Diagnosis of tracheobronchomalacia is still controversial and so is its treatment, which
accounts for a high frequency of underdiagnosed cases. It is
usually seen in adults and elder patients with history of
smoking and many times misdiagnosed as asthma, chronic
obstructive pulmonary disease (COPD) and other chronic pathologies. A high level of suspicion is required for diagnosis,
which is performed directly through fiber bronchoscopy or
by dynamic computed tomography. Standard treatment includes pharmacological management for associated diseases
(COPD, asthma, etc); nevertheless, surgery such as the tracheobronchoplasty for posterior wall strengthening is often
required for severe cases. Silicone and Y stents can also be
used in high surgical risk patients. Methods: between 20092013, we performed electrofulguration (using electrocautery)
of the posterior membranous wall in 30 adult patients with
tracheomalacia at two institutions of Pereira, Colombia. The
aim of electrofulguration is to produce fibrosis of the wall in
order to strengthen it. This was performed through endoscopy under general anesthesia, initiating electrofulguration
(15 watts) through a rigid bronchoscope at the most compromised bronchus using a monopolar electrode in continuous
mode, producing a burn of posterior walls. During the procedure, visual control was kept and supplementary oxygen
was administered with a FiO2<40%, as a precaution to avoid
fire at surgery room. Results: in all patients disease improvement was observed immediately during procedure, with a
decrease of the transverse diameter and an increase of the
anterior-posterior diameter. Additionally, a significant decrease of the posterior wall movement was achieved. Patients left the procedure without mechanical ventilation. No
complications occurred. Conclusions: with this technique a
clinical, tomographical, endoscopical, functional and spirometric improvement was achieved in all the treated patients. Additionally this was performed in one surgical time,
decreasing surgical and anesthetic risk, with a safer performance compared to open surgery, which is associated with
high mortality in these cases. Follow-up of these patients also
shows an improvement of quality of life and their respiratory
function.
149
Symposium
IP-SY14-i1
IP-SY14-i2
Some bronchoscopic observations on airflow
Development of a system for the assessment of physiological data during bronchoscopy
Germany
Heinrich D. Becker
Counter clockwise mucus transport that we described in a
previous paper proved to be a consistent observation.
Against common belief mucus transport is provided by airflow rather than by ciliary motion. In real anatomy airflow is
counter clockwise vortical and does not follow HagenPoiseulle s law as in idealized models. The reason for the
counter clockwise direction of the vortical flow is the inherent spiral structure of the airway wall, which is also found in
the gastrointestinal tract from which the lung is arising. The
asymmetric structure of the body begins at an early developmental stage and is induced by primary monocila in the organization center of the embryo. The genetic background of
body asymmetry has been recently detected and can be related to the asymmetry of the molecules constructing proteins and DNA. The handedness (chirality) of molecules is
due to the asymmetry of atoms, which is caused by the left
handed spin of electrons and neutrinos that was supposedly
formed at the creation of the universe by uneven distribution of matter and anti-matter. This is probably is also the
reason for the predominance of left rotating galaxies. Handedness is found ubiquitous in nature and can even influence
survival of individuals. Vortical flow is essential in flight of
planes, birds and insects. Especially in counter clockwise direction it has been found more efficient than laminar flow in
transportation of secretions within the airways.
150
Ruhrlandklinik Essen, Germany
Lutz Freitag
From a physiologist s perspective, bronchoscopy may be
considered the perfect data access to the lung. Only a very
few investigators have used the opportunities of this minimally invasive technique to acquire data for diagnostic purposes. We have developed a system that enables to display
functional data simultaneously with the endoscopic image.
Flow sensors, pressure sensors and various gas probes inserted through the working channel of a video-bronchoscope
are attached to a modular processing unit and a personal
computer. Data are converted to curves and superimposed
over the endoscopic image.
A typical example is the diagnostic of vocal cord dysfunction.
The patient is breathing through a dedicated mouth-piece
with built-in flow sensors during video laryngoscopy. Pathological narrowing, time delays of the opening or abnormal
flutter movements of the vocal cords are visualized together
with the effect on the airflow pattern. This is a way to verify,
visualize and quantify vocal cord dysfunctions.
Using sensors for flow and lateral pressure, collapsible airway diseases such as malacia can be investigated. The choke
point region is identified and effectve CPAP levels are easily
adjusted. The optimal pressure level is reached when the
bronchi do not collapse and flow limitation disappears. Surgical decisions are facilitated.
Another application is the determination of collateral ventilation in emphysema patients. Visualizing and processing pressure and flow signals through a balloon catheter with a oneway valve detects collateral channels and helps to exclude
patients who may not benefit from valve placement.
Based on this core technology, we have added catheter
based gas-probes for measuring local gas exchange. Lobar or
segmental capnometry and oximetry are accomplished by
moving the tip of the bronchoscope with the sampling catheter from segment to segment. The bronchoscopist sees the
curves of CO2 and O2 concentrations with typical shapes representing regions of impaired ventilation, diffusion or perfusion. A lung is functionally mapped within two minutes and
the most diseased areas are identified. In emphysema patients this helps to decide whether and where valves or coils
should be placed.
The assessment and display of functional data during bronchoscopy increases the diagnostic value, helps to reveal
causal relationships of disturbances and facilitates decision
making.
Symposium
IP-SY14-i3
IP-SY14-4
Assessment of lung ventilation and perfusion status by
lateral airway pressure and intrabronchial capnography
Interventional bronchoscopy in patients with tracheobronchial stenosis due to tuberculosis
Division of Respiratory and Infectious Diseases, Department
of Internal Medicine, St. Marianna University School of Medicine, Japan1), Department of Surgery, Division of Chest Surgery, St. Marianna University School of Medicine, Japan2)
Hiroki Nishine1), Takehiko Hiramoto1), Takeo Inoue1),
Hiromi Muraoka1), Mariko Okamoto1), Teppei Inoue1),
Naoki Furuya1), Hiroshi Handa1), Hirotaka Kida1),
Seiichi Nobuyama1), Masamichi Mineshita1),
Noriaki Kurimoto2), Teruomi Miyazawa1)
Background
In patients with severe malignant airway stenosis, interventional bronchoscopy is considered as a method of maintaining airway patency. Stenting
at the flow-limiting segment (FLS) improved expiratory flow limitation by
increasing the cross-sectional area (CSA) and supporting the weakened
airway wall. In patients with severe bronchial stenosis, impaired gas exchange occurs due to a ventilation-perfusion mismatch. Stent placement at
the FLS improves the ventilation-perfusion ratio; therefore, FLS assessment is an important point for guiding interventional bronchoscopy.
Objectives
To assess the ventilation-perfusion status by measuring Plat and CO2 concentrations during interventional bronchoscopy.
Methods
We first measured Plat in 81 patients with airway stenosis during interventional bronchoscopy. After intubation, a double lumen airway catheter
was inserted into the airway using bronchoscopy. Plat was measured simultaneously at two points before and after the procedures and these
points were plotted on a storage oscilloscope (pressure-pressure curve, P-P
curve). We then calculated the angle of P-P curve, defined as the angle between the peak inspiratory and expiratory pressure points and baseline of
the angle.
Next, we measured CO2 concentration before and after interventional
bronchoscopy in 21 patients with bronchial stenosis. After intubation, a
CO2 sampling tube was advanced into each main stem bronchus where inspired and expired gases were collected continuously. The CO2 concentration curve was recorded using a CO2 monitor.
Results
In patients with airway stenosis, the major pressure difference occurs at
the maximum obstructed area. If the CSA was restricted, the angle was
closer to 0̊. However, after intervention, the CSA significantly increased
and the angle was closer to 45̊. In patients with tracheal stenosis, dyspnea,
pressure differences, and angle of P-P curve changed significantly beyond
50% obstruction (P<0.0001). The degree of tracheal stenosis was significantly correlated with the pressure difference (r=0.83, P<0.0001) and the
angle (r=-0.84, P<0.0001). In fixed tracheal stenosis, the P-P curve was linear while in variable tracheal stenosis, the P-P curve was loop-shaped and
a significant change was observed in the angle between inspiration and expiration. In patients with bronchial stenosis, the shape of the P-P curve at
the narrowest side became loop-shaped when comparing left and right
sides.
EtCO2 was lower at the obstructed side than at the normal side. After intervention, EtCO2 increased at the obstructed side and the difference between the right and left side was reduced.
Conclusions
These approaches represent a modern assessment modality for the success of interventional bronchoscopy.
Department of Internal Medicine, St. Marianna University, Japan
Seiichi Nobuyama, Hiromi Muraoka, Mariko Okamoto,
Teppei Inoue, Naoki Furuya, Hirosi Handa,
Hirotaka Kida, Miwa Fujiwara, Hiroki Nishine,
Atsuko Ishida, Takeo Inoue, Masamichi Mineshita,
Teruomi Miyazawa
Background: The diagnosis and management of endobronchial tuberculosis (EBTB) can be challenging due to its nonspecific presentation. Current interventional bronchoscopic
techniques are unable to manage EBTB because of the high
rate of restenosis.
Objective: To assess the efficacy and complications of interventional bronchoscopic techniques in airway stenosis due to
tracheobronchial tuberculosis.
Methods: Between February 2008 and November 2012, we
performed 33 interventional bronchoscopic procedures.
Nineteen patients received interventional bronchoscopy including: stent placement, laser photo resection, argon plasma
coagulation (APC), balloon dilatation, stereoscopic bronchoscopy and endobronchial ultrasonography (EBUS).
Results: Seven patients underwent stent placement after balloon dilatation, while remaining the 12 patients underwent
balloon dilatation only. In 3 patients, Dumon stents were
placed using the bevel of a rigid bronchoscope. Dumon stents
were successfully placed to reestablish patency of the central airway in all patients. In 10 patients, stereoscopic bronchoscopy measured the diameter and cross-sectional area of
the airway. EBUS images for 4 patients demonstrated the
destruction of bronchial cartilage or thickening of the bronchial wall.
Conclusion: Interventional bronchoscopy should be considered feasible for the management of tuberculosis tracheobronchial stenosis.
151
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IP-SY14-5
IP-SY14-6
Endobronchial elastography strain ratio in the diagnosis of mediastinal lymph nodes
Elastography of lymph nodes for predicting and localizing metastastatic disease during EBUS-TBNA
Interventional pulmonology department, University Clinic
Golnik Slovenia, Slovenia1), University Clinic Golnik2)
Ales Rozman1), Mateja Marc malovrh2), Izidor Kern2)
BACKGROUND:
Elastography measures the biomechanical characteristics of
tissue and its deformation under compression. Comparing two
different areas of tissue allows numeric display of strain ratio
between the areas. The aim of this pilot study was to evaluate
EBUS elastography strain ratio in assessment of mediastinal
lymph nodes in patients with suspicion for lung cancer for the
first time. Strain ratios of mediastinal lymph nodes were compared with EBUS B-mode features and with tissue diagnosis as
a gold standard.
PATIENTS AND METHODS:
EBUS bronchoscopy was performed on 20 consenting consecutive patients referred to bronchoscopy with suspicion for lung
cancer according to chest CT-scan. Eligible patients had either
enlarged discrete N2!N3 lymph nodes, or central tumor or enlarged N1 lymph nodes with normal mediastinal lymph nodes.
Elastoghaphy evaluation with strain ratio measurements was
performed before EBUS-TBNA. Standard EBUS characteristics of lymph nodes were described. The main outcome was
the accuracy of strain ratio in differentiating between benign
and malignant lymph nodes.
RESULTS:
EBUS elastography and TBNA were performed on 50 lymph
nodes. Cytological malignancy was confirmed in 18 (36%)
nodes. The mean strain ratio for malignant lymph nodes was
20.06 21.08 and 6,69 8.61 for benign. The ROC area under the
curve for strain ratio was 0.86 (95% CI 0.74 to 0.98, p<0.0001).
Optimal cut-off point for distinguishing between malignant and
benign lymph nodes was at strain ratio 8 with accuracy of
86.0% (sens. 88.89%, spec. 84.38%, PPV 76.19%, NPV 93.10%).
CONCLUSION:
EBUS elastography strain ratio measurement is a promising
new technique for diagnosis of mediastinal lymph nodes in patients with NSCLC. It may complement standard EBUSTBNA, help in selection of biopsy spot or even reduce the
number of EBUS-TBNAs.
152
Department of General Thoracic Surgery, Graduate School of
Medicine, Chiba University, Japan1), Department of Diagnostic
Pathology, Chiba University Hospital2), Department of Diagnostic Pathology, Graduate School of Medicine, Chiba University3)
Takahiro Nakajima1), Terunaga Inage1), Yuuki Sata1),
Jyunnichi Morimoto1), Fumie Saegusa2),
Takayoshi Yamamoto1), Takamasa Yun1),
Toshiko Kamata1), Hidemi Suzuki1), Tetsuzou Tagawa1),
Takekazu Iwata1), Teruaki Mizobuchi1),
Shigetoshi Yoshida1), Yukio Nakatani3), Ichiro Yoshino1)
Background: Elastography is a relatively new technology that can generate images reflective
of tissue stiffness (elasticity). Neoplastic tissue usually shows higher cellularity and vascularity,
which results in stiffer tissue, as compared with normal structures. Elastography in combination with endoscopic ultrasound (transesophageal) has been shown to be useful for differentiating between benign and malignant paraesophageal, mediastinal, and abdominal lymph nodes.
Purpose: The aim of this study was to evaluate the feasibility and usefulness of elastography
when combined with convex-probe endobronchial ultrasound (CP-EBUS) for predicting and localizing metastastatic disease during EBUS-TBNA.
Methods: Elastography results of lymph nodes performed under EBUS-TBNA were retrospectively analyzed. Convex probe endobronchial ultrasound (BF-UC260FW, Olympus, Tokyo, Japan) was used for EBUS-TBNA. Ultrasound images were processed with a universal endoscopic ultrasound scanner (EU-Y0008, Olympus) and elastography images were acquired as
JPEG images and also recorded as video clips. Elastography allowed for visualization of relative
elasticity differences and stiffer areas were shown in blue area on the ultrasound. Stiff area ratios (Stiff areas as blue pixels)!(lymph node areas as ROI pixels) for each lymph node were calculated using Image J 1.45 software (National Institutes of Health, USA). The stiff area ratios by
elastography were collated with the metastatic regions in pathological specimens obtained by
TBNA.
Results: We evaluated 49 lymph nodes in 21 patients. There were 16 metastatic nodes, including 10 lung cancer metastases and 6 metastases from extrathoracic malignancies. Mean stiff
area ratios were significantly greater for metastatic lymph nodes: 0.478 for metastatic nodes
and 0.216 for benign nodes (p=0.0002). Using a cut-off value of 0.394 for stiff area ratios, the sensitivity and specificity for predicting metastatic disease were 0.75 and 0.63, respectively.
Conclusion: Elastography technology can be used for mediastinal and hilar lymph nodes using
CP-EBUS. Stiff area ratios on elastography images are useful for predicting metastatic lymph
nodes. Stiffer areas, which are shown as blue areas, reflect cancerous tissue. Thus, this technology may be used to localize metastatic disease within lymph nodes, and real-time elastography
guidance for EBUS-TBNA may improve diagnostic yield as it will allow for a precise puncture
of the suspicious area within the lymph node.
Symposium
IP-SY15-i1
IP-SY15-i2
Argon plasma coagulation (APC)
Ultrathin bronchoscopy for peripheral pulmonary lesions
National Jewish Health!University of Colorado, USA
Ali I. Musani
Among many heat-based therapies for endobronchial ablation and hemostasis, APC is the modality with most coagulative!
hemostatic properties. APC is a non-contact thermal
modality that is based on delivery of Argon gas thru a high
voltage catheter that ionizes the gas into plasma. The plasma
is sprayed over the bleeding surfaces that could be in hard to
reach areas. Argon plasma is sprayed thru a catheter that
can easily pass thru a working channel of a flexible bronchoscope. This modality can be also used thru a rigid bronchoscope. APC is generally not considered a powerful tool for
tissue debulking or desiccation. There are other modalities
such as laser and electrocautery for large debulking. Safety
recommendations for APC are similar to other heat based
therapies such as Fio2 of less than 40%.
Department of Respiratory Medicine, Nagoya Medical Center,
Japan
Masahide Oki
Bronchoscopy has been widely used for the diagnosis of peripheral pulmonary lesions, however, the diagnostic yield of
conventional bronchoscopy for peripheral pulmonary lesions,
for small lesions in particular, has not been satisfactory. Recent modification of this procedure using some new devises,
such as ultrathin bronchoscopes, endobronchial ultrasound
or navigation systems dramatically increased the diagnostic
yield of bronchoscopy, and seems to be reasonable as a first
diagnostic test in terms of accuracy and safety. The idea of
using thinner bronchoscopes for the evaluation of peripheral
pulmonary lesions is not novel. In fact, bronchoscope manufacturers have continued efforts for developing thinner bronchoscopes with a larger working channel and higher visibility since flexible bronchoscopes were invented. The advantage of ultrathin bronchoscopes for evaluating peripheral
pulmonary lesions is the good bronchial selectivity and
smooth maneuverability in the small airway. So, ultrathin
bronchoscopy is particularly useful when it is combined with
image guidance devices such as navigational bronchoscopy,
CT guidance or endobronchial ultrasound. The combination
of ultrathin bronchoscopy and navigational bronchoscopy
seems reasonable for making the best of mutual abilities, as
ultrathin bronchoscopes can follow the bronchial route provided by navigational devices. Unfortunately, the now available thin!
ultrathin bronchoscopes have a limited-sized working channel less than 1.2 mm, through which the ultrasound
probe cannot pass. However, some studies have reported on
the usefulness of combination of a prototype thin bronchoscope with 1.7-mm channel and a 1.4-mm thin ultrasound
probe for evaluating peripheral pulmonary lesions. In the
near future, ultrathin bronchoscopes with a working channel
large enough for an ultrasound probe to be passed through,
will be developed. Multimodal bronchoscopy using an ultrathin bronchoscope, endobronchial ultrasound and navigation
device will be available in clinical practice, and it may lead to
enhanced diagnostic yield.
153
Symposium
IP-SY15-i3
IP-SY15-4
A multifaceted approach to the solitary pulmonary
nodule
Diagnostic yield of flexible bronchoscopy in evaluating peripheral lung lesions without endobronchial lesions
Medical University of South Carolina, USA
Gerard A. Silvestri
The decetion of solitary pulmonary nodules has increased
dramatically over the past decade with increasing use of
chest CT for a myriad of pulmonary conditions. With the
likely increase in the use of CT for screening for lung cancer
in at risk patients the discovery of pulmonary nodules may
rise even further. This lecture will review the available evidence of the utility of prediction models to predict cancer in
a pulmonary nodule. This will be followed by describing both
the non-invasive and invasive testing which can be performed to make a diagnosis. Based on the probability of cancer in a nodule one of three treatment options become available; serial imaging, biopsy, or surgical resection. We will review the different options and which option should be considered. Finally, newer modalities to help predict malignancy
such as genomics and proteomics will be touched on to provide insight into what the future may hold for diagnosing
cancer in pulmonary nodules.
154
Division of Pulmonary and Critical Care and Sleep Medicine,
Department of Internal Medicine, The Catholic University of
Korea, College of Medicine, Korea
Sang Haak Lee, Hye seon Kang, Jick hwan Ha,
Hyun hui Kang, Hwa sik Moon
Ojbective: The purpose of this study was to evaluate factors
predicting the diagnostic yield of flexible bronchoscopy without guidance in peripheral pulmonary lesions without endobronchial lesion.
Methods: The medical records of 151 patients who had underwent flexible bronchoscopy for the evaluation of peripheral lesions without endobronchial lesions were reviewed
retrospectively. The analyzed variables included the etiology
of lesion, lesion size, distance from pleura, the presence of
bronchus sign. We performed a multivariate analysis of the
predictive factors of the diagnosis using logistic regression
technique.
Results: The overall diagnostic rate was 58.3%. The etiology
of lung lesion (P=<.002), lesion size (P=.018) and the presence
of bronchus sign (P<.001) were factors influencing the yield
of flexible bronchoscopy. However, multivariate logistic regression analysis demonstrated that the exposed type of
bronchus sign and benign lung lesions were determinant factors (OR 22.4, 95%CI 6.5-77.7, P<.001; OR 6.4, 95%CI 2.5-16.1),
P<.001).
Conclusion: The presence of the exposed type of bronchus
sign and the etiology of lung lesions are determinants of diagnostic yield in flexible bronchoscopy when evaluating peripheral lesions without endobronchial lesion. The yield of
bronchoscopy was low in malignant lesions and lesions without bronchus sign or with unexposed type of bronchus sign.
Symposium
IP-SY15-5
IP-SY15-6
The interfering factors for bronchoscopic diagnosis of
peripheral pulmonary nodules
Experience of prototype thin bronchoscope with rotary
function of insertion portion for peripheral pulmonary
lesions
Department of Pulmonary Medicine, Fukushima Medical University, Japan
Takashi Ishida, Kenichiro Hirai, Hiroyuki Minemura,
Satoko Sekine, Hiroshi Yokouchi, Kenya Kanazawa,
Yoshinori Tanino, Mitsuru Munakata
Purpose: Establishing bronchoscopic diagnosis of pulmonary diseases
are not always easy for the patients with peripheral lung lesions. Today we can use thin bronchoscopes, fluoroscopy, endobronchial ultrasound with a guide sheath (EBUS-GS) method, and virtual bronchoscopic navigation systems to establish diagnoses; however, we cannot
always obtain the conclusion. In this study, we retrospectively inspected the undiagnosed patients records to clarify the factors that
restrict the bronchoscopic diagnosis.
Methods: We reviewed 470 clinical records of bronchoscopy performed in the year of 2012 in our hospital. From those, we identified 24
endoscopically undiagnosed patients of peripheral pulmonary lesions.
All the lesions had been diagnosed as malignant diseases by CTguided transthoracic aspiration, surgical resection, or second bronchoscopy. We reviewed clinical charts, chest plain X-ray and fluoroscopic
images, CT scan data, and EBUS motion pictures. The routes to the lesions were re-created from the DICOM data using DirectPath, a new
product of bronchoscopic navigation system (Cybernet Corporation
and Olympus Medical Systems; Tokyo, Japan). The reconstructed rotatable 3-dimensional virtual bronchial-route images were compared
with the fluoroscopic images taken in the bronchoscopy (figure).
Results: EBUS-GS was utilized in all the 24 examinations. Virtual
bronchoscopic navigation (BF-NAVI, Olympus Medical Systems; Tokyo, Japan) assisted 22 bronchoscopies. The factors that caused undiagnostic examination were classified into six categories; (1) the inserted bronchi were inappropriate or wrong, (2) the bronchoscope
were kept in the improper position during sampling, (3) the lesion had
no bronchus sign, (4) the lesion formed ground glass nodules, and the
accessible bronchi ran through the lesion, (5) the bronchoscopist was
less-trained, and (6) the lesion has pathological features which make diagnosis difficult with small samples (diffuse necrosis, or scant tumor
cells in the connective tissue).
Discussion: There are bronchoscopically unfit peripheral lesions, we
should select the patients carefully to avoid unnecessary examinations
with thoroughly evaluations of the lesions with CT scan data and virtual reconstruction of bronchial trees. We should develop more effective navigation systems for assisting bronchoscopists to choose proper
bronchus.
First Department of Medicine, Hokkaido University School of
Medicine, Japan
Hidenori Kitai, Naofumi Shinagawa, Hajime Kikuchi,
Tetsuaki Shoji, Taichi Takashina, Yasuyuki Ikezawa,
Hajime Asahina, Jun Sakakibara-konishi, Satoshi Oizumi,
Masaharu Nishimura
【Background and purpose】Prototype thin bronchoscope
(BF-Y0041), which was developed by Olympus medical systems, has a function that a insertion portion of bronchoscope
can be rotated. Thanks to this function, Y0041 may be inserted more easily into the target bronchi compared with
the conventional bronchoscope. We attempted to evaluate
the utility of Y0041 for diagnosing peripheral pulmonary lesions.
【Methods】We performed bronchoscopy to peripheral pulmonary lesions in 40 cases, using Y0041. The outcome measurements include the bronchus generations to which the
bronchoscope was inserted, the number of rotation function
usage, the examination time, and the diagnostic yield. As a
historical control, we used 137 cases where bronchoscopy
was performed, using a conventional thin bronchoscope (BFP260F) from January 2009 to December 2010.
【Results】The average size of lesions (median) was 22mm in
Y0041 group, 27mm in P260F group(p=0.009). Y0041 could be
inserted to the 4th generations of bronchi in 52.5% of the
cases, while P260F was 67.2% of the cases (p=0.09). Rotation
function was used in 31!
40 cases (78%), among which the lesion in the in left S1+2 was the most frequent target site. Total examination time was 27 minutes on average in Y0041,
while 26.3 minutes in P260F (p=0.78). Diagnostic yield was
57.5% in Y0041, while 72.3% in P260F (p=0.08). In the lesions
whose diameter 20mm, diagnostic yield was 73.9% in Y0041
compared with 80.6% in P260F (p=0.56).
【Conclusions】There were no significant difference in the inserted bronchus generations of bronchi, the examination
time and the diagnostic yield between Y0041 and P260F.
Further experience would be warranted to determine the
role of Y0041 as a diagnostic tool.
155
Symposium
IP-SY16-i1
IP-SY16-i2
Neuroendocrine low grade malignant tumors of the
lung. Endoscopic options
Appropriate case selection strategy in bronchoscopic
lung volume reduction
Pulmonology Departement Clinica Corachan, Barcelona
Jose Pablo Diaz-Jimenez
Bronchial carcinoid tumors are part of neuroendocrine tumors and account for 1-2% of all primary lung tumors. They
are generically called low grade malignant tumors because
of their uncertain prognosis. Although they rarely metastasize, they can invade locally and recur. They occur with
equal frequency in both sexes.
For a long time they were grouped under the name of bronchial adenomas. Over the years it has been considered new
histological criteria to differentiate typical and atypical carcinoid for the classification of lung tumors of WHO and IASLC.
Histologic classification of 1999 has been filled with descriptions of abnormalities phenotypic, and molecular genetics in
2004. These neoplasms are generally identified in advanced
stages and we have to do a differential diagnosis with other
pulmonary nodules and masses. These tumors are slow
growing and low invasiveness, so its manifestations are essentially local. They develop, most of the time, in larger bronchi, often giving rise to obstructive complications.
Growth occurs both into the bronchial lumen and into the
wall, often maintaining the integrity of the overlying epithelium. This makes the broncho-aspirate cytology is often
negative. The management of carcinoid tumor is currently
dividing the different experts. The current most recommended carcinoid tumors treatment is surgery, but many
authors, and because of its low-grade malignancy, support
the endoscopic resection of endobronchial typical carcinoid
tumors as an effective alternative to surgery. In contrast,
other authors propose endobronchial resection of carcinoid
tumors curatively. The therapeutic options for low-grade tumors is discussed.
156
Pulmonology and Critical Care Medicine, Asan Medical Center, Korea
Sei won Lee
Chronic obstructive pulmonary disease (COPD) is a worldwide leading cause of disability and mortality. It is heterogeneous disease that requires an individualized treatment for
each phenotype. Emphysema is one of dominant phenotype,
and current medical treatment is based on long-acting bronchodilator. However, treatment response for emphysema is
smaller than those of airway dominant phenotype. Hyperinflation is one of important pathogenesis of emphysema,
therefore lung volume reduction modalities, such as bullectomy or lung transplantation, have been proposed. Lung volume reduction surgery (LVRS) also showed survival gain in
emphysema with upper-lobe dominant and low exercise capacity. However, the LVRS performance rather decreased,
due to high immediate post-operation mortality rate.
Bronchoscopic lung volume reduction (BLVR) was developed
to increase safety without losing the effect of LVRS. Endobronchial valve is a leading modality for BLVR and it
showed significant effect in exercise capacity and pulmonary
function in large clinical trials. Complete fissure is an important predictor of clinical response, because incomplete fissure permit collateral ventilation which prevent collapse of
targeted lobe. Chartis Console system can measure the presence of collateral and it can help to select good candidate
who will have clinical improvement after procedure.
In Korea, about 60 cases undertook BLVR until now. We will
discuss important issue about case selection strategy based
on these experiences. There are some unique Asian emphysema phenotype, and these cases will help physicians who
want to start this procedure.
BLVR has the role in the treatment of advanced emphysema
and optimizing subject selection might increase efficacy and
safety. The field of BLVR continues to evolve to make symptom palliation and to be more available to a wider range of
patients at lower risks.
Symposium
IP-SY16-3
IP-SY16-4
Sealing of esophagorespiratory fistulas by different
covered metallic stents
When the response occurs after endoscopic lung volume reduction analysis of the VENT trial
Department of Respiratory Medicine and Medical Oncology,
Meitan General Hospital, China
Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Germany
Wang Hongwu, Dongmei Li, Nan Zhang, Hang Zou,
Lingfei Luo, Hongming Ma, Yunzhi Zhou, Jing Li,
Sujuan Liang
Felix JF Herth, Daniela Gompelmann, Ralf Eberhardt
Objective: Esophagorespiratory fistula (ERF) is the most
common airway fistula, which is very difficult to be treated.
This study is to evaluate the safety and efficacy of covered
metallic stents (CMSs) in sealing of ERFs.
Methods: Patients with ERFs treated by CMSs under bronchoscopy or fluroscopy guidance were retrospectively reviewed. The fistulas were caused by esophageal(n=47), bronchial (n=16) or thyroid carcinomas(n=2).
Results: There were 69 ERFs in 65 patients with fistula
sized 0.5 cm to 7.0cm. Most of them were located at middle
or lower trachea, or bilateral bronchial orifices. Sixty-seven
tracheobronchial CMSs(48 Y-shaped, 10 L-shaped and 9 Ishaped) and 30 esophagus metal stents were placed. Out of
the 69 fistulas, the complete response rate was 2.9%; clinical
complete response(cCR), 62.3%; partial response(PR), 26.1%;
no response(NR), 8.7%. The overall effective rate was 91.3%.
The median survival of all patients was 6.5 months.
Conclusions: The use of CMS appears to be safe and feasible
for the palliative treatment of ERF. Airway stent placement
should be of a choice in patients with ERF, and esophagus
stents should be considered when airway stents were failed.
Airway bifurcation stents were especially suitable to fistulas
near the carina.
The VENT trial compared the safety and efficacy of Zephyr
valve in heterogeneous emphysema (>=15%) to medical
treatment. although most of the side effects appearing directly after the valve placement, the time point during
follow-up when they reached the responder status is still unknown.
Methods: All enrolled patients were evaluated regarding the
endpoints at 30, 90, 180 and 365 days and the time of response were evaluated.
Results: 521 subjects were enrolled into the program. An
MCID of 12% were used for FEV1, !
4 points fort he SGRQ
and a 6 MWT improvement of 26 m. As pointed out I table 1
the majority of the 1-year responders for SGRQ and 6MWT
were responders within the first 90-days whereas the FEV1
had quite a few late (post 180-day) responders.
Conclusion: The timing of the response to an endoscopic lung
volume reduction with the Zephyr valves is depending to the
specific endpoint.
Table 1
157
Symposium
IP-SY16-5
IP-SY16-6
The value of pre trial rehabilitation before endoscopic
lung volume reduction analysis of the VENT trial
Lung volume reduction coil treatment in patients with
heterogeneous and homogeneous emphysema
Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Germany
Felix JF Herth, Daniela Gompelmann, Ralf Eberhardt
Pulmonary rehabilitation prior to randomization in endoscopic lung volume reduction trials is recoommended in order to maximize function prior to intervention.
The VENT trail compared the safety and efficacy of Zephyr
valve in heterogeneous emphysema (>15%) to medical treatment. The enrolled population underwent a detailed rehabilitation programm before the official trial enrolment.
Methods:
As recommended in the GOLD standards, each patient enrolled in the study received therapy consisting of the following components: education and smoking cessation support,
pharmacological treatments including bronchodilators and
influenza and pneumococcal vaccinations, non-pharmacological
treatment including a 8 week pulmonary rehabilitation program and oxygen therapy if needed.
Results:
521 subjects were enrolled into the program. As shown in
the table, it appears that only IC!
TLC and the 6MWD show
significant improvement after participating in the PR program. None oft he patients were excluded from the final trial
participation due tot he Rehab program.
Conclusion:
Rehabilitations program are essential for advances COPD
patients. Based on the analysis the need of such as program
immediately before a clincal trial proving the value of ELVR
didńt showed any significant benefits.
158
Pulmonary diseases (AA11), University Medical Center Groningen, Netherlands1), Pneumology and Critical Care Medicine,
Hospital Thoraxklinik, University of Heidelberg, Heidelberg,
Germany2), Hopital Pasteur, CHU Nice, France3), Krankenhaus
von Roten Kreutz, Stuttgart, Germany4), Hopital Maison
Blanche CHU Reims, France5), Royal Brompton Imperial College and Chelsea & Westminster Hospital, London, United
Kingdom6)
Karin Klooster1), Dirk-jan Slebos1), Felix Herth2),
Charles-hugo Marquette3), Martin Hetzel4),
Gaetan Deslee5), Zaid Zomout6), Pallav Shah6)
BACKGROUND: The Lung Volume Reduction Coil (LVRC,
PneumRx Inc.) is a bronchoscopic implant for the treatment
of severe emphysema, proven to be effective in the treatment of severe COPD. To evaluate longer term efficacy and
perform subgroup analyses on efficacy in homogeneous disease, four European studies with nearly identical protocols
were analyzed out to one year post-treatment.
METHODS: 119 patients (mean age: 61 years, mean FEV1:
29% pred, mean RV: 245% pred., mean 6MWT 313m) were
treated by bilateral LVRC performed in two separate procedures in two contralateral lobes, with follow-up at 6 months
and one year. A post-hoc blinded CT analysis was performed
on a subset of data I) by a digital lobar CT emphysema score
assessing the percentage destruction below -950HU with a <
25% difference between ipsilateral lobes defining homogeneous emphysema, and II) by a visual pattern approach grading from 0 (no damage) to 4 (bullous disease) with a difference of <2 point defining homogeneous emphysema.
RESULTS: 2311 LVRCs were placed in 238 procedures
(mean 9.7 1.6 per lobe). Serious adverse events (SAE) in the
30 days following treatment included 13 COPD exacerbations (5.5%), 1 hemoptysis (0.5%), 11 pneumonia (4.6%), 9 pneumothorax (3.8%), no deaths or acute respiratory failure. All
SAEs resolved with standard care. Effects of LVRC treatment at 6 and 12 months showed significant and sustained
mean efficacy: ΔFEV1: +14.9% 22 and +13.2% 27; ΔRV: -0.59
L 0.76 and -0.52L 0.77; Δ6MWD: +44m 67 and +51m 62;
and ΔSGRQ: -11.2pts 12 and -10pts 12 (p<0.0001 for all values). Post-hoc analysis at 6 months was performed on 63 patients to compare homogeneous and heterogeneous response. Digital CT analyses identified 25 homogenous and 38
heterogeneous cases; the visual approach identified 34 homogeneous and 29 heterogeneous. Both RV, 6MWT and SGRQ
responses were similar between the two groups, regardless
of the calculation method. Only the FEV1 response differed
significantly in favor of the heterogeneous group.
CONCLUSIONS: LVRC treatment results in significant and
clinically relevant improvements in exercise capacity, lung
function, and quality of life for patients with homogeneous
and heterogeneous emphysema. Patient relevant improvements from LVRC treatment are sustained at one year.
Symposium
IP-SY16-7
IP-SY17-i1
Transbronchial catheter ablation of giant bulla
WABIP: From Ikeda to today
Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Canada.1), Division of Interventional Radiology, University Health Network, University of
Toronto, Toronto, Canada.2)
Kasia Czarnecka1), Stephane Collaud1), Tiago Machuca1),
Kazuhiro Yasufuku1), Dheeraj K. Rajan2),
Thomas K. Waddell1)
Background: Bullous emphysema (BE) can cause significant
morbidity. Novel therapies are needed for patients with BE.
We describe a novel technique of transbronchial giant bulla
drainage followed by talc sclerosis.
Methods: Three patients with giant bulla on a background of
smoking-related emphysema (two patients) and systemic lupus erythematous (one patient) were selected. Five procedures were performed in three patients. Each had a bulla occupying more than one third of the hemithorax resulting in
significant physiological impairment (mean 1 SD FEV1
1.13 0.29L [33.6 12.22% predicted]; FVC 2.33 0.59 L [52.67
11.68% predicted]; FEV1!
FVC 52.33 22.30%; RV 5.37 1.83L
[277.33 75.18% predicted]; RV!
TLC 68.33 6.81 [204.67%
43.66%]). Conscious sedation and nasal route were used. Depending on bulla location, different needle entry points were
chosen for bulla access: the right middle and the left lower
lobe bronchi (in a two-staged procedure in patient #1), the
right main-stem bronchus (patient #2) and the right upper
lobe bronchus (patient #3). After an unsuccessful attempt in
patient #1 technique was improved. An aspiration needle
was advanced transbronchially into the bulla under fluoroscopy. A 0.014 inch wire was advanced through the needle
into the bulla. The puncture site was dilated with an angioplasty balloon. An exchange catheter was advanced over
the wire which was then exchanged for a 0.035 inch superstiff wire over which a 12-French 60 cm pigtail catheter was
advanced into the bulla. Suction resulted in immediate decompression of the bulla in 3 out of 5 attempts (Figure.1).
Bulla sclerosis was achieved with 50 ml of sterile talc applied
via the catheter.
Results: Procedure resulted in subjective and objective improvement of respiratory parameters. In patient #1, sustained spirometry improvement was observed 11 months
post the second procedure: the FVC improved significantly
by 1.2L (26%); FEV1 increased by 0.3L (27%). Only minor
complications were encountered including bleeding (<100ml),
pneumothorax, and transient hypoxemia with no hemodynamic instability.
Conclusion: Transbronchial catheter bulla drainage with
talc sclerosis is a novel approach which might be effective in
management of giant bulla. Procedure success depends on
optimal patient selection including presence of a giant bulla
with minimal or no septations and identifiable airway adjacent to the bulla. Risk of bleeding can be minimized by selection of distal to segmental bronchus catheter entry site.
More studies are needed to optimize the procedure effect focusing on patient selection.
Pulmonology, University of Hawaii John A Burns School of
Medicine, USA
John F Beamis
This presentation will briefly discuss the initial organization
of the WAB by Dr Shigeto Ikeda in 1978. Further development of the WAB during Dr Ikeda s tenure will be reviewed.
The administrations of subsequent WAB Chairmen: Drs.
Yoshimura, Prakash, Osada, Diaz-Jimenez and Colt and the
developments of the WAB!
WABIP to date will be outlined.
The WABIP website will be introduced and current WABIP
programs will be highlighted.
159
Symposium
IP-SY17-i2
IP-SY17-i3
From Killian to Dumon, from Dumon to today
History of WABIP and APAB
Germany
Heinrich D. Becker
Department of Thoracic Surgery, Chiba University Graduate
School of Medicine, Japan1), Foundation for Health Promotion
and Disease Prevention President, Asian-Pacific Association
for Bronchology and Interventional Pulmonology (APAB)2)
Takehiko Fujisawa1,2)
History of World Association for Bronchology(WAB) began
at development of optical-glass fiber. In 1962, Professor
Horiye, Chiba University Hospital developed a bronchoscopic telescope that used a optical glass-fiber as a lightguide with approximately 700 to 1,000 times brighter than
the conventional scope and got the first award in the international medical film section at the 9th International Congress
on Diseases of the Chest on ACCP in Copenhagen, Denmark,
1966. This optical-fiber telescope followed the development
of flexible bronchofiberscopic technique. Everybody knew
that Dr. Ikeda of course contributed greatly the spread of
flexible bronchoscopy. I believe that Dr. Horiye also contributed to development and spread of bronchoscopy as same as
Dr. Ikeda did. Up to now, during the last decade in particular,
techniques and endoscopes in bronchology and interventional pulmonology dramatically progressed.
In 1978, World Congress for Bronchology was held in Tokyo
and WAB was founded by Dr. Ikeda during the Congress. In
Budapest 2010, the organization was changed from WAB to
World Association for Bronchology and Interventional Pulmonology(WABIP). The role of WAB and WABIP is to serve
as an umbrella organization that unites national and regional
bronchology association groups with a common purpose of
enhancing patient care, research and education in bronchology and related-fields.
First Asian-Pacific Congress for Bronchology and Interventional Pulmonology (APCB) was held at Chiba, Japan in November, 2005. APAB was established in 2008, 2 and half
years after I held 1st APCB. The mission of the APAB is to
contribute further progress of the art and science of bronchology and interventional pulmonology in the Asian-Pacific
region. Nowadays Asia is very hot in developing novel instruments and techniques of bronchoscopy and thoracoscopy. APAB, therefore, should play an important role in
the progress and spread of bronchoscopic and thoracoscopic
technologies from Asian-Pacific region to the world.
Each great innovation is on a line of a series of development.
Our role is to succeed the mission of WABIP and APAB to
the future. To review the history is not only to look back the
past, but also to recognize the present as well as to predict
the future for further improvement of bronchology and interventional pulmonology. Continuation is the power for innovation.
160
Symposium
IP-SY17-i4
IP-SY18-i1
Bronchoscopic management of central type early cancer
Airway stenting: General considerations
Department of Surgery, Tokyo Medical University, Japan
Norihiko Ikeda, Junichi Maeda, Keishi Ohtani,
Yoshihisa Shimada, Sachio Maehara,
Masatoshi Kakihana, Naohiro Kajiwara, Tatsuo Ohira
Tumor localization and evaluation of tumor invasion are key
issues for the management of central type early stage lung
cancer (CELC). The evaluation of the tumor spread on the
bronchial surface and the depth of tumor involvement are
important to select the optimal treatment. Autofluorescence
bronchoscopy (AFB) and endobronchial ultrasonography
(EBUS) have had large impact on diagnostic bronchoscopy
and been employed especially for the sophisticated diagnosis.
AFB has been considered to improve the sensitivity for the
intraepithelial lesions and evaluate the infiltrative area of the
tumor on the bronchial surface objectively. Surgery was replaced by photodynamic therapy (PDT) for the treatment of
CELC, however the depth of lesions should be limited within
the cartilagenous layer of the bronchial wall because of the
limitation of light penetration. EBUS has been used to determine the depth of tumor invasion. The present guidelines of
PDT for CELC were established mainly based on the data
obtained from studies since 1980 s. CELCs less than 1 cm in
diameter showed a favorable cure rate by PDT, thus this has
been a standard policy to decide the indications of PDT. To
obtain complete response (CR) by PDT, evaluation of each lesion is extremely important, including the extent of the tumor on the bronchial surface and the depth of invasion in the
bronchial wall. We postulate that the combination of AFB
and EBUS as well as the new generation of photosensitizers
may increase the CR rate and expand the indications of PDT
for larger tumors.
A total of 122 consecutive CELCs were treated by PDT using new photoseisitizer, NPe6 in Tokyo Medical University
and CR was obtained in 115 lesions (CR rate 94.3%). A total of
78 lesions were≦1.0 cm in diameter and the rest of the 44 lesions were>1.0 cm. The CR rate of CELC≦1.0 cm was 93.6%
(73!
78) and for those>1.0 cm, 95.5% (42!
44), respectively. The
CR rate to NPe6-PDT is higher than that of Photofrin-PDT in
our previous studies, especially for larger tumors>1.0 cm.
The advances in technology enables to select the optimal
treatment method and demonstrate the increased response
for CELC. New strategy of the management of CELC should
be established.
Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Departement, North University Hospital, France
Herve Dutau
The airway stents restore patency in the face of luminal
compromise from intrinsic and!
or extrinsic pathologies. Luminal compromise beyond 50% often leads to debilitating
symptoms such as dyspnea. Dr JF Dumon was the first physician to place a dedicated and specially designed airways
silicone stent in 1987 in Marseille. Consequently, several
companies started to develop other airway stents with silicone and metal. In the last 20 years numerous reports have
been published about the use of self-expanding and balloon
expandable metal stents for the treatment of tracheobronchial malignant and benign stenoses, tracheobronchomalacia,
fistulas and dehiscences.
Silicone stents remain the most commonly placed stents
worldwide and have been the gold standard for the treatment of benign and malignant airway stenoses over the past
20 years. By the way, it is interesting to notice that, in the
Thoracic Endoscopy Unit of Marseille, where the Dumonstent was conceptualized and used, the percentage of silicone stent placement has dropped from 100%, in 2000, to
65%, in 2013. The remaining 35% of the stents used are now
fully covered, self-expandable, metallic stents (SEMS). This
goes to prove that the Dumon stents are not the ideal stents
in all situations and that metallic stents can serve better in
some selected conditions.
Unlike silicone stents, there are large and increasing varieties of metallic stents available on the market. The lack of
prospective or comparative studies between various types of
metallic stents makes the choice difficult and expert-opinion
based. International guidelines are sorely lacking in this area.
161
Symposium
IP-SY18-i2
IP-SY18-i3
Customization of silicone stent and contrivance of insertion method
New techniques to approach central airway obstruction
Chest Surgery, Toyama Prefectural Central Hospital, Japan
Respiratory Medicine, Nagoya Medical Center, Japan
Hideki Miyazawa
Hideo Saka, Masahide Oki
Purpose Central airway stenting is the widely spread therapy for tracheobronchial stenosis and esophageal fistula.
However, it is difficult to adjust perfectly a ready-made stent
to the multifarious and complicated deformed bronchus. Although a covered metallic stent is capable of fitting to the irregularly curved or tapered bronchus, neither a side hole nor
a branch can be attached. On the other hand, although a silicone stent is not flexible like a metallic stent, it is relatively
easy to customize and to adjust to the irregularly deformed
tracheobronchus. The aims of stent customizing are 1) to
match a long axis of the tracheobronchus and a central axis
of the stent in order to prevent both granulation and irritable
cough, and 2) to cover the long spread region with maintaining patency of the lobar bronchus.
Methods The basic patterns of custom-made silicone stents
are as follows: (1) the curved stent to adjust to the irregularly
curved tracheobronchus, (2) the tapered type to adjust to the
different internal diameter, (3) the T-shaped stent for the region from the right upper bronchus to the intermediate
bronchus, (4) the unilaterally closed Y-stent that has a part to
prevent migration, (5) the angle adjusted Y-stent for the
changed carinal angle, (6) several small slits at a distal end of
the stent in order to soften the edge. All silicone stent was
customized on site by physician in reference to the 3D-CT,
fluoroscopic images and bronchoscopic findings. Stents are
inserted through a rigid bronchoscope with a dilating balloon
and insertion forceps. It is difficult to insert the custom-made
stent or the left arm of Y-stent into the left mainstem bronchus through the stent introducer tube when the carina angle is widened because of prior therapy or advanced lesion.
In this situation we sharpen the distal tip of the stent with
threads and insert it using a flexible bronchoscope under the
fluoroscopic image. After stenting, the threads are cut with a
scissor forceps.
Results We inserted the custom-made silicone stent for recent 38 patients. Respiratory condition and quality of life improved in all patients. No migration occurred. Granulations
were mild compared to the no customized stent.
Conclusions Although making of custom-made silicone stent
is relatively easy, insertion of this stent needs some devices
and technique. However, we consider that customization of a
silicone stent is extremely beneficial to adjust to the deformed tracheobronchus and to relieve respiratory symptoms.
162
We have been used both silicone and metallic stents to relief
symptoms from central airway obstruction mainly in malignant patients.
Even in the malignancy, we preferred to deploy Dumon silicone stents because they are easy to put and to remove, and
to make us create new approaches.
When the tumor invaded to block the airway of right upper
lobes, some methods to reserve the upper lobe bronchi
patency. One is the side hole method by Dutau s scissors,
however, it is sometimes difficult to fit the shape and size of
the hole to the upper lobe bronchus, and it may allow the tumor to invade through the hole. We used to deploy the Dumon Y-stent on the carina between upper lobe and bronchus
intermedius (RC1) (Ann Thorac Surg 2009). To improve the
fitting of the shape, we created a dedicated silicone Oki-stent
(Novatech SA, La Ciotat CEDEX, France) for the right upper
lobe departure (Chest 2013). In case of tumor invasion both
RC1 and tracheal bifurcation, we need to take care of two lesions at the same time. We have been used two Y-stents to
protect both bifurcations, i.e., double Y-senting method (Eur
Respiration 2010, Respir J 2012). Two Y-stents can be deployed in two steps. The distal one (14 mm Dumon, or Okistent) is placed first, then the proximal one (usually 16mm
Dumon) follows.
Even if we use an appropriate size of stent whether silicone
or metallic, sometimes it would migrate and slip off downward, especially after effective radiation or chemotherapies.
To prevent this complication, we have been used to ligate a
stent to anterior tracheal wall. Modified original Colt s
method, we use two stiches method. It is helpful in the case
of upper tracheal stenosis by extrinsic compression.
Symposium
IP-SY18-i4
IP-SY18-5
20-year experience of tracheo-bronchial stenting:
Indications, results and complications
a retrospective analysis of 420 stents and 309 patients
Airway stents: Indications, complications and difficulties. Experiences from Istanbul
Pneumology, Intenisve Care and Sleep Medicine, KRH
Oststadt-Heidehaus Hannover, Germany
Hermann Tonn, K-D Schneider, B Schoenhofer
Background: From July 1993 till December 2013 420 stents
of five different kinds of stents ((silicone (Dumon), dynamic
hybrid (Freitag), 2 different types of SMS of 2 companies-selfexpanding metallic stents-(Ultraflex TM, airstent)and t-tubes
(Montgomery)) were inserted in 309 patients. Indications,
outcome, especially efficacy and complications were reviewed. During the 20 year period the availability of stents
has changed. The implications of these changes on indication
in case will be discussed.
Methods: The medical records of the patients were analyzed, in some cases the patients family doctor and or their
relatives were interviewed via telephone about the patients
condition after stent insertion
Results: 330 stents were implanted in 260 patients with malignant underlying disease, 90 stents in 49 patients with an
underlying benign disease. Overall median survival was 397
days, in malignant diseases 190 days, in benign diseases 1493
days. 28 patients are still alive. The median placement duration was 151 days per stent, 205 days per patient. In malignant diseases it was 99.5 days per stent and 126 days per patient, in benign diseases it was 340,6 days per stent and 625
days per patient. Longest placement duration and survival
were 441 days in a malignant disease. It is 6.5 years in a benign disease with 5 stent exchanges during that period and
the patient is still alive.
Still complications occur up to 40%. The most common complications were infection and mucus obstruction and occurred quite frequently leading to a stent exchange. 6 (1.9%)
stent- related resp. stenting procedure-related deaths occurred. A description in detail will be given.
Conclusion: The availability of stent types has changed during the 20 year period making a comparison of the different
stents more difficult. Also the bronchoscopic approach has
made some changes during the 2 decades. Details will be
given. There are of course quite a lot of other limitations in
this study, no randomization, no measurement of lung function tests, no measurement of extend of stenosis, different
approach to malignant tumors (radio-therapy). Nevertheless
stents can relief symptoms immediately. They can stay even
for several years depending on the underlying diseases. Despite new development of stents there is still no ideal stent.
Complications remain a serious and quite frequent problem.
Department of Pulmonary Medicine, Istanbul Bilim University, School of Medicine, Turkey1), Yedikule Teaching Hospital
for Pulmonology and Thoracic Surgery, Istanbul, Turkey2)
Levent Dalar1), Levent Karasulu2), Cengiz Ozdemir2),
Sinem Sokucu2), Merve Tarhan2), Sedat Altin2)
Aim: To evaluate the airway stents inserted in a referral interventional bronchoscopy unit.
Methods: The records of 283 patients to whom an airway
stent has been inserted between 2005 and 2012 have been investigated retrospectively.
Results: A total of 390 airway stents were used in 283 patients. In 153 cases, the etiology of stenosis was neoplastic.
176 cases died during follow-up period, 101 cases are still
alive and 6 cases were lost in follow-up. Mean survival time
for deceased cases is 190.3 days. The procedure was interrupted in 10 cases because of desaturation or major hemorrhage and resuscitation has done in 1 case. There were no
deaths during procedures. The complications of stents were
granulation (25%), mucostasis (24.6%) and migration (21%).
Conclusion: Airway stent insertion seems to be the best approach in neoplastic or non-neoplastic airway obstruction in
selected patients. They may prolong the survival. However a
perfect stent is not yet available. On the other hand, the selection process of the cases who are more suitable for stent
application and the care of stent provided by the patient himself are the key points for the success.
163
Symposium
IP-SY18-6
IP-SY18-7
Complications of therapeutic rigid bronchoscopy for
the treatment of airway stenosis
Preparation and characterization of paclitaxel-loaded
PLGA coating tracheal stent
Department of Chest Surgery, Nishiyokohama International
Hospital, Japan1), Department of Chest Surgery, Toho University Omori Medical Center2)
Keigo Takagi1), Yoshinobu Hata2), Fumitomo Sato2),
Hajime Otsuka2), Kazuyoshi Tamaki2)
Background
Therapeutic rigid bronchoscopy is an invasive treatment for
airway stenosis that can induce fatal cardiopulmonary complications as a result of ventilatory impairment caused by debris from the reopening of the airway stenosis. Here, the major complications of this treatment are listed retrospectively,
and the cause and treatment of these complications are discussed.
Objectives and Methods
Between 1999 and 2013, a total of 78 patients were treated
using a rigid bronchoscope under total intravenous anesthesia. The airway stenosis had resulted from malignant disorders in 62 patients and from benign disorders in 16 patients.
The location of the stenosis was the trachea in 64 patients
and the bronchus in 14 patients. The placement of a Dumon
stent was performed in 71 patients, and debulking only was
performed in 7 patients. Intraoperative desaturation was defined as an SPO2 under 90% with a 100% oxygen supply.
Results
1. Intraoperative hypoxemia because of hypoventilation
caused by the accumulation of debris with a blood clot was
observed in 7 out of 42 patients (17%) who had an airway deviation around the tracheal bifurcation. This complication
was not observed in cases with tracheal stenosis.
2. Postoperative laryngeal edema was observed in 3 patients;
2 of these patients had SVC syndrome. The patients recovered after receiving temporary tracheal intubation.
3. Negative pressure pulmonary edema was observed in 1
patient; this patient recovered after controlled ventilation.
4. The mortality rate was 10% (8 patients). Two patients had
postoperative respiratory failure caused by sputum retension, and 6 patients died because of the progression of the
primary disease.
Conclusion
A therapeutic rigid bronchoscopy is safe and minimally invasive under controlled ventilation. Physicians should be aware
of hypoxemia when establishing airway patency in cases
with a deviated tracheal bifurcation. In the postoperative
course, close follow-up of the respiration status is essential
for the early treatment of airway complications.
164
Department of Pulmonary Medicine, Beijing Tiantan Hospital,
Capital Medical University, China
Jie Zhang, Yingying Kong, Ting Wang, Yu-ling Wang,
Juan Wang
Background: In-stent restenosis caused by airway granulation poses a challenge due to the high incidence of recurrence after treatment. Weekly applications of antiproliferative drugs have potential value in delaying the recurrence of airway obstruction. However, it is not practical
to subject patients to repeated brochoscopy and topical drug
applications. Objectives: Thus, we fabricated novel pacilitaxel(PTX)-eluting tracheal stents with sustained and slow
PTX release, which could inhibit the formation of granulation tissue. And we assessed the quality and drug release behaviors of drug-eluting stents (DESs) in vitro.
Methods: Stents were dipped vertically into a coating solution prepared by dissolving 0.5g (2% w!
v) of PLGA and 0.025
g (0.1% w!
v) of PTX in 25 ml of dichloromethane. DES morphology was examined by scanning electron microscopy
(SEM). PTX release kinetics from these DESs in vitro was investigated by shaking in PBS buffer followed by high performance liquid chromatography (HPLC).
Results: Using an orthogonal experimental design, we fabricated numerous PTX!
PLGA eluting tracheal stents to assess optimum coating proportions. The optimum coating proportion was 0.1% (w!
v) PTX and 2% (w!
v) PLGA, which resulted in total PTX loading of 16.3806 0.0021 mg!
stent. By
SEM, coating was very smooth and uniform. PTX released
from DES was at 0.3763 0.0038 mg!
day, which was at therapeutic levels. There was a prolonged, sustained release of
PTX of >40 days. Conclusions: Our novel paclitaxel-eluting
tracheal stents may be useful for preventing complications
caused by the formation of granulation tissue after tracheal
stent implantation.
Symposium
IP-SY19-i1
IP-SY19-i2
Education of multidisciplinary lung cancer management teams using the flipped classroom and problem
based learning
We must take the leap into improving medical education. The peruvian experience with the bronchoscopy
education project
Mayo Clinic, USA
Eric S. Edell
The Flipped Classroom is a form of blended learning where
students learn new content outside the classroom and what
used to be homework (assigned problems) is now done in
class. Teachers are able to offer more personalized guidance
and interaction with students, instead of lecturing. Problembased learning (PBL) is a student-centered pedagogy in
which students learn about a subject through the experience
of problem solving.
We have developed a program that uses the flipped classroom and problem based learning in the education of multidisciplinary lung cancer management teams. Team participants include Pulmonologists, Pathologists, Thoracic Surgeons and Medical Oncologists. Objectives of the program include appropriate diagnosis and staging, appropriate sample
acquisition methods, sample preparation to ensure both diagnosis and molecular analysis, and sample interpretation to
ensure best treatment options. This program is being used
to educate multispecialty tumor boards in the United States
and European. We will present the specifics of this program
and the results of this innovative educational model.
Department of Pulmonology, Guillermo Almenara HospitalPeruvian Social Security, Peru
Pedro Francisco Garcia-Mantilla
Peru has shown an excellent economic performance since 2002. Over the past few years
Peru s Gross Domestic Product has increased, to achieve a rate among the highest in the
world.
Although Peru is considered an important country in Latin America for its striking economic
growth, it still has significant gaps in health and education. In the medical field this is particularly reflected in the education of clinical procedures and has a great impact on the quality of
care.
In Peru there were so many ways to practice flexible bronchoscopy as the number of hospitals
performing the procedure. So there were a great diversity of practice and diverse training experiences.
The Bronchoscopy Education Project (BEP) is designed to provide bronchoscopy educators
with competency-oriented tools and materials that can be incorporated in whole or in part into
various training programs.
In May 2011, the First Introductory Flexible Bronchoscopy Course with Hands-on workshops
was held using inanimate models (low fidelity). This was the first simulation training in the Peruvian pulmonology history. A varied group of 24 pulmonologists attended the hands-on workshops: juniors, seniors and even professors and Pulmonolgy Department Heads. All were
working in public or private health care settings.
In May 2012, with the WABIP sponsorship, a second Introduction to Flexible Bronchoscopy
Program was conducted. Our surprise was to discover that out of 15 pulmonologists who attended the hands-on workshop in 2011 and who took the modified Bronchoscopy Skills and
Tasks Assessment Tool (BSTAT), only 4 got the passing grade. What Happened?
The first pulmonologists who were exposed to the BEP had not incorporated the Step by Step
exercises into their daily practice. These results supported a need for structured bronchoscopy education that includes programmed hands-on training for practicing physicians in
Peru. So, we had to do a more sustainable effort especially with residents.
During 2013, always with the WABIP sponsorship, we held 2 Introductory Flexible Bronchoscopy courses in Lima and the first regional course in Arequipa, the second city of Peru. The
programs had a significant participation of residents and junior Pulmonologists. Many doctors
joined the WABIP, and thus the Peruvian Bronchology Group was created.
Last December, the Peruvian Bronchology Association was born. We expect the wave we are
generating will change the Pulmonology practice in Peru and help us to improve the learning
of bronchoscopy to benefit of patients.
The best way to predict the future is to create it
165
Symposium
IP-SY19-i3
IP-SY19-i4
Bronchoscopy education: Why assessment tools and
checklists are important
Medical education in grecoroman antiquity: What can
we still learn to improve contemporary bronchoscopy
education?
Thoracic Medicine, Bellvitge Hospital, Spain
Matt Robert Salamonsen
Background: Adverse events related to medical procedures
are common. The number of procedures a doctor must perform to achieve competence varies, and the training experience differs significantly between centers. In recognition of
this, there has been a shift in medical training away from the
traditional apprenticeship model to one which is competencybased. Thus, tools are required which can assess proceduralist competence prior to unsupervised practice on patients.
Development of an Assessment tool: Before a new assessment tool can be used in the real world, studies demonstrating its validity must be performed. The validity of an instrument describes a number of key qualities. Firstly it must
measure accurately what it purports to measure, in this case
procedural competence and secondly, it has to be reliable,
giving consistent results when used by different examiners
or when applied at different times (Figure 1). Checklists are a
good way of objectively and comprehensively assessing the
many constituent elements of a safe procedure, while global
rating scales are able to capture the intangible elements of
competence gained with experience. Frequently assessment
instruments are comprised of a combination of these 2
things.
Assessment tools in practice: So what score should act as
the cutoff to delineate competence? This could be defined according to normograms obtained from large studies on
groups of operators with varying degrees of competence.
However, instruction in bronchoscopy is an example of mastery training , where the operator must become proficient at
all the individual elements that constitute a safe and effective
procedure. Thus a pass grade should be close to 100%. Further to this, a good assessment tool can contribute directly to
the training experience. With repeated application at intervals throughout training, it can provide a snapshot of the student s place on the procedural learning curve, feeding back
to the student particular deficiencies while allowing the
trainer to tailor further instruction to a student s individual
needs.
Conclusions: Validated assessment tools are needed to document the adequacy of procedural training prior to clinical
practice. If applied repeatedly during the teaching period,
they also have the potential to improve the training paradigm and enhance the learning experience for both trainer
and trainee.
1
Taken from Davoudi et al. Am J Respir Crit Care Med 2012;
186:773-9
166
Interventional Pulmonology Unit, 1st department of Pulmonary Medicine, University of Athens, Sotiria Chest Hospital
of Athens, Greece
Grigorios Stratakos
Ancient Greek medicine essentially influenced western medical practice and
education. This heritage can still inspire novel ideas on medical education. Holistic Approach Hippocratic School, considered body and soul a unity and nature
(physis) of humans could only be understood surrounded by their environmental
nature. The rationalized basis of Medicine was a physio-logy of humans idiosyncrasy. Disequilibrium of the physis elements, inevitably lead to disease(pathos) hence a Patho-logy is developed. Clinical approach was both holistic
and individualized. Medical craft was not opposed to science. Physicians would
need all their cognitive and experiential skills, physical examination, technical
abilities and their ethical principles to treat patients. Pro-gnosis Knowing in advance was essential. Physicians revealing future events reassure the patient,
gaining his trust. They may decline hopeless cases avoiding criticism and preserve their reputation. On Epidemics I,V states: We have two objects in regard
to disease: to do good or to do no harm. Prognosis is valuable in order to know
when, where and to what extent one should intervene to prevent harm. This,
has always been (and probably still is) considered as a major proof of competence. Training in Medicine Hippocrates declares the realistic prerequisites of
medical education (physical talent, proper instructor, favorable environment,
love of labor and time) without fear to be accused of elitist or aristocratic predisposition. Life is short, and Art long Knowledge and art should be transmitted
from generation to generation. Books are essential although Aristotle states: No
one can learn medicine only from books, they can be harmful to the unexperienced Given the above which aspects of ancient Greek medical education could
still be inspiring? 1.Freely and readily available literature for everyone wishing
to devote time and labor . 2.Passing from the master-apprentice to the
professor-student model signaled a shift towards a broader interpretation of
knowledge and experience. In Institutions like the Museums of Alexandria,
professors were primarily engaged in research. 3.Through autopsies, hands-on
lessons or animal simulation models, physicians acquired skills before encountering patients. Training on non consenting patients was considered as inacceptable as today. 4.Inscriptions report on Medical Contests. Medical instructors
exploited the natural ambition of young people towards distinction, honour
and reward, to promote excellence.
After describing the theoretical basis of science, the technical issues and the
moral commitments of art, Hippocrates is leaving one last precept: Wherever
there is love for humans, there is also love for (medical) art. Isn t it something we
should still remember?
Symposium
IP-SY21-i1
IP-SY21-2
The underlying mechanism and management of
postintubation tracheal stenosis
Beagle model of tracheal stenosis induced by endotracheal intubation with cuff overinflation
Department of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, China
Department of Respiratory Medicine, The First Affiliated
Hospital of Guangzhou Medical University, China
Shiyue Li
Zhuquan Su, Shiyue Li, Xiaobo Chen, Yu Chen,
Changhao Zhong
Benign tracheal stenosis (BTS) is one of the common diseases<challenges in interventional pulmonology. There is an
increasing trend in prevalence of BTS in recent years. The
etiologies of BTS include tracheal intubation (32.9%, 52!
158),
tracheotomy (28.5%, 45!
158), <tuberculosis (16.5%, 26!
158),
based on our data. The main mechanism underlying postintubation tracheal stenosis involves mucosal ischemia<necrosis caused by cuff compression, which result in excessive
granulation<scar healing at the location of airway transmural injury, followed by narrowing of the tracheal lumen.
Prolong intubation<excessive cuff pressure are the important risk factors for postintubation tracheal stenosis. In our
beagle model of tracheal stenosis induced by endotracheal
intubation with cuff overinflation, we found that higher pressure of the cuff was associated with higher incidence rate of
postintubation tracheal stenosis;<the development of tracheal stenosis was correlated with the duration of tracheal
intubation<cuff compression. We also found that cuff pressure alone did not lead to tracheal stenosis, whereas endotracheal intubation with excessive cuff pressure, oversized
tubes<prolonged intubation might lead to airway injury<tracheal stenosis. It was suggested that oversized tube could be
an important factor for postintubation tracheal stenosis.
Surgical resection is the standard treatment for benign tracheal stenosis. Recently, new interventional techniques, including balloon dilation, thermal ablation (APC, highfrequency electric knife, laser), cryotherapy, local injections
of glucocorticoid, stenting<local radiotherapy, provide new
therapeutic options for benign tracheal stenosis. Our data
showed that interventional treatments (without stenting) under bronchoscopy was effective in treating benign tracheal
stenosis in 158 cases (94.3%), but the 1-<3-month recurrence
rate were 38.3%<26.8%, respectively.
Although an important treatment for airway stenosis, implantation of conventional stents for treating BTS are limited
by a variety of complications, especially for metal stents. We
developed a novel stent, in which the both open-ends were
incurved to reduce the stimulation to tracheal wall<the
growth of granulation. Fifteen patients with BTS who failed
to continue repeated interventional treatment (>times) were
implanted with the new stent. During the 6-month follow-up,
interventional removal of granulation was needed in only 1
patient at 1 month after stent implantation.
Objectives: To establish a novel animal model of tracheal
stenosis in beagle dogs by endotracheal intubation and detect the relevant factors associated with postintubation tracheal stenosis.
Methods: 14 specially bred research beagle dogs were divided into three groups. Group A (6 dogs): endotracheal intubation with cuff pressure of 150mmHg, 175mmHg and 200
mmHg, respectively, for 24 hours by I.D.8.0 endotracheal
tube. Group B (4 dogs): endotracheal intubation by I.D.7.5 and
I.D.8.0 endotracheal tube, respectively, with cuff pressure of
200mmHg for 24 hours. Group C (4 dogs): endotracheal intubation for 12 hours and 24 hours, respectively, with cuff pressure of 200mmHg by I.D.8.0 endotracheal tube. The animals
were observed and followed up after extubation, the evaluation of stenosis progression was performed by endoscope
and histological examinations.
Results: All dogs revived after extubation without any complications related to endotracheal intubation. Tracheal stenosis developed in 6 dogs by 14th-day post extubation by I.D.8.0
tube with cuff pressure up to 200 mmHg for 24 hours, gross
and endoscopic examination showed that stenosis had been
induced, ranging from 80% to 92% decrease in diameter. Histological examination showed mucosal ulceration, submucosal thickening with formation of granulation tissues and
collagen fibers, and collapse of destroyed cartilage. Intubation with cuff pressure of 175mmHg in Group A and I.D.7.5
tube in Group B, ischemic injury resulted in posterior tracheal wall necrosis and repaired by hypertrophic scars, lumen diameter decreasing from 16％∼31%. No airway narrowing occurred with cuff pressure of 150mmHg in Group A
and intubation time for 12 hours in Group C during the 6
weeks followed up.
Conclusions: The novel animal model of tracheal stenosis induced by endotracheal intubation with cuff overinflation is
technically simple, reliable and reproducible. Excessive cuff
pressure, prolong intubation and the oversize endotracheal
tube are three important factors that lead to overgrowth of
granulation tissue and formation of tracheal stenosis.
Keywords: Intubation; Tracheal stenosis; Animal model;
Granulation tissue; Cartilage
167
Symposium
IP-SY21-3
IP-SY21-4
Withdrawn
The treatment of intractable complexity benign stenosis without use of stent
Department of Pulmonary Medicine, Beijing Tiantan Hospital,
Capital Medical University, China
Jie Zhang, Juan Wang, Yinghua Pei, Xiaojian Qiu,
Yuling Wang, Ting Wang, Min Xu, Chenyang Zhang
Background Benign airway stenosis is a life-threatening illness. The incidence rate of this disease is 10-22% among patients who receive airway intubation or tracheostomy. Benign airway stenosis can be divided into three types. The
first type is endoluminal granulation stenosis, usually with
good prognosis. The second type is cicatricial stenosis
(length of stenosis is less than 1cm), and this type also have
good prognosis. The third type is complexity cicatricial
stenosis (length of stenosis is longer than 1cm), usually with
poor prognosis. For those patients, surgical resection and reconstruction is the best choice. However, if the length of
stenosi is too long (longer than 5cm), or patients with poor
cardiac or respiratory function, the surgery couldn t be done.
For those can not tolerate surgery or with re-stenosis after
surgery, they are called intractable complexity benign airway stenosis and usually treated with silicone stent (mostly
use Dumon stent). However, stent placement often combined
with complication such as granulation, stent migration, sputum retention and so on. In this paper, we tried to use a
method without stent to treat intractable complexity benign
airway stenosis and got good prognosis.
Method Seventy-four hospitalized patients of Beijing Tiantan Hospital during Jan. 2009-Oct. 2012 with benign airway
stenosis were included. Causes included trauma, tracheal anastomosis, tracheal intubation, tracheotomy, tuberculosis,
stent placement and so on. The stenosis types were as follows: Endoluminal granulation stenosis were 9 cases, cicatricial stenosis were 12 cases, complexity cicatricial stenosis
were 53 cases. One or several of the following treatment
methods were selected depending on patients different
stenosis types: needle-shaped electric knife, balloon dilation,
cryotherapy and topical drug usage (mitomycin C or paclitaxel).
Result Four patients were lost to follow, other 70 cases were
cured at last. Endoluminal granulation stenosis and cicatricial stenosis could be cured after 1-3 times treatment by using needle-shaped electric knife, balloon dilation and (or) cryotherapy. Topical drug usage was unnecessary. Complexity
cicatricial stenosis required repeated treatment and had
high restenosis rate. Topical drug usage (mitomycin C or
paclitaxel) was necessary. One patients with left main bronchus stenosis after trauma underwent the longest treatment
period (24 months), with 17 times treatment, and was cured
at last.
Conclusion Combination application of four methods (needleshaped electric knife, balloon dilation, cryotherapy and topical drug usage) could be used to treat intractable complexity
benign airway stenosis without stent related complication.
168
Symposium
IP-SY21-5
IP-SY21-6
Efficasy and safety of cre balloonplasty in begin tracheal stenosis
Endoscopical treatment of acquired complete tracheal
stenosis and total aphonia
Department of Pulmonology and Critical Care Medicine, Sterling Groups of Hospital, Sparsh Hospital, India
Varunkumar Rameshbhai Patel, Mukesh Patel,
Amrish Patel, Gopal Raval, Harjit Dumra, Tushar Patel
Background: Benign tracheobronchial stenosis of the proximal airways can result from variety of condition and can
cause dyspnoea, cough, wheeze, strider or recurrent pulmonary infection. A variety of modalities may be used to manage this strictures, none of this documented to be uniformly
effective. Flexible bronchoscopy with balloon dilatation was
described in 1991. We are presenting our experience with
CRE Balloonplasy in tracheal stenosis.
Method: All patients with the diagnosis of benign tracheal
stenosis with some of complication referred to our department since May 2010 to Nov 2013. All patients with different
etiology of stricture treated with CRE balloon catheter (sizes
5-8-10mm, 10-11-12mm or 12-13.5-15mm) passes via working
channel of videobronchoscopy(Olympus) under deep sedation and airway was protected by i-gel, procedure done in
fully equipped endoscopy suite. The etiology, size, location
and degree of stenosis pre and post procedure, number of intervention of each patient, complication of procedure and
failure were noted.
Results: Study cohort of 20 patients: female-14 numbers. Distribution of stricture include subglottic-6, proximal trachea-5,
midtrachea-5 and distal trachea-4. Prolong intubation by endotracheal tube was the most common cause followed tracheostomy and Wegmer s granulomatoist, post Tb sequelae
and traumatic. CRE-Ballon dilatation was performed fist in
some cases of web like stenosis, cautery-kinf was used and 3
incicison at 12, 4 and 8 o clock were made. If required adjunct
other modality used like electrocautery was used in 12 pt,
Mitomycin local application in 3, intralesional steroid instillation in 7 and systemic steroid in 8. 3 Patients had mucosa laceration and bleeding, one had pneumothorax and one had
death-innominat artery aneurism rapture arising in tracheal
wall. Quarter of procedures was done on hospitalization. Average 3 times procedures done, Failure of procedure, surgical correction required in 4 patients.
Conclusion: Balloonplasty with a CRE balloon catheter performed via videobronchoscope was an effective and relatively safe procedure when use in selected cases. Failure of
procedure is high in diffuse involvement of trachea with
damaged cartilage. Web shaped fibrotic stricture response to
well. All patients were well tolerated procedure under deep
sedation and i-gel.
Clinical Implications: balloon dilation is a relatively safe procedure in the management of benign tracheal stenosis. Our
results are encouraging and combined with other adjunct
therapies may be offered to symptomatic patient as initial
treatment, diffuse involvement of trachea with cartilage
damage should be offered surgery as they get highest
chance to be failed.
Department of Interventional Pneumology and Thoracic Surgery, RESPIREMOS SAS-Interventional Pulmonology UnitComfamiliar Clinica-Clinica Saludcoop, Colombia1), Department
of Interventional Pneumology and Thoracic SurgeryRESPIREMOS SAS Unidad de Neumologia y Endoscopia
respiratoria-Clinica Comfamiliar-Clinica Saludcoop Pereira, Colombia2), Department of Interventional Pneumology and Thoracic Surgery-RESPIREMOS SAS Unidad de Neumologia y
Endoscopia respiratoria-Clinica Comfamiliar-Pereira, Colombia3)
Mauricio Cespedes Roncancio31), Mauricio Gonzalez2),
Alberto Franco2), Manuel Pacheco3)
Tracheal stenosis is an increasing complication after prolonged mechanical ventilation and tracheostomy. This is a consequence of tissue repair and scar formation after those injuries, leading to progressive airway narrowing and their related clinical symptoms, which depend on stenosis severity. In cases of complete
stenosis, partial or total aphonia can also result. Open surgery is the standard procedure, however, it may be contraindicated in some patients (due to location and
magnitude of the stricture and comorbidities). Thus, endoscopical techniques are
useful treatment options, however still underreported in literature. Methods: In
this study we report a series of 20 adult cases of complete subglottic stenosis with
total aphonia treated and followed-up between 2009 and 2013 in two institutions
of Pereira, Colombia. All subjects had previous tracheostomy, and were successfully treated with endoscopy and stent placement. Under general anesthesia, a
rigid bronchoscope was placed under vocal cords, above the stenosis. Tracheal
tube was removed and a Schieppati needle was used to pass through the center
of the stenosis. After this, dilation of stenosis was performed using Jackson dilators. Residual tissues were resected with the rigid bronchoscope, achieving the
complete clearing of airway, recovering normal oxygenation and breathing. Subsequently, a Dumon subglottic tracheal stent (Stening) was placed immediately
below the vocal cords, closing the tracheostomy. Results: All patients were successfully treated and all of them recovered speech, with 100% of recovery of the
airway (Figure) and normal spirometry in all cases. No significant complications
were observed among subjects (four out of twenty successfully treated nonimmediate tracheal infection occurred). Follow up has been conducted during a
range of four years (first patient) to two months (last patient); it included clinical
evaluation, CT-scan (every six months during one year), bronchoscopy (every
month during six months) and pulmonary function tests, which were normal in all
patients. Conclusion: This highly efficient and less invasive procedure (with no
contraindications and one surgical time) implies a low surgical risk, compared to
open tracheal resection surgery. Furthermore, leads to a minimum level of surgical complications, allowing for a complete recovery of the normal airway, speech
and esthetical neck appearance. Improving the quality of life of these patients and
even a lower cost are also benefits of these procedures. After an extensive review
of literature we did not find any series reported using a method similar to the one
reported here. Further studies and longer follow-up are expected in the future.
169
Symposium
IP-SY21-7 IP-SY21-8
IP-SY22-i1
Massive airway hemorrhage management in New York
City
Cryobiopsy
Department of Pulmonary and Critical Care, Lenox Hill Hospital, USA1), Lenox Hill Hospital and New York University, US2)
Wojciech Palka1), Klaus Lessnau2)
Severe lung bleeding is a nightmare for the pulmonologist in
the city with the highest number of malpractice lawyers in
the world. There is no established universal algorhythmic
approach. Mortality is from asphyxiation and airway occlusion rather than from exsanguination. Diagnostic and therapeutic recommendations and proceedings vary and there is a
need for a standard-of-care approach prior to such catastrophe. This presentation includes cases and approaches of an
extensive experience of more than sixty years. Considerations are rigid versus flexible bronchoscopy, emergent tracheostomy, dual bronchoscopy, hemostasis techniques and
occlusion devices. This can be compared to pilot and copilot
in an airplane in crisis. Anticipation of a potential disaster,
whether iatrogenic or spontaneous, is emphasized. One must
exactly know how to proceed despite the presence of numerous advisors at the bedside. One take home message is that
the presence of more than one experienced interventional
pulmonologist is very helpful in such high complexity emergency.
170
Internal Medicine II, University of Tuebingen, Germany
Juergen Hetzel
Forceps biopsies, needle aspiration and brushes are the bronchoscopic standard tools for harvesting bronchial or lung tissue for pathological diagnosis of lung diseases. However
these techniques inherit relevant limitations. In the central
airways the diagnostic yield of endobronchial malignancies
does not exceed 90% even if different techniques are combined. Specimens from transbronchial lung forceps biopsies
lack sufficient quality due to crush artifact and are generally
too small for the diagnosis of some diffuse lung diseases such
as IPF.
Cryobiopsy:
Cryobiopsy is a new biopsy technique, which enables to obtain large tissue samples without squeezing artifacts. Cryobiopsy uses the adhesive effect of freezing. The tip of the cryoprobe is attached to the target tissue and cooled which
causes freezing of the surrounding tissue. After being frozen,
the tissue is attached to the probe s tip, which allows extracting the by pulling on the probe. The frozen tumor tissue is
then released from the probe by thawing in a water bath.
The samples are stored in formalin. No additional processing
of the samples is required. Cryobiopsies can be performed in
flexible bronchoscopy, however orotracheal intubation of the
patient is recommended.
Histological quality of cryobiopsies:
Various studies could demonstrated, that cryobiopsies are
significant larger than forceps biopsies without any squeezing artifacts or artifacts caused by freezing. Especially the
amount of alveolar tissue in transbronchial biopsies is larger
compared to forceps biopsies. Immunohistological staining is
also possible on cryobiopsies.
Endobronchial cryobiopsy:
A prospective randomized multicentre trial demonstrated,
that endobronchial cryobiopsy is a safe technique with a
higher diagnostic yield for the diagnosis of endobronchial
malignancies than forceps biopsy. The rate of severe bleeding did not differ between the forceps biopsy and the cryobiopsy group, no perforation was observed.
Transbronchial cryobiopsy:
Transbronchial cryobiopsies allow to detect histological patters such as UIP patterns, which were in the past difficult to
diagnose on transbronchial forceps biopsies. This may add
additional information in the diagnostic process of interstitial
lung diseases, especially in idiopathic interstitial lung diseases. The risks of transbronchial cryobiopsies are pneumothorax with a rate of approximately 5% and bleeding. Therefore fluoroscopy control for probe placement and orotracheal
intubation is recommended.
Summary:
Cryobiopsy is an effective biopsy technique, which is superior to forceps biopsies in the central airways and may contribute to the diagnostic algorithm in interstitial lung diseases. However prospective trials comparing cryobiopsies
with surgical biopsies in interstitial lung diseases are lacking.
Symposium
IP-SY22-i2
IP-SY22-i3
Therapeutic flexible bronchoscopy in management of
airway obstruction
Bio-elastic patient-specific organ replication using
multi-material 3D printer in pulmonary surgery
Chhajed Pulmonology s Lung Care and Sleep Centre, India
Prashant Chhajed
Gastroenterology, Kobe University, Japan1), Chest Surgery,
Jikei University School of Medicine, JAPAN2)
Maki Sugimoto1), Toshiaki Morikawa2)
The multi-material 3D printer allows the creation of surgical
models of realistic nature and mimicking real tissues. We developed new patient-specific bio-elastic organ replica using 3
D printing system of Bio-Texture Modeling. The 3D organ
models and thoracic cavity were manufactured by simultaneous jetting of different materials. We evaluated its benefit
in pulmonary surgical simulation and procedure training.
Based on MDCT data, after generating an STL-file of the organ surface, the inkjet 3D printer created a 3D organ model.
Simultaneously we manufactured the transparent whole thoracic wall replica from the maps of inner shape of the cavity
by regenerating patient-specific MDCT data.
This system enabled the simultaneous use of three different
rigid and flexible materials to form 3D organ textures and
structures. The patient individual 3D printed models were
used to guide the successful surgical simulation in pulmonary surgery.
The 3D organ replicas using combination of transparent and
soft materials allowed creation of translucent models that
show visceral organs, tumors blood vessels and other details,
overcome the limitation of the conventional image-guided
simulation and training method.
The actual size transparent organ model with vessels and tumor such as bronchus and lung could be manufactured and
be handled. The combination of the elastic organ models and
bony structures were useful for patient-specific surgical
simulation and had benefits in educational aspects of the
medical education for students and trainees. These anatomies enable the trainee to virtually encounter and learn various thoracic conditions before they perform the exam on a
real patient. Trainees gain the ability to recognize normal
and abnormal findings and practice using the proper techniques to perform thoracic surgery.
These provided reduction of operation time and better anatomical reference tool as a tailor-made simulation and navigation in robotic surgery and contribute to improvement
We believe that our sophisticated personalized bio-elastic organ and thoracic wall replication can provide anatomically
realistic recreations of many operations and offer obvious
benefits, especially in mastering counterintuitive techniques
in minimal access surgery.
171
Symposium
IP-SY22-4
IP-SY22-5
Adjustable flow spray cryotherapy (SCT) in malignant
airway disease: Initial experience 2012-2013
The efficacy and safety of interventional bronchoscopic techniques in the management of benign airway stenosis
Interventional Pulmonary Medicine, Walter Reed National
Military Medical Center, Uniformed Services, USA
Robert Browning, Scott Parrish, Corey Carter
Background:
Endoscopic spray cryotherapy (SCT) using liquid nitrogen as the cryogen
is a novel technology that was originally developed for GI use in the
esophagus in 1999. As this tool became more widely used in GI over the
next decade, bronchoscopists with access to these devices began to use
SCT off label for ablation in the airways. Unfortunately, complications
during these airway SCT procedures were reported to be as high 19.3%.
Unlike probe based cryotherapy devices used routinely in the airways,
SCT allows for non contact delivery of liquid nitrogen droplets to the endoluminal surface through a flexible 7 French disposable catheter that instantly flash freezes the tissue (Figure 1). The liquid nitrogen immediately
transforms into a gas state producing a volume of nitrogen gas in the airway that needs to be passively vented to prevent barotrauma-associated
complications within the lungs. Using appropriate techniques to manage
this excess gas expansion is essential for the safe use of SCT. In 2012, a redesigned SCT device (TruFreeze system, CSA Medical Inc., Boston, USA)
that allowed for a more uniform delivery of the liquid nitrogen at adjustable flow rates was developed. We report on our initial experience with
this new device.
Methods:
Case series study of consecutive patients enrolled in our IRB approved
bronchoscopy database presenting with malignant central airway disease
who received bronchoscopy with SCT using the TruFreeze spray cryotherapy device during the period of NOV 2012 through NOV 2013. Patient data from our bronchoscopy database was reviewed to characterize
our initial experience in the first year of SCT (TruFreeze) use at our institution.
Results:
18 patients were identified with malignant airway disease who received
SCT (TruFreeze) during the 12 month period. Many of these patients underwent multiple bronchoscopies with SCT and a total of 56 SCT bronchoscopies were performed. In 32 of the 56 cases, SCT was used in the immediate area of endobronchial stents for treatment of tumor, granulation
tissue and!or bleeding. No stent degradation or compromise was observed. The stents were primarily silicone or silicone covered stents although 2 patients had uncovered nitinol stents. No adverse events occurred during any of these procedures.
Conclusion:
SCT (TruFreeze) is a unique non contact endoscopic tool that allows for
the safe treatment of endobronchial tumor, granulation tissue and bleeding within the large airways with or without existing endobronchial
stents.
172
Department of Pulmonary and Critic Care Medicine, Peking
University First Hospital, China
Nan Li, Guangfa Wang, Ying Zhou, Wei Zhang,
Hong Zhang
Background: Compared with malignant airway stenosis, the treatment of benign airway stenosis was a difficult problem because of patient s highly expectations. Proximal
airway stenosis may cause severe symptoms. Endoscopic therapies achieved relatively
good results comparing to surgical procedure. Otherwise, application of interventional
bronchoscopic techniques hasn t been fully standardized. To analyze the efficacy and
safety of varieties of endoscopic techniques in the management of benign airway stenosis, a retrospective analyze was studied.
Methods: Patients with benign proximal tracheobronchial stenosis were included, who
were received the interventional bronchoscopic management during 2007 January to
2011 March, in the department of Respiratory and Critic Care Medicine of Peking University First Hospital. Airway stenosis caused by foreign body or extrinsic compression were excluded. Clinical material including CT, lung functions, and bronchoscopic
results were retrospectively analyzed. Follow-up with telephone call evaluated the severity of breathlessness with Modified Medical Research Council Questionnaire
(mMRC). The type and severity of airway stenosis were assessed by two professional
interventional pulmonologists.
Results: 44 patients (24 males, 20 females) with 49 stenosis locations were included, with
average age 49.9士17.88y. The main causes of tracheobronchial stenosis were tuberculosis(14, 31.81%), lobectomy (11, 25%), endotracheal intubation or tracheotomy (6,
13.64%),unspecific inflammation (5, 11.36%), trauma (3, 6.82%) and some rare diseases.
195 therapeutic bronchoscopic procedures were finished (4.75 士 4.19!patient, median 3
(1,19). All the endoscopic techniques including cryotherapy combining balloon dilatation, cryotherapy combining electrocautery, electrocautery, balloon dilation and cryotherapy, could achieve immediately airway lumen improvement significantly, with effective rate 92.7%, 93.8%, 85.7%, 100% and 66.0% respectively. No difference was
showed in immediate effect of cryotherapy combining balloon dilatation in granulation
stenosis, scar stricture and granulation-scar mixture stenosis, similar effect was seen in
cryotherapy treatment. Airway diameter was significantly improved in a serial interventional therapy mainly based on cryotherapy and balloon dilatation. 67.78% (27!39)
patients recovered after 90 days of the first treatment, and 82.05% (32!39) patients
would not need any treatment after 180 days of the first treatment. Twelve patients
had follow-up with bronchoscopy at 82(13,671) days after the last treatment. The airway stenosis percentage was significantly decreased from 80%(60%,100%) before treatment to 35%(0%, 70%) after last therapy. The mMRC scale and FEV1 were also improved dramatically at 363 (27,1552) days and 166.5 (35,587) days after the last treatment (P<0.05). No serious complication was found during and after interventional therapy.
Conclusion: A serial of interventional therapy based on cryotherapy after balloon dilation or electrocautery achieved good results, improved dyspnea and pulmonary function, with good safety.
Symposium
IP-SY22-6
IP-SY23-i1
Analysis of malignant central airway noeplasmas in
881 cases
Multi-modal bronchoscope in (WLI+HD, NBI, AFI,
PDD, index Hb, EBUS ) diagnostics of the occult early
central lung cancer (ECLC)
Department of Respiratory Medicine and Medical Oncology,
Meitan General Hospital, China
Wang Hongwu, Zhang Nan, Li Dongmei, Zou Hang,
Zhang Jieli, Zhou Yunzhi, Liang Sujuan, Li Jing
Objective: To propose a new diagnosis and classification system of malignant central airway noeplasmas by reviewing of
881 cases with this disease.
Materials and methods: The bronchoscopy and pathology
data were retrospectively reviewed in 881 cases with malignant central airway noeplasmas from 2005.10.08 to 2013.4.30
at our center.
Results: The central airway was divided into 8 regions and
the lesions were classified to 4 types due to location. Malignant central airway noeplasmas were mainly found at region
3,5,6 and 7 of the airway, with primary, mixted or squamous
carcinoma pathologically. Adenocarcinoma, small cell lung
carcinoma(SCLC) and mucoepidermoid carcinoma(MEC)
were mainly located at bronchus, while esophagus carcinoma often occurred at region 2,3,5,7 of the airway, and thyroid carcinoma was the most common tumor of region 1.
Conclusion: The new diagnosis and classification system
provide a helpful tool to exactly and easily determine the location of malignant central airway noeplasmas, and may
profit the diagnosis and treatment.
Hertzen Moscow Oncology Research Institute, Russia1), Department of Endoscopy, Hertzen Moscow Oncology Research
Institute, Russia2)
Victor Sokolov1), Larisa Telegina2), Tatiana Karmakova2)
Purpose. Studying in a comparative form the possibility to
reveal and verify the occult ECLC when we apply modern
techniques of fluorescent and ultra-sonographic bronchoscopic diagnostic research.
Goals. Developing the optimal version of multi-modal bronchoscopic diagnostics of ECLC when we investigate the tracheobronchial tree in the white light mode at high resolution
(WLI+HD), narrow-band imaging (NBI), autofluorescence imaging (AFI), 5-ALA induced fluorescence- photodynamic diagnosis (PDD), fluorescence with exogenic photosensitizers
(FD), virtual spectroscopy with estimation of Hb index (IHb),
local fluorescent spectroscopy with three-wave excitation
(LFS), endobronchial ultra-sonography (EBUS), fluorescent
microscopy of bronchial mucous MUC I scratch test.
Materials and methods. The research is based on the clinical data obtained from 1992 through 2013 in P.A.Herzen Moscow Oncology Research Institute in the course of bronchoscopic investigation and diagnostics of 172 ECLC tumors in
125 patients.
Results. The applied new mode of integrated bronchoscopic
and immune-cytochemical investigation has increased more
than twice the accuracy in diagnostics of occult ECLC, while
immune-cytochemical MUC1 investigation makes it possible
to predict the occurrence of precancerous lesions of bronchial mucous.
Conclusions. Each of the modern methods in early central
lung cancer bronchoscopic diagnostics has got its own high
sensibility, but different specificity. Therefore, it is necessary
to compose an optimal mode for integrated endoscopic and
morphological ECLC diagnostics.
173
Symposium
IP-SY23-i2
IP-SY23-i3
Bronchoscopy in India past, present and future
Respiratory endoscopy and interventional pulmonology in China
Thoracic Surgery, Dr. Sarkar Bronchoscopy Centre, Jaipur,
India, India
Sukant Kumar Sarkar
The birth of bronchoscope dates back to 1897 when Gustav
Killian of Freiburg used Kirstein laryngoscope to examine
the trachea and main bronchus.
Shigeto Ikeda introduced flexible bronchoscope in 1966 and
later founded WAB in 1979. The Japan Society for Bronchology (JSB) was founded in 1983.
In India, Rigid Bronchoscope was in practice since early
nineties. At Chest Hospital Jaipur, the first FOB procedure
was done in 1978. We established the role of FOB in Smear
Negative Pulmonary Tuberculosis, as peluroscope (1985).
Our studies established that bronchial washings should be
examined routinely for tubercle bacilli (1982). By 1993 more
than 7,500 procedures were completed by us. With the use of
FOB number of Rigid Bronchoscopy procedures declined
gradually at our centre.
The Indian Association for Bronchology (IAB) was founded
in 1995.
In early Eighties (1980-85) we tried to evaluate the role of
FOB in diagnosing lung cancer using different tissue sampling techniques and the combined diagnostic yield was
88.2% (1988).
The surveys carried out by Dr Sandhya (Bangalore) in 1997
and July 2011 helped the spread of FOB and Rigid Bronchoscopy in India. As per the survey the major highlights were:
1 More than 40% of higher centres were using Rigid Bronchoscopy with Laser, Cryotherapy, Electrocautery, APC,
AFB and stents.
2 Video-bronchoscopy was being used at many teaching centres along with PDT and AFB.
3 The necessity for re-introduction of Rigid Bronchoscopy to
combine with FOB reemerged.
The strongest impact in the last decade was EBUS TBNA.
Other new methods include BLVR and Thermoplasty, however being used by a select few in India.
The future of bronchoscopy is bright. The landmarks of the
last decade include EBUS TBNA, BLVR, RFA, EBI, narrow
band imaging, confocal fluorescence microscopy, optical coherence tomography and endocytoscopy.
We recently organized 4th APCB in January 2012 at Jaipur
India which had an everlasting impact and it made bronchoscopists of India more enthusiastic.
Current developments and newer technologies like 3D optical ultrasound imaging, nanotechnology, man machine interface, Endoscopic OCT and even endoscopic MRT and new
research in gene therapy may become available for patients
use in clinical practice.
In my considered view, it will take time for these developments to come to India due to numerous constraints.
The future role of WABIP and APAB should continue to develop newer innovations in the field of Bronchology and Thoracoscopy techniques and disseminate them to the world.
174
Professor and President Dept of Respiratory and Critical Care
Medicine Peking University First Hospital, China
Guangfa Wang
Symposium
IP-SY23-4
IP-SY23-5
Interventional pulmonology: A single center experience
Interventional pulmonary procedures for patients with
central airway obstruction: Experience in our institution
Department of Pulmonary Medicine, Istanbul Bilim University, School of Medicine, Turkey1), Yedikule Teaching Hospital
for Pulmonology and Thoracic Surgery, Istanbul, Turkey2)
Levent Dalar1), Levent Karasulu2), Cengiz Ozdemir2),
Sinem Sokucu2), Merve Tarhan2), Sedat Altin2)
Aim: To evaluate the experience of a reference interventional pulmonology (IP) center and to determine the correct
approach to the cases who need IP procedures.
Methods: The records of 954 patients who had an IP procedure between 2005 and 2012 were investigated retrospectively.
Results: A total of 1683 rigid bronchoscopy, 1655 fiberoptic
flexible bronchoscopy and 21 medical thoracoscopy procedures have been applied in 954 patients. The main indications were malignant airway obstruction (n: 388, 41.1%), benign airway stenosis (n: 132, 13.9%), and hemoptysis (n: 56,
5.9%) respectively. 510 cases died in follow-up, 417 cases are
still alive and 16 cases were lost in follow-up. There were no
deaths during procedures, but 33 cases died in intensive care
unit in the early period following procedure. The main procedure was diode laser or argon plasma coagulation assisted
mechanical resection. Cryotherapy has been applied in 119
procedures.
Conclusion: An IP unit can be build up with minimum equipment. Physicians dealing with IP must be well educated and
should know the correct approach for each individual patient. IP procedures can prolong the survival but the complications and the management of the cases can be challenging.
First Department of Medicine, Hokkaido University Hospital,
Japan
Hajime Kikuchi, Naofumi Shinagawa, Hidenori Kitai,
Taichi Takashina, Yasuyuki Ikezawa, Hajime Asahina,
Jun Sakakibara-konishi, Satoshi Oizumi,
Masaharu Nishimura
【Background】Patients with central airway obstruction
(CAO) sometimes need bronchoscopic intervention urgently
to relieve its associated symptoms. Interventional pulmonary
procedures, including airway stenting, may be inevitable to
save life or to improve quality of life.
【Methods】We conducted a retrospective analysis of 22 patients with CAO who had undergone pulmonary intervention in our institution from January 2008 to September 2013.
【Results】The patient characteristics were: male!
female=14!
8; median age (range)=70 (43-77) years; diagnosis: 12 lung cancer (Sq!
adeno!
NSCLC!
SCLC=9!
1!
1!
1), 3 adenoid cystic carcinoma, 1 carcinoid tumor, 2 esophagus cancer, 2 colon cancer, 1 hepatocellular carcinoma, 1 lymphoma. Lesions were
trachea!
carina!
main bronchus=5!
10!
7. Ten patients required airway stents, 3 Dumon-Y stents or 7 Ultraflex stents
were placed. Eleven patients underwent only dilation of the
airway stenosis and the last patient required tracheotomy
followed by T-tube placement. Rigid bronchoscope was used
for 17 patients. Complications were none!
bleeding!
suffocation!
cerebral infarction!
pneumonia!
pneumothorax=15!
2!
1!
1!
3!
1. The median survival time (MST) after the diagnosis of
CAO was 378 days overall, and it was 230 days in patients
who had lung cancer or esophageal cancer. Among them,
those who underwent adjuvant treatment (n=8), including
chemotherapy and!
or radiotherapy, demonstrated significantly longer MST than those who could not receive any adjuvant treatments (n=6) (378 days vs. 56 days; p<0.05).
【Conclusion】In patients with CAO, interventional pulmonary procedures were generally safe and effective not to relieve QOL but also to prolong overall survival in some patients with cancer who could receive adjuvant treatment afterward.
175
Symposium
IP-SY23-6
IP-SY24-i1
Endobronchial ultrasound study in diagnostics of pulmonary cancer and mediastinal neoplasms
What kind of surgical intervention should be performed
for postoperative bronchopleural fistula?
Blokhin Russian Cancer Research Center of the Russian Academy of Medical Sciences, Russia
Department of Thoracic and Thyroid Surgery, Kyorin University School of Medicine, Japan
Elena Sergeevna Vakurova, Elena Vakurova,
Guram Ungiadze, Sergey Gerasimov
Riken Kawachi, Reiko Shimizu, Keisei Tachibana,
Shin Karita, Yoko Ohno, Yasushi Nagashima,
Hidefumi Takei, Haruhiko Kondo, Tomoyuki Goya
Study objective: To show the capabilities of endobronchial
ultrasound study for the diagnostics of ultrasound cancer
and pulmonary neoplasms.
Materials and methods: We performed 189 endobronchial ultrasound studies at the Blokhin Russian Cancer Research
Center of the Russian Academy of Medical Sciences. All the
patients underwent pulmonary X-ray imaging, CTangiography of chest and standard bronchoscopy before the
study as part of diagnostics research algorithm.
Endobronchial study using radial sensor (scanning frequency
20 MHz) was performed in 54 patients with peripheral neoplasms. The main objective of the study was to receive the
samples for morphological verification. Visualization of tumor was achieved in all patients. The endosonography detected differently sized hypoechogeneous lesions with unclear, irregular contours, of non-homogeneous structure. In
38 cases the tumor was sleeve-like around the bronchus, in
the rest of the cases it was partially adjacent to the semicircle of the bronchus. In 15 cases there were signs of the
growth though all the layers of the wall, violated differentiation of bronchi walls layer, rough irregular contour. Morphological confirmation of malignant neoplasm was received in
48 (88.9%) patients, in 6 cases (11.1%) the material was poorly
informative, which is most likely caused by small size of tumor (<10 mm) or the lack of the invasion of tumor into bronchial wall.
Ultrasound study with convex sensor with scanning frequency 7.5 MHz with subsequent thin needle puncture aspiration biopsy with ultrasound control in real time was performed to 135 patients. The study was performed in order to
visualize mediastinal lymph nodes, bronchopulmonary nodules, mediastinum neoplasms, with subsequent puncture biopsy for morphological verification of the process. We performed the puncture of the following groups of lymph nodes
(Mountain-Dressler classification: upper paratracheal, lower
paratracheal, subcarinal, hilum lymph nodes, intralobular
lymph nodes. The scanning evaluates the shape of nodule
(flat, round, presence of thickened rim), contours (sharp, nonsharp), structure of lymph node (homogeneous or heterogeneous), presence of hyperechogeneous inclusions, septa (always present in sarcoidosis), vascularization degree as well
as the type of vascular component-linear or bent vessels.
Morphological confirmation of tumor damage of lymph nodes
was received in 125 (92.6%) of patients. Out of them in 18 patients we detected lymph proliferative damage, in 85 patients we detected cancer metastases to mediastinal lymph
nodes and bronchopulmonary metastases of different localizations, in 22 patients there was detected pulmonary sarcoidosis.
176
Background.
Postoperative bronchopleural fistula (BPF) is a serious complication that can lead to mortality. The purpose of this study
was to investigate how postoperative BPF should be treated.
Patients and Methods.
From January 2000 to December 2013, 1,296 patients underwent surgical resection for primary lung cancer at Kyorin
University Hospital. Of these, 1,114 patients who underwent
pulmonary resection greater than lobectomy were included.
Results.
Of the 1,296 patients, 20 developed BPF (1.5%). Surgical resection consisted of lobectomy in 13 patients, bilobectomy in
3, and pneumonectomy in 3. The pathologic stage was IA in
4 patients, IB in 6, IIB in 4, IIIA in 3, IIIB in 1, and IV in 1.
These patients were treated with conservative therapy including chest tube drainage in 6 patients, open drainage using a modified Eloesser flap technique in 10, and direct bronchial stump closure in 3 (including omentopexy in 2 and middle lobectomy and omentopexy in 1). Six patients developed
pneumonia due to aspiration of infected pleural effusion from
the fistula, and all patients needed mechanical ventilation.
The 90-day, 30-day and in-hospital mortality were 2 patients
(0.15%), 1 (0.08%), and 2 (0.15%), respectively. Regarding the
two patients who died in-hospital, one developed respiratory
failure due to bronchial anastomotic leakage after sleeve resection in the ninth postoperative day, and another had severe interstitial pneumonia and underwent steroid-pulse
therapy. Consequently, mechanical ventilation with high
pressure led to BPF and thereafter mortality in the 44th
postoperative day. There were no patients with uncontrollable infection of pleural cavity.
Conclusion.
Our basic treatment strategy for postoperative BPF is to
clean-up the infected pleural cavity and airway control. In
this study, treatment for postoperative BPF could be classified as conservative therapy, open drainage, and simultaneous closure of fistula. Open drainage with a modified Eloesser flap was the most frequently used and the most useful
drainage procedure in postoperative BPF. However, in cases
with aspiration pneumonia from fistula, mechanical ventilation is often needed.
Symposium
IP-SY24-i2
IP-SY24-3
Strategy of treatment for postoperative bronchopleural
fistura (BPF)
Bronchial!
pulmonary fistula treated by laparoscopic
omental flap transposition and endoscopic bronchial
occlusion
Department of General Thoracic Surgery, Jichi Medical University, Japan
Shinichi Yamamoto, Kentaro Minegishi,
Tomoki Shibano, Sayaka Mitsuda, Tomoyuki Nakano,
Kenji Tetsuka, Tsuyoshi Hasegawa, Shunsuke Endo
Background
Bronchopleural fistula (BPF) is one of the most feared complications in lobectomies and pneumonectomies because of the
high associated mortality. To detect the early state of BPF,
we perform fiberoptic bronchoscopy around 7 days after pulmonary resection over segmentectomy, especially in patients with a high risk of BPF. Accordingly, we enable endoscopic treatment for early state of BPF without invasive
treatments such as thoracoplasty, Elosser muscle flap, omental flap, and so on. Our first option for endobronchial treatment of BPF is bronchoscopic occlusion with polyglicolic acid
mesh (PGA). PGA mesh is absorbable, soft, thin, and easy to
cut. We describe the strategy of treatment for postoperative
BPF and the use of PGA mesh for bronchoscopic occlusion.
Method
From 2009 to 2013, surgical resection for lung cancer was
performed in 731 patients at our institution. Bronchoscopy
was performed around postoperative day 7 or immediately if
suggestive signs of BPF (fiver, hyperleukocytosis, and altered sputum) are present. When the endoscopic finding reveals BPF clearly, we performed bronchoscopic occlusion
with PGA mesh consecutively.
The bronchoscopic procedure was carried out under local
anesthesia and conscious sedation. The fiberoptic bronchoscope was introduced transorally with endotracheal intubation and advanced to view the BPF. PGA mesh was cut by 5
mm square sheet, and several sheets were occluded with biopsy forceps via working channel of bronchoscope. The obliteration of the air leakage from the chest drain were confirmed after the procedure. If air leakage remained, repeated
bronchoscopic occlusion was performed.
Result
BPF was observed in ten patients (1.37%, all males), with a
mean age of 70.8 years (range: 62-77). They were all treated
at our institution with bronchoscopic PGA mesh occlusion
for BPF. The obliteration of the fistula was confirmed in 9 patients. The number of times of the procedure was 1-3 per patient. In one case we performed open pleural drainage for a
post left pneumonectomy patient where 6 times treatments
of bronchoscopic PGA mesh occlusion proved ineffective.
Conclusion
Bronchoscopy performed around postoperative day 7 was effective to detect asymptomatic or early state of BPF. We recommend that bronchoscopic PGA mesh occlusion should be
the first line of management in patients with postoperative
BPF.
Department of Surgery II, Kochi Medical School, Kochi University, Japan
Takashi Anayama, Ryohei Miyazaki, Hironobu Okada,
Nobutaka Kawamoto, Kentaro Hirohashi,
Motohiko Kume, Kazumasa Orihashi
Background: The points of the treatment of chronic empyema are purification of the empyema cavity, the reduction
of the volume of the cavity, and the closure of bronchial!
pulmonary fistula. Fenestration of the thoracic cavity should be
performed as early as possible. The following thoracoplasty
and omentopexy should be performed electively after
achieving the infection control and completion of debridement. Some combination of appropriate surgical and bronchoscopic techniques should be performed in some cases. We
experienced two cases of postoperative bronchial!
pulmonary fistula which were successfully treated with the combination of surgery and endobronchial occlusion with silicon
spigots (EWS: Endobronchial Watanabe Spigot).
Case presentations:
Case1: A 76-year-old man, who had undergone a rt. Lower
lobectomy 5 months earlier, was admitted to the hospital
with the complaints of cough. He was diagnosed as pyothorax with bronchial fistula. Fenestration of rt. Thoracic cavity
was immediately performed. After another 6 months of sterilization of the thoracic cavity, the patient underwent a direct closure of the bronchial fistula, decortication of thoracic
cavity, thoracoplasty, and laparoscopic omentopexy to the
bronchial fistula. Protracted minor air leakage from the chest
tube was managed by endobronchial sclerotherapy followed
by embolization of bronchial stump of B6 with EWS. Air leak
was disappeared and chest tube was removed. After the final treatment, 9 months passed without any infection sign.
Case 2: 71-year-old man, who had undergone a rt. Lower
lobectomy 4 months earlier, was admitted to the hospital
with the complaint of fever up. The patient was diagnosed as
pyothorax with pulmonary fistula. Thracoplasty and omentopexy to the rt. Thoracic cavity were performed. Minor air
leakage from chest drainage tube was observed on 7th post
operative day. The responsibility site was identified as B4b
and B5 by bronchoscopic occlusion test with Fogerty catheter. EWSs were plugged in those bronchus. Air leak disappeared immediately after the treatment. 6 months passed
without infection sign.
Conclusion: the cases of chronic pyothorax with bronchial!
pulmonary fistula after lung resection were treated with thoracoplasty and laparoscopic omental flap transposition. Minor air leakage from bronchial pulmonary fistula was successfully managed by bronchoscopic intervention including
EWS embolization.
177
Symposium
IP-SY24-4
Comparison of endoscopic bronchial occlusion and intrapleural fibrin glue sealing for intractable pneumothorax
Department of Thoracic, Endocrine Surgery and Oncology,
The University of Tokushima Graduate School, Japan1), Department of Oncological Medical Services, The University of
Tokushima Graduate School, Japan2)
Mitsuhiro Tsuboi1), Hiromitsu Takizawa1),
Atsushi Morishita1), Takeshi Nishino1), Koichiro Kajiura1),
Yasushi Nakagawa1), Yukikiyo Kawakami1),
Mitsuteru Yoshida1), Shoji Sakiyama1), Kazuya Kondo2),
Akira Tangoku1)
Background:
The treatment of intractable pneumothorax varies. Endoscopic bronchial occlusion (EBO) and intrapleural fibrin glue
sealing (IFS) are treatments of choice for high-risk patients
with intractable pneumothorax in our institution.
Patients and methods:
We retrospectively reviewed the medical records of patients
treated by EBO or IFS. EBO was performed with endobronchial Watanabe spigots (EWS). IFS was performed with 4fold diluted fibrin glue with saline and contrast media which
were infused through a chest tube under X-ray fluoroscopy.
Between July 2005 and June 2012, 8 patients underwent
EBO and 17 patients IFS. Patient characteristics of EBO
group were as follows: median age of 69 (range: 67-80); male!
female: 7!
1; postoperative pulmonary fistula!
interstitial
pneumonia!
eosinophilic pneumonia!mesothelioma!emphysema: 3!
2!
1!
1!
1. Patient characteristics of IFS group were
as follows: median age of 72.5 (range: 60-85); male!
female: 14!
2; postoperative pulmonary fistula!
lung cancer!
interstitial
pneumonia!
emphysema!
radiation pneumonitis: 5!
3!
2!
2!
2.
In this study, we compared success rate of treatment, the duration of the tube drainage and days of hospital stay after
treatment between EBO and IFS groups.
Results:
The overall success rate of EBO was 50.0% (4!
8) and that of
IFS was 75.0% (12!
16), while the initial success rate of EBO
was 37.5% (3!
8) and that of IFS was 56.3% (9!
16). In successful cases, the duration of the tube drainage after treatment
was 7.5 7.1 days in EBO group and 6.3 4.4 days in IFS
group. Days of hospital stay after treatment was 11.5 9.3
days in EBO group and 17.5 12.7 days in IFS group. There
were no significant differences between the two groups in
the duration of the tube drainage and days of hospital stay
after treatment.
Conclusion:
The success rate of IFS was superior to that of EBO, though
there was no significant difference between the two groups.
Because background of the patients with intractable pneumothorax varies we have to choose the treatments considering the characteristics of them. IFS is relative easy, however,
it must be performed under X-ray fluoroscopy and patients
are required to change their positions. EBO requires skill
and experience, but it will be useful for patients with poorer
physical condition, such as on ventilators, because it can be
performed at the bedside.
178
Symposium
IP-SY24-5
IP-SY24-5
The clinical usefulness of endobronchial watanabe
spigot (EWS) for intractable pneumothorax and postoperative air leaks
Health care center, Fukujuji Hospital, Japan AntiTuberculosis Association, Japan1), Department of Respiratory
Medicine, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Japan2), Department of Thoracic Surgery, Fukujuji Hospital, Japan Anti-Tuberculosis Association, Japan3), Department
of Pulmonary Medicine and Oncology, Graduate School of
Medicine, Nippon Medical School, Japan4), Department of Pulmonary Diseases, Japanese Red Cross Okayama Hospital, Japan5)
Masako Ueyama1), Kozo Yoshimori2), Shingo Tsuji2),
Takeshi Osawa2), Kazunari Yamana2), Kozo Morimoto2),
Yoshitaka Nakagawa2), Ryozo Yano2), Masato Watanabe2),
Hiroyuki Kokuto2), Masao Okumura2), Yuka Sasaki2),
Takashi Uchiyama2), Mikio Saotome2),
Takashi Yoshiyama2), Hideo Ogata2), Yuji Shiraishi3),
Koichiro Kudoh2), Atsuyuki Kurashima2), Takashi Arai1),
Akihiko Gemma4), Shoji Kudoh2), Yoichi Watanabe5)
Background: Secondary spontaneous pneumothorax occurs as a complication of an underlying lung disease and is more difficult to treat. The
longer the hospitalization period becomes, the worse the management
of patient s condition becomes especially in elderly patients. Persistent
air leaks are also troublesome for many clinicians with the prediction
that improvement is unclear. The purpose of this study is to evaluate
the usefulness and efficacy of using Endobronchial Watanabe Spigot
(EWS) on pulmonary air leaks, measured by whether EWS can reduce
or stop them, can achieve the expansion of the lung and can result in
the successful removal of chest tubes. We, therefore, report our experience in those management with EWS, and hope that our treatment
method will be the useful method for many clinicians.
Methods: A retrospective clinical study was conducted on 40 intractable pneumothorax and 5 postoperative patients between January 2004
and March 2013. EWS is a silicone made bronchial blocker developed by
Watanabe in 1989. In case with persistent air leaks, chest tubes were inserted into the thorax firstly and then the bronchial occlusion with EWS
was performed. If there were no improvements shown, we applied the
occlusion several times, and sometimes gave the combination therapy
with pleurodesis or coagulation factor XIIIagent as the multiple treatment method.
Results: The most underlying diseases were COPD that were noted in
24 cases (60%). The size of pneumothorax was greater than medium
size in all patients and home oxygen therapy had already been prescribed before pneumothorax occurred in 12 patients (26.6%). The success rates of the treatment with EWS alone and of which including combination treatment with pleurodesis or factor XIIIwere 85.7% and 77.8%,
respectively. EWS alone and combination therapy enabled the complete
expansion of the lung in intractable pneumothorax cases (except 3 fenestration cases) in 81.1% (30!37). The effect of EWS was obvious, which
often enabled pleurodesis to be more successful. Chest tube removal
was achieved in 41 cases (91.1%). Concerning complications, three cases
showed pneumonia suggestive of fungal infection after long time placement (8months, 21months, 4years) of EWS and we think that caution
must be taken in long term placement of EWS especially in compromised or infected patients with severe bullous changes in their lungs.
Conclusion: By stopping air leaks and curing intractable pneumothorax,
EWS is of great use as a bronchial blocker for patients who are unlikely
able to have chest tubes removed.
179
Symposium
IP-SY24-6
IP-SY24-7
Airway stenting for emergency treatment of severe
cancerous tracheal stenosis
Withdrawn
Department of respiratory diseases, Southwest Hospital,
Third Military Medical University, China
Jianlin Hu, Liang Gong, Wei Fan, Xiangdong Zhou,
Chunlan Tang, Yongfeng Chen
BACKGROUND: Tracheal stenosis can be caused by primary bronchogenic carcinoma and other cancers, such as
esophageal cancer. Sometimes, severe cancerous tracheal
stenosis leads to lethal respiratory failure. Airway stenting,
wich is useful for common tracheal stenosis treatment, is
considered to be dangerous for severe bronchial stenosis
treatment. This article is to evaluate the efficacy and safety
of airway stenting in treating severe cancerous airway
stenosis. METHOD: From 2!
2002 to 4!
2013, five patients
with cancerous tracheal stenosis developed severe respiratory failure with carbon dioxide narcosis during hospitalization. Nickel-titanium stents were implanted into affected areas of the five patients emergently at bedside. Four stents
expanded to satisfactory extent automatically several minutes later. One stent expanded after balloon dilation. All the
five patients recovered from respiratory failure in 8 to 15
minutes after stenting. Four patients died from lung infection and recurrence of tracheal stenosis in 2 to 6 month. One
patient suicided on 10th day after stenting. CONCLUSION:
Emergent tracheal stenting at bedside is valuable to patients
with severe cancerous tracheal stenosis, Time and opportunity for more effective therapy could be obtained by this procedure in some patients.
References:
[1] Saad CP, Murthy S, Krizmanich G, et al. Self-expandable
metallic airway stents and flexible bronchoscopy: long-term
outcomes analysis[J]. Chest, 2003; 124(5): 1993∼1999.
[2]Andreetti C, D Andrilli A, Ibrahim M, Rendina EA.Treatment of a complex tracheobronchial malignant stenosis with
a modified conical semicovered self-expanding stent.J Thorac Cardiovasc Surg. 2013 Aug;146(2):488-9.
180
Symposium
IP-SY25-i1
IP-SY25-2
Ion mobility spectrometry for breath analysis
New developed simple method to evaluate human
bronchial ciliary movement using bronchoscopic sample
Faculty Applied Chemistry, Reutlingen University, Germany
Jörg Ingo Baumbach
Actually, different analytical methods are used to investigate
exhaled breath, including mass-spectrometric (MS) and ion
mobility spectrometric (IMS) methods. Here, IMS is on the
way towards identification and quantification of gas traces
down to the pg!
L-range (pptv) within rather complex matrixes. For proven applications of IMS-technology in exhale
analysis it́s not only the detection of the ingredients on trace
level to be realized (measurement, identification, quantification). With respect to the medical question behind, the classification of different groups of patients (training and validation groups) must be realized and statistical and bioinformatic methods are used for comparison.
Ion mobility spectrometry (IMS) of exhaled breath started
some years ago and arrived today in integrative systems biology and metabolomics using volatile metabolites in science
directly. Actually, about 10 mL of breath are necessary to
carry out a full analysis. For investigations of human breath
at a high level of humidity a combination of a Multi-Capillary
Column (MCC) partly pre-separating the analytes is used in
combination with a conventional ion mobility spectrometer
(IMS). An IMS coupled to a MCC allows the identification
and quantification of volatile metabolites occurring in human
breath down to the ng!
L- and pg!
L-range of analytes within
less than 12 minutes and without any pre-concentration
steps directly. In addition, time series during medication of
patients could be realized bed-side.
Proven applications will be considered and recent results in
metabolomics and breath gas analysis presented. In addition,
the possibilities to correlate the peaks in IMS-Chromatograms
with the corresponding analytes a software solution based
on investigations using parallel measurements of exhaled
breath using gas chromatography coupled to a mass selective detector (GC!
MSD) and MCC!
IMS will be introduced. In
this way, the direct identification of analytes occurring in exhale will be supported.
Finally, a database (DB-Breath-1402) supported systems approach will be presented to locate correlations on the way
from peaks towards analytes- metabolites- biomarkers.
Results of proven applications are presented: differentiation
of chronic obstructive pulmonary disease (COPD) including
lung cancer from healthy control group, correlation of signals
in breath and FEV1-values, pharmaco-kinetic and -dynamic
monitor for Propofol, a rat model to compare time series under different antibiotic therapies investigating the exhale
with respect to markers of SEPSIS, metabolites occurring in
the human breath in relation to bacterial infections.
Division of Respiratory Medicine and Oncology, Gifu Municipal Hospital, Japan1), Department of Central Clinical Laboratory, Gufu Municipal Hospital, Japan2), Department of Respiratory Medicine, Gifu University, Japan3), Department of Circuratory Medicine, Gifu University, Japan4)
Toshiyuki Sawa1), Tsutomu Yoshida1), Takashi Ishiguro1),
Akane Horiba1), Yohei Futamura1), Takaaki Hasegawa1),
Tominori Fukagawa2), Toshihiro Mutoh2),
Takafumi Naiki2), Yasushi Ohno3), Shinya Minatoguchi4)
Background: As mucociliary transport (MCT) of airway plays
an important role as a defense mechanism in chronic lower
respiratory tract infection, to know the ability to defend
against infection of individual patients is also useful clinically.
We report that the human bronchial ciliary movement and
clinical applications was evaluated by a newly developed
simple direct observation method using a bronchoscope sample.
Method: when the bronchoscopy was performed to identify
pathogens and pathological diagnosis in the patients with
respiratory disease, bronchial lavage to the transbronchial
biopsy site was examined to collect peripheral bronchial epithelial cells.
After the epithelial cells moving around by ciliary motion
were observed to identify with microscopy without staining.
the cilliary beat were captured at 240 frames per second using a high-speed photographing function of the generalpurpose digital video camera on the market.
By analysis of the videos captured, frequency and amplitude
of the ciliary movement was measured.
Results: Human ciliary epithelium in the patients with respiratory disease was confirmed that they are exercising in the
amplitude of 3∼5μm and frequency of 5∼15bps.
In addition, in the non-tuberculous mycobacterial disease of
the lungs, the frequency was reduced slightly.
It was observed that ciliary movement is activated by tiotropium load in the case whom ciliated epithelium has declined.
Conclusion. Even in general hospitals without specialized
equipment, it is possible to observe easily and directly the
movement of human airway ciliary epithelium using a bronchoscopic sample, to evaluate the frequency of ciliary movement. It was suggested.that the tiotropium may improve the
ciliary movement in the clinical dose.
181
Symposium
IP-SY25-3
IP-SY25-4
Prospective randomized controlled trial comparing a
novel hybrid EBUS to conventional EBUS
OCT in bronchoscopic diagnosis and treatment of preinvasive endobronchial lesions
Johns Hopkins Medical Institutions, USA
Lonny Yarmus, Hans Lee, Ricardo Ortiz, Jason Akulian,
Molly Hayes, Sixto Arias, David Feller-kopman,
Kopen Wang
Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the gold standard
for the staging of lung cancer. However, conventional EBUS
(C-EBUS) bronchoscopes are limited in their ability to perform a full airway examination due to a 35-degree forward
oblique viewing field and limited scope flexion (120 degrees)
and larger outer diameter (6.9mm) that often requires the
use of an additional bronchoscope. Recently, a hybrid EBUS
bronchoscope (H-EBUS) with a 10-degree oblique viewing
field, 130 degree flexion and narrower external diameter has
been introduced. We hypothesized that the H-EBUS scope
would reduce the need for an additional bronchoscope and
decrease cost during lung cancer staging procedures.
Methods: A prospective, randomized controlled trial was
performed to evaluate the differences between H-EBUS
(Fuji, Japan) and C-EBUS (Olympus, Center Valley, PA) for
the diagnosis and staging of lung cancer. Prior to lymph node
sampling, a full airway examination was attempted utilizing
either the H-EBUS or the C-EBUS. The primary outcome
was to compare the number of bronchoscopes used per procedure. Secondary outcomes included the number of visualized airways segments, overall cost per procedure, and adequacy and diagnostic yield of TBNA.
Results: 62 patients were randomized to undergo EBUSTBNA with either the H-EBUS (n=30) or C-EBUS (n=32. In
patients requiring nodal staging only, conversion rates for
the use of a second bronchoscope were 0!
15 H-EBUS and 5!
17 C-EBUS (p=0.046). H-EBUS allowed for visualization of
more airway segments in the left upper lobe (p=0.0047), left
lower lobe (p=0.0012), and right lower lobe (p=0.0054). There
were no differences in overall adequacy and diagnostic yield.
When comparing procedures requiring the use of one EBUS
scope to those requiring a second bronchoscope, the mean
procedural time was reduced from 38 minutes to 28 minutes
(p=0.007). There was an overall cost reduction of $380.15
(95% CI=$153.62, $606.68) per procedure with H-EBUS.
Conclusion: H-EBUS (Fuji, Japan) when compared to CEBUS allowed for improved airway visualization limiting the
need for additional bronchoscopes during lung cancer staging thus reducing procedural costs.
182
Pulmonology Service. University Clinical Hospital of Valladolid, Valladolid, Spain.1), Cardiology Service. University
Clinical Hospital of Valladolid, Valladolid, Spain.2), Pathology
Service. University Clinical Hospital of Valladolid, Valladolid,
Spain.3), Thoracic Surgery Service. University Clinical Hospital
of Valladolid, Valladolid, Spain.4), Oncology Service. University
Clinical Hospital of Valladolid, Valladolid, Spain.5)
Carlos Disdier1), Dagoberto Bejarano1),
Hipolito Gutierrez2), Henar Borrego3), Jose M Matilla4),
Rafael Lopez5), Isabel Ramos1), David Vielba1),
Enrique Macias1), Santiago Juarros1)
Introduction: Optical coherence tomography (OCT) is a noncontact imaging technique with high resolution and real-time
axial images of cellular microstructure of superficial bronchial wall via flexible fiberoptic bronchoscopy. The axial
resolution of 10 to 20 μm and depth penetration of ∼2 mm
may provide near-histologic images ideal to study preinvasive bronchial lesions.
Aim: To determine the usefulness of this technique in the
bronchoscopic study of carcinoma in situ and severe dysplasia and evaluate the role of OCT in deciding endoscopic
treatment with curative intent by endobronchial cryotherapy in early central bronchogenic carcinoma (Stage 0 or IA).
Methods: We performed in all patients with suspected early
lung cancer a protocol with chest CT scan, PET!
CT and autofluorescence bronchoscopy (AFB). OCT probe was inserting though the working channel of the bronchoscope and endobronquial characteristics, wall thickness and length of the
endoscopic lesions were recordered. After OCT study, a forceps or cryoprobe biopsy was taken in the same procedure
and cryotherapy was performed to treat suspected or confirmed preinvasive lesions.
Results: Seven patients with eleven endobronchial preinvasive lesions were included (ten in situ carcinomas and one severe displasia). Nine lesions with structural changes and
thickening of mucosal layer: Carcinoma in situ thickening
were between 0.28 to 0.73 mm. (Moderate and severe dysplasia: 0.36 to 0.59 mm). Two in situ carcinomas, one after biopsy
before treatment and other patient after one session of cryotherapy had OCT normal findings. One patient was treated
with surgery and cryotherapy in a bilateral sincronic tumor.
Complete response with cryotherapy was achieved after one
session in 6 lesions and after two sessions in other three.
Conclusions: OCT combined with AFB is a useful technique
to select candidates for endoscopic treatment with curative
intent and evaluating degree of depth invasion into the mucosa.
OCT study must be performed in suspected preinvasive endobronchial lesion before endobronquial biopsy.
OCT imaging could become a useful tool in the early recognition of lung cancer and can direct the biopsy and the decision
to treat endoscopically central early lung tumors.
Symposium
IP-SY25-5
IP-SY25-6
Probe-based confocal laser endomicroscopy in the diagnosis of diffuse parenchymal lung disease
Multi center controlled trial of confocal laser endomicroscopy in the diagnosis of malignant pulmonary lesions
Interventional Pulmonary Program, Louisiana State University Health Sciences Center, USA
Adam Wellikoff, Ashley Ferraro, Robert Holladay
Backgound: The diagnosis of diffuse parenchymal lung disease (DPLD) can be challenging and many patients are poor candidates for surgical biopsy. The role of transbronchial biopsy (TBBx) in DPLD has been debated, with a diagnostic yield of 50-75%,
due the heterogeneity associated with these disorders. Probe-based confocal laser endomicroscopy (pCLE) is a technology that may improve the diagnostic yield of TBBx
for DPLD. pCLE uses a 488nm wavelength laser in a 1.4mm fiberoptic probe passed
through the working channel of a bronchoscope. Elastin!collagen have natural autofluorescence and therefore can be seen using pCLE. Normal alveolar tissue has an organized appearance with smooth alveolar septae and microvessels whereas abnormal
tissue has varying degrees of disorganization and friability. DPLD causes alterations in
the elastin!collagen framework that can be detected using pCLE to guide TBBx s.
Case Series: Three patients with abnormal interstitial findings on CT were identified.
The first patient, a 40-year-old male with history of acute lymphocytic leukemia statuspost allogeneic bone marrow transplant with subsequent development of chronic
graft-versus-host disease treated with methotrexate presented with progressive dyspnea and nonproductive cough. Chest CT showed thickening of the bronchovascular
bundles with interstitial changes. A second patient, a 57-year-old female with history
of pulmonary alveolar proteinosis (PAP) presented with progressive dyspnea and
cough. Chest CT was consistent with PAP exacerbation and whole lung lavage was
performed. Our final patient, a 58-year-old female with a history of rheumatoid arthritis and a lifetime non-smoker presented with a productive cough and dyspnea refractory to antibiotics. Chest CT showed a nodular sub-solid consolidation in the right upper lobe. All three patients underwent bronchoscopy with the use of pCLE to target
abnormal lung parenchyma. In all patients, varying amounts of elastin disorganization
and septal thickening was demonstrated with pCLE with the exception of PAP where
large autofluorescent globules were seen representing lipoproteinaceous material. The
abnormal areas identified by pCLE were sampled revealing changes consistent with
methotrexate toxicity, PAP and pulmonary Langerhans cell histiocytosis, respectively.
Conclusion: pCLE in our series of patients demonstrated usefulness in confirming parenchymal abnormalites at the site of TBBx. Being able to distinguish normal from abnormal tissue, based on changes in the tissues microscopic appearance, allows confidence when selecting the site for TBBx. pCLE may be able to increase the diagnostic
yield of TBBx in DPLD. Moving forward, future studies are undoubtedly needed to
help determine the role of pCLE in DPLD.
Interventional Pulmonology, Department of Medicine, Ohio
State University, USA1), Walter Reed National Military Medical Center, USA2), Louisiana State University, Shreveport,
USA3), University of Rochester, USA4), Columbus Regional Hospital, USA5), University of Chicago, USA6), University of Michigan, USA7)
Shaheen Islam1), Robert Browning, jr2), Adam Wellikoff3),
Sandhya Khurana4), David Wilson5), Kyle Hogarth6),
Douglas Arenberg7), Robert Holladay3)
Background:
In the recent National Lung Screening Trial (NLST), 24.2% had
positive findings with low dose computed tomogram (CT). However, 96.4% of all positive CT findings were classified as false positive demonstrating the need for diagnostic tests with high negative predictive value to further identify true malignant lesions to
reduce the costs, resource utilization, morbidity and mortality associated with unnecessary procedures. Probe-based confocal laser endomicroscopy (pCLE) is currently used successfully in the
gastrointestinal tract to diagnose Barrett s esophagus and biliary
strictures. We evaluated the role of pCLE during bronchoscopy
to identify distinct imaging patterns suggestive of malignancy.
Methods:
This is an IRB approved multicenter, prospective trial. In Phase
1, the pCLE imaging criteria were developed; and in Phase 2
these criteria will be validated, with 30 patients in each phase. All
patients with discrete pulmonary nodules suspicious for malignancy based on clinical presentation were enrolled. Bronchoscopy
with guidance (navigation or radial probe ultrasound) was used to
access the discrete nodule. pCLE images were collected prior to
transbronchial biopsy, TBNA, and brushings. Use of the guidesheath confirmed that the imaging and biopsy were obtained
from the exact same location. All patients were followed when
the initial bronchoscopic biopsy was non-diagnostic to obtain a final pathological diagnosis from additional tests. The images acquired were reviewed and interpreted based on previously established criteria and were further modified. Three blinded investigators later used these criteria to determine the diagnostic accuracy of the pCLE images from malignant lesions.
Results:
In phase 1, 30 patients from 4 centers with discrete lung lesions
were enrolled between February and September 2013. 9 patients
had malignant lesions (7 Adenocarcinoma, 2 Squamous cell carcinoma) confirmed by pathology. The characteristics of the pCLE
images for the malignant lesions are; i) Loss of normal alveolar
high density elastin wall architecture with abnormal clumps , ii)
Friable elastin, and iii) Presence of holes or negative space. In addition, some lesions showed a granular appearance that may indicate necrotic tissue. Of these malignant lesions, 7 were correctly
identified as malignant from the pCLE images by the blinded investigators using these imaging criteria.
Conclusion:
Malignant lesions have a distinct imaging pattern identifiable
with pCLE that can be used successfully for additional guidance
during bronchoscopy.
Funding: Mauna Kea Technologies; Paris, France
183
BLVR Symposium
IP-SY-B1-1
IP-SY-B1-2
BLVR: State of the art
Lessons from endoscopic lung volume reduction trials
Pulmonary Diseases Unit, Polytechnic University of Marche
Region, Italy
Respiratory Medicine, University Hospital Lewisham &
Greenwich NHS Trust, UK
Stefano Gasparini
Tudor Toma
In recent years, different bronchoscopic techniques have
been proposed for the treatment of emphysema, with the
aim to obtain the same clinical and functional advantages of
lung volume reduction surgery, while reducing risks and
costs.
The topic is fascinating and it seems interesting and timely
to attempt to answer, on the basis of the available literature
results, the following questions: 1)what is the current state of
the bronchoscopic management of emphysema, 2) what are
the technical characteristics, the advantages and limits of
each procedure, and 3) what are the implications for the daily
clinical practice?
The different bronchoscopic techniques that have been proposed for bronchoscopic treatment of emphysema may be
classified on the basis of the underlying mechanism into
three main groups: blocking devices that act at proximal
bronchi level with the aim to produce bronchial occlusion
and atelectasis, devices that work at the pulmonary parenchymal level, and methods that create extra-anatomical airways to facilitate lung deflation.
The emerging scenario is characterized by the definition of
different emphysema phenotypes, since not all the procedures are indicated in all the cases and each technique appears to provide greater benefit to specific subgroups of patients. The assessments of collateral ventilation, emphysema
heterogeneity and distribution, degree of hyperinflation and
lung tissue consistency are all elements that must be carefully considered to identify the best technique for each individual patient.
Therefore, patient selection is key to a successful treatment
and close cooperation between bronchoscopists, pulmonary
pathophysiologists and radiologists is an essential step in
achieving this aim.
The main points of this presentation will be:
1) the physiopathological basis and how does it work the lung
volume reduction in emphysema;
2) the indications for the bronchoscopic treatment of emphysema and the various emphysema phenotypes that could
benefit from the different kind of treatment;
3) the methodological steps for performing each procedure;
4) the results, contraindications and limits of each technique,
as provided by the more recent literature.
According to the complexity of this therapy, bronchoscopic
treatment of emphysema should be performed in selected
Centers with expertise in various treatment modalities. Such
centers should also have the expertise to carefully select subjects based on clinical, functional and imaging characteristics
and have the ability to follow the patients, providing alternative therapies in case of bronchoscopic treatment failure.
184
Endoscopic lung volume reduction is a term that we associate today with a number of minimally invasive techniques
aimed at improving quality of life and functional status in patients with severe emphysema. There are now over 300 publications listed in Pubmed on this topic only. What have we
learned so far since the initial reports presented in 2001?
The firstly introduced and most studied technique is based
on unidirectional valves that stop the entry of air into parts
of the lungs. Volume reduction is achieved through atelectasis. We have learned from case series and from few randomized studies that the insertion of valves is safe and can make
patients feel better. However, the reasons why patients do
not respond to valve treatment and the precise criteria for
patient selection are not clear. Interlobar collateral ventilation has a role to play, but even in patients with no collateral
ventilation the success is not entirely predictable. Although
the valves are removable, strategies based on trials of treatment have not been systematically tested.
The understanding that endobronchial valves are safe has
opened up the field to other innovative bronchoscopic strategies. Most studied are coils, polymeric based techniques, and
steam. Although their mechanism of action is different from
the valves and independent of the presence of collateral ventilation, the efficacy remains variable and unpredictable.
Moreover, coils, polymers and steam are irreversible treatments.
Most trials so far used selection criteria largely based on surgical volume reduction publications. In setting up the primary outcomes there was also a pressure for early pivotal
all or nothing studies in terms of benefits, both from regulators, and also from investors, and some of the randomized trials were done prematurely. With these methodologies endoscopic volume reduction is at risk of being labeled as inefficient and rejected from the routine clinical practice.
A novel approach to clinical research is probably required
when we are evaluating new treatments for emphysema. Severe emphysema is a truly unique end result of a combination of factors, and an individualized approach to each patient should be considered. Multidisciplinary meetings,
where individual endoscopic treatment options and selection
algorithms are discussed, represent a limited solution to the
problem, and should be evaluated in prospective trials.
BLVR Symposium
IP-SY-B2-1
IP-SY-B2-2
Functional CT imaging for chronic obstructive pulmonary disease
Pulmonary functional MR imaging for COPD
Department of Radiology, St. Marianna University School of
Medicine, Japan
Shin Matsuoka
CT has been recognized to be morphological imaging, however, the recent development of CT technology and computer software, and several scan techniques such as expiratory CT or dynamic respiratory CT contribute to quantitative analysis of pulmonary function in several lung disorders.
These functional evaluations are of assistance to pathophysiological clarification of several pulmonary diseases, and the
evaluation of therapeutic effects. In particular, various quantitative methods have been introduced in chronic obstructive pulmonary disease (COPD) that are damaged variety of
lung components including lung parenchyma, large and
small airway and small vascular structure.
As for the lung parenchyma, the extent of emphysema can
be measured using CT threshold technique. This technique
has been used for the evaluation of lung volume reduction.
COPD is characterized by the presence of airflow limitation,
with the most likely site of airflow obstruction in the small
airways. Several studies have showed that the densitometric
parameters of the lung parenchyma calculated on paired inspiratory and expiratory CT scans allow indirect evaluation
of small airway obstruction and air trapping. In regard to
large airway, several studies suggest that airways visible on
CT are also associated with airflow limitation in COPD. For
the evaluation of large airway, bronchial wall thickness,
bronchial luminal area, and bronchial wall attenuation have
been used for the quantitative analysis. These CT parameters have significant correlations with airflow limitation in
the results of pulmonary function test.
Pulmonary vascular alteration is one of the characteristic
features of COPD. Passive vascular compression by emphysema and hypoxic vasoconstriction has been considered the
major pathogenesis of vascular alteration in COPD. Histologically, pulmonary vascular alterations are not exclusive to advanced COPD, however, as they are present in patients with
mild COPD and even in smokers with normal pulmonary
function. Recently, several studies have shown that the
cross-sectional area (CSA) of small pulmonary vessels, which
can be quantitatively measured on chest CT, is reliable for
evaluating the vascular alterations of small pulmonary vessels in vivo. This CSA method also can be used for the evaluation of pulmonary hypertension and pulmonary perfusion.
In this presentation, with a central focus on COPD, a variety
of quantitative CT analyses including emphysema, large and
small airway disease, and pulmonary vascular disease will be
explained.
Advanced Biomedical Imaging Research, Kobe University
Graduate School of Medicine, Japan
Yoshiharu Ohno
Pulmonary magnetic resonance (MR) imaging has been put
forward as a new research and diagnostic tool mainly to
overcome the limitations of CT and nuclear medicine study.
However, pulmonary MR imaging has been difficult to use
because of inherently low proton density, a multitude of airtissue interfaces, which create significant magnetic field distortions and are commonly referred to as susceptibility artifacts, diminishing signal in the lung, and respiratory and!
or
cardiac motion artifacts.
To overcome these drawbacks of pulmonary MR imaging,
technical advances made during the last decade in developing and advancement of sequence, scanner and coil, adaptation of parallel imaging techniques, and utilization of contrast
media have been reported as useful for functional and morphological assessment of various pulmonary diseases.
Pulmonary MR imaging currently provides not only morphology related, but also pulmonary function related information. It has the potential to replace nuclear medicine studies for the identification of regional pulmonary function and
may perform a complementary role in various pulmonary
disease assessments and patient managements instead of nuclear medicine study. In addition, pulmonary functional MR
imaging can provide morphological and functional changes of
lung structures, circulation, ventilation and oxygen diffusion
using qualitative and quantitative assessments. In addition,
pulmonary functional MR imaging is currently applied at 1.5
Tesla (T) MR system, and will be gradually move to 3T MR
system.
This lecture covers 1) state of the art pulmonary MR techniques for morphological and functional assessment, 2) its
clinical applications in COPD and 3) future direction of pulmonary functional MR imaging.
We believe that the findings of further basic studies as well
as clinical applications of this new technique will validate the
real significance of pulmonary MR imaging for the future of
pulmonary disease assessment and its usefulness for diagnostic radiology and pulmonary medicine.
185
BLVR Symposium
IP-SY-B3-1
IP-SY-B3-2
Bronchoscopic lung volume reduction coil treatment
for patients with severe emphysema
Endobronchial sealant and steam
Department of Pulmonary Diseases, University Medical Center Groningen, Netherlands
Dirk-Jan Slebos
The Lung volume reduction coil (LVR-coil) treatment is a
promising novel bronchoscopic technique for the treatment
of patients with severe emphysema. The LVR-coil treatment
works independently of collateral flow, can be used in upperand lower lobe emphysema and in patients with homogeneous disease. Furthermore, already in these early phase clinical trials, a high responder rate is observed. The LVR-coil
procedure is technically feasible and results in significant improvements in pulmonary function, exercise capacity and
quality of life with an good safety profile. Overall data form
four European studies with nearly identical protocols were
analyzed out to one year post-treatment. In this analyses 119
patients (mean age: 61 years, mean FEV1: 29% pred, mean
RV: 245% pred., mean 6MWT 313m) were treated by bilateral LVRC performed in two separate procedures in two
contralateral lobes, with follow-up at 6 months and one year.
In these patients a toatl of 2311 LVR-coils were placed in 238
procedures (mean 9.7 1.6 per lobe). Serious adverse events
(SAE) in the 30 days following treatment included 13 COPD
exacerbations (5.5%), 1 hemoptysis (0.5%), 11 pneumonia
(4.6%), 9 pneumothorax (3.8%), no deaths or acute respiratory
failure. All SAEs resolved with standard care. Effects of
LVRC treatment at 6 and 12 months showed significant and
sustained mean efficacy: ΔFEV1: +14.9% 22 and +13.2% 27;
ΔRV: -0.59L 0.76 and -0.52L 0.77; Δ6MWD: +44m 67 and
+51m 62; and ΔSGRQ: -11.2pts 12 and -10pts 12 (p<0.0001
for all values). Post-hoc analysis at 6 months was performed
on 63 patients to compare homogeneous and heterogeneous
response. Both RV, 6MWT and SGRQ responses were similar between the two groups, regardless of the calculation
method. Only the FEV1 response differed significantly in favor of the heterogeneous group. LVRC treatment results in
significant and clinically relevant improvements in exercise
capacity, lung function, and quality of life for patients with
homogeneous and heterogeneous emphysema. Patient relevant improvements from LVRC treatment are sustained at
one year.
References
・DJ Slebos, et al. Bronchoscopic lung volume reduction coil
treatment of patients with severe heterogeneous emphysema. Chest 2012;142:574-82.
・PL Shah, et al. Endobronchial coils for the treatment of severe emphysema with hyperinflation (RESET): a randomised
controlled trial. Lancet Respir Med 2013;1:233-40.
186
Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Germany
Felix JF Herth
The 10 years of resurgent interest in lung volume reduction
surgery (LVRS) and recent National Emphysema Treatment
Trial findings for emphysema have stimulated a range of innovative alternative ideas aimed at improving outcomes and
reducing complications associated with current LVRS techniques. Concepts being actively investigated at this time include surgical resection with compression!
banding devices,
endobronchial blockers, sealants, obstructing de¬vices and
valves, and bronchial bypass methods. These novel approaches are reaching the stage of clinical trials at this time.
Theory, design issues, methods, potential advantages and
limitations, and available results are presented. Extensive research in the near future will help to determine the potential
clinical applicability of these new approaches to the treatment of emphysema symptoms.
Given the evidence that lung volume reduction (LVR) can be
beneficial, but recognizing the cost and morbidity of major
surgery,investigators have been vigorously pursuing research into innovative alternative methods for achieving
LVR in recent years.
In theory, LVR could be accomplished by the blockage or closure of conducting airways and by the collapse of the distal
alveoli from an endoscopic lation of fibrin glue leading to regional collapse and approach. A variety of methods have
been proposed bronchoscopic volume reduction. The theoretical for this, including the injection of biopolymers or advantages of this approach include the following: tissue glues,
the installation of biologically active nonsurgical minimally
invasive procedures can be mediators to cause contraction
and fibrosis, endo-used; incremental application is possible
with the bronchial valves or plugs, and!
or combinations of
ability to perform repeated limited procedures; air¬these
methods. Leak risk may be reduced or eliminated; cost reduc
¬tion could be considerable; and the procedure potentially
could be performed on an outpatient basis. Ingenito et al.
published the first manuscript Theoretical risks and technical hurdles that must be describing bronchoscopic LVR involving the instal-addressed include the potential for ventilation per¬fusion mismatch and hypoxemia if lung regions
with persistent pulmonary blood flow are obstructed (without concurrent elimination of the correspond¬ing circulation). Questions arise about the risk of postobstructive infection. Methods must ensure that the occluded regions will collapse despite collateral ventilation and will not spontaneously
reopen over time. In addition, it is uncertain whether the ana
¬tomic distribution effects and physiologic response of segmental or subsegmental volume reduction will provide similar results to current peripheral lung tissue reduction approaches.
BLVR Symposium
IP-SY-B3-3
IP-SY-B3-4
Endobronchial one-way valves? 15mns
Bronchoscopic lung volume reduction: Patient selection & treatment algorithm
Ruhrlandklinik Essen, Germany
Lutz Freitag
Respiratory Medicine, Royal Brompton Hospital, UK
Pallav L. Shah
Emphysema is abnormal, permanent enlargement of air
spaces distal to the terminal bronchioles and the destruction
of their walls associated with loss of the elastic connective
tissue but without obvious fibrosis. This has the dual effect of
reducing gas exchange and inducing expiratory airway collapse with consequent airflow obstruction. This leads to air
trapping and the effect is exaggerated during exercise as the
increased respiratory rate leads to decreased expiratory
time and hence further air trapping. This process is termed
as dynamic hyperinflation. Breathing at higher lung volumes
shifts the compliance curve to the right and hence a greater
effort is required for a given change in tidal volume. In addition with hyperinflation the changes in the length-tension relationship of inspiratory muscle and splinting of the diaphragm further impairs ventilation.
Patients have significant symptoms despite maximal medical
therapy and pulmonary rehabilitation. Single lung transplantation is a possible treatment option but organ availability is
limited. Lung volume reduction surgery (LVRS) has been
shown to be a potential option in patients with significant upper zone disease and poor exercise capacity. Improvements
in quality of life, reduction in breathlessness and improvements in exercise capacity have been reported in a large randomised control study (NETT study 2003). The success of
LVRS has prompted the developments of bronchoscopic
techniques that reduce the lung volume.
A full clinical assessment, pulmonary function tests and a CT
scan of the thorax is required for patient selection. Patients
with clinical features of emphysema on maximal medical
treatment who have evidence of severe airflow obstruction
(FEV1<50%) and hyperinflation (Residual Volume>180%).
The pattern of emphysema, area of the lung that is predominantly involved, and integrity of the inter lobar fissures on
the pulmonary CT scan guides the optimal treatment strategy.
187
Lung Cancer One Day Symposium
IP-SY-L1-1
IP-SY-L1-2
Free lung cancer screening with low dose CT scan:
Single institution experience Lahey Hospital and
Medical Center
Lung cancer screening in japan using reduced-dose
CT
Department of Pulmonary & Critical Care Medicine!Interventional Pulmonology, Lahey Hospital and Medical Center,
United States
Carla Lamb
Lung cancer is the leading cause of cancer-related mortality
in both men and women in the United States. Despite advances in lung cancer management and diagnosis, the majority of patients present with advanced disease with overall
poor longterm survival. In 2011, the National Lung Screening
Trial ( NLST)demonstrated a 20% reduction in lung cancer
specific mortality with annual screening chest ct scanning in
asymptomatic high risk patients between the ages of 55 to
74. In 2011, there was an estimated 8.9 million NLST eligible
individuals in the United States alone. To accomodate this
new screening recommendation, medical centers across the
country will need to develop responsible and cost effective
multi-disciplinary lung cancer screening programs to minimize risks inherent with radiographic population screening
while hopefully realizing the mortality benefit observed in
NLST. While the results of the NLST are encouraging, the
real-world experience with the development of CT lung cancer screening programs outside of the context of large multicenter clinical trials remains limited. Lahey Hospital and
Medical Center introduced a CT lung cancer screening program in January of 2012. Given that during this time most
public and private payers did not reimburse for CT lung cancer screening, the decision was made to initially offer CT
lung cancer screening exams at no cost to patients who met
set criteria for high risk based on pre-established guidelines.
The purpose of this symposium is to present the initial experience with the implementation of such a real-world program
as compared to that of the NLST.
188
Radiology, St. Marianna University School of Medicine, Japan1),
Radiology, University of the Ryukyus, Japan2)
Tsuneo Yamashiro1), Sadayuki Murayama2),
Yasuo Nakajima1)
The clinical advantage of computed tomography (CT)
screening for lung cancer is still controversial. Although the
National Lung Screening Trial (NLST), which is being conducted in the US, has clarified that mortality from lung cancer and any cause is significantly reduced by CT screening
of high-risk groups for lung cancer, other major trials have
not concluded that CT-based lung screening is truly beneficial for reducing lung cancer-related deaths in the general
population or smokers. In contrast, it has been reported that
small-sized lung cancers or lung cancers consisting of
ground-glass opacities (GGOs) are very difficult to detect on
conventional chest radiographs, thus CT screening is recommended to diagnose these small or early-stage lung cancers.
A major drawback of CT-based lung screening is the increase in radiation exposure compared to conventional radiography. Currently, all major clinical trials involving CT
screening for lung cancer have adopted reduced-dose chest
CT (typically<80 mAs); however, the total radiation exposure by CT screening is still much higher than a conventional radiograph, and it is often 10-fold higher than chest radiography. Thus, selecting targeted subjects, the interval of
time between CT screenings, and a larger reduction in radiation dose is necessary to manage CT screening for lung cancer.
In Japan, CT screening for lung cancer is widely used in
place of conventional chest radiography during general
medical examinations, reflecting the large number of multidetector CT (MDCT) scanners available nationwide. The
Japanese Society of CT Screening has defined the guidelines
for lung cancer screening, and a board certification for CTbased lung screening is being offered by the Japan Accreditation Council for Lung Cancer CT Screening. In this lecture,
I would like to introduce the progress which has been made
regarding CT-based lung screening in Japan and some attempts to reduce radiation exposure for CT screening, including our multicenter trial using ultra low-dose CT with a
unique iterative reconstruction method.
Lung Cancer One Day Symposium
IP-SY-L1-3
IP-SY-L2-1
Screening for lung cancer with low-dose CT scans
Solitary pulmonary nodule
Department of Medicine, National Jewish Health, United
States
Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Germany
James R Jett
Felix JF Herth
Screening for lung cancer with low-dose (radiation) computed tomography (LDCT) was initiated by Japanese investigators in the 1990s. Many more of the LDCT detected lung
cancers were earlier stage. These studies and others conducted in the US helped set the stage for the definitive randomized control trial with LDCT. In 2011, the results of the
National Lung Screening Trial (NLST) were reported. The
NLST randomized 53,454 persons at high risk for lung cancer to screening with LDCT or chest radiograph for three
years. Participants were followed for a median duration of
6.5 years. Screening with LDCT resulted in a 20% relative reduction in mortality from lung cancer as compared to chest
radiographic screening and a 6.7% all cause mortality reduction.
In 2013, the results of the initial or baseline screening and the
two incidence screenings have been reported. More lung
cancers were detected with LDCT after three scans than
with chest radiographs (715 vs. 467). More stage I lung cancers and fewer stage III!
IV cancers were detected with
each round of screening. The sensitivity and specificity of
LDCT screening for detecting lung cancer were approximately 94% and 73% for each round.
It has been estimated that screening with LDCT could decrease lung cancer deaths by 12,000-18,000 persons each
year in the United States if screening were to be implemented in all eligible participants. The eligibility criteria for
screening in the NLST currently applies to only 26.7% of the
160,000 lung cancer deaths in the US. So there is need for a
better lung cancer risk prediction to use for deciding on
whom to screen.
In North America, a risk prediction model was developed
based on data from the PLCO trial. The PLCO risk model
was more sensitive than the NLST criteria for lung cancer
detection. Overall, the model identified 81 more of the 678
lung cancers (11.9%) than did the NLST criteria. The PLCO
risk calculator is available on line at http:!
!
www.brocku.ca!
lung-cancer-risk-calculator.
In order to broaden the number of lung cancers detected
during screening, investigators need to better define those at
risk who are not in our current definition of high risk . Risk
assessment will likely be enhanced by identifying biomarkers in the sputum, blood, urine, or breath.
A solitary pulmonary nodule (SPN) is a round or oval opacity
smaller than 3 cm in diameter that is completely surrounded
by pulmonary parenchyma. Other abnormalities are not present. In contrast, pulmonary lesions with a diameter larger
than 3cm are classified as pulmonary masses and differ from
SPN due to their higher likelihood of being malignant.
Owing to the high aetiological diversity and the potential for
malignancy, SPN represent a clinical challenge, which becomes increasingly frequent as the number of CT examinations rises. Workup of these nodules is rather expensive and
emotionally burdensome, especially when the patient has
risk factors for bronchial carcinoma.
SPNs are noted in up to 0.2% of chest radiograph, whereas
27.3% of patients undergoing the national lung screening
trial (NLST) had at least one SPN with a diameter of more
than 4mm on their CT examination6. Differential diagnosis is
extensive but the majority of the identified nodules are comprised of granulomas, lung cancers and hamartomas.
Against the background of potential malignancy and the
poor prognosis of advanced lung cancer, rapid identification
and resection of malignant SPN is crucial, leading to a fiveyear survival rate of 60-80% in stage I non-small-cell lung carcinoma (NSCLC).
The management of a SPN should aim to identify malignancy as fast as possible, in order to provide the option of potentially curative surgical treatment, whilst avoiding invasive diagnostic procedures in case of benign lesions.
Numerous articles!
papers have been published addressing
the optimal strategy of evaluating individuals with lung nodules, including the most recently published ACCP guideline
for the diagnosis and management of lung cancer. Those
strategies are generally based on the individuals risk of developing lung cancer, the pulmonary nodule characteristics
and the capability of the current diagnostic and therapeutic
approaches.
189
Lung Cancer One Day Symposium
IP-SY-L2-2
IP-SY-L2-3
EBUS-GS for peripheral lung cancer
EBUS-TBNA in the era of personalized cancer therapy
Department of Chest Surgery, St. Marianna University, Japan1), Department of pulmonary and infectious diseases, St.
marianna University2), Deapartment of Surgery, Iwakuni Minami Hospital3)
Noriaki Kurimoto1), Hiromi Muraoka2), Mariko Okamoto2),
Ayano Usuba2), Teppei Inoue2), Miwa Fujiwara2),
Naoki Furuya2), Kei Morikawa2), Hirotaka Kida2),
Hiroshi Handa2), Hiroki Nishine2), Atsuko Ishida2),
Takeo Inoue2), Seiichi Nobuyama2),
Masamichi Mineshita2), Katsuhiko Morita3),
Seishi Nosaka3), Masaki Murayama3),
Haruhiko Nakamura1), Teruomi Miyazawa2)
I.How to draw the bronchus leading to the peripheral lesion
Right upper lobe: CT images rotated 90 degree counterclockwise
Left superior segment: CT images rotated 90 degree clockwise
Right middle lobe, left lingular, bilateral S6: reversed CT and
MPR images
Bilateral basal segment: reversed CT
II. Techniques of EBUS-GS for peripheral pulmonary lesions
I will show some knacks as follows.
1) To confirm of the location of the guide sheath; after you
get ultrasonic image of the lesion, you should pull back the
probe slowly. While the transducer locates inside the sheath,
the brightness of the ultrasonic image decreases. We can
confirm the tip of the guide sheath is located in the lesion.
When you get the ultrasonic image as adjacent to the lesion
2) To select the better bronchial branch lead into the lesion
under bronchoscopic findings,
3) To change the direction of the probe for leading to the lesion using up and down of the bronchoscope under fluoroscopy,
4) To change the direction the probe for leading the lesion
using up and down of the bronchoscope under EBUS images,
5) To change the direction the probe for leading the lesion
using a curettage.
III. EBUS using a thin Guide Sheath
One hundred sixty-eight malignant lesions were evaluated.
The total diagnostic yield with thin GS was 83.9%. When the
probe was within the lesion, the diagnostic yield was 94.6%.
When the probe was adjacent to the lesion, the diagnostic
yield was 78.2%. The diagnostic yield by brushing cytology,
lavage cytology, and lavage cytology flushed out from guide
sheath for malignant lesions with thin GS was 77.6%, 39.8%,
and 60.6%, respectively.
190
Department of Pulmonary Medicine, The University of Texas
MD Anderson Cancer Center, USA
Rodolfo C. Morice
This presentation will review the evolving role of EBUS as a
result of emerging changes in the treatment of lung cancer.
Particular attention will be given to strategies for effective
tissue acquisition for de novo molecular characterization of
tumors prior to therapy and to the utility of additional tissue
acquisition via EBUS for tumors that become resistant to
treatment after an initial response. We will also review the
value of mediastinal nodal staging via EBUS for nonsurgical
patients with clinically early stage lung cancer undergoing
radiation therapy with curative intent and for patients with
oligometastatic disease.
Lung Cancer One Day Symposium
IP-SY-L3-1
IP-SY-L3-2
Lung cancer detection with molecular markers
Targeted treatment for lung cancer harboring driver
mutations
Department of Interventional Pneumology, Ruhrlandklinik,
University Clinic Essen, University Duisburg-Essen, Germany1), Pulmonary Department, G. Papanikolaou General
Hospital, Aristotle University of Thessaloniki, Thessaloniki,
Greece2)
Kaid Darwiche1), Filiz Oezkan1), Amir Khan1),
Paul Zarogoulidis2), Lutz Freitag1)
Recently published studies as the National Lung Screening
Trial (NLST) and the NELSON trial established the potential
for low dose CT screening to reduce lung cancer specific
mortality in high-risk individuals. CT screening can detect
tumours in early stages. However majority of lesions detected by computed tomography maybe benign and unsuitable for surgery or any intervention. Furthermore therapeutic decisions are difficult to make, especially if the lesions are
small, standard bronchoscopic procedures also have a low
yield.
The inclusion of molecular biomarkers into clinical prediction
models for early diagnosis may improve the diagnostic accuracy in these settings. It may also play a role in improving
the accuracy of lung cancer staging with EBUS-TBNA and
validate its histopathologic assessment.
A number of potential molecular biomarkers have been identified. However, no molecular biomarker has been validated
for clinical use. This review aims to give an overview of the
latest developments in diagnostic biomarker in lung cancer
and focuses on its methodology an aspect important for bronchoscopists.
Department of Respiratory Medicine, Miyagi Cancer Center,
Japan
Makoto Maemondo
Treatments for lung cancer have progressed rapidly in recent years. One of the biggest contributor to this progress is
discovery of driver mutations in lung cancer including EGFR
mutations and fusion gene of genes such as ALK, ROS1 and
RET. Gene abnormalities related to cancer have been studied for a number of years. Accumulation of mutations is just
one part of multistep carcinogenesis. However, unlike these
mutations, driver mutations strongly affect oncogenesis. Just
a single driver mutation can cause development of cancer
without any other additional gene abnormalities. This phenomenon is called oncogene addiction . Consequently, the
effect of molecular targeted treatment for driver mutations
is significant superior to that of conventional chemotherapies.
We performed the NEJ002 study which showed that gefitinib prolonged progression-free survival (PFS) of patients
with EGFR mutations as compared to chemotherapy. However, we think that EGFR-TKI as first-line treatment is insufficient for improvement of PFS and OS. Thus, we are currently conducting the NEJ005 and NEJ009 studies of gefitinib plus chemotherapy with carboplatin and pemetrexed.
Moreover, the need for strategies to overcome EGFR-TKI
resistance is increasingly important. Some strategies against
EGFR-TKI resistance may develop by new molecules or
combination of those.
In this session, I will explain driver mutations of EGFR and
the management of EGFR mutated lung cancer including
overcoming EGFR-TKI resistance.
191
Lung Cancer One Day Symposium
IP-SY-L3-3
IP-SY-L4-1
Molecular markers for personalized medicine
Bronchoscopic treatment of peripheral lung cancer
Pulmonary and Critical Care Medicine, University of Chicago,
USA
Septimiu Dan Murgu
In the growing era of personalized cancer medicine it is becoming increasingly relevant that sufficient quality and
quantity of tumor tissue are available for morphologic diagnosis and molecular analysis. This lecture will address the rationale for individualized treatment decisions for patients
with NSCLC, molecular pathways and specific molecular
predictors relevant to personalized NSCLC therapy, common assay technologies for molecular marker analysis, and
specifics regarding tumor specimen selection, acquisition,
and handling.
192
Hospital of the University of Pennsylvania, USA
Daniel Howard Sterman
The importance of novel treatments for peripheral lung cancer is increasing due to implementation of chest computed
tomography (CT) screening. Bronchoscopic modalities to diagnose these small, peripheral cancers have also advanced to
include radial probe ultrasound, electromagnetic navigation,
ultrathin bronchoscopes, and virtual bronchoscopic guidance. Although surgical resection of malignant nodules is the
treatment modality of choice, many patients are not optimal
surgical candidates, thus prompting the exploration of other
treatment options such as stereotactic body radiotherapy
(SBRT). With endoscopic advances, it is anticipated that therapy provided through the bronchoscope will bring additional
advantages to patients with early malignancy. Bronchoscopic guidance for identification of small peripheral nodules
to facilitate minimally invasive surgical resection has been
described, as has been the bronchoscopic placement of fiducials to facilitate SBRT. Brachytherapy catheters have been
placed via bronchoscopes to allow for focal radiation treatment of peripheral lung cancers. Preliminary clinical studies
of bronchoscopic radiofrequency ablation probes show the
ability to at least partially ablate extraluminal tumors with
thermal technologies. I will provide in this presentation a
thorough overview of modalities that apply the revolutionary techniques of advanced bronchoscopy for treatment of
malignant nodules.
Lung Cancer One Day Symposium
IP-SY-L4-2
IP-SY-L4-3
Photodynamic therapy for peripheral lung cancers
Oncologic emergencies: A pulmonologist s perspective
Department of Thoracic Surgery, Nippon Medical School, Japan
Jitsuo Usuda, Taichiro Ishizumi, Tatsuya Inoue,
Shingo Takeuchi, Yoshihito Iijima, Takayuki Ibi
Ground-glass opacity (GGO) nodules at peripheral parenchyma of the lung noted at thin section computed tomography (CT) scan have shown to have a histopathologic relationship with atypical adenomatous hyperplasia (AAH) and adenocarcinoma (AIS) which is newly classified by International
Association for the study of Lung Cancer (IASLC). These
preinvasive lesions, which corresponds to type A or B adenocarcinoma according to Noguchi classification, are favorable
prognosis. We hypothesize that those early lung cancers in
peripheral parenchyma such as AIS, do not need surgical resection may be cured by interventional approach such as
Photodynamic therapy (PDT). For peripheral type early lung
cancer, it is unable to observe using bronchoscopy nor to
treat by PDT. Therefore, we have developed a new minimally invasive laser device using a 1.0 mm in diameter
composite-type optical fiberscope (COF), which could transmit laser energy and images for observation in parallel, consisting a laser Doppler blood-flow meter. The use of COF
technology was previously used in the field of atomic energy.
It enables the acquisition of an image while simultaneously
performing laser treatment such as PDT, measuring the
blood-flow, estimating the irradiational distance.
In this study, we aimed to develop a new endoscopical treatment for peripheral parenchymal cancer by NPe6-PDT and a
COF.
Methods: We administered NPe6, 10mg!
kg to pigs and we
observed the peripheral parenchyma through the bronchus
using COF. One h after the administration of NPe6, we irradiated 664 nm laser (120 mW, 100J) for normal lesion of the
peripheral lung using COF. Seven days after PDT, we extracted lungs and examined pathologically.
We were able to introduce the 1.0 mm COF into pig peripheral parenchyma of the lungs and observed feasibly and
clearly, and then we performed NPe6-PDT safely. We measured the blood-flow at the irradiated area by COF during
PDT, and we observed gradually disappearance of the bloodflow. The mean diameter of necrosis in normal peripheral
lung caused by NPe6-PDT was 16 mm.
The 1.0 mm COF was a very useful device of NPe6-PDT for
peripheral parenchyma of the lung. In the future, for noninvasive adenocarcinoma such as AIS, NPe6-PDT using COF
will become one option of standard treatment and play a important role for the treatment of syncronous or metachronous multiple primary lung cancer lesions.
Department of Medicine, Cancer Treatment Centers of America, USA
J. Francis Turner
BRONCHOSCOPY FOR LUNG CANCER THERAPY
Oncologic Emergencies
A Pulmonologist s Perspective
Pulmonary emergencies occur frequently due to primary
lung cancer or complications of metastatic disease. The nature of these emergencies most often is related to direct invasion or compression of the lung parenchyma, airways, or
vascular structures. In this overview we will review common acute pulmonary questions that arise in association with
malignancy and outline the diagnosis and proposed therapeutic modalities to aid the patient.
Anatomically these emergencies are related to involvement
of the:
Pleural space
Lung parenchyma
Vascular structures
Tracheo-bronchial tree
Some of these common emergent problems for which the
pulmonary consultant is often contacted are:
Massive Pleural Effusion
Pneumonitis associated with therapy such as radiation or
chemotherapy induced ARDS
Pulmonary embolism
SVC syndrome
Massive hemoptysis
Tracheo-esophageal fistula
Intrinsic and!
or extrinsic obstruction of the trachea of bronchi
193
Lung Cancer One Day Symposium
IP-SY-L4-4
Survival and quality of life after efficient debulking in
lung cancer. Is a stent required?: The answers following SPOC protocol
Department of Chest Diseases and Thoracic Oncology, Hôpital
Nord, University Hospital of St Etienne, France
Jean!
Michel Vergnon
Therapeutic bronchoscopy (TB) with a rigid bronchoscope
can resect endoluminal tumor and improve quality of life in
patients with symptomatic obstructive lung cancer involving
central airways. Several retrospective reports but also some
prospective studies underline the benefit of TB on quality of
life (QOL) and exercise capacity. However, up to now, 2
points remain controversial. What is the impact of the general treatment of the cancer (chemotherapy or irradiation)
on the evolution of the obstruction and on QOL? Is a stent
useful to maintain the initial benefit of TB?
The prospective multi-centric SPOC trial was conducted in
France with a grant of the French National Cancer Institute
(INCA). It tries to answer these questions. 78 patients were
included in 3 years by 9 academic centers. Quality of life, assessed by Borg scale and EORTC QOL questionnaires were
analyzed before and after the resection, then 3, 6 and 12
months after treatment in 2 randomized groups with or
without stent insertion. Moreover, the patients were analyzed in subgroups depending on the associated treatment
(chemotherapy, irradiation, palliation…). Survival, death
causes, local re-stenosis were also analyzed.
40 patients were randomized in the stent arm and 38 in the
no stent arm. Performans status, dyspnea score and scale,
initial QOL, TNM status and groups according to the parallel
treatment were similar in the 2 arms.
We have observed in both arms an initial dramatic improvement in dyspnea and in QOL after TB but these benefits
slowly decrease during the follow-up. Mean survival is similar in both arms (5 months). Thanks to the TB, only 7.5% of
deaths are related to bronchial obstruction. To insert a silicone stent does not modify the initial improvement in QOL,
is well tolerated and prevents local restenosis and thus increase QOL stability.
A first line parallel chemotherapy or chemo-radiotherapy is
efficient to prevent bronchial re-stenosis. The barrier effect
of a stent is in this situation useless. In contrast, in all other
situations, stent insertion is fruitful to prevent bronchial
stenosis.
For these obstructive cancers, a multidisciplinary approach
is crucial to maintain as long as possible the airway patency
and QOL. Therapeutic bronchoscopists and oncologists contribute both in this goal. Efficient debulking is the first step,
first line chemotherapy or chemo-irradiation the second step
and stent insertion the palliative step.
194
Sponsored Seminar
IP-SS-1
IP-SS-2
TBNA. Past, present and future
EBUS overview
Johns Hopkins Hospital, USA
Ko Pen Wang
Transbronchial needle aspiration (TBNA) has been used for
over 65 years to sample the mediastinum and hilar lymph
nodes for diagnosis and staging. Although originally described in Argentina in 1949 by Dr. Eduardo Schieppati using a rigid bronchoscope and rigid needle, it was first
adapted to the flexible bronchoscope in 1983 at Johns Hopkins Hospital, by Wang et al. In the first report for lung cancer staging, the overall diagnostic yield for staging was 85%
for lung cancer and 96% in right side lesions.1 Numerous experts since have reported their diagnostic yield using this
technique with a sensitivity and specificity of over 90%.2 Endobronchial ultrasound (EBUS) for TBNA has recently generated new attention and interest in TBNA. EBUS TBNA
now allows the bronchoscopist the ability to visualize and locate the target lymph node with ultrasound rather than relying only on the anatomic natural landmarks that correlate to
the CT image of the mediastinum as described in 1994 by
Wang.3 The EBUS bronchoscope and needle apparatus is
more uncomfortable for the patient and more difficult to use.
The availability and cost of the equipment are also significant barriers to its widespread use. Continuous improvement of the equipment, instruments and technology is
needed. In fact, the EBUS bronchoscopes have already begun this evolution. EBUS bronchoscopes have slowly been
adapted to incorporate a larger working channel, better optics, improved ultrasound imaging and additional doppler
functions. Most recently, a videobronchoscope that allows
the bronchoscopist to visualize the distal and of the bronchoscope and the needle during TBNA has been developed.4
This continued evolution incorporates the best of conventional TBNA with EBUS TBNA and moves closer towards
the goal of allowing one scope to be used for the entire procedure. In the end, no matter what the technology, the future
of TBNA relies on the operator s skill, understanding of the
anatomy, and the technique in obtaining the biopsy.
1
Wang KP, Brower R, Haponik EF, Stiegelman S. Flexible
transbronchial needle aspiration for staging of bronchogenic
carcinoma, Chest 1983; 84(5): 571-6.
2
Patel NM, Pohlman A, Husain A, et al. Conventional transbronchial needle aspiration decreases the rate of surgical
sampling of intrathoracic lymphadenopathy. Chest 2007; 131:
773-8.
3
Wang KP. Staging of bronchogenic carcinoma by bronchoscopy. Chest 1994; 106:588-93.
4
Xiang Y, Zhang F, Akulian J, Yarmus L, Feller-Kopman D,
Wang KP. EBUS-TBNA by a new Fuji EBUS scope (with
video). Journal of thoracic disease. 2013;5(1):36-39.
Interventional Pulmonology, The Johns Hopkins University,
USA
David Feller-Kopman
Endobronchial ultrasound (EBUS) is perhaps the greatest advance in the field of diagnostic bronchoscopy since the flexible bronchoscope was introduced into clinical practice by
Dr. Ikeda in the late 1960s. Convex-probe EBUS (CP-EBUS)
has revolutionized the approach to patients with mediastinal
and hilar adenopathy, and radial-probe EBUS (RP-EBUS) remains an invaluable tool for the real-time identification of parenchymal nodules and masses. The benefits of CP-EBUS include the ability to reach almost all nodal stations as well as
being the only method that allows real-time image guided
sampling of hilar nodes. This is extremely important in cases
where patients are being considered for definitive treatment
with stereotactic body radiation therapy. The yield of CPEBUS is better than that of mediastinoscopy and can easily
provide sufficient tissue for tumor marker analysis in the setting of adenocarcinoma. RP-EBUS is primarily utilized for
the identification of parenchymal nodules!
masses, defining
extent of tumor within the airway, and assessing if tumor external to the airway is invading or solely compressing the
airway. Both techniques have an associated cost an learning
curve. This lecture will review the history of EBUS, as well
as the data supporting its use.
195
Sponsored Seminar
IP-SS-3
EBUS techniques
Duke University Medical Center, USA
Momen Wahidi
Endobronchial Ultrasound (EBUS) has empowered chest
physicians to sample the mediastinum in a minimallyinvasive fashion and is now a common chest procedure.
EBUS can be performed under moderate sedation or deep
sedation. EBUS needles come in two sizes: 21 gauge and 22
gauge, with current data suggesting that there is no difference in the diagnostic yield between the two sizes. EBUS
needles are equipped with suction but a randomized controlled trial has shown no difference in specimen quality or
diagnostic accuracy with or without suction. The recommended number of aspirates per lymph node to establish the
diagnosis of lung cancer is three aspirations based on limited
data. Additional aspirates are required if testing for molecular markers in adenocarcinoma is desired. The availability of
rapid-on-site-evaluation (ROSE) by a cytology team was essential for conventional transbronchial needle aspiration
(TBNA), however, recent studies have shown that ROSE is
not needed to increase the diagnostic yield for EBUS-TBNA
but it may save time and additional needle aspirates. EBUS
remains a very safe technique with a minimal number of reported complications.
196
Luncheon Seminar
IP-LSA-1
IP-LSA-2
EBUS-TBNA
EBUS-TBNA
Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Germany
Division of Thoracic Surgery, University of Toronto, Toronto
General Hospital, Canada
Felix JF Herth
Kazuhiro Yasufuku
The world s first curved linear array ultrasonic bronchoscope was introduced to the market by Olympus in 2004.
The success story of EBUS-TBNA starts in 2003 with a publication by M. Krasnik. This article gave the first description
of the principle of EBUS-TBNA. Herth et al. chronicled their
study on 502 patients that showed that EBUS-TBNA resulted in 93% diagnostic yield, a sensitivity of 94%, specificity
of 100% and accuracy of 94%, with PPV at 100% and NPV at
11%.
With the strong acceptance of EBUS-TBNA as a reliable diagnostic tool for enlarged lymph nodes in patients with nonsmall cell lung cancer (NSCLC), it soon became clear that
EBUS provides the best lymph nodes access.
A lot of very important work was also done by for Dr.
Yasufuku. He and his group shown strong dedication to
evaluate the benefits of EBUS-TBNA samples for immunohistochemical analysis, molecular staging and reported encouraging results with cell cycle related proteins in chemotherapy patients.
In several published meta-analysis EBUS-TBNA has been
shown to have a high-pooled sensitivity of 93% and specificity of 100%.
Multiple publications have shown that even in patients with
lymph nodes under 1cm (which had been termed N0 by CT
criteria), with the use of EBUS-TBNA a large percentage
could still be shown to have N2!
N3 disease (some despite
also being negative on PET-CT).
Complications such as bleeding or infection are very rare
and have only been reported as case reports.
At least it was the work of J. Annema, which also convinced
guidelines authorities. The group showed that among patients with (suspected) NSCLC, a staging strategy combining
endosonography and surgical staging compared with surgical staging alone resulted in greater sensitivity for mediastinal nodal metastases and fewer unnecessary thoracotomies.
In the recent published guideline of the American College
of Chest Physicans is clearly pointed now. The ACCP recommends In patients with high suspicion of N2,3 involvement,
either by discrete mediastinal lymph node enlargement or
PET uptake (and no distant metastases), a needle technique
(endo- bronchial ultrasound [EBUS]-needle aspiration [NA],
EUS-NA or combined EBUS!
EUS-NA) is recommended over
surgical staging as a best first test (Grade 1B).
After 10 years and a lot of scientific work from several
groups, a small scope becomes the state of the art.
Minimally invasive ultrasound based endoscopic technology
has revolutionized the approach to the mediastinum, hilum
as well as the lung. The convex probe endobronchial ultrasound (CP-EBUS) allows real-time endobronchial ultrasound
guided transbronchial needle aspiration (EBUS-TBNA) with
access to all of the mediastinal lymph nodes accessible by
mediastinoscopy as well as N1 nodes. EBUS-TBNA is primarily used for lymph node staging and diagnosis of lung
cancer, but also used for the diagnosis of unexplained mediastinal and hilar lymphadenopathy. On the other hand, the
radial probe EBUS is used for detailed assessment of the central airway as well as assistance during transbronchial biopsy of peripheral lung nodules.
The CP-EBUS is a flexible bronchoscope integrated with a
convex transducer on the tip which scans parallel to the insertion direction of the bronchoscope. The outer diameter of
the insertion tube of the flexible bronchoscope is 6.2 mm.
The angle of view is 90 degrees and the direction of view is
30 degrees forward oblique. Both the direct contact method
and the balloon method are available for ultrasound scanning, but images using the balloon are superior to the direct
contact method. The CP-EBUS can be connected to the dedicated ultrasound scanner (EU-C60, Olympus, Tokyo, Japan),
the universal endoscopic ultrasound scanner with capabilities of radial probe EBUS imaging (EU-ME1, Olympus, Tokyo, Japan) as well as the Aloka Prosound Alpha5 (Aloka) for
excellent image quality. The EU-ME1 is equipped with the
power Doppler mode as well as the color Doppler mode. Two
types of dedicated needles are available for EBUS-TBNA.
The 21-gauge (NA-201SX-4021) or the 22-gauge needle (NA201SX-4022) passed through the 2.2 mm instrument channel
allows real-time EBUS-TBNA.
EBUS-TBNA is now an established modality for invasive
staging of the mediastinum in patients with lung cancer.
Based on the guidelines (ACCP Evidence-Based Clinical
Practical Guideline 3rd Edition), minimally invasive needle
techniques including EBUS-TBNA to stage the mediastinum
have become increasingly accepted and are the tests of first
choice to confirm mediastinal disease in accessible lymph
node stations. However if negative, these needle techniques
should be followed by surgical biopsy. In the era of personalized medicine, EBUS-TBNA can provide adequate quality
and quantity for performing immunohistochemical testings,
DNA analysis and RNA analysis. Further development in ultrasound image analysis technology may allow bronchoscopists to perform a more targeted biopsy. EBUS is a technology that is invaluable in the management of patients with
lung cancer.
197
Luncheon Seminar
IP-LSA-3
IP-LSB
Aim for ideal procedure of EBUS-GS
Stenting in the management of tracheobronchial disease with a focus on the AERO hybrid stent
Department of Chest Surgery, St. Marianna University, Japan1), Department of pulmonary and infectious diseases, St.
marianna University2), Deapartment of Surgery, Iwakuni Minami Hospital3)
Noriaki Kurimoto1), Hiromi Muraoka2), Mariko Okamoto2),
Ayano Usuba2), Teppei Inoue2), Miwa Fujiwara2),
Naoki Furuya2), Kei Morikawa2), Hirotaka Kida2),
Hiroshi Handa2), Hiroki Nishine2), Atsuko Ishida2),
Takeo Inoue2), Seiichi Nobuyama2),
Masamichi Mineshita2), Katsuhiko Morita3),
Seishi Nosaka3), Masaki Murayama3),
Haruhiko Nakamura1), Teruomi Miyazawa2)
Recently, studies have shown the efficacy of a new procedure, EBUS using a Guide Sheath (EBUS-GS), for sampling of
peripheral lesions to increase the diagnostic yield of TBB under EBUS guidance. A guide sheath covered the miniature
radial probe is then advanced through the working channel
of a therapeutic bronchoscope with the probe tip outside the
sheath until the lesion is visualized. Under fluoroscopy, the
sheath is held in place while the EBUS probe is withdrawn.
An instrument such as a brush, or biopsy forceps is then inserted through the sheath and the lesion is sampled. EBUSGS increases the reliability of specimen collection via bronchoscopy.
1.Diagnostic yields of Endobronchial Ultrasonography using
the thin guide sheath for peripheral pulmonary lesions
We devised the technique of EBUS using a thin guide sheath
(2.0 mm in diameter) covering a miniature probe for the diagnosis, and evaluated 168 peripheral malignant lesions.
The total diagnostic yield with thin GS was 83.9%. When the
probe was within the lesion, the diagnostic yield was 94.6%.
When the probe was adjacent to the lesion, the diagnostic
yield was 78.2%. The diagnostic yield by brushing cytology,
lavage cytology, and lavage cytology flushed out from guide
sheath for malignant lesions with thin GS was 77.6%, 39.8%,
and 60.6%, respectively.
2. Techniques of EBUS-GS for peripheral pulmonary lesions
I will show some knacks as follows.
1) To confirm of the location of the guide sheath; after you
get ultrasonic image of the lesion, you should pull back the
probe slowly. While the transducer locates inside the sheath,
the brightness of the ultrasonic image decreases. We can
confirm the tip of the guide sheath is located in the lesion.
When you get the ultrasonic image as adjacent to the lesion
2) To select the better bronchial branch lead into the lesion
under bronchoscopic findings,
3) To change the direction of the probe for leading to the lesion using up and down of the bronchoscope under fluoroscopy,
4) To change the direction the probe for leading the lesion
using up and down of the bronchoscope under EBUS images,
5) To change the direction the probe for leading the lesion
using a curettage.
198
Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, USA
Michael Jantz
Airway stenting is highly effective in palliating symptoms of
airway obstruction. Several types of stents are available with
different advantages and disadvantages depending on stent
design and construction. More recently a hybrid metal stent,
the AERO stent, has been available for management of tracheobronchial obstruction. This seminar will review the current status of stenting for airway obstruction. The presenter
will review his experience with the AERO stent and provide
recommendations for potential uses and management after
implantation.
Luncheon Seminar
IP-LSC
IP-LSD
Respiratory infections based on branches of the respiratory tract
Emphysema revisited
Department of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus, Japan
Jiro Fujita
Names of respiratory infections are determined based on the
branches of the respiratory tract. In addition, it is possible to
speculate causative pathogens based on location of the infection. Using high-resolution computed tomography, it has become possible to identify the location of infections exactly.
Using a chest CT, bronchus, bronchiole, terminal bronchiole
and respiratory bronchiole are easily identified. With a subpleural lesion, it is important to note the secondary pulmonary lobule (1.5-2.0 cm). Next, note the acinus (5 mm) within
the secondary pulmonary lobule. The center of the acinus is
determined to be a respiratory bronchiole. When inflammations of respiratory bronchioles are diffusely observed, a diagnosis of diffuse panbronchiolitis can be made with confidence. If bronchial thickening is observed without inflammation of the respiratory bronchiole, a diagnosis of bronchiectasis applies to that part. If inflammation reaching to the
pleura is observed inside the acinus, a diagnosis of pneumonia applies to that part. Centrilobular structures of tree-inbud appearance are also observed.
Sleep and Lung function Department, University Hospital Birmingham, UK
Robert Andrew Stockley
Chronic Obstructive Pulmonary Disease (COPD) has become
a widely used generic term to describe patients with lung
problems where a degree of fixed obstruction is present as
defined by routine spirometry. GOLD described COPD as
being due to an enhanced chronic inflammatory response to
noxious particles or gases . This global statement derives
from an initial observation that subjects with alpha-1antitrypsin (AAT) deficiency were particularly susceptible
to the development of early onset emphysema. The implicated factor was neutrophil elastase which is released during
neutrophil migration is normally controlled!
inactivated by
AAT to prevent excessive damage leading to emphysema.
Neutrophil lung inflammation is a feature of both AAT deficiency and usual COPD hence providing a common theme
with increased susceptibility in AAT deficiency.
Once neutrophilic inflammation had been identified as a central feature (enhanced by cigarette smoking) the lack of
AAT deficiency in most patients with COPD required an alternative explanation. The inflammatory cascade has been
studied widely, immunity and cell death have been implicated and oxidant stress (driving inflammation and possibly
inactivating AAT) has also been considered to play a role
both cigarette smoke and inflammatory cell derived. These
concepts have been supported by a variety of knockout,
transgenic and challenge animal studies that have alveolar
airspace (a surrogate for emphysema) as the readout.
However studies in man have failed to provide such clear cut
answers. Inflammation, oxidant stress and cell death are all
present and yet rarely identified in emphysema alone largely
due to poor patient characterisation. With the advent of CT
scanning, the presence and severity of emphysema in COPD
has become more routinely assessed providing an opportunity to examine the emphysema process in more detail. Not
only does emphysema increase mortality but also the likelihood of spirometric decline and exacerbations of COPD. Furthermore the pathological process is still more likely to relate
to neutrophilic activation rather than other parts of the inflammatory cascade. The causes of airways disease in the absence of emphysema are however less well defined although
metalloproteinases may play a role. It is of interest to note
that even in AAT deficiency emphysema may be absent or a
minimal component of the airflow obstruction and AAT augmentation may have limited efficacy suggesting even this
monogenic susceptibility is more complex than previously
assumed.
199
Luncheon Seminar
IP-LSE
IP-LSH
Shifting paradigms in targeting therapy for non-small
cell lung cancer
The asthma-COPD overlap syndrome-An update
Keio University, Japan
Kenzo Soejima
Medicine and Head of the Department for Pulmonary Medicine at the Philipps-University of Marburg, Germany, Germany
Claus Vogelmeier
For patients that have features of both asthma and COPD
the term asthma-COPD overlap syndrome (ACOS) has been
suggested, although there is no generally accepted definition
of this condition. Nevertheless, it is generally accepted that
patients with ACOS suffer from a more rapid decline in lung
function, poor health related quality of life, frequent exacerbations and high mortality. Prevalence rates between 15 and
55% have been reported.
There are several conditions that may be diagnosed as
ACOS: a) asthma with fixed airflow limitation. This may be a
consequence of smoking. Cigarette smoking leads to a more
rapid loss of lung function and a partial inactivation of inhaled corticosteroids in asthma patients; b) COPD with bronchial hyperreactivity. It has been shown that patients with
COPD with significant bronchial hyperreactivity have a
rapid decline of lung function and a higher mortality; c) a specific COPD phenotype. In a cluster analysis one of the clusters had the following characteristics: severe!
markedly variable airflow obstruction with features of atopic asthma,
chronic bronchitis, and emphysema.
For patients considered to have ACOS it is prudent to start
therapy as for asthma. This acknowledges the pivotal role of
inhaled corticosteroids in order to reduce morbidity and
mortality in patients with asthma symptoms. In addition, a
long-acting beta2-agonist should be applied. But, patients
should not be treated with a long-acting ß2-agonist without
an inhaled corticosteroid as this may lead to a worsening of
asthma and even an increase in mortality. Future concepts
of pharmacological treatment of ACOS may also contain a
long-acting anticholinergic as several studies suggest that
tiotropium is effective in asthma. This may lead to triple
therapy-inhaled corticosteroid and long-acting ß2-agonist and
long-acting anticholinergic. In addition, smoking cessation,
vaccinations, pulmonary rehabilitation, and measures to increase physical activity are advised.
200
Luncheon Seminar
IP-LSI
IP-LSG-1
Targeted therapy of lung cancer: current status and
future direction
Keynote Lecture
Department of Medicine, National Jewish Health, USA
Ko Pen Wang
James R Jett
The driver mutations in EGFR were discovered in 2004 and
explained the dramatic results of treatment with the tyrosine kinase inhibitor (TKI), gefitinib, in a small subset of patients. Subsequently, multiple randomized trials have evaluated front-line treatment with an EGFR TKI (gefitinib, erlotinib or afatinib) or doublet chemotherapy and have observed superior response rates, progression-free survival,
and quality of life with front-line TKI treatment. The second
driver mutation, identified in 2007, in lung cancer was the
ALK gene rearrangement (fusion). Treatment with the TKI
crizotinib has been shown to have a response rate of about
60% in stage IV NSCLC with ALK fusions and results in a
median-survival time (MST) of approximately nine months.
TKI for EGFR or ALK mutations is recommended as frontline therapy over systemic chemotherapy.
Mutations in EGFR, ALK, and KRAS are almost always mutually exclusive. The IASLC and CAP guidelines advised
against using phenotypic profiling to decide on which patients to test for mutations. All stage IV adenocarcinoma
should be tested before deciding on initial therapy.
At the Lung Cancer World Congress, Sydney, Australia, November 2013, the Lung Cancer Mutation Consortium reported results of testing for ten genetic (driver) mutations in
1,000 lung adenocarcinoma patients. The most common mutations were in KRAS (25%), EGFR (17%), and ALK (8%).
Other less common mutations were seen in HER2 (3%),
BRAF (2%), and PIK3CA (1%). Only 3% of tumors!
patients
had mutation in more than one of the genes tested. Over 900
patients had follow-up data available. Of 264 patients with a
driver mutation and treatment with an appropriate targeted
agent, the MST was 3.5 years. The MST was 2.4 years if targeted therapy was not given. ROS1 and RET fusions have
been identified in 1-2% of lung adenocarcinomas and will account for 2,000-3,000 cases per year in the USA alone. Early
reports have also shown encouraging treatment results with
dabrafenib in lung cancer patients with BRAF V600E mutations.
Most of the early mutational testing has been performed in
adenocarcinomas or non-squamous lung cancer. Recently, investigators have focused on molecular mutations in
squamous cell lung cancer. Initial results have demonstrated
FGFR1 amplification, EGFR amplification, DDR2 mutations,
PIK3CA mutations, BRAF mutations, and others.
In conclusion, mutational testing of lung cancers has become
main stream. Adequate amounts of tumor tissue must be obtained at the time of the diagnostic procedure to allow for
both a histologic diagnosis as well as molecular testing.
Johns Hopkins Hospital, USA
Transbronchial needle aspiration (TBNA) has been used as
an effective and minimally invasive technique for the diagnosis and staging of mediastinal and hilar adenopathy since
originally described in 1949. The technique began as a rigid
procedure until adapted to the flexible bronchoscope in 1983
at Johns Hopkins Hospital, by Wang et.1 Further innovation
in the late 1990 s and early 2000 s resulted in the development endobronchial ultrasound (EBUS) for TBNA. EBUS
TBNA is different than conventional TBNA in several significant ways. First and most obvious is the ability to visualize and locate the target lymph node with ultrasound beyond
the bronchial wall and perform the needle aspiration with
real time ultrasound guidance. Visualization of the lesion before biopsy and during biopsy may not play any important
role once the lesion is entered, but it does ensure the lesion is
reached. Even with this new ability to directly visualize the
needle in the lesion, an adequate specimen is still not guaranteed. The needle design and characteristics is and has been
extremely important in the post rigid era performance of
TBNA. Further innovations in the evolution of the EBUS
bronchoscope have included the enlargement of the working
channel with no increase in the size of the outer scope diameter, improved optics and improved ultrasound capabilities.
More recently another step was made forward when a scope
was designed that the distal tip could be visualized during
the procedure, making the EBUS bronchoscope close to being interchangeable with a standard bronchoscope.2 We still
have a lot of progress to make for this to become an affordable reality but these exciting technological advances are
very promising. Regardless of the technology, the real innovation remains with bronchoscopists and how they apply
these new technologies to the patients. EBUS is an interesting technological advancement that has important applications in performing and training in TBNA. Still today, for
most pulmonologist in the world, conventional TBNA is the
simplest, safest and most cost effective procedure for staging
of lung cancer in the vast majority of patients.
1
Wang KP, Brower R, Haponik EF, Stiegelman S. Flexible
transbronchial needle aspiration for staging of bronchogenic
carcinoma, Chest 1983; 84(5): 571-6.
2
Xiang Y, Zhang F, Akulian J, Yarmus L, Feller-Kopman D,
Wang KP. EBUS-TBNA by a new Fuji EBUS scope (with
video). Journal of thoracic disease. 2013;5(1):36-39.
201
Luncheon Seminar
IP-LSG-2
IP-LSG-3
An experience on Fuji EBUS scope
Experience with the Fuji EBUS.
Respiratory Medicine, Nagoya Medical Center, Japan
Respiratory division, University Hospitals Leuven, Belgium.
Hideo Saka
Christophe Dooms
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been one of the most useful tools
for bronchoscopists all over the world. It will help us to approach to the mediastinal lymph nodes or masses adjacent to
the airway with minor invasiveness to the patients.
I have a chance to use new Fuji EBUS scope (EB-530 US,
Fuji Film Co., Tokyo, Japan), kindly borrowed from the
manufacturer. It has some different features from that of
Olympus s one.
First, the angle of endoscopic view is 10 degrees oblique upward from the scope direction. As Olympus scope has 35 degrees, the visual image is quite different. We can estimate
that it is easier to go through vocal cords, and can be used to
survey thoroughly in the proximal bronchi, especially on the
examination without intubation. As the Fuji EBUS has relatively long radius of curvature at the top, there would be
some learning curve in the training phase.
Second, the image from the scope is created by CCD camera.
The view from the scope is better. It is also helpful to observe the bronchial lumen, and to find a spot to penetrate.
Third, the diameter at the distal end is 0.1mm thinner. It
might be helpful to reach a little bit more distally.
Forth, the upward degree of the needle from the scope direction is larger. It might be helpful to compensate a larger curvature radius. There is a small resistance when the needle
going out from the sheath.
Fifth, the needle is coming out from the center of the scope
and the view. I can see the whole way go into the site centrally. It is easier to see the punctured site when it is hit.
I could get samples from lymph nodes of #4R, #7, #11S, and
even #4L. The scope could be used in trans-esophageal approach.
202
Indication.
The use of endobronchial ultrasound guided transbronchial
needle aspiration has rapidly increased since the first study
published in 2003. Current indications are diagnosis and staging of (suspected) lung cancer, diagnosis and staging of extrathoracic malignancies, and diagnosis of granulomatous diseases (such as sarcoidosis or tuberculosis).
Methodology.
A Fuji EBUS procedure is usually performed under local anaesthesia and moderate or conscious sedation.
Technical aspects.
Equipped with a CCD chip at the tip of the endoscope, Fuji
EBUS (EB-530US) offers high-resolution endoscopic images
which enable accurate assesment of the mucosae within the
central airways. The position of the needle with 10̊ forward
oblique view facilitates insertion of the scope: arythenoids
and vocal cords can easily be visualized facilitating tracheal
intubation and minimalizing patient discomfort upon insertion. The bending angle 130̊ up improves the access towards
the lateral wall in the proximal main bronchus at the right
(station 10R) and tracheobronchial angle at the left main
bronchus (station 4L), even with the needle sheath in position. In addition, the combined bending angle of 130̊ and 10̊
forward oblique view make the use of a balloon redundant.
The flexibility and maneuverability of the Fuji EBUS scope
can offer an access to the basal bronchi of the lower or
ostium of the middle lobe in order to reach stations 11R inferior or station 12. Morfologic ultrasound features of interest
are evaluated in B-mode, while vascular structures within or
around lymph nodes of interest are evaluated in dopplermode. Once the endobronchial procedure is terminated, the
Fuji EBUS scope can be elegantly inserted into the esophagus whenever an additional exploration of mediastinal nodal
stations 4L, 8 and 9 is warranted.
Conclusion.
Tissue remains the issue. Fuji EBUS is an ultrasonic
videobronchoscope with easy handling and excellent maneuverability. Fuji EBUS obtaines white light and ultrasound images of high quality, enabling optimal procedural tissue sampling.
Luncheon Seminar
IP-LSG-4
IP-LSL
EBUS innovations
Current and future treatment strategy in EGFR mutated non-small cell lung cancer
Department of Interventional Pulmonology, Johns Hopkins
Medical Institutions, USA
Lonny Yarmus
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the gold standard for the staging of
lung cancer. However, conventional EBUS (C-EBUS) bronchoscopes are limited in their ability to perform a full airway
examination due to a 35-degree forward oblique viewing
field and limited scope flexion (120 degrees) and larger outer
diameter (6.9mm) that often requires the use of an additional
bronchoscope. Recently, a hybrid EBUS bronchoscope (HEBUS) with a 10-degree oblique viewing field, 130 degree
flexion and narrower external diameter has been introduced.
We hypothesized that the H-EBUS scope would reduce the
need for an additional bronchoscope and decrease cost during lung cancer staging procedures.
Methods: A prospective, randomized controlled trial was
performed to evaluate the differences between H-EBUS
(Fuji, Japan) and C-EBUS (Olympus, Center Valley, PA) for
the diagnosis and staging of lung cancer. Prior to lymph node
sampling, a full airway examination was attempted utilizing
either the H-EBUS or the C-EBUS. The primary outcome
was to compare the number of bronchoscopes used per procedure. Secondary outcomes included the number of visualized airways segments, overall cost per procedure, and adequacy and diagnostic yield of TBNA.
Results: 62 patients were randomized to undergo EBUSTBNA with either the H-EBUS (n=30) or C-EBUS (n=32. In
patients requiring nodal staging only, conversion rates for
the use of a second bronchoscope were 0!
15 H-EBUS and 5!
17 C-EBUS (p=0.046). H-EBUS allowed for visualization of
more airway segments in the left upper lobe (p=0.0047), left
lower lobe (p=0.0012), and right lower lobe (p=0.0054). There
were no differences in overall adequacy and diagnostic yield.
When comparing procedures requiring the use of one EBUS
scope to those requiring a second bronchoscope, the mean
procedural time was reduced from 38 minutes to 28 minutes
(p=0.007). There was an overall cost reduction of $380.15
(95% CI=$153.6 2, $606.68) per procedure with H-EBUS.
Conclusion:
H-EBUS (Fuji, Japan) when compared to C-EBUS allowed for
improved airway visualization limiting the need for additional bronchoscopes during lung cancer staging thus reducing procedural costs.
Division of Respiratory Medicine, Hokkaido University Graduate School of Medicine, Japan
Satoshi Oizumi
In the past decade, the treatment strategy for non-small cell
lung cancer (NSCLC) has dramatically changed. Especially, a
major breakthrough was discovery of activating mutations
of the epidermal growth factor receptor gene (EGFR ) in a
subset of NSCLC, and tumors with EGFR mutations are
highly sensitive to EGFR tyrosine kinase inhibitors (TKI).
Subsequently, several phase III studies showed the superiority of EGFR-TKI over standard chemotherapy in
progression-free survival, and first-line EGFR-TKI treatment
became standard first-line therapy for EGFR -mutant
NSCLC.
However, there are several issues to be delineated. How can
we define clinical progression post RECIST progression?
Should we continue TKI treatment after RECIST progression? Do we have to worry about disease flare? Having these
concerns, most of physicians treat their patients with EGFRTKI in daily clinical practice.
Patients with EGFR -mutant lung cancer inevitably develop
acquired resistance to EGFR-TKI even after the unprecedented response. Several possible mechanisms for acquired
resistance have been identified, the most common being the
development of an EGFR T790M mutation in more than 50%
of cases. There are several strategies for patients who have
acquired such resistance; 1) switch to chemotherapy, 2) continuation of TKI therapy along with chemotherapy, and 3)
readministration of EGFR-TKI following a cessation of TKI.
In addition, efficacy of the first-line combination of EGFRTKI and platinum-based doublet chemotherapy is currently
being examined in the EGFR -mutated setting.
In this seminar, these important topics and future treatment
strategies in EGFR -mutated NSCLC will be discussed.
203
Oral Presentation
IP-O1-1
IP-O1-2
Benefit of bronchial thermoplasty (BT) in severe
asthma patients equivalent to Japan asthma guideline
step 4
Bronchial thermoplasty for severe asthma patients
results from daily practise
Medicine, McMaster University, Canada1), QST Consultations
Ltd, Allendale, MI, USA2), Boston Scientific Corporation, San
Jose, CA, USA3)
Gerard Cox1), Brian Armstrong2), Narinder Shargill3)
Background: BT is a device-based therapy that has been
shown to improve asthma control out to 5 years in patients
with persistent severe asthma. The response to BT was assessed in a subgroup of patients from the Asthma Intervention Research 2 (AIR2) Trial who were equivalent in asthma
severity to Step 4 of the Japan Asthma Guidelines (JAG-s4)
(Ohta et al, Allergology International. 2011; 60: 115-145).
Methods: Data were analyzed for subjects with 3 or more
maintenance asthma medications at Baseline (AIR2 Subgroup GT JAG-s4: Alair 58!
190 ITT subjects, Sham 25!
98
ITT subjects) and those with less than 3 maintenance
asthma medications (AIR2 Subgroup LT: Alair 132!
190 ITT
subjects, Sham 73!
98 ITT subjects).
Results: Baseline demographic and clinical characteristics
and key outcomes at 12 months post-treatment are summarized in the Table below.
Conclusion: BT is effective in patients with severe asthma,
equivalent to Step 4 of the Japan Asthma Guidelines (JAGs4).
Funded by Boston Scientific Corporation, Marlborough, MA.
204
Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Germany
Felix JF Herth, Daniela Gompelmann, Philine Kaukel,
Ralf Eberhardt
Background: Bronchial thermoplasty (BT) is an approved
and accepted device-based therapy for patients with severe
asthma. Data from randomized clinical trials have demonstrated that BT improves asthma control (based on reduction in severe exacerbations and emergency department
(ED) visits and that the benefits of a one-time BT treatment
persist for at least 5 years. To date there is limited clinical
data outside of clinical trials. We report on our initial experience with BT as a routine procedure for appropriately selected patients.
Methods: Patients undergoing BT with the Alair System at
the Thoraxklinik (Heidelberg, Germany) outside of clinical
trials were followed up after 6 months.
Results: Between November 2011 and April 2013, 23 patients
were treated (18 females, 5 males; mean age 42.3 years; mean
pre-broncholdilator FEV1 67% predicted; mean inhaled corticosteroid (ICS) dose 1231μg!
day beclomethasone or the
equivalent). All patients received the 3 bronchoscopic procedures without major complications. Compared to before BT,
at 6 months after the last BT session, 18 patients had an improved Asthma Quality of Life Questionnaire score, 17 patients had a reduced number of ED visits, and 20 patients
had a reduced number of hospitalizations for respiratory issues. Every patient showed a benefit in at least one measure
of asthma control. There was no significant change in FEV1
(% predicted) or the daily ICS dosage. None of the patients
worsened after the treatment.
Conclusion: Bronchial thermoplasty is a safe, routine procedure in patients with severe asthma. The majority of the patients in our initial cohort benefited from the therapy.
Oral Presentation
IP-O1-3
IP-O1-4
Withdrawn
Five cases of plastic bronchitis with influenza (H1N1)
2009 infection
Respiratory Disease Center, Showa University Northern Yokohama Hospital, Japan
Kosuke Suzuki, Akihiko Kitami, Shinichi Ohashi,
Humitoshi Sano, Shoko Hayashi, Shugo Uematsu,
Yoshito Kamio, Takashi Suzuki
Background. Influenza (H1N1) 2009 spread on a pandemic
scale in 2009, which resulted in a large number of infected
cases in Japan. Even in 2010, numerous cases of H1N1 2009
infection were reported. Those afflicted were predominantly
young people. Many children were admitted to our hospital,
some of whom experienced respiratory failure and required
artificial respiration.
Objective. To determine the pathology of respiratory failure
associated with H1N1 2009 infection.
Subjects and Methods. Between September 2009 and the
first week of December 2009, a total of 89 patients (65 males
and 24 females) were admitted to our hospital for influenzarelated conditions. Among these, 5 suffered from respiratory
failure that required bronchial intubation and artificial respiration; bronchoscopy was performed for all of these cases.
Representative case. The patient was a 7-year-old male who
presented with rapidly progressed respiratory failure. He
was intubated and underwent bronchoscopy because of decreased lucency in the entire right lung field and respiratory
failure. Plastic bronchitis was diagnosed based on endobronchial obstruction due to a mucus plug. After removing the
mucus plug, his respiratory condition improved.
Conclusions. A high incidence of plastic bronchitis is observed among pediatric patients with H1N1 2009 infection.
Bronchoscopy should be considered for treating cases when
plastic bronchitis is present.
205
Oral Presentation
IP-O1-5
IP-O1-6
Passive smoking impairs protein phosphatase 2A activity in children with severe asthma
Respiratory condition and life expectancy in the mirror
of bronchoscopy results of primary ciliary dyskinesia
(PCD)
Department of Otolaryngology, Kansai Medical University, Japan1), Airway Disease Section, National Heart and Lung Institute, Imperial College London, UK2)
Yoshiki Kobayashi1), Nicolas Mercado2), Koichi Tomoda1),
Peter J Barnes2), Andrew Bush2), Kazuhiro Ito2)
Background: Exposure to parental smoking is known to
worsen asthma symptoms in their children. As one of the
molecular mechanisms, we recently reported that cigarette
smoke-induced oxidative stress impairs histone deacetylase2 (HDAC2) via phosphoinositide-3-kinase (PI3K) signalling activation, resulting in corticosteroid insensitivity in alveolar
macrophages. Here we further investigated the involvement
of protein phosphatase 2A (PP2A) in oxidative stressmediated PI3K-Akt signalling activation.
Methods: To investigate passive smoking-dependent molecular abnormalities, bronchoalveolar lavage fluid (BALF) samples were obtained from 19 children with severe asthma (10
non-passive smoking and 9 passive smoking subjects). Immunoprecipitated PP2A!
HDAC2 activities, PP2A!
Akt phosphorylation levels, responsiveness to corticosteroid and PP2
A!
Akt association were evaluated in alveolar macrophages
and PMA-differentiated macrophage-like U937 cells under
oxidative stress.
Results: Passive smoking reduced PP2A activity with negative correlation to Akt phosphorylation level and with positive correlation to HDAC2 activity in alveolar macrophages.
Also in PMA-U937 cells exposed to oxidative stress which
can induce steroid insensitivity, PP2A activity was reduced
with concomitant enhancement of Akt phosphorylation level
and reduction of HDAC2 activity. Oxidative stress not only
reduced PP2A activity, but also dissociated PP2A from Akt.
Even more importantly, PP2A overexpression reduced Akt
phosphorylation levels.
Conclusion: Passive smoking impaired PP2A function, which
could contribute to Akt signal-dependent corticosteroid insensitivity in children with refractory asthma. PP2A appears
to be a negative regulator of PI3K-Akt signalling and impaired PP2A may be a potential therapeutic target.
206
Paediatric Pulmonology, Svabhegy Pediatric Institute Ltd.,
Budapest, Hungary
Andrea Banfi, Erzsebet Peterffy, Gyorgy Baktai
PCD is a rare but severe respiratory disorder in children (incidence is 1!
15000) characterized by altered ciliary pattern,
beat frequency or both. Early diagnosis and treatment are
important to prevent progression of lung damage.
Our aim is to summarize bronchoscopic aspects of the diagnosis and treatment in PCD children in the viewpoints of respiratory conditions and life expectancy.
In our presentation we exhibit those diagnostic bronchoscopy samples techniques-bronchial brushing and mucosal
biopsy-, which have an important role of identification of ciliary structure by transmission electro microscopy (TEM) and
abnormal ciliary function by ciliary beat pattern and frequency analysis using video recording. Bronchoscopic gaining of secretion and!
or bronchoalveolar lavage (BAL) is necessary in non-sputum-producing children to obtain adequate
specimens for bacteriological culture and sensitivity.
We registered and followed 42 patients (13 females, 29 males;
current age range 11-33 years) in our National PCD Care
Centre from 1998. 10 of these 42 cases have Kartagener s
syndrome. Mucosal biopsy for TEM analysis and bacteriological sampling were carried out in all 42 patients. Airway
infection with Haemophilus influenzae, Staphylococcus
aureus, Streptococcus pneumoniae frequently occurred, nevertheless Pseudomonas aeruginosa was verified in one case
as well.
Indications of therapeutic bronchoscopy in children with
PCD are pulmonary atelectasis and mucous plug. Therapeutic bronchoscopy is indicated in cases of worsening respiratory symptoms and deterioration of lung function in spite of
adequate conservative therapy as well.
Summarizing, PCD is a serious condition in childhood, which
continues into adulthood. Bronchoscopy and the different
sampling techniques contribute to early diagnosis and aggressive treatment of disease and help to prevent the definitive damage of the lung, ensuring better quality of life of the
patients.
Oral Presentation
IP-O1-7
IP-O1-8
Management of upper airway symptoms in primary ciliary dyskinesia (PCD)
Improving awareness of PCD with the implementation
of european state-of-the-art standard in Hungary
Svabhegy Pediatric Institute Budapest, Hungary
Erzsebet Peterffy, Andrea Banfi, Gyorgy Baktai
Primary ciliary dyskinesia (PCD) is a rare genetic disease
characterized by abnormal ciliary structure and function
leading to impaired mucociliary clearance and chronic progressive sinopulmonary disease. The respiratory tract manifestations that begin early in childhood are cardinal features
of PCD. The clinical manifestations of PCD in upper airways
include otitis media with effusion, chronic rhinosinusitis and
paranasal sinusitis. The prevalence, persistence and severity
of symptoms are greater in PCD patients than in the general
population and more frequent in Kartagener s subgroup.
Our Foundation is a PCD Care Centre where the diagnosis
and regular follow-up has been carried out in 42 patients (13
females, 29 males; current age range 11-33 years) since 1998.
10 of these 42 cases have Kartagener s syndrome.
As disturbed ciliary motion causes mucus to be retained in
the middle ear, 81% of the patients have chronic and sometimes severe otitis media with effusion leading to conductive
hearing loss. Therapy of acute middle ear infection is prompt
use of antibiotics. The hearing loss is usually persistent
throughout childhood, continues well into adulthood. By providing ventilation tube (VT) insertion for children with severe hearing loss a normal hearing thresholds are obtainable
in critical language development period. Notwithstanding
the placement of VT is discouraged since it frequently
causes otorrhoea, tympanic membrane atrophy, ossicular
chain erosion or cholesteatoma which prevent wearing of a
hearing aid. Conservative therapy such as treatment of nasopharynx, periodical tympanotomy to remove the thick mucoid content from the tympanic cavity, hearing aid is provided. 2 of our patients have undergone bilateral ear surgery
because of serious otorrhoea with complications, 2 had VT
for a short time, others are being treated conservatively.
Chronic rhinosinusitis and paranasal sinusitis are the other
otolaryngologic manifestation. The nasal secretions are
abundant, watery to mucoid, purulent during infections and
transported by gravity because of the absence of mucociliary clearance. Nasal polyps are found in around 15% of the
patients and underdevelopment of the frontal and sphenoidal
sinuses may occur. Saline nasal douches, prolonged antibiotic
treatment, anticholinergs are the non-invasive therapies. In
two of our patients endoscopic sinus surgery was necessary
because of nasal polyp, in the other case because of acute sinusitis.
However, the role of paediatrics, pulmonary, otolaryngology
in the therapy of the individual cases may vary depending
upon the phenotype, therefore the medical attendance of the
patients is a multidisciplinary task. Their importance in the
management of PCD is equal.
Svabhegy Pediatric Inst Ltd., & The Bronchus Foundation Budapest, Hungary
Gyorgy Baktai, Andrea Banfi, Erzsebet Peterffy
Primary ciliary dyskinesia (PCD) is considered a rare disease
with a low average incidence of about 1!
15000 in the population. In the PCD patients the abnormal ciliary structure and
function depending of the genetic background result in large
range disease severity. The sites of impaired mucociliary
clearance determines the phenotype, that is the dominant
upper or lower involvement, in practice the severity either
chronic progressive sinopulmonary disease either bronchiectasis, atelectasis, and lung damage. Early diagnosis and treatment are essential in preventing the progression of lung
damage.
Over viewing the number of diagnosed cases, our general
knowledge on PCD is far from the realities. Approximately
600-800 children and adults have PCD in Hungary. We registered only 42 patients (13 females, 29 males; current age
range 11-33 years) in our National PCD Care Centre from
1998. 10 of these 42 cases have Kartagener s syndrome.
Consequently, we intend to set up a comprehensive plan to
improve yield of PCD diagnosis in Hungary. We have a lot of
work to do to improve the awareness of PCD in our country.
We decided to take action, with sharing the stories of our patients, to get involved the community, the family doctors,
and the specialists of the attached fields. We must to shine
the spotlight on what PCD is, how we develop our diagnostic
tools for better recognition of the disease. Aimed screening
with measuring of nasal nitric oxide in the patients suffering
from chronic inflammatory airway symptoms might also improve the recognition of PCD. We should underline that we
are able to improve the lives of those living with PCD, that
means how try to find better and better cure for this illness.
We are convinced that our effectiveness may be enhanced
with the implementation of European state-of-the-art standard diagnosis in Hungary.
207
Oral Presentation
IP-O2-1
IP-O2-2
Clinical experience of transbronchial laser ablation for
central airway stenosis using high-power diode laser
Respiratory compensation after lobectomy mainly occurs in the lobes on the operated side
Department of General Thoracic Surgery, Department of General Thoracic Surgery Graduate School of Medicine, Chiba
University, Japan
Department of Thoracic and Cardiovascular Surgery,
Wakayama Medical University, Japan1), Wakayama-minami
Radiology Clinic, Japan2)
Kazuhisa Tanaka, Takahiro Nakajima, Terunaga Inage,
Takayoshi Yamamoto, Takamasa Yun, Toshiko Kamata,
Junichi Morimoto, Hidemi Suzuki, Tetsuzo Tagawa,
Takekazu Iwata, Teruaki Mizobuchi,
Shigetoshi Yoshida, Ichiro Yoshino
Tatsuya Yoshimasu1), Shoji Oura1), Yozo Kokawa1),
Mitsumasa Kawago1), Hirai Yoshimitsu1),
Takuya Ohashi1), Megumi Kiyoi1), Haruka Nishiguchi1),
Masako Matsutani1), Yoshitaka Okamura1),
Masaki Terada2), Katsuji Nakagawa2)
【Background】
High power diode (GaAlAs) laser system has been used for the endobronchial laser ablation for central airway stenosis. Compared
with the conventional Nd-YAG laser, diode laser system showed
equal clinical effect for ablation and the instrument is compact and
easier handling. We use high power diode laser system (ULD-60,
Olympus) with non-contact probe for the transbronchial treatment.
【Purpose】
The purpose of this study is to review our experience of transbronchial laser ablation to explore the better clinical approach for central airway stenosis.
【Method】
We retrospectively reviewed the patients who were treated for
central airway stenosis by transbronchial laser ablation using
noncontact-type probe from January 2005 to November 2013 at
Chiba University Hospital. The cases are treated by high power diode laser (GaA1As) system which generates laser light (wavelength 810 20nm) with a maximum power of 60W. We investigated
the cause of stenosis, the number of treatment, laser setting, total
amount of energy, complication, and simultaneously performed modality.
【Result】
31 patients underwent 66 times of the treatment in total. There
were 21 males with an average age of 60.3 years-old. The primary
cause of airway stenosis are 20 neoplastic diseases (13 malignant
tumors, 7 benign tumors) and 11 non-neoplastic diseases. Within
the malignant tumors, there were 8 tracheal cancer or lung cancer
patients and 5 patients with metastatic tumor. As for the benign
tumors, there were 3 hamartoma and each one patient with polymorphic adenoma, papilloma, smooth muscle tumor, and glomus tumor. The non-neoplastic causes of airways stenosis were 4 intubation or tracheotomy patients, each 2 patients with trauma, surgery,
and tuberculosis and one another cause. The numbers of treatment
were 26 times (1.3 times!patient) for neoplastic diseases and 40
times (3.64 times!patient) for non-neoplastic disease. In nonneoplastic diseases, we did more treatments per case. The total
amount of energy was 1870.1J on average (1760.7J for neoplastic
diseasae and 1979.6J for non-neoplastic disease. For the neoplastic
disease, 18 out of 21 patients were treated with other modality
such as snaring, ethanol injection and stent insertion. Four out of 11
non-neoplastic poatients were treated with balloon dilatation.
There was no major complication related with transbronchial laser
ablation.
【Conclusion】
Transbronchial laser ablation using diode laser system with noncontact probe can be safely performed and useful for transbronchial treatment for the central airway stenosis.
208
[Introduction]
Respiratory function after surgical resection of the lung cancer is often better than predicted. Some compensatory responses might be existed. Lobectomy is the standard procedure of lung cancer surgery. However, spirometry cannot
evaluate lung function of individual lobe as single units. We
evaluated vital capacity (VC) of each lobe using volumetric
computed tomography (CT) in patients with lung cancer. In
this study, we evaluated the compensatory response in ventilation after lobectomy was evaluated using volumetric CT
as individual lobes.
[Pateints and methods]
Volumetric CT was evaluated before and 1 year after lobectomy in 42 patients. The operative procedures were right
upper lobectomy in 18, right upper and middle lobectomy in
1, right middle lobectomy in 2, right lower lobectomy in 10,
left upper lobectomy in 8, and left lower lobectomy in 3.
Chest CT scans at inspiratory and expiratory levels were
performed at the same time. We then calculated the volume
of individual lobes using reconstruction and analysis software. VC of each lobe (VCL) was calculated as; VCL=lobar
volume at the inspiratory level-lobar volume at the expiratory level.
[Results]
VCL of resected lobes was 0.30 0.25L. VCL of residual lobes
on the operated side was 0.452 0.204L before surgery, and
significantly (p<0.0001) increased to 0.558 0.336L after lobectomy. An average of 32.6% increase was observed. However,
no significant difference (p=0.3592) in VCL was observed in
the lobes on the unoperated side between before (0.749
0.374L) and after (0.797 0.377L) lobectomy. When VCL of residual lobes on the operated side was evaluated as an individual lobe, VCL before and after lobectomy were 0.255L and
0.337L in right upper lobe, 0.083L and 0.113L in right middle
lobe, 0.415L and 0.456L in right lower lobe, 0.417L and 0.70 L
in left upper lobe, and 0.431L and 0.587L in left lower lobe, respectively. There seems to be no specific difference on the
compensatory response in ventilation among individual
lobes.
[Conclusion]
Compensatory response in ventilation after lobectomy
mainly occurs in the lobes on the operated side.
Oral Presentation
IP-O2-3
IP-O2-4
Bronchoscopic characters and therapy of pulmonary
atelectasis in 1360 patients
Should an interventional pulmonologist be doing all of
your bronchoscopies?
Department of Respirology & Critical Care Medicine, Xiangya
Hospital of Central South University, China
Yuanyuan Li, Chengping Hu, Huaping Yang
OBJECTIVE: To summit causes and flexible bronchoscopic
characters of pulmonary atelectasis, meanwhile, relationships between causes and lesion sites of it for a better bronchoscopy were also discussed.
METHODS: The clinical data(including history characters,
imaging data, bronchoscopic findings, pathological results
and the methods and effect of bronchoscopic treatment) in
1360 patients with pulmonary atelectasis admitted to
Xiangya Hospital between October 2006 and May 2013 was
retrospectively analyzed.
RESULTS: ① 1295 of 1360 patients could be diagnosed by
flexible bronchoscopy combined with pathological examination which brought a 95.2% diagnostic rates. In all these
cases, tumor took up 37.2%, while inflammation was 35.5%
and tuberculosis took the other 19.9%. ② Bronchoscopic
manifestations including cauliflower-like neoplasm which
were caused by tumor (74.6%). Achymucosa, congestion,
unsmooth were not specific findings in bronchoscopy examination. Tracheal cavity scar strictures or closures were often
seen in tuberculosis (80.6%), and purulent secretions were almost caused by inflammation (92.9%). ③ Bronchoscopic
manifestations were also related to lesion sites of different
lobes. ④ Bronchoscopic treatment could be bronchoalveolar
lavage, freezing and balloon dilatation, etc.
CONCLUSION: Flexible bronchoscopy combined with pathological examination remain the main methods for the diagnosis of pulmonary atelectasis. Manifestations of pulmonary
atelectasis were related to causes and lesion sites. Bronchoscopic therapy could ease airway obstruction to some degree
in which could relief pulmonary atelectasis, thus, improving
respiratory function.
Dept of Internal Medicine, University of South Carolina, USA
Franklin Riley McGuire, Christina Carter, Husam Najjar,
Matthew D Kolok
BACKGROUND:
In regards to safety of flexible bronchoscopy, we know novice trainees expose patients to
higher risk at the beginning of their training.1 We also know structured training programs
that includes simulation provide transferrable skills and improves performance of pulmonary
fellows.2 We do not know if advanced training in bronchoscopic procedures provides a safety
benefit. To address this question we did a retrospective study in our hospital system.
METHODS:
As part of a quality assurance project, we reviewed adverse events (AEs) during bronchoscopies in our hospital. We recorded training level of performing physician for 1200 procedures.
There were 600 procedures done by an interventional pulmonologist (IP) and 600 procedures
done by non-IPs. Procedures were categorized as simple (airway exam＋!-lavage), diagnostic
bronchoscopy (DB) (Brushing and!or any biopsies), and therapeutic bronchoscopy (TB) (dilatation, debulking and!or stenting). The AEs were categorized as major or minor, with the former needing higher level of care, and the later recovering without any intervention.
RESULTS:
Over the course of 1200 procedures, AEs occurred 164 times, with 141 being minor (11.8%) and
23 being major (1.9%). The only statistically significant difference between non-IP and IP was
the rate of major AEs that occurred during diagnostic bronchoscopy, with a rate of 5.50% (12!
218) in the non-IP group compared to a rate of 0.86% (3!348) that occurred in the IP group (p=
0.002). During simple procedures and therapeutic procedures, the rate of major AEs was
slightly higher when the IP performed the procedure; however the numbers were not statistically significant. Including all bronchoscopy, the IP had a higher rate of total AEs (14.3% vs.
13.0%), but a higher percentage of those events were classified as minor as compared to the
non-IP group (90.7% vs. 80.8%). This did not take into account lower risk procedures performed by the non-IP group.
CONCLUSION:
We discovered that the percentage of major AEs was lower when an IP was performing DB
procedures. There was a smaller percentage of major AEs in simple procedures as well, but
the values were not significant. Overall, the percentage of major AEs was lower for the IP performing group raising the question, should an interventionally trained pulmonologist be performing all of your system s bronchoscopy?
1.Ouellette D. Safety of Bronchoscopy in Pulmonary Fellowship Program. CHEST 2006; 130(4):
1185-1190.
2.Wahidi M, Silvestri G, Prospective Multicenter Study of Competency Metrics and Educational Interventions in the Learning Bronchosocpy Among New Pulmonary Fellows. CHEST
2010; 137(5): 1040-1049.
209
Oral Presentation
IP-O2-5
IP-O2-6
Pediatric airway foreign bodies: Development and usage results of foreign-body grasping forceps
Experience with rigid bronchoscopy under general anaesthesia using TIVA in a peninsular Malaysia state
Department of Surgery II, Faculty of Medicine, Yamagata
University, Japan
Makoto Endoh, Oizumi Hiroyuki, Kato Hirohisa,
Watarai Hikaru, Sadahiro Mitsuaki
【Background】Although a foreign body in the airway of children constitutes an emergency, available therapeutic tools are insufficient and treatment can be difficult. Here
we examined our pre- and intraoperative modifications and evaluated the treatment results.
【Methods】The subjects included 24 children (13 boys, 11 girls; median, 18 [range, 9-60]
months) treated for airway foreign bodies from January 1994 to October 2013. We examined retrospectively the preoperative diagnoses, anesthesia and surgical methods.
【Results】The foreign body was a bean in 21 cases, a chestnut, dental prosthesis and a
bead respectively. General anesthesia was used in all cases, and the airway was maintained with a laryngeal mask whenever a flexible endoscope was used. The bronchoscopes were from the BF-p series (outer diameter, 2.8-5.3 mm; Olympus Medical Science Sales, Tokyo, Japan). The mean operation time was 51 32 min. Grasping forceps
were used in 14 cases, basket forceps in 7 cases, and a Fogarty catheter in 2 cases. In
July 2003, 3-pronged foreign-body grasping forceps with a 2.0-mm diameter built to be
used with a thin bronchoscope were introduced. Of the 16 treated cases, 8 accomplished with the only forceps. The mean operation time was significantly shortened to
38 24 min (range, 7-91 min) compared to the traditional operation time of 82 42 min
(range, 23-147 min) (p=0.01).
【Conclusions】Thus, we successfully reduced the operation time by using a novel
3-pronged grasping forceps for the removal of airway foreign bodies.
210
Department of Internal Medicine, Universiti Putra Malaysia,
Malaysia1), Department of Internal Medicine, Serdang Hospital2)
Liza Ahmad Fisal1), Azlina Samsudin2),
Jamalul Azizi Abdul Rahaman2)
Background: Globally, rigid bronchoscopy is making a comeback owing to progress made in interventional pulmonology.
However, there are reservations amongst local pulmonologists in adopting rigid bronchoscopy due to its perceived
complications. The aim of this this study was to assess the
feasibility, safety and complication rates of rigid bronchoscopy under general anaesthesia using TIVA in a Peninsular
Malaysia state tertiary referral centre.
Methods: Retrospective analysis of all patients who underwent elective diagnostic and therapeutic rigid bronchoscopy
from 1st December 2011 to 30th September 2013 was performed.
Results: 114 rigid bronchoscopies in 91 patients were included. The median age was 54 years and 80 (70.2%) were
male. Most patients were ASA I and II (77.6%) with an ECOG
performance status of 2 or less (78.4%). The main indications
were respiratory symptoms with abnormal radiological findings (74.6%), incidental abnormal radiological findings (9.0%)
and tuberculosis-related complications (7.5%). Most procedures were diagnostic (73.8%) where endobronchial biopsy
was the commonest procedure performed (65.2%). The overall rate of intra-operative complications was 30.1% (bleeding
16.3%, desaturation 5%, hypotension 11.3%) & post-operative
complications was 7.5%. Only 3 cases required endotracheal
tube insertion & mechanical ventilation for laryngoedema,
severe bleeding & iatrogenic pneumothorax. There were no
fatal complications in this analysis. The median recovery
room time was 76.6 minutes and most cases were discharged
within 24 hours post-procedure (81.3%). Complications occurred more commonly in cases with poor ECOG status (p=
0.025). Other factors such as age, gender, ASA score, presentation, indications, location of lesion, diagnostic procedure
and diagnosis were not associated with increased complications.
Conclusion: Our survey showed that rigid bronchoscopy under general anaesthesia using TIVA is safe, where complications were attributed to the bronchoscopic procedures and
were reversible. The patients overall status should be assessed prior to the procedure and extra care should be given
to patients with poor performance status.
Oral Presentation
IP-O2-7
IP-O2-8
Assessment of BCV for prevention of hypoventilation
during interventional bronchoscopy using a rigid bronchoscope
Bronchoscopic management of endobronchial fire
with severe airway obstruction
Department of Pulmonary Medicine, National Hospital Organization Matsue Medical Center, Japan1), Department of Pulmonary Medicine, Shimane Medical University, Japan2)
Mitsuhiro Tada1), Hibiki Kanda1), Shinichi Iwamoto1),
Emiko Nishikawa1), Toru Kadowaki1), Masahiro Kimura1),
Kanako Kobayashi1), Ikeda Toshikazu1), Takeshi Isobe2),
Shuichi Yano1)
Background:
Interventional bronchoscopy using a rigid bronchoscope requires deep general anesthesia to prevent bucking and body
movement during treatment, and the weak point about this
technique is the possibility that excessively deep anesthesia
can inhibit patient respiration and result in hypoxia. There is
no effective way to overcome this problem.
Objectives:
The purpose of this study was to investigate whether the
use of Biphasic Cuirass Ventilation (BCV) using a rigid bronchoscope can prevent hypoventilation during interventional
bronchoscopy.
Methods:
Between August 2010 and October 2013,14 patients received
interventional bronchoscopy by a rigid bronchoscope with
combined use of BCV. The underlying diseases!
disorders in
these 14 patients included tracheal stenosis secondary to
lung cancer in 11 patients, post-intubation tracheal stenosis
in 1, rt. bronchial stenosis due to esophageal cancer in 1, and
post-tuberculosis bronchial stenosis in 1. BCV was used in all
patients, and Tidal volume, SaO2, PaCO2, and frequency of
discontinuation of procedure were monitored.
Results:
The treatment procedure could be safely performed in all
the patients. It was possible to fully maintain minute ventilation during treatment and none of the patients experienced
discontinuation of procedure due to hypoxia. Therefore, patients were able to receive sufficient anesthesia, which could
lead to reduced bucking during treatment. There were no
complications associated with BCV.
Conclusion:
During interventional bronchoscopy using a rigid bronchoscope, the use of BCV enabled the maintenance of ventilation
during treatment and administration of sufficient anesthesia,
suggesting potential clinical usefulness. We strongly recommend this technique to be tested further, especially in medical facilities that have hesitated to use a rigid bronchoscope
or those anxious about respiratory management during
treatment using a rigid bronchoscope.
Respiratory Institute, Cleveland Clinic, USA1), Department of
Pulmonary and Critical Care Medicine, University of Alabama
at Birmingham2)
Danai Khemasuwan1), Wissam Jaber2), Abdul Alraiyes1),
Thomas Gildea1), Michael Machuzak1)
Endobronchial fire is a rare complication of airway ablative procedures. The long-term
complication is airway obstruction from granulation tissue, stricture and tracheobronchomalacia. A retrospective chart review from 2009 through 2013 was conducted.
Four patients with endobronchial fire were identified. We present the long-term bronchoscopic management in this entity.
Case 1:
A 56 year old patient developed diffuse tracheobronchial stenosis after airway fire during uvuloplasty. A silicone Y-stent was placed restoring patency to the trachea and bilateral mainstem bronchi. Her functional status improved, but required multiple procedures for stent maintenance. Stent-related complications included MRSA infection and
granulation tissue necessitating cryoablation, dilation and stent revision. She maintains
good functional status with mild cough.
Case 2:
A 68 year old patient developed a complete subglottic stenosis after a prolonged recovery and tracheostomy after a cardiac procedure. An outside facility made numerous attempts to manage her stenosis, complicated by an airway fire. A T-tube and a Y-stent
were placed to relieve her subglottic and bilateral mainstem stenosis as well as restore
subglottic patency. Multiple procedures were required to manage stents. Her functional and respiratory status improved and her voice was restored. She died at home 2
years later.
Case 3:
A 68 year old patient with an airway fire injuring the larynx to mainstem bronchi during laser ablation of a vocal cord cancer. This resulted in complete laryngeal obstruction, tracheal and bronchial strictures and tracheomalacia. A T-tube and Y stent were
placed. The patient had three Y-stent revisions during follow up. He has marked improvement in functional and respiratory status as well as restoration of voice.
Case 4:
29 year old patient with recurrent respiratory papillomatosis had many laser ablations.
At age 18 she had an endobronchial fire at an outside institution which left her with
marked central airway stenosis. She underwent an open airway reconstruction with
rib grafting. However, after several years of multiple balloon dilatations, ablations, topical application of mitomycin-C, a Y stent placement and stent modifications was performed. She is improved though she still has secretions, MRSA colonization and requires multiple stent revisions every few months.
Endobronchial fire is one of the most devastating complications related to airway procedures. The management is difficult, tedious and long-term, requiring multi-modality
bronchoscopic therapies. These patients often require complex silicone stent modifications. These patients will need frequent follow-up for an extended period, but with optimal care may still enjoy an improved quality of life.
211
Oral Presentation
IP-O2-9
IP-O3-1
The experience using rigid thoracoscopy in management of loculated pleural effusion
Traps and surprises in diagnostic bronchoscopy
Pulmonology & Respiratory Medicine, Faculty of Medicine
University of Indonesia, Indonesia
Heru Wiyono
Background:
Loculated pleural effusion is one of many problem in pleural
disease management. Many modalities can be used to resolve the problem. One of theme is to use rigid thoracoscopy
to clean up the pleural cavity from adhesions. Our aim study
is to know the role of rigid thoracoscopy in loculated pleural
effusion patients.
Methods:
Rigid thoracoscopy was performed in 30 patients with loculated pleural effusion diagnosed by thoracal ultrasonography. We examined pulmonary function test also before and
after thoracoscopy beside evaluation of clinical symptoms.
Results:
There are improvement in clinical symptom and pulmonary
function in all patients after thoracoscopy.
Conclusion:
Rigid thoracoscopy gave benefit clinically and improve pulmonary function in our patients with loculated pleural effusion.
212
Bronchology, Pneumology Clinic Cluj-Napoca, Romania1),
Pneumology Clinic, Cluj-Napoca, Romania2), Pnemology Clinic,
Timisoara, Romania3), Pneumology Clinic, Craiova, Romania4)
Marioara Simon1), Petrut Vremaroiu2), Milena Man2),
Dorin Vancea3), Mihai Olteanu4)
Fibrobronchoscopy is a routine method in pneumology but
doing it isn t a routine procedure for the bronchologist, no
matter how much experience he!
she might have.
Material and method: We present a retrospective analysis of
9800 fibrobronchoscopies performed between 2007-2012 in
the Bronchology Department of Pneumology Hospital ClujNapoca, Romania. The examinations were performed using
Olympus fibrobronchoscope, in local anesthesia with Lidocaine 2%, and mild sedation.
Results: We will present some cases which represented real
traps or surprises for us. The diagnosis difficulties were
due to the rarity of the pathology or to the discrepancy between the radiological and the endoscopical aspects.
Conclusion: Among the cluster of the current methods of diagnosis in pneumology, fibrobronchoscopy holds a central
position through direct visualization of the pathology and
histopathological diseases confirmation.
Oral Presentation
IP-O3-2
IP-O3-3
Learning curves on bronchoscopy procedure among
pulmonary residents
Bronchoscopy training using a multi-modality method:
Skill evaluation
Department of Pulmonology, University of Indonesia, Indonesia
Ginanjar Arum Desianti, Wahju Aniwidyaningsih,
Faisal Yunus
Background:
Learning process is a continuous process, as well as medical procedures. Medical
bronchoscopy is a key skill for respiratory physician and taking time to achieve
competency. Some issues related to the process are the knowledge about the procedure, the quality and quantity of procedure performed, and self-courage for doing the procedure. Bronchoscopy Self Assessment Tool (BSAT) and Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) are some method to identify
procedure competency. Learning curves of competency assessment and factors
affecting these curves are needed to evaluate bronchoscopy training program.
This study aimed to identify learning curves of bronchoscopy procedure by using
BSAT and modified self-assessment BSTAT (mBSTAT) questionnaires for pulmonary residents and also to identify factors which correlated.
Methods:
This study is an analytical cross-sectional study design identifying learning
curves of bronchoscopy procedure. First, the score of BSAT and mBSTAT
quetionnaires to pulmonary residents in Persahabatan Hospital, Jakarta was calculated. These scores are crossed and analyzed with other variable that contributing. Subject is choosen by consecutive sampling which consist of pulmonry residents that alrealy passed bronchoscopy round based on curriculum.
Results:
Among 33 subjects who participated in this study, 7 subjects have not reached
the qualification number of procedure, set by curriculum (15 procedures). However, BSAT scores and mBSTAT are not correlated with the number of bronchoscopy procedures that had already been done. By Spearman rank test, BSAT
scores has a strong negative correlation with the level of specialist program (p<
0.01; r=-0.756) and very strong negative correlation with time periode after bronchoscopy round (p<0.01; r=-0.857). mBSTAT scores has a moderate negative correlation, both with the level of specialist program (p<0.05; r=-0.413) and also with
time periode after bronchoscopy round (p<0.05; r=-0.437). BSAT scores were positively correlated with mBSTAT score (p<0.01; r=0.479). For multivariate analysis,
by using linear regression, only variable period after bronchoscopy round which
can predict BSAT scores (r=-0,840) for about 69,6%.
Conclusion:
Learning curve of pulmonary resident in bronchoscopy procedure is not related
to how much procedures that had already been done, but with the time period after the last procedure. So repetition for doing the procedure is needed to get a
better self-assessment result.
Department of Thoracic, Endocrine Surgery and Oncology,
University of Tokushima, Japan1), Department of Oncological
Medical Services, University of Tokushima, Japan2)
Shoji Sakiyama1), Yukikiyo Kawakami1),
Mitsuhiro Tsuboi1), Koichiro Kajiura1), Hiroaki Toba1),
Yasushi Nakagawa1), Mitsuteru Yoshida1),
Hiromitsu Takizawa1), Kazuya Kondo2), Akira Tangoku1)
Background: Regarding training for performing bronchoscopies, it is most important to maintain the patients safety and
to reduce the patients burden related to bronchoscopy examinations. It is important to keep these priorities in mind
when creating a curriculum for training medical residents in
how to perform bronchoscopies and for evaluating trainees
performance.
Methods: From 2010 to the present, we have used a multimodality method designed by our department for bronchoscopy training. The method is composed of a pre-patient
module and a patient module. The pre-patient module uses a
self-assessment of knowledge regarding bronchoscopy issues
including medical safety concerns, and self-training using virtual bronchoscopy navigation systems (Bf­NAVIR and Lung
PointsR). The trainees bronchoscopy procedure skills are
evaluated with a bronchoscopy simulator (AccuTouchR). In
the patient module, each procedure by the trainee in a clinical setting is evaluated by an instructor certified by the Japan Society for Respirator Endoscopy. Assessments are performed for the following items based on the criteria: local anesthesia (time, effectiveness), handling of a bronchoscope,
passage through the vocal cords, the number of times the patient coughs, anatomical orientation, total time of bronchoscopy, and biopsy technique. The assessments are done and
recorded on-site using a computer-based management software program developed in our department. Each comment
by the instructor is also recorded. By analyzing these data,
we are able to determine the ability of each trainee and his
or her learning curve. Feedback about this information is
provided to the trainees after each bronchoscopy.
Results: Our assessment system can be used to demonstrate
the bronchoscopy ability and the learning curve to each
trainee. With the database comprised of the training data obtained, we can set a standard time for local anesthesia and
ordinary observation. We have found that it is important to
record feedback comments, as this information shows the
best ways to effectively instruct trainees. Potential pitfalls
into which trainees can easily fall can also be identified with
this program.
Conclusions: We will continue to introduce our bronchoscopy training program to newcomers. The program facilitates the step-by-step acquisition of bronchoscopy skills and
will reduce the burden placed on patients related to bronchoscopies.
213
Oral Presentation
IP-O3-4
IP-O3-5
Virtual-reality simulator training for endobronchial ultrasound: A multi-centre randomized controlled trial
Long term results of lung cancer after heart trasplantation
Center for Clinical Education, University of Copenhagen and
the Capital Region of Denmark, Denmark1), Department of Pulmonology, Copenhagen University Hospital Gentofte, Denmark2), Department of Pulmonology, Academic Medical Centre, University of Amsterdam, The Netherlands3)
Lars Konge1), Paul Clementsen2), Jouke Annema3)
Background: According to new guidelines endosonography is the
method of choice for staging lung cancer. However, the technique
is highly operator dependent, and focus on training and certification is essential before results from expert centers can be generalized. Newly developed simulators have made it possible to practice endobronchial ultrasound-guided fine-needle aspiration
(EBUS-TBNA) in a virtual-reality environment. The aim of this
study was to determine whether simulator training could replace
practicing on patients.
Methods: An international volunteer sample of 16 respiratory
physicians without EBUS experience and a convenience sample
of two EBUS experts were included in the study. The respiratory
physicians attended an 8-hour theoretical course and participated
in two EBUS procedures on patients. Then they were randomized to either control group (=a half-day, standard, supervised
hands-on training on patients) or intervention group (=a standardized, individual 4-hour training program on a virtual-reality
EBUS simulator administered by the same operator). Following
the training and a retention period each physician performed
three consecutive EBUS-TBNA procedures. The endoscopic and
the ultrasound videos were recorded and assessed blindly and independently by three EBUS experts using the newly developed
12-item EndoBronchial UltraSound Assessment Tool (EBUSAT).
Each item was scored from 0 to 4 points giving a maximum score
of 48 points. Ten consecutive procedures by EBUS experts were
assessed simultaneously to gather validity evidence.
Procedures
performed
by
simulator-trained
novices,
apprenticeship-trained novices, and endosonography experts respectively were compared using independent samples t-tests. Reliability was explored using Generalizability Theory (a two-facet
design with participants crossed with procedures crossed with
raters).
Results: The simulator group performed significantly better than
the standard training group; 24.2 points vs. 20.1 points, p=0.006.
The EBUSAT scores were very reliable; generalizability coefficient=0.85. An acceptable Generalizability Coefficient for highstakes assessment of 0.8 could be achieved by using 3 raters assessing 2 procedures, 2 raters assessing 3 procedures, or 1 rater
assessing 6 procedures. The experts scored significantly higher
than the novices indicating that the EBUSAT possess construct
validity; 35.3 points, p<0.001.
Conclusion: EBUS training on a virtual-reality simulator is more
efficient than standard apprenticeship training in the initial part
of the learning curve but subsequent supervised training on patients are necessary to ensure basic competency. The EBUSAT
can be used to assess performances in an un-biased, reliable and
valid way. Focus on patient safety and competency-based education makes virtual-reality training and assessment of competence
very relevant issues in the implementation of endosonography.
214
Thoracic Surgery Division Niguarda Hospital Milano Italy
Massimo Torre, Conforti S., Bruschi G., Rinaldo A.,
Fieschi S.
Background: The risk of cancer in solid-organ transplant recipients is recognized to be higher than in general population.
Prognosis of most solid organ tumors occurring in transplant
recipients is poor and cancer remains the most frequent nongraft related cause of late deaths after heart transplantation.
Lung cancer is one of the most common solid organ neoplasm
in the transplant population. The main predisposing factor,
cigarette smoking, is also a predisposing factor for ischemic
heart failure. As a consequence, many recipients of thoracic
transplants are at high risk of lung cancer. We retrospectively reviewed data from the clinical cases of heart transplant (HTx) patients treated in our Institution for lung cancer.
Incidence, treatment procedures and outcome in our transplant recipient patients over a 25-year period were analyzed.
Patients and methods: From November 1985 to December
2013, 905 HTx were performed in our Center. Pediatric patients (younger than 15 years), patients who underwent retransplantation or died within 3 months after primary transplant were excluded from the analysis.
Results: Among 823 heart transplant recipients fulfilling the
study criteria, 25 developed a lung cancer (23 male, 91%),
their mean age at time of HTx was 54.5 5.2 years (range, 4265). All patients received standard triple immunosuppressive
therapy with steroids, azathioprine and cyclosporine. The
mean time from transplantation to lung cancer diagnosis was
73.7 30 months. Lung tumors were detected by routine
follow-up chest roentgenograms in all patients. Fourteen pts
patients were asymptomatic for lung cancer, the other eleven
exhibited clinical symptoms (eg, cough, shortness of breath,
weight loss, anorexia). Eleven patients with lung cancer were
in clinical stage IIIB or higher at the time of presentation and
surgery was considered contraindicated. One patient in clinical I stage refused operation and the diagnosis was confirmed
by fine needle aspiration biopsy (squamous cell tumor, stage
I), the remaining 13 were early stage. This group of patients
who underwent surgical procedures consisted of 12 lobectomies with complete mediastinal lymphadenectomy and one
wedge resection of locally invasive lung tumor infiltrating the
pericardium. The mortality rate was 10%, one patient with
coexistent coronary artery vasculopathy died 8 days after
lobectomy. No major complications occurred in the other patients. The mean follow-up period for the entire study population was 24.4 25.1 months (range, 1 to 142 months). The 5year survival rate of the entire study population was 21.4%,
with a median survival of 10.1 months. In the group of operated patients we observed 5 deaths, with a mean follow-up
time after diagnosis of 43 27 months.
Conclusions: Long-term results following lung cancer surgery
in heart transplant recipients are satisfactory when performed at the early stage of the disease. Preventive computed tomography screen should be considered as a routine
method for early diagnosis in this group of high-risk patients.
Oral Presentation
IP-O3-6
IP-O3-7
Histological diagnosis of lung cancer using small biopsy samples
Tumor gene mutation in lung cancer evaluated by using combination of EBUS-GS and EBUS-TBNA
Department of Surgery, Tokyo Medical University, Japan
Tatsuo Ohira, Takefumi Oikawa, Keishi Otani,
Koichi Yoshida, Yasufumi Kato, Junichi Maeda,
Masaru Hagiwara, Seisuke Nagase, Masatoshi Kakihana,
Naohiro Kajiwara, Norihiko Ikeda
Background-Previously, it was important to decide strategy
of lung cancer treatment that small cell carcinoma or nonsmall cell carcinoma was diagnosed. EGFR-TKI was very effective for EGFR mutation positive lung cancer. EGFR mutation was especially found in adenocarcinoma. EGFR mutation was rarely found in non-adenocarcinoma. Some anticancer drugs were effective for non-squamous cell carcinoma. Recently, it is important that squamous cell carcinoma
or non-squamous cell carcinoma was determined especially
in case of advanced or recurrent lung cancers after surgery.
Methods-We can get only small samples in case of advanced
lung cancer by bronchial biopsy and so on. After surgery, we
can get enough materials to decide definitive diagnosis of
squamous or non-squamous cell carcinoma. So, we compared
diagnosis of pre-operative diagnosis and post-operative diagnosis to examine possibility of histological diagnosis using
small biopsy samples getting by bronchial biopsy. 573 patients who were received tans-bronchial lung biopsy (TBLB)
in 2011 were retrospectively examined.
Results-122 patients of 573 cases were received operation because lung cancer was suspicious. 104 cases were primary
lung cancer. The others were diagnosed metastatic lung cancer or inflammation. In 104 primary lung cancer cases, 66
cases were diagnosed same result compared to pre-operative
diagnosis. 31 cases were not diagnosed before operation. 7
cases were diagnosed lung cancer, but histological diagnosis
was different.
Conclusion-Some cases were diagnosed non-small cell carcinoma before operation. Only two cases were difficult to diagnose adenocarcinoma or squamous cell carcinoma. In case of
poor differenciated lung cancer, it is difficult to decide histological type. Adeno-squamous cell carcinoma was also difficult to determine by pre-operative small samples. Some
cases were difficult to decide histological type of lung cancer
only by Hematoxylin-Eosin (HE) staining. Immunohistochemistry (IHC) was important to determine appropriate diagnosis. Cell block was effective for cytological specimen. IHC
was possible using cell block. If mediastinal lymph node was
swollen, EBUS-TBNA was useful to get enough materials for
IHC. We would like to show what kind of cases was difficult
to determine histological diagnosis with small samples.
Department of Internal Medicine, Bangkok Hospital Group,
Thailand1), Department of Surgery, St. Marianna University
School of Medicine, Japan2), Department of Surgery, Chiba University Graduate Scool of Medicine, Japan3)
Sawang Saenghirunvattana1), Noriaki Kurimoto2),
Takahiro Nakajima3), Supada Chusaktrakul1),
Chittisak Napairee1), Cecille lorraine Castillon1),
Kritsana Sutthisri1), Chitchamai Siangproh1),
Cheewantorn Boonpeng1), Maria Christina Gonzales1)
Objective This study aims to determine the efficacy of the
combined use of EBUS-GS and EBUS-TBNA for the diagnosis and evaluation of lung cancer particularly tumor gene
mutation.
Material and Method During 2012-2013, Combined EBUS-GS
and EBUS-TBNA were performed on 28 patients. On-site pathology!
Rapid on-site evaluation (ROSE) of samples was utilized. The remaining specimens were processed for tumor
gene mutation testing (ALK!
EGFR) and flow cytometry for
lymphoma.
Results Average for combined male and female EGFR results was 26.6% while 7.6% for ALK. Among males 22.22%
were EGFR positive and none were ALK positive. Among females, 33.33% were EGFR positive and 20% was ALK positive.
Conclusion EBUS-GS is a useful method for collecting samples from peripheral pulmonary lesions, including those
which are too small to be visualized under fluoroscopy.
EBUS-TBNA can be used for obtaining both cellular and tissue specimen collection; with this capability, administering
these procedures in tandem can diagnose multiple diseases
in addition to lung cancer. Using EBUS-GS and EBUS-TBNA
together was effective. This pioneer report may mark the
beginning for replacing lung surgery as the primary diagnostic method.
215
Oral Presentation
IP-O3-8
IP-O3-9
Pleural lymph flows by the ICG fluorescence method
with near-infrared camera <A hundred cases experience>
CT lymphography by transbronchial injection of
iopamidol to identify sentinel nodes in preoperative
NSCLC patients
Department of General Thoracic Surgery, Graduate School of
Medical and Dental Sciences, Kagoshima University, Japan
Aya Harada, Yoshihiro Nakamura, Tadashi Umehara,
Soichi Suzuki, Go Kamimura, Kazuhiro Wakida,
Yui Watanabe, Masaya Aoki, Toshihiro Nagata,
Tsunayuki Otsuka, Naoya Yokomakura,
Kota Kariatsumari, Koichi Sakasegawa,
Masakazu Yanagi, Masami Sato
Background: Pulmonary lymph flows are mainly regarded to run along bronchi. In addition, limited resections such as segmentectomy are increasing recently. However there
are some cases suggesting alternative lymph pathways, such as the skip metastases.
Studies of pulmonary lymph flows have been principally investigated by radioisotope. It
is so beneficial that the detection of hot spots by counter enables to identify sentinel
lymph nodes, however it cannot describe lymph flows themselves with a little accumulation of RI. Recently, devices visualizing lymph flows by indocyanine green (ICG) are developed and used in various organs. We herein observed pleural lymph flows by the ICG
fluorescence method with a near-infrared camera device in patients who underwent
lung resections.
Methods: After thoracotomy, we injected 3-5 ml ICG (25mg!10mL) to several subpleural
spaces of the lung lobe that planned to resect in 100 cases. Five minutes later, we observed the fluorescence image in real time pointing the near-infrared camera from the
outside of the thoracic cavity. Patients with pleural involvement were excluded.
Results: They consisted of 60 men and 40 women. Their ages at operation varied from 35
to 85 years, with a mean of 68.6 years. Their histological diagnoses were as follows: 98 patients had lung cancer, 2 patients had infection. Operative procedures were as follows: 3
patients underwent pneumonectomy, 86 patients underwent lobectomy, and 11 patients
underwent segmentectomy. In 55 out of 100 cases, ICG movements were observed in
subpleural space. In 23 out of the 55 cases, ICG flowed into adjacent lobes over the interlobular line. In 12 out of 100 cases, ICG flowed into the mediastinum directly. In 7 out of
100 cases, ICG were moved to the superior direction along phrenic nerves.
Conclusions: In our study, in more than half of the cases, pleural lymph flows were observed. In addition, there were lymph flows that flowed into the adjacent lobe and the
mediastinum directly. In conclusion, the pleural lymph flow was more considerable than
we expected. In the future, we will be able to choose an appropriate operative procedure
based on it for each case. It might provide important information for us.
216
Department of Thoracic, Endocrine Surgery and Oncology,
The University of Tokushima Graduate School, Japan1), Department of Oncological Medical Services, The University of
Tokushima Graduate School, Japan2)
Hiromitsu Takizawa1), Kazuya Kondo2), Hiroaki Toba1),
Koichiro Kajiura1), Atsushi Morishita1),
Mitsuhiro Tsuboi1), Yasushi Nakagawa1),
Mitsuteru Yoshida1), Yukikiyo Kawakami1),
Shoji Sakiyama1), Akira Tangoku1)
Background: Sentinel node (SN) is defined as the first node draining a tumor, and should be the
first site affected in lymphatic dissemination. Recently, with the increased incidence of small
sized non-small cell lung cancer (NSCLC), segmentectomy is again under evaluation for clinical T
1a N0 NSCLC patients. In the ongoing trial regarding segmentectomy (JCOG0802), the eligibility
criteria for segmentectomy include a prerequisite of no lymph node metastasis by intraoperative
findings because node-positive cases have a chance to be locoregionaly controlled and to be correctly staged by converting to lobectomy. Therefore, intraoperative sampling and frozen sectioning of true SNs is important in ensuring the radicality of segmentectomy. The objective of this
study was to assess the safety and the feasibility of computed tomography (CT) lymphography
by transbronchial injection of a water-soluble extracellular CT contrast agent which was developed as a new method for identifying SNs in patient with NSCLC.
Methods: Between April, 2010 and September, 2013, clinical stage I NSCLC patients who were
candidates for lobectomy or segmentectomy were enrolled in this study. An ultrathin bronchoscope was inserted to the target bronchus under the guidance of virtual bronchoscopic navigation images. CT images of the chest were obtained 30 seconds after 2 or 3ml of iopamidol was injected through a microcatheter. SNs were identified when the maximum CT attenuation value of
the lymph nodes in postcontrast CT images increased by 30 Hounsfield units or more compared
to precontrast images. Patients underwent video-assisted thoracic surgery lobectomy with standard lymph node dissection. SNs were harvested according to findings of CTLG and to intraoperative findings of near-infrared fluorescence imaging with indocyanine green. All lymph nodes,
including SNs, were histopathologically examined by standard hematoxylin and eosin staining.
Results: The ultrathin bronchoscope could access targeted bronchus, and iopamidol was delivered into the peritumoral area in all 35 patients without any complications. SNs were identified in
32 of 35 patients (91.4%), and the average number of SNs was 1.5 (range: 1-4). Two patients with
metastatic node were included in 3 patients whose SNs were not identified because of iopamidol
leakage to the airway. However, in another 4 patients with metastatic node, metastatic nodes
were included in the SNs.
Conclusion: CT lymphography by transbronchial injection of iopamidol was a safe and feasible
method to identify SNs in clinical stage I NSCLC patients.
Oral Presentation
IP-O4-1
IP-O4-2
Diagnostic yield of EBUS-TBNA for mediastinal lymph
node and masses assessment. Results from 472 patients
EBUS-TBNA for the diagnosis of hilar and mediastinal
lymphadenopathy
Pneumology, Rouen University Hospital, France1), Department
of Pneumology, Nantes Saint-Augustin Hospital, France2), Department of Pathology & Cytology, Rouen University Hospital,
France3), Cabinet de Pathologie, Nantes, France4)
Samy Lachkar1), Jennifer Gallego1), Jean-Yves Jasnot2),
Mathieu Salaun1), Francis Roussel3), Patrick Kerlo4),
Catherine Morin4), Luc Thiberville1)
Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a safe mini-invasive
procedure for the assessment of mediastinal lymph nodes
and masses. The aim of this study was to assess the diagnostic yield of EBUS-TBNA in two French institutions.
Methods: 472 consecutive patients undergoing EBUS-TBNA
between August 2006 and May 2013 were retrospectively included. Clinical and cytological data were reviewed. Factors
associated with higher diagnostic yield were assessed by univariate analysis.
Results: EBUS-TBNA was performed for the aetiological diagnosis of lymph nodes (53,6%), for lung cancer staging
(12,3%), for the diagnosis and staging of a thoracic (9,1%) or
extra-thoracic (1,9%) malignancy, for the diagnosis of the relapse of a thoracic (12,9%) or extra-thoracic (10%) malignancy,
or to obtain material for molecular analysis (0,2%). 1.81 0.97
(mean SD) nodal stations were assessed, with a mean number of needle aspiration of 4.2 1.2 (mean SD).
EBUS-TBNA procedures were achieved under local anaesthesia (6%), deep sedation (61%) or general anaesthesia (33%).
Specimen aspiration was suitable for cell block processing in
275 procedures (60%).
Cytological analysis was informative in 95% of the procedures, including 290 malignancies and 160 normal or benign
lymph nodes (including 44 sarcoidosis and 3 tuberculosis).
The diagnostic yield was higher in malignancies (314!
323 vs.
136!
149; p=0.008, Chi2 Test), larger lymph nodes (16,32 6,87
mm; p=0.006), when cell block was available (272!
275 vs. 173!
192; p<0.001, Chi2 Test), when a higher number of punctures
were performed (3 or more punctures vs. <3 punctures; p<
0.001, Chi2 Test) and in procedures under deep sedation or
general anaesthesia vs. local anaesthesia (426!
442 vs. 23!
29;
p<0.001, Chi2 Test).
EBUS-TBNA sensitivity and specificity were 94% and 99%
respectively. Positive and negative predictive values were
100% and 81% respectively. When EBUS-TBNA was performed for lymph node staging in lung cancer, c-TNM were
confirmed in 50% cases, upstaging occurred in 4% and downstaging in 46%. A surgical procedure was avoided for 83%
patients, and mediastinoscopy was avoided for 63% patients
undergoing EBUS-TBNA for mediastinal staging.
Conclusion: EBUS-TBNA is a reliable procedure with a high
diagnostic accuracy for the assessment of mediastinal lymph
nodes and masses.
Dept. Cardiopneumology, Division of Thoracic Surgery, InCor
(Heart Institute)-HCFMUSP, University of Sao Paulo School of
Medicine, Brazil1), Service of Respiratory Endoscopy, Division
of Thoracic Surgery. Heart Institute (InCor)-Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo, Brazil2)
Paulo F.G. Cardoso1), Evelise Lima2), Marcia Jacomelli2),
Ascedio J. Rodrigues2), Sergio E. Demarzo2),
Addy L. M. Palomino2), Luciana P. B. Tavares2),
Ricardo Bammann2), Eduardo Q. Oliveira2),
Viviane R. Figueiredo2)
Background: There are many causes of hilar and mediastinal lymphadenopathy, such as neoplasms, granulomatous diseases, infectious diseases
and reactive lymphadenopathy.
Different diagnostic modalities are available including surgical and endoscopic procedures such as mediastinoscopy, VATS, bronchoscopic fine
needle aspiration (FNA), ultrasound-guided transbronchial neddle aspiration (EBUS-TBNA) or esophageal ultrasound endoscopic FNA (EUS).
EBUS-TBNA is a safe and effective method for obtaining lymphnode samples and has a significantly higher diagnostic yield compared to conventional bronchoscopic FNA. This study evaluated the diagnostic yield of
EBUS-TBNA in patients presenting with mediastinal lymphadenopathy.
Methods: Retrospective analysis patients who underwent EBUS-TBNA
between August 2011 and September 2013. EBUS-TBNA (Olympus, BFUC 180F) was performed under conscious sedation or general anesthesia
with a laryngeal mask. Hilar and mediastinal lymphnode samples were
collected in a standardized fashion with and without ROSE. Samples were
processed as smear for cytopathology and cell block were for histopathology. Samples were also collected for bacterial and fungal processing. Results: 230 EBUS-TBNA were performed during the study period. The results are summarized on the Table below. Among the patients with nonspecific inflammatory or inconclusive lymphnode samples, 36 were submitted to surgical procedures. Twenty-seven patients with inflammatory
lymphnodes underwent mediastinoscopy or thoracotomy: 21 (78%)
showed reactive lymphadenopathy, 5 (18%) were neoplastic and 1 (4%)
was diagnosed with tuberculosis. Among the 9 inconclusive samples,
there were 4 (45%) with reactive lymphadenopathy, 2 (22%) neoplastic, 1
(11%) sarcoidosis, 1 (11%) histoplasmosis and 1 (11%) was found to be thyroid glandular tissue. No complications were observed in this series. Conclusion: EBUS-TBNA is a minimally invasive and safe procedure with
good accuracy and sensitivity for the diagnosis of malignancy, infections
and other diseases that can affect the mediastinal and hilar lymphnodes.
Patients with inconclusive results may require invasive procedures for
definitive diagnosis.
217
Oral Presentation
IP-O4-3
IP-O4-4
Can EBUS-TBNA differentiate pulmonary large cell
neuroendocrine carcinoma from other histologic subtypes?
Relationship between 18F-FDG uptake, biomarkers
and histologic types of lung cancer in lymph nodes by
EBUS and tumors
Department of General Thoracic Surgery, Chiba University
Graduate School of Medicine, Japan1), Department of Diagnostic Pathology, Chiba University Graduate School of Medicine,
Japan2)
Terunaga Inage1), Takahiro Nakajima1), Hidemi Suzuki1),
Tetsuzo Tagawa1), Teruaki Mizobut1),
Shigetosi Yoshida1), Yukio Nakatani2), Ichiro Yoshino1)
Background
Endobronchial ultrasound-guided transbronchial needle aspiration
(EBUS-TBNA) is known to be the best first test modality for mediastinal staging in patients with lung cancer who is suspected to have lymph
node metastasis by radiology. Large cell neuroendocrine carcinoma
(LCNEC) is a subtype of high-grade neuroendocrine carcinoma of the
lung like as small cell lung cancer (SCLC). The prognosis of the patients
with this type of tumor shows poorer survival and therapeutic strategy
for the LCNEC is a unique; i.e. surgical indication is conformed to nonsmall cell lung cancer (NSCLC) but chemotherapeutic regimen is conformed to SCLC. Hence, it is very important to differentiate LCNEC
from other histologic subtypes.
Methods
We performed retrospective chart review of the 1365 patients who underwent EBUS-TBNA for the diagnosis or staging of lung cancer between January 2004 and December 2011.
Results
In this study, 471 Lung Cancer patients with mediastinum or hiliar
lymph node metastasis were enrolled and 13 patients were diagnosed
as LCNEC by EBUS-TBNA. 12 out of 13 (92.3%) cases were histologically diagnosed and one case was diagnosed by cytology alone. Within
the 12 cases, 6 cases were diagnosed by morphology and other 6 cases
were diagnosed by immunohistochemistry. The histological diagnosis
rate for LCNEC (92.3%) was higher than for other histologic subtypes
(Adenocarcinoma 91.1% 206!223 or Squamous carcinoma 83.3% 40!65).
Eleven out of the 13 LCNEC cases were treated with platinum-based
combined chemotherapies including etoposide or irinotecan. In 2 out of
the 11 cases, the chemo therapies were performed in neoadjuvant setting.
Conclusion
LCNEC can be diagnosed by EBUS-TBNA if adequate sampling was
performed including histological evaluation. EBUS-TBNA is useful modality for the diagnosis of lymph node metastasis as well as determines
the histological subtypes and contributes to improve the quality of lung
cancer treatments.
218
Department of Pulmonology, Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Korea1),
Department of Pathology, Research Institute and Hospital, National Cancer Center, Goyang, Korea2), Department Nuclear
Medicine, Research Institute and Hospital, National Cancer
Center, Goyang, Korea3)
Hyo Jae Kang1), Bin Hwangbo1), Hye Suk Lee1),
Kyeong Ji Kim1), Geon-Kook Lee2), Seok-Ki Kim3),
Hee Seok Lee1)
Background;
We performed this study to find the relationship between 18
F-FDG uptake, bio-marker proteins related to PET uptake
and histologic types of lung cancer in metastatic lymph
nodes sampled by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and primary tumors.
Methods;
We investigated 55 adenocarcinoma (ADC) and 53 sauamous
cell carcinoma (SQC) patients who were enrolled in a prospective study that evaluated roles of PET!
CT and EBUSTBNA in the mediastinal staging of operable lung cancer.
Size and PET findings of primary tumors and EBUSdiagnosed metastatic nodes were evaluated. Expressions of
glucose transporter 1 (glut-1) and hexokinase II in primary
tumors (ADC n=38, SQC n=50) and metastatic mediastinal
nodes (ADC n=11, SQC n=7) were assessed using immunohistochemical staining.
Results;
Compared with SQC, primary tumors were smaller for ADC
(mean SD; 34.9 21.0mm vs. 42.4 18.2mm, p=0.048). Metastatic mediastinal nodes were smaller for ADC compared to
SQC, but the difference did not reach statistical significance
(9.7 3.6mm vs. 12.0 3.7mm, p=0.155). ADC had lower PET
uptakes in primary tumors (6.32 4.27 vs. 10.39 4.45, p<0.001)
and metastatic nodes (3.22 2.13 vs. 5.07 2.73, p=0.044). Staining intensity of positive cells of glut-1 was lower in ADC
compared to SQC in primary tumors (P<0.0001) and in metastatic lymph nodes as well (p=0.048). The intensity of
hexokinase II was also lower in ADC compared to SQC in
primary tumors (p<0.0001) and in metastatic lymph nodes
(p=0.013). Expressions of these biomarkers were correlated
with the maximum standardized uptake value of primary tumors.
Conclusion;
Lower FDG uptake and lower intensity of PET related biomarkers were observed in ADC compared with SQC in primary tumors and metastatic lymph nodes. Our results suggest that ADC should be carefully staged with EBUS-TBNA,
even in cases with low PET uptakes in the mediastinum.
Oral Presentation
IP-O4-5
IP-O4-6
Metastases in PET negative small lymp nodes
Rapid on-site evaluation with BIOEVALUATOR(R)
during EBUS-TBNA for diagnosing pulmonary and mediastinal diseases
Dpt of Thoracic and Cardiovasc. Surg, University of Copenhagen, Denmark1), Thorax Klinik Heidelberg Germany2)
Mark Krasnik1), Felix Herth2)
Background
In May 2013 published the American College of Chest Phycisians (CHEST) new guidelines for the investigation of lung
cancers. It follows that if there is PET-CT negative mediastinal and IA tumor (evidence 2B), there is no evidence of mediastinal investigation.
Aim of the study
The aim of this survey is to assess the proportion of missed
metastases in the mediastinum using the above criteria.
Methods
Included in the study was patients staged for lung cancer at
the department of pulmonology Gentofte during the period
1.1.2011 to 1.6.2013 until the new guidelines were published.
All patients appeared with PET negative mediastinal lymph
nodes less than 1 cm.
EBUS TBNA were performed routinely in all patients and at
least station 4R,4L and 7 were biopsied
Results
89 patients were included in the study. EBUS TBNA were
performed and 266 lymph nodes were biopsied. 3 biopsies
were not representative for lymphatic tissue. In 6 patients
(7%) with PET negative lymph nodes less than 10 mm were
found with metastases from lung cancer in 9 stations (3%).
Metastases were only found in pT stages T2a or higher.
The results are seen in table 1 and 2.
Conclusion
This study only includes a small number but it suggests that
that the recommendations from CHEST should be considered to involve also stage T1b.
Department of Respiratory Medicine, Okayama University
Hospital, Japan1), Department of General Internal Medicine 4,
Kawasaki Medical School, Japan2), Department of Pathology,
Okayama University Hospital, Japan3)
Daisuke Minami1), Nagio Takigawa2), Hirofumi Inoue3),
Toshio Kubo1), Akiko Sato1), Katsuyuki Hotta1),
Masahiro Tabata1), Mitsune Tanimoto1), Katsuyuki Kiura1)
AIM: Rapid on-site evaluation (ROSE) is used widely during
endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). BIOEVALUATOR(R) is a device used
for determining whether the tissues obtained by EBUSTBNA are appropriate for a pathological diagnosis. This
study describes our experience with ROSE using BIOEVALUATOR(R) during EBUS-TBNA for diagnosing pulmonary and mediastinal diseases.
MATERIALS AND METHODS: We retrospectively evaluated the results of 60 patients who underwent EBUS-TBNA
with BIOEVALUATOR(R) between December 2011 and November 2013. For the diagnosis, the tissue areas were appearing white and red through BIOEVALUATOR(R) are
considered to be appropriate and inappropriate, respectively.
We examined their medical records to obtain information
concerning the examination of BIOEVALUATOR(R) results
of the patient s materials (white!
red), the diagnosis yield, site
and size of lymph nodes and number of needle passes.
RESULTS: The median longest diameter of 72 lymph nodes
(35 #7, 20 #4R, 7 #4L and 10 #11) from 60 patients was 26.7
(range 12.4-50.6) mm and the median number of needle
passes was 2 (range 1-5). The definitive diagnosis was made
by EBUS-TBNA in 48 of 60 patients, by thoracotomy in one
patient. BIOEVALUATOR(R) results were white and lymphocytes were seen in the 9 patients, and red were seen in
the rest 2 patients. Finally, the 7 patients were judged as
having benign lymphadenopathy because the lymph node
size on computed tomography decreased or remained stable
after for at least 6 months, and the 2 patients by thoracotomy. The rest 2 patients were judged as insufficient material because the samples contained only red areas, which
contained few lymphocytes pathologically.
CONCLUSIONS: Checking aspirated samples using BIOEVALUATOR(R) appears useful for determining their adequacy for pathological diagnosis.
219
Oral Presentation
IP-O4-7
IP-O4-8
Usefulness of EBUS-TBNA in distinguishing sarcoidosis from recurrent cancer with lymphadenopathy after
surgery
EBUS-TBNA for suspicious lymph nodes after primary
treatment for malignant disease
Department of Respiratory Medicine, Okayama University
Hospital, Japan1), Department of General Internal Medicine 4,
Kawasaki Medical School, Japan2)
Daisuke Morichika1), Daisuke Minami1), Nagio Takigawa2),
Hiromi Hayakawa1), Makoto Mizuta1), Kenichiro Kudo1),
Kozi Uchida1), Eiki Ichihara1), Akiko Sato1),
Katsuyuki Hotta1), Masahiro Tabata1),
Mitsune Tanimoto1), Katsuyuki Kiura1)
Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new minimally invasive test for investigating mediastinal and hilar lymphadenopathy. It is sometimes difficult to distinguish between a recurrent malignant lymph node and lymphadenopathy due to
sarcoidosis in patients who develop lymphadenopathy after
surgery for a malignant tumor.
Methods: Between December 2009 and November 2013 we
performed EBUS-TBNA in 17 selected patients with a suspected recurrence in the mediastinum and!
or hilum of the
lung after surgical resection of a malignant tumor. We examined their medical records to obtain information concerning
the diagnosis, the sizes of lymph nodes, the number of needle
passes, and other complications.
Results: Definitive diagnoses were made using EBUS-TBNA
in 13 patients (five lung adenocarcinomas, one breast cancer,
one prostate carcinoma, one renal cell carcinoma, one
neuroendocrine tumor, and four sarcoidosis). Pathological
specimens showing non-caseating granulomas led to a diagnosis of sarcoidosis in four patients; their previous malignancies had been papillary adenocarcinoma of the thyroid, carcinoma of the gingiva, thymoma, and bladder cancer, but no
recurrences were observed. The median of the longest diameter in 19 lymph nodes was 22 mm (range 13-35), and the
median number of needle passes was 2 times (range 1-5)
without severe complications.
Conclusion: EBUS-TBNA might be useful in differentiating
between benign lymphadenopathy, including sarcoidosis,
and cancer recurrence in patients with mediastinal or hilar
lymphadenopathy after surgical resection of a malignant tumor.
220
Division of Thoracic Surgery, NHO Yamaguchi-Ube Medical
Center, Japan
Hiroyuki Tao, Toshiki Tanaka, Eisuke Matsuda,
Kumiko Yoshida, Tatsuro Hayashi, Akihiro Takahagi,
Kazunori Okabe
Background: EBUS-TBNA has been widely used as an important diagnostic procedure for mediastinal!
hilar lesions.
We evaluated the usefulness of EBUS-TBNA in the assessment of suspicious lymph nodes in patients previously
treated with malignant disease.
Patients: Records of a total of 113 patients who underwent
EBUS-TBNA in our institute between December 2009 and
November 2013 were reviewed. Of those, 23 (20.4%) patients
had a history of treatment for malignant neoplasm.
Results: Fourteen males, with mean age of 69.8 (range: 44-83)
years old. Previous malignancies were lung cancer in 20 patients, head and neck carcinoma in two, and thyroid cancer
in one. Primary treatments were surgery for 22 and
chemoradiotherapy for one. All the patients were found suspicious lymph nodes by chest CT. Nineteen (82.6%) patients
subsequently underwent PET!
CT and detected FDGuptakes in suspicious nodes. Hilar nodes were examined in 5
patients and mediastinal nodes in 17 patients. Both hilar and
mediastinal nodes were examined in one patient. Tumor recurrence was detected in 18 (78.3%) patients by EBUSTBNA. Six patients were diagnosed as tumor negative, including 4 (17.4%) patients detected granulomatous lesion
which is compatible with sarcoid-like reaction. No procedurerelated complications were seen. During a median follow-up
period of 34 months (range: 11-37), one patient among 6 diagnosed as tumor negative by EBUS-TBNA developed metastatic lung tumors. The patients had a history of thyroid cancer and granulomatous lesion in hilar nodes was observed by
EBUS-TBNA.
Conclusion: EBUS-TBNA is a safe and useful procedure in
the assessment of suspicious lymph nodes in patients previously treated with malignant disease. However, continuous
follow-up is needed even after negative findings by EBUSTBNA.
Oral Presentation
IP-O5-1
IP-O5-2
Long term follow-up of three different kinds of Y-stent
for the management of benign and malignant airway
diseases
A retrospective analysis of 146 Y-stent and 101 patients
New generation of Y-shaped endoscopic bilateral
stent
Pneumology, Intenisve Care and Sleep Medicine, KRH
Oststadt-Heidehaus Hannover, Germany
Hermann Tonn, Klaus-detlef Schneider,
Bernd Schoenhofer
Background: From July 1994 till December 2013 146 Y-stents
of three different kinds ((silicone Dumon stents, dynamic hybrid (Freitag) stents and self-expanding metallic fully silicone
covered)) were inserted in 101 patients. Indications, outcome,
especially efficacy and complications were reviewed. The different technical features of the stents and the need for different bronchoscopic insertion techniques are discussed.
Methods: The medical records of the patients were analyzed,
in some cases the patients family doctor and or their relatives were interviewed via telephone about the patients condition after stent insertion.
Results: Overall median survival was 264 days, in malignant
diseases 117 days, in benign diseases 1258 days. 5 patients
are still alive. The median placement duration was 142 days
per stent, 205 days per patient. In malignant diseases it was
100 days per stent and 137 days per patient, in benign diseases it was 332 days per stent and 664 days per patient.
Longest placement duration and survival were 441 days in a
malignant disease. It is 6.5 years in a benign disease with 5
stent exchanges during that period and the patient is still
alive.
The most common complications were infection and mucus
obstruction and occurred quite frequently leading to a stent
exchange. 2 stent-related resp. stenting procedure-related
deaths occurred. A description in detail will be given.
Conclusion: There are of course quite a lot of limitations in
this study, no randomization, no measurement of lung function tests, no measurement of extend of stenosis, different
approach to malignant tumors (radio-therapy) and different
times of availability of Y-stents. Nevertheless Y-stents can
relief symptoms when the main carina is involved in airway
diseases. They can relief symptoms even for several years
depending on the underlying diseases. Still complications are
quite common and therefore the different technical features
of the stents and the different bronchoscopic insertion techniques have to be considered to choose the appropriate stent
for the individual indication.
Thoracic Surgery Division Niguarda Hospital Milano Italy
Massimo Torre, Conforti S., Lomonaco A., Rinaldo A.,
Fieschi S.
Background
Tracheobronchial obstruction due to malignancy is a lifethreatening condition. The intraluminal neoplasm in end
stage cancer patients results in worsening dyspnea, coughing, difficulty in handling sputum, massive haemorrhage and
symptoms of suffocation.
This kind of patients have a poor overall prognosis, so palliative procedures should be appropriately performed if taken
to relieve respiratory symptoms, reduce the rate of infection
and improve survival. The main problem in improving airway patency in inoperable cases of stenosis of the carina and
large airways is the Y-shaped configuration of the carinal bifurcation.
Objective
Evaluation of the palliative benefit of new y-shaped stent
placement in a group of patient with severe main carina airways obstruction due to terminal cancer.
Methods
We employed a new self-expanding totally covered metallic
stent which is characterized by easily placement under direct vision, in 17 cases of severe stenosis of the carina and
main bronchi at danger of imminent suffocation due to endstage esophageal cancer (4) and lung cancer (13). They included 13 male and 4 female patients, with an age range of
53-81 years (68,9 median age of years). All prosthesis were
easily placed, under general anesthesia, through a rigid tracheoscope under bronchoscopic of fluoroscopic guidance,
within 24 hours of admission. The average time of all procedure was 30 minutes, the insertion procedure lasted less
than 2 minutes.
Results
All patients reported immediate benefit after stenting, and
there were no immediate or late adverse effects directly related to the stent. No infectious tracheobronchitis was reported. The 3 deaths within 1 week of stent placement were
unrelated to the stent (acute pulmonary edema (2) and acute
myocardial infarction). The average survival after stent
placement was 13,4 week.
Conclusion
This device has excellent stability and resistance to compression and has added benefit of easy insertion. It is therefore another useful, safe and effective, weapon in the arsenal
that can be used to maintain the airway and improve quality
of life in inoperable terminal cancer cases with severe stenosis.
221
Oral Presentation
IP-O5-3
IP-O5-4
Clinical applications of rigid bronchoscopy in complicated central airway obstruction
A novel technique for endoluminal delivery of mitomycin C for airway stenosis
Department of Respiratory and Critical Care Medicine, Peking Universith First Hospital, China
Department of Pulmonary Medicine, Beijing Tiantan Hospital,
Capital Medical University, Beijing, China
Hong Zhang, Guangfa Wang, Wei Zhang, Nan Li,
Yuhong Gong
Ting Wang, Jie Zhang, Juan Wang, Yinghua Pei,
Yuling Wang, Min Xu
Objective Thanks to the advancement of interventional pulmonary
medicine, rigid bronchoscopy has expanded for therapeutic purposes. It has large diameter of the working channel, the ability to
maintain proper ventilation during operation, and can deal with
massive bleeding and other complications. Methods Retrospectively
analyze all patients underwent rigid bronchoscopy for complicated
central airway obstruction in one respiratory department of teaching hospital and explore the effectiveness and safety of the operations. Results Totally 46 rigid bronchoscopic procedures were accomplished in 37 patients with critical central airway stenosis between December 2008 and June 2012. The rigid bronchoscopy provided immediate relief of central airway obstruction after the first
operation. Trachea obstruction fraction decreased from 74.0%
15.2% to 20.3% 18.4%; left main bronchus from 76.9% 16.0% to
31.5% 30.2%; right main bronchus from 80.6% 17.0% to 41.7%
29.4%, P<0.001 (Fig.), accompanied by alleviating of symptoms. Spirometry revealed the parameters on flow rate (FEV1, FEV1!FVC)
improved while parameters on volumes (VC, TLC) stay unchanged.
Besides, many sophisticated procedures, such as stent implantation,
corrupted metal stent removing and lithotripsy were done under
rigid bronchoscopy. There were no fatal complications. Conclusion
Rigid bronchoscopy can provide immediate relief of central airway
obstruction and maintain proper ventilation during sophisticated
intra-bronchial operations. It provides better visualization for advanced procedures and it is optimal selection for securing the airway in severe central airway obstruction and those operations
bearing the risk of massive bleeding.
Fig: comparison of the degree of airway stenosis before and after
first procedure of the rigid bronchoscopy. Case number was included in the parentheses under each column. Only lesions with>
50% stenosis were counted.
Degree of stenosis (%)=(Diameter of normal airway-diameter of the
narrow airway)!Diameter of normal airway 100%
＊statistical significance between pre and post procedures. P<0.01
222
Background: Stenosis of the airway is a devastating disease,
which is challenging for doctors to treat. The endoluminal
application of Mitomycin C (MMC) shows promise as a nonsurgical approach to treating recalcitrant stricture. However, complications such as acute airway obstruction may
still occur due to delayed wound healing and necrosis of mucosa. In this report, we describe a novel technique that uses
an irrigating catheter to endoluminally deliver MMC to the
target tissue while minimizing non-target drug application.
Case report: A 74-year-old female with a severe proximal airway stenosis of about 2.5mm was hospitalized. After bronchoscopic treatment, restenosis of the airway occured. A irrigating catheter (about 125cm long and 2mm in diameter) for
alveolar lavage was used and one end of the catheter was
heated and sealed. A small pinhole was made at the remote
part of catheter to allow the MMC solution to drip. A sterile
vial containing 10 mg of MMC was diluted with 25 ml of normal saline solution using an aseptic technique to achieve a final concentration of 0.4 mg MMC!
ml. The length of the airway stenosis segment was measured to calculate the volume
of MMC solution needed at a dose of 1ml!
cm. For the procedure, the MMC solution was injected into the irrigating
catheter until the whole catheter was full. Then, the catheter
was inserted into the airway through the working channel of
the bronchoscope, and this assembly was moved around on
the airway wall while the MMC solution was being injected
into the irrigating catheter using a 1ml syringes to ensure
that the volume used was accurate. Once the volume of the
added MMC solution inflated the catheter beyond its threshold volume, intraluminal fluid would leak across its porous
surface, and was manually smeared around the airway
stenosis segment.
Following the initial combination procedure (bronchoscopic
treatment and MMC), the patient returned to the hospital
two more times. She was given same treatment using same
method. Following the third treatment with the topical application of diluted Mitomycin C solution, the stenotic segment
of airway became stable. The patient has no symptom of airway and no side effects until now (it has been more than 3
years).
Conclusion: We think that the irrigating catheter used in this
report offers a safe, accurate, and economic approach for the
endoluminal delivery of mitommycin C as a complementary
treatment for airway stenosis.
Oral Presentation
IP-O5-5
IP-O5-6
Therapeutic strategy for multiple central-type lung
cancer
New option of PDT for peripheral lung cancer
Department of Thoracic Surgery, Nippon Medical University,
Japan
Taichiro Ishizumi, Jitsuo Usuda, Tatsuya Inoue,
Shingo Takeuchi, Takayuki Ibi
BACKGROUND: With improvements in diagnostic and
therapeutic methods, incidence of multiple primary lung cancer has been reported with greater frequency. However, it is
often difficult to perform surgery while maintaining lung
function especially in aged patient. Photodynamic therapy
(PDT) is a good therapeutic modality for multiple lung cancer in retaining respiratory functions. The aim of this study
is to evaluate the efficacy of treatment for multiple primary
lung cancer utilizing a combination of photodynamic therapy
(PDT) and surgery.
METHODS: From January 1992 to December 2012, 60 patients with 133 lesions of multiple primary lung cancer had
been treated with a combination of PDT and surgery in our
institution. PDT was applied for central type early-stage lesion and surgery was performed for advanced cancer. Thirteen of these were synchronous cases and the rest were metachronous. The age ranged from 54 to 82 years old and the
average 69.5 years old. The histological types of lesions were
124 squamous cell carcinoma, 8 adenocarcinoma and 1 small
cell carcinoma.
RESULTS: In synchronous patient with 53 lesions, PDT was
performed in 29 early-stage lesions showing complete remission except for 1. Surgery was performed in 21 lesions of advanced cancer. Five patients died due to original disease and
10 due to other diseases. Thirty-six patients with 80 lesions
were metachronous cases. Regarding stage 0 and 1A lesions,
33 lesions resulted in complete remission with PDT, while 37
lesions were treated with surgery. As a result, 11 patients
had died within 5 years, however, only 3 deaths were due to
the original disease.
CONCLUSION: Combination therapy of PDT and surgery
may be an effective modality that can be used in the treatment of multiple primary lung cancer while preserving lung
functions.
Department of Surgery, Tokyo Medical University, Japan1),
Department of Applied Physics and Physico-informatics, Faculty of Science and Technology, Keio University, Japan2)
Keishi Ohtani1), Sachio Maehara1), Yujin Kudo1),
Hideyuki Furumoto1), Masatoshi Kakihana1),
Naohiro Kajiwara1), Tatsuo Ohira1), Tsunenori Arai2),
Norihiko Ikeda1)
[Background] In Japan, photodynamic therapy (PDT) was
previously recommended only as a treatment option for centrally located early lung cancers. However, it has recently
been approved for the treatment of other cancers including
advanced lung cancer and peripheral lung cancer by the
Japanese Ministry of Health, Labour and Welfare. PDT for
peripheral lung cancer could be one of the good treatment
options for patients without surgical indication such as poor
lung function. To perform PDT for peripheral lung nodules,
it is necessary to use a thin and flexible laser fiber that can
sufficiently reach the peripheral lung parenchyma. In this
study, we evaluated the feasibility of a plastic laser fiber for
peripheral PDT.
[Methods] The cylindrical light diffuser Model RD (Medlight,
Switzerland) was used as a laser fiber for peripheral PDT. It
is a radially emitting fiber that was produced for intraluminal PDT. This fiber is thin (0.98 mm), very flexible, and made
of plastic; therefore, we thought that it is suitable as a laser fiber to irradiate laser light for peripheral nodules. The PD laser (Panasonic, Japan) was used for NPe6 PDT, thus a connector PD laser and an RD cylindrical light diffuser were
produced. The laser output and the light irradiation distribution of the RD cylindrical light diffuser were measured and
compared with those of the Panasonic cylindrical probe currently used for PDT.
[Results] The mean difference in laser output and displayed
power on the PD laser was 17.7 1.6% for the Panasonic cylindrical fiber and 11.6 3.1% for the RD cylindrical light diffuser. For the light irradiation distribution, the RD cylindrical light diffuser was able to produce equal or more uniform
irradiation than the Panasonic cylindrical fiber.
[Conclusion] The cylindrical light diffuser Model RD showed
comparable laser irradiation to the Panasonic cylindrical fiber. We conclude that it is feasible to treat peripheral lung
cancer by PDT using this new fiber.
223
Oral Presentation
IP-O5-7
IP-O5-8
Photodynamic therapy for peripheral metastatic lesions: Proof of concept
Withdrawn
Dept of Internal Medicine, University of South Carolina, USA
Franklin Riley McGuire, Mohammed Moizuddin
Background
Photodynamic therapy (PDT) has been used for early stage
peripheral lung cancer in a research protocol with promising
results.1 Data on treating peripheral metastases with this approach is sparse. Although systemic chemotherapy is a
mainstay of treatment in endometrial cancer, PDT has been
used as an alternative therapy with reasonable rates at
66.7% to 77%.2,3 There is also a potential for an immune response with PDT.4
We report a case of metastatic endometrial cancer treated
with electro-magnetic navigational bronchoscopy (ENB) that
guided PDT to the tumor. This is the first case reported in
the literature, to our knowledge.
Case Report
A 63 year old female with well differentiated Stage I-B,
Grade I uterine adenocarcinoma was with prior hysterectomy, bilateral salphigo-oopherectomy and peri-aortic lymph
node dissection three years ago. She suffered vaginal recurrence one year after diagnosis which was treated with excision and radiation treatment. She received six cycles of combination chemotherapy with carboplatin and paclitaxel chemotherapy followed by doxorubicin for liver and pulmonary
metastasis with successful resolution of liver metastasis.
Follow-up computerized tomography (CT) scans of her chest
revealed persisting 3.1 2 cm right upper lobe spiculated
mass and 3.7 3.4 cm mass in the left lower lob. After a review of her options and an extensive literature search, she
was treated with PDT. ENB was used to navigate the right
upper lobe lesion 62 hours after intravenous photophrin injection. Radial ultrasound confirmed the catheter placement
before insertion of the diffusing fiber. She received 375 seconds of treatment with 150 joules, 400 mW power with a 15
mm diffuser to the anterior portion of the lesion The therapy
was repeated 2 days later. Follow-up CT scans of the chest
one month after treatment revealed stability in the pulmonary metastasis with evidence of inflammatory response in
the parenchyma.
Conclusion
Our case proves that PDT delivered using ENB guidance is
feasible as can be used an alternative therapy for metastatic
disease.
1. Photodynamic therapy for peripheral lung cancer, Tetsuya
Okunaka etal. Lung Can (2004) 43, 77-82.
2. Photodynamic therapy in gynecologic cancer, H Korean, J
Photochem and Photobio: Biology 36(1996)189-19.
3. Photodynamic therapy in gynaecological neoplastic diseases, L. Corti, J Photochem and Photobio: Biology 36(1996)
193-197.
4. Brackett CM, Gollnick SO. Photodynamic therapy enhancement of anti-tumor immunity. Photochemical and photobiological sciences 2011; 10(5): 649-652.
224
Oral Presentation
IP-O5-9
IP-O6-1
Optical coherence tomography for managment of major airway stenosis
Radial-EBUS in peripheral lung lesions in a tertiary
hospital in Sao Paulo, Brazil
Department of Integrative Oncology, British Columbia Cancer
Agency, Canada
Tawimas Shaipanich, Anthony Lee, Wei Zhang,
Pierre Lane, Rashika Raizada, Rosa Lopez lisbona,
Stephen Lam
Stenosis of major airways occurs in a number of benign pulmonary diseases such as vasculitis, endobronchial tuberculosis, and post lung transplantation. Currently, high resolution
CT scan, pulmonary function test and visual examination via
bronchoscopy are used to determine the severity of the
stenosis. However, these only give a rough estimated measurement of airway stenosis. We hypothesize that Optical Coherence Tomography (OCT) imaging via flexible bronchoscopy allows more precise measurement of airway size and
structure to guide choice of therapy.
Method: OCT imaging was performed in 7 main airways
stenosis in three symptomatic patients with underlying vasculitis who underwent bronchoscopy for therapeutic airway
balloon dilation. OCT imaging was done pre- and post dilatation at the same airway segments by inserting a 1.5 mm diameter probe through the stenotic region. 3-D OCT imaging
of 5 cm long airway segments was performed the Lightlabs
C7XR system (St. Jude Medical, Inc., St. Paul, MN, USA).
Result: Five stenotic areas were in the left main bronchus,
one at the right bronchus intermediate and one at the mid
trachea. A total of 11 studies were performed. OCT imaging
was found to be useful in assessing the integrity of the cartilage, presence or absence of inflammation, degree of fibrosis
in the non-cartilaginous region of the airways and for determining the balloon size for dilatation. Changes in the cross
sectional area of the stenotic segments pre- and post balloon
dilation correlated with the clinical outcome. OCT imaging
allows delineation of the airway wall structures that were dilated.
Conclusion: OCT imaging via flexible bronchoscopy is a safe
and accurate method to measure airway dimension and
structure as well as changes after balloon dilation. These
measurements can be used for therapeutic guidance and follow up.
Dept. Cardiopneumology, Division of Thoracic Surgery, InCor
(Heart Institute)-HCFMUSP, University of Sao Paulo School of
Medicine, Brazil1), Service of Respiratory Endoscopy, Division
of Thoracic Surgery. Heart Institute (InCor)-Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo, Brazil2)
Paulo F.G. Cardoso1), Marcia Jacomelli2),
Sergio E. Demarzo2), Addy L. M. Palomino2),
Anaregia Pontes2), Viviane R. Figueiredo2)
Background: Conventional bronchoscopy has a low diagnostic yield for peripheral lung lesions. Radial probe endobronchial ultrasound (R-EBUS) employs a rotating ultrasound
transducer at the end of a probe that is passed through the
working channel of the scope. It is used to assist locating the
peripheral lung nodules thereby increasing the diagnostic
yield. This study presents our initial experience using REBUS in the diagnosis of peripheral lung lesions in a tertiary
hospital. Methods: Retrospective analysis of respiratory endoscopies performed using R-EBUS between February 2012
to July 2013 in patients with pulmonary nodules or masses.
The R-EBUS was performed with a flexible 20 MHz miniprobe (Olympus UM-3R) passed through the working channel of the therapeutic bronchoscope (Olympus BF-1T180)
and advanced into the bronchus adjacent to the target lesion.
Fluoroscopy was used both for location of the lesion and for
collection procedures (bronchial brushing, transbronchial
needle aspiration and transbronchial biopsy). Results: Fiftyfour patients (57.4% female) with a mean age of 64.8 11.1
years. R-EBUS found 39 nodules (1.8 0.73cm) and 19 masses
(3.9 0.83cm). The overall sensitivity was 63% (73.8% for the
lesions visible to the R-EBUS and 25% for non-visible lesions).
In the subgroup of visible lesions on R-EBUS, the sensitivity
was 91.7% for masses and 74.1% for nodules. The complications were pneumothorax (3.7%) and bronchial bleeding controlled bronchoscopically (9.3%). Conclusions: Our initial experience with EBUS-R showed good diagnostic sensitivity
for peripheral pulmonary lesions with a good safety profile
and low complication rate. The diagnostic yield was higher
for lung masses and for lesions visualized by R-EBUS.
225
Oral Presentation
IP-O6-2
IP-O6-3
Efficacy of endobronchial ultrasonography with a
guide sheath for diagnosing peripheral lesions with benign disease
Endobronchial ultrasonography with a guide sheath
∼How many times we need to do biopsy for correct
diagnosis？∼
Department of Pulmonology, Kameda Medical Center, Japan
Department of Respiratory Medicine, National Center for
Global Health and Medicine, Japan
Kei Nakashima, Masafumi Misawa, Ayumu Otsuki,
Junko Watanabe, Motohisa Takai, Masahiro Katsurada,
Naoko Katsurada, Masahiro Aoshima
Background: Diagnosis of benign pulmonary lesions located
at peripheral site is crucial since accurate diagnosis could directly influence treatment strategy. Study objective: To
evaluate the ability of endobronchial ultrasonography with a
guide sheath (EBUS-GS) for diagnosing benign pulmonary lesions at peripheral pulmonary site. Methods: We retrospectively reviewed 49 patients with 49 peripheral pulmonary lesions (PPLs) finally diagnosed as benign diseases from Octorber 2010 to September 2013 in our hospital. To assess the
efficacy of bronchoscopy with EBUS-GS, we defined grade
for bronchoscopy contribution according to the previous report as follows: grade A, definitive diagnosis obtained by
bronchoscopy alone; grade B, definitive diagnosis obtained
by bronchoscopy with information about clinical features;
grade C, definitive diagnosis not obtained by bronchoscopy
even with information about clinical features, although suspected findings were obtained by bronchoscopy; and grade
D, no suspected findings obtained by bronchoscopy and no
definitive diagnosis obtained. Grade A and B were defined as
positive results with definitive diagnosis of benign pulmonary disease. Results: Final diagnosis of 49 PPLs included 14
cases of bronchopneumonia, 10 cases of mycobacteriosis, 5
cases of organizing pneumonia, 5 cases of abscesses, 6 cases
of inflammatory change and 9 other benign diseases. Among
49 PPLs, definitive diagnosis was obtained by EBUS-GS in 37
lesions (72.5%). Lesions in which the probe was advanced to
within the lesion had a higher diagnostic yield (81.8%) than
did lesions in which the probe was adjacent to the lesion
(58.3%; p<0.05) or outside the lesion (50%). Conclusions:
EBUS-GS is a useful method for diagnosis of PPLs with benign disease.
226
Taichi Miyawaki, Satoru Ishii, Yuichiro Takeda,
Masao Hashimoto, Haruna Masaki, Shion Miyoshi,
Manabu Suzuki, Go Naka, Motoyasu Iikura,
Haruhito Sugiyama
【Background】Endobronchial ultrasonography with a guide
sheath (EBUS-GS) enables us to confirm the place of pulmonary peripheral lesions. And positioning the guide sheath, we
can repeat biopsy through same branch many times.
But we have a weak point that the tissues we collect are
sometimes small. Not only to diagnose correctly, we need to
check oncogene mutation of tumor with tissues. We investigated retrospectively whether a diagnostic yield would improve, when carrying out the biopsy how many times with
each fiber (BF-1T260 or BF-P-260F).
【Method】In 187 cases we have conduted bronchoscopic examination since January 2012 to October 2013 at our hospital,
we assessed 147 cases that we can diagnose correctly and
get number labels of tissues.
【Result】The median age of 147 patients is 74 years (range,45
to 90years), 92 patients are male,55 patients are female. We
achieved correct diagnosis in 98 cases with BF-1T260. Median time of biopsy is 9th (range, 2to17). The accumulation diagnostic yield exceeded 95% in the 6th biopsy.
We achieved correct diagnosis in 49 cases with BF-P-260F.
the median time of biopsy is 10th (range3to18).The accumulation diagnostic yield exceeded 95% in the 9th biopsy.
The case which is diagnosed as lung adenocarcinoma and is
investigating EGFR mutation was an example of 56, and the
all cases had adequate tissue to asses EGFR mutation.
【Conclusion】In order to decide diagnosis, BF-P-260F needs
many times of a biopsy, more than BF-1T260.
Oral Presentation
IP-O6-4
IP-O6-5
Comparing 4.0-mm and 5.9-mm bronchoscope with
endobronchial ultrasound and guide steath - Is larger
the better?
Effect of diagnostic techniques during endobronchial
ultrasonography for diagnosis of peripheral pulmonary
lesions
Department of Pulmonary Medicine, Kameda Medical Center,
Japan
Department of Internal Medicine, Phramongkutklao Hospital,
Thailand
Motohisa Takai, Masafumi Misawa, Kei Nakashima,
Masahiro Katsurada, Naoko Katsurada,
Jyunko Watanabe, Ayumu Otsuki, Norihiro Kaneko,
Masahiro Aoshima
Pornanan Domthong, Anan Wattanathum
Introduction: Thin bronchoscopes are better in their reach
during biopsy than that of thicker ones, whereas specimens
obtained with them are smaller. So far, however, it is unclear
whether specimens from a thin bronchoscope can yield as
accurate diagnosis as those from conventional thicker ones.
Study objective: The purpose of this study was to compare
the diagnostic accuracy of malignant peripheral pulmonary
lesion (PPL) between a thin and conventional bronchoscopes
with the assistance of Virtual bronchoscopic navigation
(VBN) and endobronchial ultrasound (EBUS) with guide
steath.
Methods: From October 2010 to September 2013, a total of
207 consecutive subjects with small PPLs (30 mm or less in
diameter) were received bronchoscopy with conventional
(1T260; 5.9 mm in external diameter, Olympus Ltd., Japan)
(n=19) or thin bronchoscope (P260; 4.0 mm in external diameter, Olympus Ltd., Japan) (n=188) with the assistance of VBN
and EBUS with guide steath in our hospital. One hundred
thirty one patients were finally diagnosed as malignant diseases during the study period. We retrospectively compared
the diagnostic yield between each of the bronchoscopes. We
also compared the diagnostic yield between each of the bronchoscopes in the cases in which EBUS was located within the
PPLs.
Results: Among 131 patients who were diagnosed as malignant PPLs, 11 were diagnosed with 1T260 and 120 were with
P260. The diagnostic yield were 54.5% by 1T260 and 70.8%
by P260 (p=0.262). In 60 patients to whom EBUS were located within their PPLs, the diagnostic yields were 83.3% (1T
260) and 85.2% (P260; p=0.904).
Conclusions: The diagnostic yields were similar between
conventional (1T260) and thin (P260) bronchoscopes when
specimens were obtained inside PPLs with the assistance of
VBN and EBUS.
Background: Endobronchial ultrasonography (EBUS) has
been used for imaging guidance in diagnosis of peripheral
pulmonary lesions (PPLs). A guide sheath (GS) was left in the
lesion in performing forceps biopsy and bronchial brush, obtained repeatedly and easily. Bronchial washing (BW) was
also routinely performed after the biopsy and brushing techniques. The primary objective of this study was to evaluate
the effectiveness of adding BW fluid examination to the histological analysis of the forceps biopsy and cytological examinations of the brushing samples.
Methods: We retrospectively recruited all patients with
PPLs receiving EBUS-GS for obtaining the biopsy and brush
specimens combined with BW fluid at Phramongkutklao hospital between January 2011 and November 2013. We performed standard histological exam on the biopsy specimens
and cytological exam on the brushing and BW specimens.
We also had microbiological evaluation on the BW fluid.
Results: One hundred and sixty patients were enrolled in the
study (103 male and 57 female; mean age 58.2 years). Diagnosis of the PPLs were found in 85 of 160 (53.1%) patients included 45 (53%) bronchogenic carcinoma, 25 (29.4%) tuberculosis, and 15 (17.6%) other diseases. The bronchial brushes, biopsy, and BW were diagnostic in 48 (90.6%), 42 (79.2%), and 9
(17%) patients with malignancy and in 21 (65.6%), 16 (50%),
and 20 (62.5%) patients with benign diseases, respectively.
Although BW specimens did not add to overall diagnostic
yield of positive results in the malignant group, the specimens significantly increased the yield by 18.8% (6 of 32, p=
0.002) in patients with benign diseases.
Conclusions: Routinely, cytological examination of bronchial
washings does not increase the diagnostic yield of EBUS-GS
for diagnosis of PPLs in patients with malignancy. However,
the diagnostic yield can be significantly increased by combining bronchial washings with bronchial brushing and forceps
biopsy in patients with benign diseases. Bronchial washing
for microbiological examination should be considered in
cases of suspected infectious disease, especially tuberculosis.
227
Oral Presentation
IP-O6-6
IP-O6-7
Radiofrequency (RF) spectral analysis of endobronchial ultrasonography (EBUS) for peripheral lung lesions
The role of spectrum analysis in lung cancer imaging:
A preliminary animal study
Division of Respiratory and Infectious Diseases, Department
of Internal Medicine, St. Marianna University School of Medicine, Japan1), Department of Chest Surgery, St. Marianna University School of Medicine, Japan2)
Kei Morikawa , Noriaki Kurimoto ,
Kazutaka Kakinuma1), Shinya Azagami1),
Hiromi Muraoka1), Mariko Okamoto1), Ayano Usuba1),
Teppei Inoue1), Naoki Furuya1), Hirotaka Kida1),
Hiroshi Handa1), Miwa Fujiwara1), Hiroki Nishine1),
Atsuko Ishida1), Seiichi Nobuyama1), Takeo Inoue1),
Masamichi Mineshita1), Teruomi Miyazawa1)
1)
2)
Background: We previously reported the utility of
histogram-based quantitative evaluation of EBUS B-mode
images, but these images are based on reconstructed RF signals. Hence, the analysis of radiofrequency (RF) signals are
more precisely reflected to the lesion s ultrasound information.
Objective: RF spectral analyses of endobronchial ultrasonography (EBUS) were conducted to differentiate benign
and malignant peripheral lung lesions.
Methods: In a prospective study, 76 images were obtained
with 54 lung cancers and 22 inflammatory diseases. We imported RF data into an analysis software program and compared RF spectrum characterizations by the following three
parameters; slope (dB!
MHz), midband fit (dB) and yintercept (dB).
Results: Categorizing benign and malignant lesions into six
subgroups (inflammation: acute!
chronic, lung cancer: Ad!
Sq!
La!
Sm), significant differences were observed for slope
and y-intercept in acute inflammation and chronic inflammation, and acute inflammation and adenocarcinoma.
Conclusion: RF spectral parameters provide a method to
quantitatively differentiate not just benign and malignant lesions, but also possibly the duration for inflammatory diseases.
228
Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Canada1), Department of General
Thoracic Surgery, Graduate School of Medicine, Chiba University, Japan2)
Hironobu Wada1), Takashi Anayama1),
Takahiro Nakajima1), Kentaro Hirohashi1), Tatsuya Kato1),
Ichiro Yoshino2), Kazuhiro Yasufuku1)
Background: Quantitative spectrum analysis is a unique ultrasound
technology which involves quantification of spectral parameters and enables objective tissue characterization. This has been proven to be effective in distinguishing and detecting malignant tumors from normal
tissue in breast and pancreas cancer patients. However, the technology
has not been applied for localization of lung tumors during the use of
the thoracoscopic ultrasound, and the factors which significantly influence the spectral parameters remain unclear. The aim of this study was
to demonstrate the feasibility of spectrum analysis for localization of
lung malignancy using multiple animal models and to identify the cytological factors which reflect the spectral parameters.
Methods: Lung cancer tissues were evaluated using a convex probe endoscopic ultrasound and an ultrasound scanner (EU-Y0005, Olympus,
Tokyo, Japan) with software capable of calculating the spectral parameters. Initially, the rabbit orthotopic VX2 lung tumor models were used
to distinguish tumor from lung parenchyma. Regions of interest were
selected within ultrasound images captured from the model. Three
spectral parameters including midband-fit (dB), intercept (dB), and slope
(dB!MHz) were calculated and compared between the tumor and the
lung. Thereafter, the nude mice subcutaneous tumor models made with
three human lung cancer cell lines, normal pig mediastinal lymph nodes,
and normal rabbit lung were used to compare cytological findings,
mainly nucleus size in each tissue, to the spectral parameters in each region of interest.
Results: In the rabbit tumor model (n=5), the B-mode showed similar ultrasound contrast in both the tumor and the lung, however, spectral parameters of the tumors revealed a significantly lower midband-fit and
intercept, as well as a higher slope than normal lungs (p<0.001). The
subcutaneous tumors (n=3 in each cell lines) showed a significantly
lower intercept, a higher slope, and a larger nucleus size than those of
the pig lymph nodes and rabbit lungs (n=3) (p<0.001). Intercept and
slope showed statistically significant correlation with the nucleus size of
the tissues (r=-0.49, p<0.001 for intercept and r=0.60, p<0.001 for slope).
Conclusion: Spectral parameters showed a significant difference between tumors and normal lung tissue. Slope represented moderate correlation with the nucleus size of the target tissues. Spectrum analysis is
a feasible way to identify malignant tumors in the normal lung which
may improve detectability of small-sized malignant lung tumors using
ultrasound technology.
Oral Presentation
IP-O6-8
IP-O7-1
In vivo probe-based confocal laser endomicroscopy in
chronic diffuse parenchymal lung diseases
Comparison of pleural pressure measuring instruments
Pneumology, Rouen University Hospital, France1), Department
of Pathology & Cytology, Rouen University Hospital, France2),
Department of Radiology, Rouen University Hospital, France3),
Department of Pneumology & Intensive Care Unit, Amiens
University Hospital, France4), Department of Pneumology &
Thoracic Oncology, Caen University Hospital, France5)
Hans Joo Lee, David Kidd, Ricardo Ortiz, Lonny Yarmus,
Sixto Arias, Jason Akhulian, Andrew Hughes,
Richard Thompson, David Feller-Kopman
Samy Lachkar1), Mathieu Salaun1), Stephane Dominique1),
Francis Roussel2), Anne Genevois3), Vincent Jounieaux4),
Gerard Zalcman5), Luc Thiberville1)
Diagnosis of diffuse parenchymal lung diseases (DPLDs) is
challenging and requires a multidisciplinary approach.
Probe-based confocal laser endomicroscopy (pCLE) enables
microimaging of the distal lung in vivo.
Objective: to describe pCLE features in DPLD patients.
Methods: pCLE was performed in 52 DPLD patients and 21
healthy volunteers (HV). Results were compared between
HV and each of the pathologic groups, blindly to the diagnosis (Fisher exact test and Bonferroni correction). The association between the pCLE and CTscan features was assessed
using multivariate analysis.
Results: 9 of the 17 pCLE descriptors were significantly more
frequent in DPLD patients than in HV (131 areas). pCLE differed in sarcoidosis (16 patients, 105 areas) by the presence
of fluorescent bronchiolar cells, convoluted acinar elastic fibers, alveolar nodules; in idiopathic pulmonary fibrosis (n=8,
36 areas) by interalveolar septal fibers and a rigid acinar elastic network; hypersensitivity pneumonitis (n=6, 34 areas) by
bronchiolar and alveolar cells; non-specific interstitial pneumonia (n=6, 38 areas) by fluorescent bronchiolar cells, septal
fibers and a rigid network; asbestosis (n=10, 72 areas) by alveolar mouths<200 μm, axial fibers>20μm, septal fibers, and
a rigid and dense acinar elastic network; systemic sclerosis
(n=6, 38 areas) by fluorescent alveolar cells, septal fibers and
a rigid network. HRCT honeycombing was associated to
pCLE large alveolar mouths and a disorganized elastic network; both interlobular septa thickening and cysts were associated to the presence of septal fibers using pCLE.
Conclusion: pCLE could be added to the multidisciplinary
discussion for the etiological diagnosis of DPLD.
Interventional Pulmonary, Johns Hopkins Univeristy, USA
Purpose: To compare the accuracy of a handheld digital manometer with an electronic transducer manometer and Utube water manometer during thoracentesis and diagnosing
non-expandable lung.
Methods: Thirty-three consecutive patients undergoing thoracentesis were enrolled in the study. Pleural pressure (Ppl)
measurements were made by using a disposable handheld
digital manometer (DM, Mirador Biomedical, Seattle, WA),
electronic transducer system (ET), and a U-tube water (UT)
manometer. End expiratory Ppl was recorded after catheter
insertion, after every 240 mL of fluid aspiration, and prior to
catheter removal. Volume of fluid removed, symptoms during thoracentesis, pleural elastance, radiographs, and fluid
chemistries were also evaluated.
Results: 594 Ppl measurements were made in thirty patients
during their thoracentesis. There was a strong correlation
between elastance for the DM and ET (R2=0.9582, P<0.001).
Correlation was poor for UT and ET (R2=0.0448, p=0.84).
Among the 15 patients with cough, recorded transducer manometer pressures ranged from -9 to +9 cmH2O at the time
of symptom development, with a mean (SD)=-2.93 (4.89) cmH
2O. Nine patients developed chest discomfort and had recorded transducer manometer pressures that ranged from 26 to +6 cmH2O, with a mean (SD)=-7.89 (9.97) cmH2O.
Conclusion: The digital manometer provided a valid method
to measure pleural pressures during thoracentesis.
229
Oral Presentation
IP-O7-2
IP-O7-3
Novel use of pleural ultrasound can identify malignant
trapped lung prior to effusion drainage
Analyze the clinical features and medical thoracoscopic characteristics in 8 cases oflymphoma
Thoracic Medicine, Bellvitge Hospital, Spain1), Department of
Cardiology, The Royal Brisbane and Women s Hospital, Australia2), Department of Cardiology, The Princess Alexandra
Hospital, Australia3), Department of Thoracic Medicine, The
Royal Brisbane and Women s Hospital, Australia4)
Matt Robert Salamonsen , Ada Lo , Arnold Ng ,
Farzad Bashirzadeh4), David Fielding4)
1)
2)
3)
Rationale The presence of trapped lung changes the appropriate management of
malignant pleural effusion from pleurodesis to insertion of an indwelling pleural
catheter (IPC). Trapped lung resists expansion following drainage of an effusion
and so is associated with an elevated pleural elastance (PEL). However, no methods currently exist to identify trapped lung prior to effusion drainage, and so definitive management of malignant pleural effusion requires at least 2 procedures.
Ultrasound (US) can quantify both tissue movement and tissue deformation
(strain). This study documents a novel method to identify trapped lung prior to effusion drainage, using tissue movement and strain analysis with thoracic US and
compares it with PEL.
Methods Prior to drainage, 81 patients with suspected malignant pleural effusion
underwent thoracic ultrasound using an echocardiogram machine. Images of the
atelectatic lower lobe were acquired during breath-hold, allowing motion and
strain related to the cardiac impulse to be analysed using motion-mode (M Mode)
and speckle-tracking imaging (STI) respectively. PEL was measured during effusion drainage. The gold standard diagnosis of trapped lung was the consensus
opinion of two interventional pulmonologists according to post-drainage imaging.
Participants were randomly divided into development and validation sets.
Results Both total movement and strain were significantly reduced in trapped
lung (Figure 1). The area under the receiver-operating curves calculated using
data from the development set were 0.86 (STI), 0.79 (M Mode) and 0.69 (PEL). Cutoffs chosen to maximise sensitivity and specificity for STI, M Mode and PEL
were 6%, 1mm and 19cmH20 respectively. Applying these cut-offs to the validation set, the sensitivity!specificity was 71％!85% for STI, 50％!85% for M Mode
and 40％!100% for PEL.
Conclusions This study has introduced a novel US technique which can identify
trapped lung prior to effusion drainage. This could allow appropriate choice of definitive management early (pleurodesis vs IPC), reducing the number of interventions required to treat malignant pleural effusion. It may be that with further
study, its use could be applied to other areas of pleural disease, such as investigation of non-malignant lung entrapment or as a guide to when surgical intervention is required for loculated pleural infections.
230
Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chaoyang
Hospital, Capital Medical University, China1), Respitatory Deparment, Beijing LuHe Hospital, China2)
Zhen Wang1), Ting Zhang2), Li-li Xu1), Xiao-juan Wang1),
Yan-bing Wu1), Hong-jie Li1), Zhan Lu1)
Background: Lymphoma is a kind of lymphocytes and!
or tissue cell malignant proliferative disease. Patients with lymphoma often go to the Department of respiration due to fever, pleural effusion and pulmonary shadow. The pleural effusion usually was exudative and difficult to confirm the diagnosis by cytology. Medical thoracoscopy has been used
widely, more and more cases of lymphoma involving the
pleura were found.
Objective: To summarize the features of pleural disease and
pleural effusion caused by lymphoma.
Methods: Review the clinical data of patients with pleural effusion caused by lymphoma from 2005 July to 2012 September in our hospital. These patients were diagnosed by medical thorocoscopy. Analyze their clinical feature, laboratory
examinations, radiographic images and images of medical
thoracoscopy. Summarize the features of pleural diease
caused by lymphoma.
Results and conclusion: All of the 8 cases of pleural effusion
caused by lymphoma were diagnosed non-Hodgkin s lymphoma through pathology and immune histochemistry. The
origin of 6 cases were B lymphocyte and 2 cases were T lymphocyte. Medical thoracoscopy was valuable to diagnose
lymphoma with pleural involved. We could see the pathological changes directly through medical thorocoscopy. The
main changes of the pleural diseases caused by lymphoma
include nubs with different sizes, white spots or white lacker
and localized incrassation of the pleura.
Oral Presentation
IP-O7-4
IP-O7-5
Role of medical thoracoscopy in suspected malignant
pleural effusion patients from high burden country of
tuberculosis
Efficiency of performing pulmonary procedures in a
shared endoscopy unit
Department of Pulmonary Medicine, King George s Medical
University UP, Lucknow, India1), Department of Pathology,
RML Institute of Medical Sciences, UP, Lucknow2)
Rajiv Garg1), Sk Verma1), Ras Kushwaha1),
Santosh Kumar1), Surya Kant1), Shardulam Thakur1),
Rashmi Upadhyay1), Nuzhat Hussain2)
Background: Cause of pleural effusion is not ascertained in about 1!4th of cases and
about half of those will later on be diagnosed with a malignant pleural effusion. The situation is dicier in areas with high prevalence of tuberculosis as tuberculosis can mimic
any disease and any disease may present as tuberculosis.
Objective: To study the role of medical thoracoscopy in patients of suspected malignant
pleural effusion.
Method: All consecutive patients coming to the department with suspected malignant
pleural effusion between September 2010 to August 2012, who underwent medical thoracoscopy for biopsy of parietal pleura were studied at the department of Pulmonary
Medicine King George s Medical University U.P., Lucknow and were further followed up
for one year. All patients included for the study had symptoms of >30 days, recurrent
pleural effusion, chest radiograph and chest CT scan suggestive of malignant pleural effusion. Prior to inclusion they had at least one thoracentesis for pleural fluid study (determination of protein, glucose, adenosine deaminase, mycobacterial and cytological examination with total and differential cell count and detection of neoplastic cells). Prior to
medical thoracoscopy patients were prospectively evaluated to obtain clinical variables.
Results: After histopathological examination, the results were analysed using various
statistical tools. Out of 51 patients, 36 were diagnosed as metastatic pleural disease with
29!51having adenocarcinoma, 04!51 squamous cell carcinoma, 02!51 non Hodgkins lymphoma and one small cell carcinoma, rest 15 had non malignant effusion having nonspecific (04 patients), tubercular (08 patients) and acute!chronic inflammatory pathology in
03 patients. In follow up after thoracoscopy out of 07 patients in non malignant pathology
03 responded to anti tubercular treatment and were finally labeled as tubercular. Definite diagnosis of malignancy was made in 70.6% cases and that of pleural tuberculosis
was made in 15.7% of cases. After follow up there was 100% sensitivity and specificity of
medical thoracoscopy for malignant diseases and 78.6% sensitivity and 100% specificity
for diagnosing pleural tuberculosis.
Conclusion: Medical thoracoscopy is an excellent diagnostic tool for diagnosing suspected malignant pleural effusion and must be deployed early to confirm the diagnosis
and to differentiate between malignant and tubercular pleural effusion. Role of this diagnostic tool is particularly important in high burden countries of tuberculosis like ours
where presentation of pleural tuberculosis can be variable and mimic malignant pleural
effusion.
Department of Respiratory Medicine, Changi General Hospital, Singapore
Akash Verma, Mui Yok Lee, Chunhong Wang,
Nurmalah Binte Mat Hussein, Kalai Selvi, Augustine Tee
Aim: To assess the efficiency of performing pulmonary procedures in the endoscopy unit in a large teaching hospital.
Design: Prospective study from 20th May to 19th July 2013.
Main outcome measurements: Procedure delays and their
reasons; duration of procedural steps starting from patient s
arrival to endoscopy unit; turnaround time; total case durations, and procedure wait time.
Results: 65 procedures were observed. The most common
procedure was BAL (61%) followed by TBLB (31%). Overall
procedures for 35 (53.8%) of 65 patients were delayed by
greater or equal to 30 minutes, (60%) 21!
35 because of
spillover of the gastrointestinal & surgical cases into the
time block of pulmonary procedure. Time elapsed between
end of pulmonary procedure and start of the next procedure
was greater or equal to 30 minutes in (16%) 8!
51 of cases. In
(35%) 18!
51 patients there was no next case in the room after
completion of the pulmonary procedure. The average idle
time of the room after the end of pulmonary procedure and
start of next case or end of shift at 5:00 PM if no next case
was 58 53 minutes. In (33%) 17!
51 patients the room s idle
time was >60 minutes. 52.3% of patients had the wait time >
2 days and 11% had it more than or equal to 6 days, reason in
(71%) 15!
21 being unavailability of the slot.
Conclusions: Most pulmonary procedures were delayed due
to spillover of the gastrointestinal & surgical cases into the
block time allocated to pulmonary procedures. The most
common reason for difficulty encountered in scheduling the
pulmonary procedure was slot unavailability. This caused increased procedure waiting time. The strategies to reduce
procedure delays and turnaround times along with improved
scheduling methods may have a favorable impact on the volume of procedures performed in the unit thereby optimizing
the existing resources.
231
Oral Presentation
IP-O7-6
IP-O7-7
Mediastinal adenopathies biopsy CT-guided endoscopical transbronchial schieppati needle: 113 cases
colombian experience
Diagnostic utility of algorithmic and combined use of
conventional and EBUS-TBNA in mediastinal!
hilar
lymphadenopathy
Department of Interventional Pneumology and Thoracic Surgery, RESPIREMOS SAS Unit of Respiratory Endoscopy Clinica Comfamiliar - Clinica Saludcoop Pereira, Colombia1),
Respiremos SAS Unit of Interventional Pulmonology - Clinica
Comfamiliar - Clinica Saludcoop2)
Interventional Pulmonology Unit, 1st Department of Pulmonary Medicine, University of Athens, Sotiria Chest Hospital
of Athens, Greece1), Cytology Dept, Sotiria General Hospital,
Athens Greece2), Pathology Dept, Sotiria General Hospital,
Athens Greece3)
Mauricio Cespedes Roncancio31), Mauricio Gonzalez2),
Alberto Franco2), Manuel Pacheco2)
Grigorios Stratakos1), Philip Emmanouil1),
Nikolaos Koufos1), Aggeliki Kokkini2),
Rodoula Triggidou3), Eirini Karabela1), Vlassis Vitsas1),
Nikolaos Koulouris1)
Background: Mediastinal adenopathies are manifestations of
multiple diseases including primary and secondary processes
at these lymphoid organs. These can be related to benign or
malignant pathologies. Depending on mass size, biopsy studies
should be performed, usually through thoracoscopy or mediastinoscopy. In the last decade, endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA), particularly in developed countries, is used for those purposes.
However EBUS-TBNA is not available in most developing
countries due to costs and lack of training. For these reasons,
endoscopical techniques guided by CT-location of lymph node
stations could be used as a diagnostic alternative for lesions
>2 cm. Methods: We present herein results and experience
with 113 patients with mediastinal adenopathies evaluated between 2009-2013, at two-institutions of Pereira, Colombia. In
these cases, an endoscopy study with rigid bronchoscopy
placed under general anesthesia and a Schieppati needle were
employed. Previous computed tomography scan (CT-scan)
looking for adenopathies allowed to locate them at stations 2R,
2L, 4R, 4L and 7. Checking for CT-scan anatomical location of
lymph nodes, points for transbronchial approach to them were
identified at endoscopy. All lesions had different diameters
(>2 cm) and were located close to the tracheal, bronchial and
subcarinal walls. Using a Schieppati needle (which was used
with a negative pressure of 20 cm H2O), the trachea or bronchi were punctured and a first tissue sample was taken. It was
then extended at glass slides and immediately assessed by the
pathologist for an initial diagnosis. If lymph node tissue was
found at the sample, a further lymph node tissue biopsy was
taken with forceps, using the orifice previously created with
the Schieppati needle. Forceps and needle introduction is kept
at a maximum distance of 2 cm from the wall. HematoxylinEosin staining and immunohistochemistry were used. Results:
In more than 95% of patients, first sample contained lymph
node tissue, allowing taking forceps biopsy and further performance of immunohistochemistry for a precise pathological
diagnosis which included squamous cell carcinoma, small cells
carcinoma, adenocarcinoma, lymphoma, tuberculosis, sarcoidosis and anthracosilicosis, among others. There were no complications to the procedure such as bleeding, infection or respiratory problems. Conclusions: In our experience, CT-guided
endoscopical transbronchial Schieppati needle biopsy represents a low cost, highly accurate (which allow staging disease)
and minimally invasive diagnostic procedure for mediastinal
adenopathies, with no complications, safe, suitable and affordable for resource-constrained settings, such as Colombia and
other countries in Latin America and developing regions of
the World.
232
Background: Conventional and EBUS-TBNA are both well
established in the diagnostic approach of mediastinal enlargements. We performed a prospective study to investigate the diagnostic efficacy of an algorithm integrating C-19
G-TBNA and EBUS-22G-TBNA.
Methods: CTBNA was performed for nodal stations (n.s.) 4, 7
and 10 when nodal size was >1.5 cm. EBUS-TBNA was performed for n.s. 2, 11 irrespective of size. Stations 4, 7 and 10
were sampled by EBUS-TBNA when nodal size was <1.5 cm
and when CTBNA results were inconclusive. Non diagnostic
cases underwent exploration by mediastinoscopy or thoracotomy. If patients declined surgical exploration, they were
followed for 3-6 months.
Results: One hundred and thirty nine nodal stations were
sampled in 120 patients without complications. CTBNA was
performed in 77 (55.4%) and EBUS-TBNA in 62 (44.6%) nodal
stations. CTBNA n.s. were: 4R (37 n.s.-48%), 7 (27 n.s.-35%), 4L
(7 n.s.-9.1%), 10R (5 n.s.-6.5%) and 10L (1 n.s.-1.3%). EBUSTBNA n.s. were: 2R (4 n.s.-6.5%), 4R (20 n.s.-32.3%), 4L (6 n.s.9.7%), 7 (8 n.s.-12.9%), 10R (13 n.s.-21%), 10L (3 n.s.-4.8%), 11R (4
n.s.-6.5%), 11L (4 n.s.-6.5%). Overall diagnosis was set by both
techniques in 115 stations (82.7%). EBUS was performed as a
second procedure in 5 patients (6 n.s.) without setting an alternative diagnosis. Mediastinoscopy!
thoracotomy was performed for exploration of 17 non-diagnostic stations in 15 patients, resulting to alternative diagnosis (NSCLC and metastatic cancer) in 12 (70.6%) and confirming negative n.s. in 5
(29.4%). Long term follow up of 5 patients did not reveal an alternative diagnosis in 7 n.s. Overall diagnosis was set by the
algorithmic approach in 127 n.s. (91.4%): NSCLC (58.3%),
SCLC (22.3%), Granulomatous diseases (7.2%), Metastatic disease (3.6%). Sensitivity, diagnostic accuracy and negative
predictive value were: 93%, 94% and 68%.
Conclusion: Following the proposed algorithm, we used
EBUS-TBNA in only 44.6% of cases attaining an overall sensitivity, diagnostic accuracy and negative predictive value of
93%, 94% and 68% respectively. Our algorithm merits further investigation as it can lead to EBUS resources rationalization.
Oral Presentation
IP-O7-8
IP-O7-9
Determinants of false negative results in non-small cell
lung cancer staging by EBUS-NA
Learning curve of endobronchial ultrasound as a diagnostic tool in patients with mediastinal lymphadenopathy
Department of Respiratory Diseases, Hospital Universitari
Parc Tauli, Spain1), Hospital Universitari Germans Trias i Pujol, Badalona, Spain2), Hospital Universitari Son Espases, Palma
de Mallorca, Spain3), Complexo Hospitalario Universitario de
Vigo, Vigo, Spain.4), Hospital Universitario 12 de Octubre, Madrid, Spain5), Complejo Asistencial de Salamanca, Salamanca,
Spain.6), Hospital Universitari La Fe, Valencia, Spain7)
Eduard Monso1), Mireia Serra1), Jose Sanz-santos2),
Miguel Gallego1), Concepcion Monton1), Borja Cosio3),
Jaume Sauleda3), Alberto Fernandez-Villar4),
Ricardo Garcia-lujan5), Eduardo De Miguel5),
Felipe Andreo2), Rosa Cordovilla6), Gonzalo Varela6),
Enrique Cases7)
Background: False negative (FN) results of EBUS-NA in NSCLC staging
have shown significant variability in previous series. The aim of our
study was to identify tumour- and procedure-related determinants of
EBUS-NA FN results.
Methods: We conducted a prospective study that included NSCLC patients staged as N0!N1 by EBUS-NA and undergoing therapeutic surgery. Frequency of FN results in the mediastinum was calculated and
tumour- and procedure-related determinants of FN results in stations
reachable and non-reachable by EBUS-NA were determined by multivariate logistic regression.
Results: EBUS-NA obtained adequate samples from a median of two
(IQR 1-2) mediastinal stations, and achieved adequate sampling of three
stations in 41 patients (24.8%). Pathologic staging after surgery identified EBUS-NA FN procedures for mediastinal malignancy in 23 participants (13.9%), with metastasis in >1 mediastinal station in two of them.
FN results were observed mainly in stations reachable by EBUS-NA
(17, 10.3%), and less often in stations beyond the reach of EBUS-NA (7,
4.2%). FN results were related to the extensiveness of EBUS-NA sampling, with a low prevalence (2.4%) when sampling of three mediastinal
stations was satisfactory, rising above 10% when this requirement was
not fulfilled (p=0.043). The inverse relationship between the extensiveness of EBUS-NA sampling and FN results was only found for results in
reachable stations (p=0.038, chi-square). FN results in non-reachable stations were independent of the extensiveness of sampling and related to
tumour location. Six out of seven cases (85.7%) with FN results in stations non-reachable by EBUS-NA were observed in tumours in the left
lung (upper=2 and lower=4), with a statistically significant difference
with respect to right-sided tumours (p=0.012, Fisher s exact test). The
assessment of determinants of FN results in NSCLC staging by EBUSNA in a multivariate model confirmed that statistically significant risk
factors for FN results in stations reachable by EBUS-NA were an abnormal mediastinum on CT!PET (OR 7.77; 95%CI 2.19-27.51, p=0.001),
and the extensiveness of satisfactory sampling of mediastinal stations
(OR 0.37, 95%CI 0.16-0.89, p=0.026). Location of LC was the only criterion
for non-reachable nodes, with a higher risk in left-sided tumours (OR
10.11, 95%CI 1.17-87.52, p=0.036).
Conclusions: EBUS-NA FN results were observed in nearly 15% of
NSCLC patients but reduced to 3% when satisfactory samples from
three mediastinal stations were obtained. FN results in stations reachable by EBUS-NA were associated with the extensiveness of sampling,
and, in stations out of reach of EBUS-NA, with left-sided primary tumours.
Funded by FIS and Ciberes
Department of Pulmonary and Critical Care, KTU Faculty of
Medicine, Turkey1), Karadeniz Technical University Faculty
of Medicine Dept. of Pathology, Turkey2)
Yasin Abul1), Savas Ozsu1), Yilmaz Bulbul1),
Ismail Yilmaz1), Safak Ersoz2), Funda Oztuna1),
Tevfik Ozlu1)
Background: EBUS has been used in the sampling of patients
with a mediastinal pathologies. The diagnostic performance
and possible learning curve effects of EBUS was evaluated.
Methods: Exclusion criteria included patients inability to tolerate EBUS and no available lymph node sampled during the
procedure. Final definitive diagnosis was defined by EBUSTBNA and!
or mediastinoscopy, other invasive procedures
(thoracentesis,transthoracic needle biopsy). Diagnostic ability
of EBUS to detect positive diagnosis was evaluated according to the time frames in order to evaluate potential learning
curve effects.
Results: Over a 15 month period,118 patients underwent
EBUS at our institution. 17 (14.4%) patients were excluded
from the review. Intravenous sedation was used in all patients, general anesthesia was used in the 3 patients. The
male: female ratio was 1.8:1, the median age was 60 years
(range 16-82). Final diagnoses were non-small cell lung cancer (25.7%), benign lymph node tissue (20.8%), small cell lung
cancer (4.9%), hematological malignancy (4%), tuberculosis
(4%), sarcoidosis (33.7%), and others (6.9%). There were no
complications. The diagnostic yield of EBUS was 75.2%. The
most commonly sampled stations were: 7 (67.5%), 4R and 4L
(14.9%), 10R and 10L (13.1). The sensitivity and specificity of
EBUS to detect lung cancer were 80.6% (95% confidence interval [CI], 61.9 to 91.8) and 100% (95% CI, 93.5 to 100) respectively. The PPV and NPV was 100% (95% CI, 83.4 to 100) and
92.1% (95% CI, 83 to 96.7) respectively. The prevalence of
lung cancer was 30.6% (31 to 101). The accuracy of EBUS for
lung cancer was 94%. Diagnostic ability of EBUS as according to the evaluated time frames increased significantly by
the time period (p=0.02). The optimal cutoff value of number
of procedures for obtaining positive EBUS was 42. The AUC
of number of procedures was 0.558 (CI: 0.424-0.693).
Conclusion: EBUS is a safe method with a learning curve. It
should be considered complementary to mediastinoscopy.
Keywords: EBUS, learning curve, diagnosis.
＊ This abstract was previously presented in national congress named Turkish Thoracic Society 15th Congress in
2012 at Antalya,Turkey as a oral presentation.
233
Poster Presentation
IP-P1-1
IP-P1-2
Trachea lymphoma treated by rigid bronchoscope:
Two cases reports
Pulmonary mucosa-associated lymphoid tissue lymphoma misdiagnosed as pulmonary tuberculosis for 3
year: A case report
Department of respiratory medicine, Peking University First
Hospital, China
Junfang Huang, Ying Liu, Guangfa Wang
Background: Primary malignant lymphoma of the trachea is
extremely rare. We report two cases of tracheal lymphoma
treated with rigid bronchoscope in order to help improve diagnosis and management in central airway stenosis.
Case Report: Case 1 is a 46-year-old female with the complaint of dyspnea for 2 years. Fiberoptic bronchoscopy
showed papillary nodules which were fragile and hemorrhagic causing narrowing of most of the proximal tracheal lumen and there re some similar nodules at the opening of
right main bronchus. Considering the severity of stenosis in
the airway and the risk of hemorrhage during operation, we
chose rigid bronchoscope to debulk most of the tumor, drainage through working channel then cauterized and froze the
residual malignant tissue. The post-operative pathological
analysis confirmed a diagnosis of MALT-small B cell lymphoma. The patient relieved after the remission of obstruction. She received 6 CHOPE chemotherapies afterwards. In
1-year followup further bronchoscope proved the trachea
was completely unobstructed. Case 2 is a 79-year-old female
complained of shortness of breath and weight loss for 4
month. Bronchoscopy confirmed multiple nodular neoplasms
distributed from the proximal trachea to the carina, the neoplasm was lobular in distal trachea which narrowed 80% of
the tracheal lumen. The opening of left main bronchus, crest
of right middle and lower lobar bronchi had been slightly invaded by the neoplasm. The case was unresectable. The patient was then treated successfully with rigid bronchoscope
by debulking the mass from the trachea to the left main
bronchus without bleeding a lot. Postoperative pathology
showed a MALT lymphoma, possibly B cell originated. The
patient s symptom alleviated obviously soon after the procedure. She refused any chemotherapy or radiotherapy and
discharged two days later. She didn t announce any discomfort in the 5-month follow-up and fiberoptic bronchoscopy revealed some papillose scattered through the middle and
lower trachea without any obvious masses or stenosis in
either the trachea or the bronchi.
Conclusion: These are two cases of tracheal MALT lymphoma whose initial manifestation is severe central airway
obstruction which may be fatal to the patients. Relieving of
the airway obstruction is more important than its diagnosis.
Rigid bronchoscope can be a favorable choice for a patient
with tracheal stenosis caused by primary MALT lymphoma
to relieve obstruction immediately and maintain the curative
effect for a relative long time.
234
First Department of Respiratory Medicine, First Hospital Affiliated to Kunming Medical University, China
Jiao Yang, Xi-qian Xing, Xu-wei Wu
Background To explore the diagnosis and treatment of pulmonary mucosa-associated lymphoid tissue lymphoma and
to reduce misdiagnosis.
Case report The patient who was male, 58years old, was
surferring from intermittent fever, cough, sputum with chest
tightness, fatigue for 4 years. The patient was diagnosed as
pulmonary tuberculosis, tuberculous pleurisy and was
given anti-tuberculosis treatment for 3 years. The CT of the
chest showed consolidation in the right middle lobe, right
low lobe and left lower lobe with bronchial ventilation levy,
miliary nodules in the right middle lobe, interstitial thickening, right pleural effusion. Ultrasound guided lung biopsy pathology of the right lung showed diffuse small lymphocytes
infiltration. The Immunohistochemistry showed CD20, CD79
α, Vim were positive, Ki67 weakly positive (15% positive).
Therefore, the pulmonary mucosa-associated lymphoid tissue lymphoma was final diagnosed.
Conclusion Pulmonary mucosa-associated lymphoid tissue
lymphoma had no specific clinical manifestations, often was
misdiagnosed as pulmonary tuberculosis, pneumonia or lung
cancer. The patients with suspicious pulmonary mucosaassociated lymphoid tissue lymphoma need percutaneous
lung biopsy, transbronchial lung biopsy or open lung biopsy
and immunohistochemistry to confirm the diagnosis.
Poster Presentation
IP-P1-3
IP-P1-4
Primary tracheal B cell lymphoma
A case of Behcet s disease patients with pulmonary
arterial aneurysms was completely resolved
Pulmonology, Medical University Cluj Napoca Romania, Romania1), Pulmonology Hospital Cluj Napoca2), Cluj napoca Medical University3), Cluj Napoca Pulmonology Hospital4)
Bianca Domokos1), Marioara Simon2), Monica Pop3),
Alexandru Vasilescu4)
Background
Primary neoplasms of the trachea are rare, accounting for
only 0.1% of all malignancies. Approximately 75% are
squamous cell carcinomas or adenoid cystic carcinomas. Primary tracheal non-Hodgkin s lymphoma accounts for only
0.2% to 3% of all tracheal tumors. Extranodal lymphoma itself is not uncommon, but patients with extranodal lymphoma only have a 3.6% rate of tracheal-bronchial involvement. From 1973 to 2000, only 28 cases of primary tracheal
lymphoma were reported in the literature.
Case report:
A 71 year old woman presented to the Pulmonology hospital
for progressive dyspneea on excertion, coug, haemoptisys
with an acute onset two weeks prior to submission. The patient was a lifelong smoker. The patients medical hystory included COPD, obesity, arterial hypertension. On examination
the patient presented stridot during minimal activity. The vital signs and oxigen saturation was normal. The cest x ray
revealed the presence of an upper right lobe atelectasis. Fiberbronchoscopy was performed which reaveles subglottioc
stenosis due to a prolifferative lession with severe tracheal
lumen redduction to 1!
3 that can not be exceeded by the endoscope, biopsy was performed. Given the accelerated decline in pulmonary function with emphasis of the dyspneea a
second fiberbronchoscopy was performed for therapeutic
purposes and bronchoscopic electrocauterization of the tumoral surface and resection with forceps was performed.
Deobstruction of the tracheea was obtained following the
procedure and endoscopic access was possible and massive
tumor invasion was described, multiple biopsies were taken.
The hystopathological exam sustained the diagnosis of
B cell Lymphoma. The patient was treated with deffinitive
radioteraphy.
Conclusion:
This case highlights the importance of bronchoscopy both
for diagnostics and treatment of tracheal tumors.
pneumonology, Ataturk Chest Diseases and Surgery Center,
Turkey
Arzu Erturk
Behcet s disease (BD) is the only systemic vasculitis involving both arteries and vein in any sizes. Pulmonary artery
vasculitis itself is rare; affects mainly young men presenting
with dyspnoea, cough, chest pain and haemoptysis. It carries
a bad prognosis in patients with BD; although systemic glucocorticoid and cyclophosphamide pulse therapy have
shown some limited benefit in some case reports.
An 41year old Turkish male had been attending the pneumonology clinic for deep vein thrombosis for the last few
months and receiving anticoagulant therapy. He presented
to the emergency room with massive hemoptysis. A pulmonary CT angiography revealed bilateral pulmonary arterial
aneurysms (PAA). BD was diagnosed based on these findings. Anticoagulant therapy was stopped. The treatment
was started with intravenous pulse methylprednisolone (250
mg per day for 3days) and monthly 1,000mg cyclophosphamide, and followed by 1mg!
kg per day of methylprednisolone orally, and intravenous pulse of 1,000mg cyclophosphamide monthly. Thorax CT was repeated after 2 months
of treatment. It showed that PAAs were reduced and in situ
thrombosis in PAAs was completely resolved with immunosuppressive treatment. The steroids were then tapered
down over 12 months and intravenous pulse of 1,000mg cyclophosphamide monthly during 18 months. His treatment
was changed to azathiprine 75 mg daily after PAA completely resolved, deep vein thrombosis is treatment with anticoagulation in this case. His repeated CT scan chest
showed all pulmonary arterial aneurysms resolved after almost three years of first diagnosis.
Venous thrombosis could be as the initial presentation of BD.
Deep vein thrombosis of the lower extremities is the most
frequent site for thrombosis in BD (60-80% of vascular lesion).
If the patient with PAA presenting with profuse haemoptysis had the worst prognosis. Behcet s diseases related PAA
was successfully treated with high-dose corticosteroids (oral
and intravenous) and pulsed intravenous cyclophosphamide.
After PAA completely resolved, deep vein thrombosis is
treatment with anticoagulation in Behcet s case.
235
Poster Presentation
IP-P1-5
IP-P1-6
A case report of diaphragmatic hernia in adult
A case of rib exostosis with chest X-ray abnormality
and exertional dyspnea
Department of Pulmonology and Respiratory Medicine, University of Indonesia, Indonesia1), Department of Cardiothoracic
and Vascular Surgery, Persahabatan Hospital, Jakarta, Indonesia2), Department of Surgery (Digestive), Persahabatan Hospital, Jakarta, Indonesia3)
Herman Suryatama1), Agung Wibawanto2),
Susan Hendriarini2), Seno Budi3),
Wahjuani Widyaningsih1), Faisal Yunus1)
Background
Diaphragmatic hernia presentation in adults is a very rare
case. Diaphragmatic hernia usually begins during childhood,
but may be an occasional finding in adults. The real prevalence in adults is unknown, with an estimated range between
0.17% and 12%. Diaphragmatic hernia detection in adults is
usually accidental because most patients are asymptomatic
or present with a wide variety of symptoms, and diagnosis
can be difficult. Diaphragmatic hernia may occur through
the esophageal hiatus, through other congenital openings
(such as the foramina of Bochdalek or Morgagni), or through
post-traumatic defects. Most diaphragmatic hernias are sliding hiatal hernias of the stomach through the diaphragmatic
esophageal hiatus. Incidence of hiatal hernias increases with
age, approximately 60% of individuals aged 50 or older have
a hiatal hernia. The most common strategy to treat diaphragmatic hernia is via a thoracotomy or laparotomy or
both.
Case report
We report a case of a 64 year old male who was admitted
with epigastric cramp like pain for 5 days and tenderness in
the left upper abdominal quadrants. There were no respiratory symptoms, or specific abnormality from chest and abdominal physical examination. He acknowledged that there
was a heavy physical exercise done one week before admitted to hospital. The laboratory data showed an increased
number of leukocytes and neutrophiles. Chest X-Rays and
CT Scan with intravenous contrast showed the presence of
gastric segment and mesenterium within the left hemithorax
with free air and fluid around it. Barium enema examination
also showed the presence of heterogenous consolidation with
intraperitoneal free air and air fluid level. These findings confirmed the diagnosis of left diaphragmatic hernia and gastric
perforation. The patient underwent thoracotomy and laparotomy done by cardiothoracic and digestive surgeons.
There was gastric herniation found in the inferior lobe of left
lung and pleura. The gastric contents were removed and the
defect in diaphragma was closed. Post-operatively, the patient was placed under intensive care with cardiac and respiratory support.
Conclusion
Diaphragmatic hernia are usually asymptomatic, or with
minimal respiratory and abdominal complaints. In this case,
we presented an adult male with diaphragmatic hernias and
gastric perforation diagnosed accidentally from chest X-ray,
CT Scan, Barium enema examination and treated with thoracotomy and laparotomy surgery.
236
Department of Respiratory Medicine, Hashimoto Municipal
Hospital, Japan1), Department of Otolaryngology, Hashimoto
Municipal Hospital2), Department of Radiology, Hashimoto Municipal Hospital3), Depratment of BreastTthoracic Surgery,
Hashimoto Municipal Hospital4), Otemae Hospital5), Department of Respiratory Medicine & Allergology, Kinki University
School of Medicine, Sakai Hospital6), Department of Respiratory Medicine & Allergology, Kinki University School of Medicine7)
Etsuo Fujita1), Hideko Nishimura2), Kazuyuki Tsunoi3),
Sayoko Kawashima4), Fuminori Ohta4),
Masaaki Kawahara5), Yusaku Nishikawa6),
Hiroyuki Miyajima7), Yuji Tohda7), Katsuhiro Yamamoto7)
Introduction: Exostosis of the rib was accidentally detected
by chest X-ray. There have been some reports of this condition being asymptomatic or having pulmonary complications.
We experienced a-25 year old man who had exertional dyspnea in the inspiratory phase. Examination by otolaryngological endoscope, found nothing significant, and he was introduced to the Respiratory Division. His pulmonary function
test (%VC122%, FEV1.4,36 L) was normal. Chest X-ray revealed right-sided consolidation, and from chest CT, the rib
exostosis was pointed out. The patient had no severe symptoms and wished to be observed conservatively. Conclusion:
We experienced an almost asymptomatic case of exostosis in
the rib discovered by X-ray and CT.
Poster Presentation
IP-P1-7
IP-P1-8
A giant mediastinal teratoma presenting as orthopnea
and dyspnea in adult
A tumor excision case of castleman disease in pulmonary hilum
Radiology, Seka State Hospital, Turkey1), THORACIC SURGERY DEPARTMENT SEKA STATE HOSPITAL IZMIT
TURKEY2), CHEST DISSEASES DEPARTMENT UZUNMEHMET CHEST MEDICINE HOSPITAL ZONGULDAK
TURKEY3)
Bora Kalaycioglu1), Hasan Kapicibasi2), Ferzat Zanuzzi2),
Murat Altuntas3)
40 year old female admitted with dyspnea and orthopnea
and shadow in the right lung field on a chest X ray. She was
examined by chest CT, MRI and PET CT of chest. All radiologic images showed a large tumor mass pressing the right
subclavian vena and neighboring the ascending aorta, right
pulmonary vena. The clinical and radiological diagnosis was
mature teratoma arising from anterior mediastinum. She underwent an anterolateral thoracotomy and tumor was removed. The size of the resected specimen, filled with sebaceous material, hair and teeth, was 16 10 9,6 cm. Histopatologic examination of the specimen revealed a mediastinal
mature teratoma. She has been well for 2 months postoperatively.
Department of General Thoracic Surgery, Kagoshima University School of Medicine, Japan
Masaya Aoki, Tsunayuki Otsuka, Kazuhiro Wakida,
Tadashi Umehara, Aya Harada, Go Kamimura,
Yui Watanabe, Toshiyuki Nagata, Naoya Yokomakura,
Kota Kariatsumari, Koichi Sakasegawa,
Yoshihiro Nakamura, Masami Sato
Castleman disease (CD) is a rare disorder of lymph propagation. In histological classification, there are three types which
are hyaline vascular type (HV type), plasma cell type (PC
type) and mixed type. In clinical classification, localized type
is enlarged lymph node centralized in one part. The multicentric type is lymph node enlargement throughout the
body. It is extremely rare that CD occurs in pulmonary hilm,
and it was reported that the patients were mainly treated by
lobectomy. We report a tumor excision case of localized HV
type CD in pulmonary hilm. A 15-year-old boy with no symptom was referred to our hospital because he was noted as
having an abnormal shadow on chest X-ray at a health
checkup. No abnormal findings were observed on his hematological and biochemical examinations. On chest enhanced
CT, 35mm wide tumor shadow with clear boundary in right
pulmonary hilum was found. The tumor was strongly enhanced in early phase. Abnormal finding were not found in
the lung field, mediastinum and so on besides it. The biopsy
under ultrasonic bronchial endoscope didn t show malignant
findings. However he was hospitalized in our department for
a surgery because 18F-fluorodeoxyglucose positron emission
tomography (FDG-PET) showed moderate accumulation in
the tumor; SUV (standard uptake value) max was 4.4, which
suggested potential malignancy. On operative findings, the
tumor existed between upper and middle lobe of the right
lung with no pleural involvement. The interlobar pulmonary
artery was revealed on the back side of the tumor, and it
turned out that the tumor existed in the corresponding part
of interlober lymph node. We performed 18Ga needle biopsy
for interoperative frozen section diagnosis which showed no
malignant feature. Macroscopically, no tumor invasion into
the pulmonary artery or lung parenchyma was found, only
the tumor was extracted. The extirpated specimen showed
that 30 23mm smooth-surface and well-encapsulated tumor.
Histologically, the lesion had fibrous capsule with clear
boundary which consisted of hyperplasia of lymph follicle.
There were clearly hyalizing concentric fibrotic nest around
the lymph follicle and vessel hyperplasia on hyalizing wall.
There was scarcely breeding of plasma cell outside the follicle, and we concluded HV type CD. He was now under
follow-up observation with no recurrence for two years after
the operation.
237
Poster Presentation
IP-P2-1
IP-P2-2
Volatile organic compound in exhaled breath of idiopathic pulmonary fibrosis using ion mobility spectrometer
Volatile organic compounds from silicone stent-related
biofilm formation detected by ion mobility spectrometry
Department of Respiratory Medicine and Allergology, Sapporo Medical University, School of Medicine, Japan
Yuichi Yamada, Gen Yamada, Kimiyuki Ikeda,
Junya Kitada, Koji Kuronuma, Mitsuo Otsuka,
Hiroki Takahashi
Background:
It is known that a characteristic volatile organic compound
(VOC) exists in exhaled breath of the patients with lung cancer. Analysis of VOC in the exhaled breath has been reported by gas chromatography or multi-capillary column!
ion
mobility spectrometer (MCC!
IMS). Since the measurement
of the VOC using MCC!
IMS is the noninvasive test, we can
analyze VOC even if the patients have limited pulmonary
function. In respiratory diseases, it has been reported that
there is a peak of VOC peculiar to the diseases such as sarcoidosis and COPD, however, there is no report of idiopathic
pulmonary fibrosis (IPF).
Aim:
In order to seek the peak of VOC which is characteristic in
idiopathic pulmonary fibrosis, we compare the difference between the patients of IPF and the healthy subjects by measuring the VOC included in the exhaled breath using MCC!
IMS.
Method:
We measured VOC in the exhaled breath of 40 IPF patients
in our hospital and 55 healthy subjects by using MCC!
IMS.
Results:
We detected 85 points for the peaks of VOC from the both
groups. Comparing these peaks, significant deference of the
peak intensity was provided in five points. The five peaks
were shown at peak (p)2, p5, p10, p18 and p67, which may indicate p-Cymol, 3-Hydroxy-2-Butanon, Isopren, Ethylbenzol,
Butanal, respectively. These peaks were novel as the disease
marker, except Isopren which is analyzed as the other disease marker. There was a positive correlation between p2
and KL-6, and negative correlations between p2 and VC, p5
and PaO2, p18 and DLCO!
VA.
Conclusions:
There were five peaks that was characteristic in IPF. It was
considered that measurement of VOC using MCC!
IMS
might be applied in the diagnosis of IPF.
238
Division of Respiratory and Infectious Disease, Department of
Internal Medicine, St. Marianna University School of Medicine, Japan
Teppei Inoue, Hiroshi Handa, Hiromi Muraoka,
Mariko Okamoto, Ayano Usuba, Kei Morikawa,
Naoki Furuya, Hirotaka Kida, Miwa Fujiwara,
Hiroki Nishine, Atsuko Ishida, Seiichi Nobuyama,
Takeo Inoue, Masamichi Mineshita, Teruomi Miyazawa
Background: Stent related biofilm formation is an encountered problem in interventional pulmonology that can result
in pneumonia and granulations. Breath analysis such as canine scent, electronic nose and ion mobility spectrometry
(IMS) have been reported to detect volatile organic compounds (VOCs)1-4.
Objective: We hypothesized that IMS can detect specific
VOCs in patients with biofilm resulting from silicone stent
placement.
Methods: Breath samples of 4 patients before and after silicone stent removal or replacement were analyzed using IMS
coupled to a multi-capillary column (MCC!
IMS). VOC peaks
were characterized using Visual Now 2.2 software.
Results: A total of 36 peaks were used to determine
Wilcoxon-Rank tests. Box-and Whisker plots were prepared
and 12 peaks were identified to contribute to separation
power. Five of the 12 peaks had a separation power better
than 95%. From the identified peaks using the database provided, a decrease was observed for Limonene, 1-Octanole,
Phenylacetaldehyde, 2,2,4,6,6-Pentaheptylmethane, Nonanal,
Cyclohexanole, Acetophenone and p-Cymol. In particular, Limonene and Phenylacetaldehyde showed clear decreased
differentiation.
Conclusions: IMS was able to evaluate the degree of biofilm
resulting from stent placement. From these results, we can
consider whether to replace or extract stents in conjunction
with clinical symptoms using IMS.
Poster Presentation
IP-P2-3
IP-P2-4
In vitro evaluation of silver-coated silicone tracheobronchial stents on growth and attachment of
clinical isolates
Efficacy of omalizumab in patients with severe asthma
using the asthma health questionnaire and asthma
control test
Department of Respiratory Medicine, Hospital Universitari de
Bellvitge, Spain1), Department of Microbiology, Hospital Universitari de Bellvitge, Spain2), Grup d Enginyeria de Materials
(GEMAT), Institut Quimic de Sarria!
Universitat Ramon Llull,
Spain3)
Division of Respiratory Disease, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, St. Marianna University School of Medicine, Japan1), Division of Respiratory and
Infectious Disease, Department of Internal Medicine, St. Marianna University School of Medicine2)
Marta Diez-Ferrer1), S Marti2), L Calatayud2), J Gilabert3),
C Ardanuy2), S Borros3), R Lopez-lisbona1), N Cubero1),
J Linares2), A Rosell1)
Junko Saji1), Motonaka Arai1), Takahito Yamamoto1),
Masamichi Mineshita2), Teruomi Miyazawa2)
OBJECTIVES
Silicone stents are often used for treating obstructions of the
central airways. Bacterial colonization can result in halitosis,
respiratory infections and even sepsis. The main objectives
were to determine the microorganisms involved in stent
colonization and to evaluate silver-coating as a mechanism to
reduce bacterial growth and adhesion.
METHODOLOGY
Clinical isolates were obtained from bronchial washing (BW)
in 32 patients during routine flexible bronchoscopy after 1
month of stenting. Silver was deposited on PDMS (polydimethylsiloxane) by a process based in the activation of silicone surface through low pressure plasma treatment. Silicone and silver-coated silicone slides were covered with 106
cfu!
ml bacterial cultures and incubated 24h at 37̊C. Viability
of adhered bacteria was assessed by confocal examination of
Live!
Dead staining on Pseudomonas aeruginosa (PA01 &
clinical isolates) and Staphylococcus aureus clinical isolates.
RESULTS
The main microorganisms isolated from BW were P. aeruginosa (22%), S. viridans (22%) and S. aureus (15%). After 24h of
static growth, bacteria adhered to the silver-coated slides
were dead in contrast to bacteria on uncoated silicone slides.
Clinical isolates were more resistant to silver than the P.
aeruginosa PA01 type strain usually used for these experiments, with the need of concentrations 0.8-0.9 mcg!
mm2 for
the clinical P. aeruginosa isolates, >1 mcg!
mm2 for S. aureus
and 0.4 mcg!
mm2 for PA01 strain.
CONCLUSIONS
S. aureus and P. aeruginosa were the main pathogens associated to tracheobronchial silicone stent colonization. Clinical
pathogens were more resistant to silver-mediated killing
than the P. aeruginosa PA01 type-strain, with a silver concentration above 1 mcg!
mm2 needed to kill clinical pathogens adhered to the silver-coated silicone slides.
Background and Aim of Study: The efficacy of omalizumab,
an anti-IgE antibody, has been studied in patients with severe bronchial asthma. It has been reported that omalizumab was unable to improve objective results; however, improvements were seen for subjective symptoms in asthmatic
patients. The aim of this study is to evaluate the efficacy of
omalizumab as a long-term disease therapy in severe and
persistent asthmatic patients assessed by pulmonary function tests, AHQ scores, ACT scores, number of emergency
visits and the dosage of methylprednisolone.
Methods: Omalizumab was administered subcutaneously
every 2 or 4 weeks based on serum IgE levels and body
weight in patients. Pulmonary function tests, AHQ, ACT,
number of emergency visits and dosage of methylprednisolone during the 12-month period were compared with the
previous year.
Results: Ten patients were enrolled. Treatment with omalizumab yielded no improves for lung function; however, the
number of emergency visits (19.3 to 1.2, p=0.020) and dosage
of methylprednisolone (871.5 mg to 119.0mg, p=0.046)
showed significant reductions when compared to the previous year. AHQ and ACT at 16 weeks improved significantly
compared to study baseline but after week 20, no significant
improvement was noted.
Conclusion: Omalizumab significantly reduced the number of
emergency visits and methylprednisolone usage. AHQ and
ACT were considered useful in the assessment of subjective
symptoms in asthmaic patients.
239
Poster Presentation
IP-P2-5
IP-P2-6
Let-7a is differentially expressed in bronchial biopsies
of severe asthmatics
Benign tracheal stenosis granulation tissue fibroblasts
cultured in vitro
Pulmology, University Clinic Golnik, Slovenia1), Laboratory for
clinical immunology & molecular genetics, University Clinic
Golnik, Slovenia2), Laboratory for cytology and pathology, University Clinic Golnik, Slovenia3)
Mateja Marc Malovrh1), Ales Rozman1), Peter Korosec2),
Mateja Zavbi2), Izidor Kern3), Matija Rijavec2)
Background. 5-10% of asthma patients cannot be adequately controlled
despite the use of all currently available therapeutic approaches. Selected miRNAs, including let-7a, miR-21 and miR-223 are emerging as
important biomarkers and regulatory molecules involved in the pathogenesis of asthma. Further, the role of let-7a in lung inflammatory processes by modulation of TH2 responses, mainly by targeting IL-13 and
IL-6, has been described in mouse models and several cell lines. Overexpression of let-7a reduces airway inflammation and airway hyperresponsiveness in lungs of induced mouse model of asthma. We therefore wanted to find out whether let-7a, miR-21 and miR-223 are differentially expressed in bronchial biopsies of severe asthmatics.
Methods. Twenty-four asthmatics treated at the University Clinic Golnik (2010-2012) were included. We divided them into two subgroups according to the asthma severity (GINA guidelines), 12 in mild asthmatic
group and 12 in severe uncontrolled asthmatic group. They were in a
stable phase of a disease, with no evidence of exacerbation in the past
four weeks. As controls we used 10 patients with no known chronic
disease, in six of them bronchoscopy was indicated because of prolonged cough that was finally attributed as a consequence of gastroesophageal reflux disease (GERD) and four of them had hemoptysis
with normal radiologic, endoscopic and lung function findings.
Bronchial biopsies were taken with flexible bronchoscope during diagnostic procedures and were immediately formalin fixed and than paraffin embedded using standard procedures. Total RNA was extracted
from 10 FFPE tissue sections 5 mcm thick using the miRNeasy FFPE
Kit following the manufacturer s instructions. Quantitative PCR was
used to analyze the expression of selected miRNAs (let-7a, miR-21, miR
223).
Results. We found significantly reduced expression of let-7a in patients
with severe asthma in comparison to both, patients with mild asthma
as well as to the control group (p<0,05). When comparing the entire
group of asthma patients to the controls we didn t observe any difference in expression of let-7a (Figure 1). No significant differences in miR21 and miR-223 expression were found between different groups analyzed.
Conclusion. Reduced let-7a levels in bronchial biopsies of patients with
severe, therapy resistant asthma, could not only be used as a potential
biomarker to discriminate between different asthma phenotypes, but
also might be a potential novel therapeutic for rapid and fine tuned
modulation of response at the inflammatory site for a group of patients
that are most affected and still lack the efficient treatment.
240
The First Affiliated Hospital of Guangzhou Medical University, China
Ying Zhi Wang, Shiyue Li, Yu Chen
objective:Using people benign tracheal stenosis granulation
tissue small specimens which obtained by transbronchial biopsy cultured primary fibroblasts with tissue culture
method. Method: By transbronchial biopsies we obtained
some intratracheal hyperplastic granulation tissue of 6 patients with benign tracheal stenosis, pretreated with different method, cultured with tissue culture method in different
conditions. Results: We received a total of 7 specimens of 6
patients which were cultured with tissue culture method, 3
of them could be successfully cultured fibroblasts, 4 could
not be cultured fibroblast cells. Conclusion: With the high
concentration of antibiotics or alcohol rinse pretreated, small
specimens which obtained by transbronchial biopsy cultured
with tissue culture method to obtain primary fibroblasts is
feasible.
Poster Presentation
IP-P2-7
IP-P2-8
Withdrawn
Closed suction system versus open suction
pulmonology, Ain Shams University!Cairo!
Egypt, UAE1), Ainshams Universty, cairo, Eygpt2)
Ahmed Riad Almansoury1), Hedya Said2)
Background: catheter suction are used to remove tracheal
secretions through the endotracheal tube in mechanically
ventilated patients, which may be either closed suction system (css) or open one. In css the catheter is a part of ventilator circuit and there is no need disconnect the ventilator and
it seems that the css prevent soiling and spraying of respiratory secretion into the ICU. Objective: to compare css system in comparison with an open tracheal suction system in
adult patients receiving mechanical ventilation for more than
24 hours in terms of VAP incidence, length of stay in the intensive care unit and mortality. Method: We prospectively
recruited all mechanically ventilated patient in our general
ICU, Darelshefa hospital between January 2012 and January
2013. Group A are those with open tracheal suction system
(OTSS) and group B with closed tracheal suction system
(CTSS), comparing VAP incidence, length of stay in the intensive care unit and mortality between the two groups. Results group A (OTSS) where the incidence of VAP was
30.13!
1000 ventilator days not statistically significant in comparison with patients in group B with CTSS with VAP incidence 17.48!
1000 ventilator days. Conclusion: There is no difference in the incidence of ventilator associated pneumonia
and mortality rates between the two groups. The average
length of stay declined in patients with OTSS group.
241
Poster Presentation
IP-P3-1
IP-P3-2
Branching patterns of segmental bronchi and arteries
in the medial basal segment
Preoperative diagnostic accuracy and survival outcomes in resected high-grade neuroendocrine carcinoma
Division of Surgery, Kitsuki Central Hospital, Japan
Masao Chujo, Kentaro Anami, Toshihiko Kaku,
Takafumi Ando
Background: We investigated the branching patterns of the
right medial basal segmental bronchus (B7) and the right medial basal segmental artery (A7) on computed tomography.
Methods: The study population was 2,150 patients. The
branching patterns were classified into 5 types.
Results: Pattern 1 (the entire medial basal segment was ventral to the inferior pulmonary vein, and A7 branched from
the basal segmental artery and ran on the ventral side of the
basal bronchus) was found in 1373, pattern 2 (B7 showed double branching into the dorsal and ventral sides of the inferior
pulmonary vein. A7 flowed into the lung on the dorsal side of
the inferior pulmonary vein and ran on the dorsal side of the
basal bronchus after branching from the basal segmental artery) in 226, pattern 3 (B7 showed double branching into the
dorsal and ventral sides of the inferior pulmonary vein. A7
ran on the ventral side of the basal bronchus after branching
from the basal segmental artery) in 170, pattern 4 (the entire
medial basal segment was dorsal to the inferior pulmonary
vein, and A7 ran on the dorsal side of the basal bronchus after branching from the basal segmental artery) in 99, and
pattern 5 (although the entire medial basal segment was dorsal to the inferior pulmonary vein, A7 either ran on the dorsal side of the basal bronchus after branching from the basal
segmental artery or ran on the ventral side of the basal bronchus after branching from the basal segmental artery) in 24.
Conclusion: Because segmentectomy of the basal segment is
anticipated to become more frequent, the results of this
study may serve as useful reference data.
242
Department of Surgery I, Tokyo Medical University, Japan1),
Department of Pathology, Tokyo Medical University, Japan2)
Yoshihisa Shimada1), Jun Matsubayashi2),
Masatoshi Kakihana1), Yujin Kudo1), Junichi Maeda1),
Koichi Yoshida1), Masaru Hagiwara1), Seisuke Nagase1),
Yasufumi Kato1), Naohiro Kajiwara1), Tatsuo Ohira1),
Norihiko Ikeda1)
【 Introduction 】 Large cell neuroendocrine carcinoma
(LCNEC) and small cell carcinoma (SCLC) are both considered to be high-grade neuroendocrine carcinomas (HGNEC)
arising in the lung. The primary diagnosis of most of HGNEC
is performed on limited biopsy specimens, which may not
translate well when one is confronted with a nomenclature
that is based on resected material. Especially, it is difficult to
diagnose LCNEC with biopsy materials by transbronchial
lung biopsy. The aim of this study was to compare survival
and preoperative diagnostic accuracy between resected
LCNEC and SCLC.【Methods】From 2006 through 2012, a total of 1489 patients underwent complete resection for lung
cancer at our hospital, and 71 patients (4.8%) with a histologic
diagnosis of HGNEC (LCNEC; n=48, SCLC; n=23) were identified. Of these, we retrospectively reviewed the data of 52
patients (LCNEC; n=36, SCLC; n=16) who underwent preoperative biopsy. As a control, we extracted the prognostic
data of 14 patients with clinical stage IIB-IV LCNEC who
had completed a minimum of 1 course of chemotherapy or
chemo-radiotherapy. Overall survival (OS) and postrecurrence survival (PRS) were estimated using the Kaplan-Meier
method.【Results】The median follow-up for survivors was
2.4 years. For 48 LCNEC and 23 SCLC patients, the 3-year
OS rates were 59.2% and 37.8% (p=NS). Pathologic stage was
I, II, III, and IV in 43.8% (n=21), 33.3% (n=16), 18.8% (n=9), and
2.1% (n=1) of LCNECs, and 56.5% (n=13), 34.8% (n=8), 4.3%
(n=1), and 4.3% (n=1) of SCLCs, respectively. Among 36 patients with resected LCNEC, 10 tumors (27.8%) were confirmed to be LCNEC by preoperative biopsy. Among 16 patients with SCLC, 12 cases (75.0%) were confirmed to be
SCLC preoperatively. Of resected 72 HGNEC, 33 patients
(45.8%) had recurrence during a period of this study, and any
postrecurrent therapy was performed in 30 patients
(LCNEC; n=20, SCLC; n=10). The 2-year PRS rates were
24.3% in recurrent LCNECs, 38.9% in recurrent SCLCs, and
the 2-year OS rate was 46.4% in unresectabe LCNECs, respectively (p=NS).【Conclusion】OS and PRS outcomes of
LCNEC were comparable to those of SCLC. Obtaining a diagnosis of LCNEC using small biopsy specimens is difficult
compared to those of SCLC. Therefore, there is an urgent
need to establish the biopsy-based diagnostic criteria for
HGNEC, and it will be important to analyze the biological features of HGNEC.
Poster Presentation
IP-P3-3
IP-P3-4
Thoracoscopic lobectomy for advanced-stage nonsmall cell lung cancer
Lymphogenic skip metastases and adjacent segmental metastases may occur in limited resection for subpleural lung cancer
Department of Thoracic Surgery, Shin-Kokura Hospital, Federation of National Public Service Personnel Mutual Aid Associations, Japan1), Department of Respiratory Internal Medicine
Shin-Kokura Hospital, Federation of National Public Service
Personnel Mutual Aid Associations Japan2)
Shinji Shinohara1), Tetsuya Hanaka2),
Toshihiro Yamashita1), Satoshi Kuboi2),
Ryoichi Nakanishi1)
Objectives: We evaluated the safety and technical feasibility of performing thoracoscopic lobectomy to treat advanced-stage non-small
cell lung cancer.
Methods: Between April 2002 and May 2011, we retrospectively reviewed 85 consecutive patients who underwent lobectomy for preoperative stage II or greater non-small cell lung cancer at a single institution. Data regarding the patient characteristics, operative details
and outcomes were analyzed. The subjects were divided chronologically into three groups.
Results: Pathologic analysis demonstrated stage I in 12 patients
(14.1%), stage II in 27 patients (31.8%), stage III in 34 patients (40.0%)
and stage IV in 12 patients (14.1%). Thoracoscopic lobectomy was
successfully performed in 83 patients (97.6%). There were 36 complications in 28 patients (32.9%), and three patients (3.5%) had grade 3 or
higher complications. Both the operative and perioperative (30-day)
mortality were 0%. The hospital mortality was 2.4% (two patients). A
significantly decreased length of the operation and lower blood loss
and an increased number of bronchoplasties were seen chronologically, although there were no differences in the patient characteristics or other outcomes among the three groups. At a mean follow-up
time of 35 months, the overall 3-year survival rates for pathologic
stages I, II, III and IV were 100%, 63.3%, 32.5% and 33.3%, respectively.
Conclusions: Thoracoscopic lobectomy is feasible, with acceptable
morbidity and mortality rates, as well as favorable oncologic outcomes, in selected patients with advanced-stage non-small cell lung
cancer. The learning curve for thoracoscopic lobectomy for advanced
disease appears to be overcome after 28 consecutive patients.
Department of General Thoracic Surgery, Graduate School of
Medical and Dental Sciences, Kagoshima University, Japan
Yui Watanabe, Toshiyuki Nagata, Masaya Aoki,
Aya Harada, Soichi Suzuki, Masashi Umehara,
Go Kamimura, Kazuhiro Wakida, Tsunayuki Otsuka,
Naoya Yokomakura, Kota Kariatsumari,
Yoshihiro Nakamura, Masami Sato
Background: Limited pulmonary resections including lung segmentectomy
for peripheral small lung cancer have attracted attention in recent years.
However, a surgical consensus has not been established. It has been pointed
out that there are not only lymph flows to pulmonary hilum along pulmonary vessels or bronchi but also pleural lymph flows directory into the mediastinum or adjacent lung lobe. There are some lung cancer cases with pleural indentation less than twenty millimeters. In these cases, it is concerned
that lymph flows carry metastases from the lung segment directly into the
mediastinal lymph nodes and adjacent segments without passing through
the hilar lymph nodes. In other words, skip lymph node metastases and adjacent segmental metastases might be caused. However, there have been
few reports investigating pleural lymph flows exceeding the lung segment.
Objective: The present study was designed to evaluate whether pleural
lymph flows exceeding the lung segment could be detected using indocyanine green (ICG) and a fluorescence imaging system intraoperatively.
Methods: Twenty patients (Twenty one lung segments) undergoing lung
segmentectomy or lobectomy for a tumor were enrolled in this study. A jet
ventilation is selectively applied under bronchofiberscopy to the burdened
bronchus to develop an anatomic border between the inflated segment to be
evaluated and the deflated area. A 1.0 ml solution containing the fluorescent
dye ICG (2.5 mg!ml) was injected into three to five subpleural sites of the
segment. Fluorescence imaging device (HyperEye Medical System, MIZUHO IKAKOGYO CO.,LTD. Tokyo, Japan) was used to monitor the ICGcontaining lymph flows from the injection site for five minutes. We evaluated the presence of pleural lymph flows exceeding the lung segment.
Results: We observed pleural lymph flows in fifteen out of twenty one cases
(71.4%), and pleural lymph flows exceeding the lung segment in eleven out of
twenty one cases (52.4%). There is no pleural lymph flow from superior segment of bilateral lower lobe exceeding the segment in studies of several segments.
Conclusions: Pleural lymph flows exceeding the lung segment can be observed in vivo. Skip lymph node metastases and adjacent segmental metastases may occur through subpleural lymph channels in limited pulmonary
resections for subpleural lung cancer cases.
243
Poster Presentation
IP-P3-5
IP-P3-6
The results of operation in young adult patients with
bronchiectasis
Adverse outcomes after surgery in patients with
asthma: A matched nationwide retrospective cohort
study
Thoracic surgery, GATA Haidarpasha Teaching Hospital,
Turkey
Ahmet Rauf Gorur
Background: Despite improvements in medication techniques, resection of the bronchiectatic lung remains the only
potential possibility of cure in patients with bronchiectasis.
Surgical therapy and preoperative fiberoptic bronchoscopy
is always carried out in order to eliminate the disease, and
prevent possible complications due to chronic disease. We
present our results who treated surgically and absence of
preoperative fiberoptic bronchoscopy (FOB) with the diagnosis of bronchiectasis.
Method: Between January 2011 and Novamber 2013, 21 male
patients were operated. Increased number of resected segments and absence of preoperative fiberoptic bronchoscopy
were analyzed as the potential risk factors on postoperative
complications such as, length of hospital stay, persistent air
leak, and, atelectasis.
Results: Complete resection was achieved in 21 patients.
Morbidity was observed in only 2 patients (9.5%). The increased number of resected segments and absence of preoperative FOB were not found to be significantly associated
with increased morbidity and lenght of hospital stay.
Conclusion: Surgical therapy is always carried out in order to
eliminate the bronchiectasis. Multi-segmental resection and
absence of preoperative FOB are not associated with significant increased risk on postoperative morbidity and lenght of
hospital stay.
244
School of Medicine, Taipei Medical University, Taiwan
Chien-Chang Liao, Chao-shun Lin, Ta-liang Chen
Background: Asthma is a well known risk factor among the
hospitalized patients. However, limited information was
available in population-based regarding the postoperative adverse outcomes among surgical patients with asthma.
Objective: To investigate postoperative major complications
and mortality in surgical patients with asthma.
Methods: Using reimbursement claims from the Taiwan National Health Insurance Research Database, we identified
surgical patients with (n=24,678) and without (n=24,678) preoperative asthma undergoing major surgeries using matching procedure with propensity score. Adjusted odds ratios
(ORs) and 95% confidence intervals (CIs) of postoperative
complications and mortality associated with asthma were
analyzed under the multivariate logistic regressions.
Results: Asthma increased postoperative pneumonia (OR,
1.13; 95% CI, 1.18-1.46), septicemia (OR, 1.09; 95% CI, 1.00-1.19),
and urinary tract infection (OR, 1.13; 95% CI, 1.05-1.22). Preoperative emergency care (OR, 2.02; 95% CI, 1.25-3.26) and hospitalization (OR, 2.09; 95% CI, 1.04-4.18) for asthma were significantly associated with postoperative 30-day in-hospital
mortality. Preoperative steroid use, emergency service and
hospitalization for asthma were also associated with higher
postoperative complication rates for asthmatic patients.
Conclusion: Postoperative complication and 30-day mortality
rates were increased in asthma patients undergoing inhospital major surgeries. History of prior asthma exacerbations was highly associated with postoperative adverse outcomes. We suggest the urgency revising the protocol of perioperative care for this specific population.
Poster Presentation
IP-P3-7
IP-P3-8
Postoperative pneumonia in surgical patients with epilepsy
Thoracoscopic removal of scalpel blade
School of Medicine, Taipei Medical University, Taiwan
Chien-Chang Liao, Ta-liang Chen
Purpose: People with epilepsy are more likely than healthy
people to experience respiratory comorbidities and complications in various medical situations. However, the prevalence
of postoperative pneumonia in surgical patients with epilepsy has not been studied. The purpose of this study is to
examine whether epilepsy is an independent risk factor for
postoperative pneumonia.
Methods: Retrospective cohort study using the National
Health Insurance Research Database to identify patients
with epilepsy who underwent major surgery in Taiwan between the years 2004 and 2007. For each epilepsy patients,
four age and sex-matched participants without epilepsy
were selected. Postoperative 30-day pneumonia was considered as major outcome. We used multivariate logistic regression to calculated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of postoperative pneumonia associated
with epielpsy after the adjustment for age, sex, low income,
urbanization, operation in teaching hospital, coexisting medical conditions, types of surgery and types of anesthesia.
Results: A total of 13,103 patients with epilepsy and 52,412
non-epilepsy participants were included. Patients with epilepsy have significantly more preoperative coexisting medical conditions and demonstrated more risk of postoperative
pneumonia (9.6% vs. 2.8%, p<0.0001). Epilepsy was associated
with postoperative pneumonia (adjusted OR=2.54, 95% CI=
2.32-2.79). In particular, those with preoperative epilepsyrelated hospitalization (adjusted OR=3.54, 95% CI=3.16-3.97)
or epilepsy-related emergency care (OR=2.73, 95% CI=2.343.18) had significantly risk of postoperative pneumonia.
Conclusion: Epilepsy is a risk factor for postoperative pneumonia. Better management of postoperative pneumonia for
people with epilepsy is needed.
Depatment of Pulmonary medicine, Nagpur chest center, India1), Department of pulmonary medicine, LMH hospital Nagpur2)
Vikrant Suresh Deshmukh1), Balkrishna Tayade2)
Background: Occurrence of foreign body in pleural space in
uncommon. An iatrogenic slipping of scalpel blade occurred
during intercostal drainage for left pneumothorax. Thoracoscopic removal of foreign body was successfully done without any trauma to adjacent mediastinal structure. Slippage
of scalpel blade in pleural space is known during intercostal
drain insertion. Thoracoscopic removal is safe procedure for
removal of foreign body instead of thoracotomy.
Case report: A 24 year male presented with history of chest
pain and dyspnoea. He was diagnosed to have massive left
sided pneumothorax. Intercostal drainage was advised for
management of pneumothorax. However, during the ICD insertion the scalpel blade slipped into the pleural space. ICD
was secured in place and patient was referred for Thoracoscopic removal of FB. Thoracoscopy was done with thoracic epidural blockage with two ports. Scalpel blade was
seen in mediastinal recess of pleura space. Adjacent structures were normal. No evidence of trauma secondary to FB.
Lung expansion was noted post Thoracoscopy. ICD was removed on 2nd day. Discussion: Foreign body in pleura space
is rare in occurrence. Broken tip of intercostal drain and pellets inserted by psychotics person has been reported. Iatrogenic slippage of scalpel is also reported. However, several
different methods of removal are reported. Thoracotomy,
Trans abdominal through diaphragmatic approach has been
reported.
Conclusion: Thoracoscopic removal of scalpel blade can be
done to avoid thoracotomy. Danger of damage to adjacent
mediastinal structure and underlying lung are feared complications during thoracoscopic removal.
245
Poster Presentation
IP-P4-1
IP-P4-2
The usefulness of laryngotracheal separation in neurologically impaired children
Surgical closure of bronchial stump fistula using a
pedicled intercostal muscle flap plug
Division of Thoracic Surgery, Respiratory disease center,
Seirei Mikatahara General Hospital, Japan
Respiratory Disease Center, Showa University Northern Yokohama Hospital, Japan
Eriko Suzuki, Hiroshi Niwa, Masayuki Tanahashi,
Haruhiro Yukiue, Hiroshi Haneda, Naoko Yoshii
Shugo Uematsu, Akihiko Kitami, Humitoshi Sano,
Shinichi Ohashi, Shoko Hayashi, Kosuke Suzuki,
Yoshito Kamio, Takashi Suzuki
Objectives: Aspiration pneumonia is a severe complication in
patients with neurologically impaired children (NIC). Laryngo tracheal separation (LTS) is a surgical procedure to
prevent the intractable aspiration and to provide oral intake.
We evaluated the outcome of this surgical method.
Methods: Twenty-six patients with NIC underwent LTS between 2006 and 2013. There are 8 women and 18 men, with a
median age of 18.6 years, range 1 to 34 years. The details of
the underlying disease are cerebral palsy in 15, acute encephalitis in 2, acute encephalopathy in 2, muscular dystrophy in 2, cerebral disorder after resuscitation in 1 and others.
All patients were stopped oral intake because of intractable
pneumonia or dysfunction of swallowing. Before LTS, 22 patients underwent bronchoscopy to evaluate the tracheobronchial collapsibility. Tracheo-bronchial tree tend to collapse without physiological PEEP by vocal cord in the patients with tracheo-bronchial malacia (TBM). Tracheobronchial collapsibility is essential to decide indication of
LTS. The LTS procedure was performed by dividing the trachea horizontally at the level of the second or third tracheal
rings under general anesthesia. The tracheal stump on the
proximal side was united with esophagus by end-to-side anastomosis and the tracheal stump on the distal side was
treated by tracheostomy. Partial sternal resection was added
in the patients with narrow thoracic inlet.
Results: After LTS, aspiration pneumonia was completely
improved. Oral feeding was achieved in 7 (26.9%) patients.
The occurrence of a tracheoesophageal fistula was observed
in 3 (11.5%) patients. All 3 patients improved conservatively.
The infection was observed in 4 (15.5%), granulation was observed in 2 (7.3%) patients. Trachea-innominate artery fistula
was observed in 2 (7.3%) patients, 1 of the two patients died.
Conclusion: The decrease of the aspiration pneumonia for
NIC improves their nutritional status and promote their
quality of life. These results indicate that the LTS is a very
useful procedure.
246
Objectives
Treatment of a post-lobectomy bronchial stump fistula is
very difficult. Various endoscopic procedures have been reported for fistula closure; however, surgical treatment is required for larger fistulae with empyema. In this study, a
bronchial stump fistula was plugged and caulked with a pedicled intercostal muscle flap while simultaneously perfoming
open-window thoracostomy for empyema.
Methods
A 69-year-old man with dysphagia caused by olivopontocerebellar atrophy and emphysema underwent right lobe lobectomy for lung cancer. A chest radiograph obtained on POD
15 showed the air-fluid level, and computed tomography revealed the cavity. Bronchoscopy revealed a bronchial stump
fistula with a diameter of 5 mm. It was difficult to perform
bronchoscopic interventions. Because of the closed fistula
and the need for methicillin-resistant Staphylococcus aureus
(MRSA) infection control to manage the empyema, openwindow thoracostomy and surgical closure were performed
on POD 36. Direct stump closure from the thoracic cavity
side was difficult due to the severe inflammatory changes
caused by the infection. The tip of the 6th pedicled intercostal muscle flap was induced in the bronchus lumen from the
thoracic cavity, thereby ensuring tight plugging of the hole.
The intercostal muscles were sutured and glued to the surrounding tissue with fibrin.
Results
The muscle tissue protruding from the bronchial lumen was
smoothened and could not be distinguished from the bronchial tissue. Infection control was achieved without antibiotics and patient discharge was possible on POD 75. However,
nine months after fistula stump closure and open-window
thoracostomy, the patient succumbed to pneumonia.
Conclusions
The findings of our study suggest that the use of a pedicled
intercostal muscle flap as a plug can be effective for closure
of large fistulas in the bronchial stump.
Poster Presentation
IP-P4-3
IP-P4-4
Simultaneous vessel stapling in the course of right upper lobectomy
Withdrawn
Division of Thoracic Surgery, Niguarda Hospital, Italy
Sava Durkovic, Massimo Torre, Serena Conforti,
Mario Ravini
Right upper lobectomy is routinely performed all over the
world for various indications. Differences among surgeons
exist with respect to the choice of access incision, surgical instruments, intraoperative strategy, and perioperative treatment. This articles describes a safe, effective, and cost saving
surgical technique which consists of simultaneous stapling of
individually dissected right superior pulmonary vein and anterior trunk of the right main pulmonary artery done in the
course of right upper lobectomy. Due to favourable anatomy
this approach may be used almost systematically. We believe
that this technique might become an integral part of videoand robotic-assisted right upper lobectomies.
247
Poster Presentation
IP-P4-5
IP-P4-6
Dexmedetomidine is useful as the sedative for thoracoscopic procedures for acute empyema
Dexmedetomidine is useful for bronchoscopic procedures of lung cancer complicating abdominal aortic
aneurysm
Department of Surgery, Yaizu City Hospital, Japan1), Department of Surgery!
Suzukake Central Hospital, Japan2)
Yusuke Kita , Ryo Kobayashi , Hiroshi Nogimura ,
Kazuya Suzuki2)
1)
1)
1)
Introduction Thoracoscopic procedures permit adequate aspiration, evacuation and thoracic drainage. We have tried to
manage acute empyema by thoracoscopic treatment under
local anesthesia. Dexmedetomidine (Dex) is a centrally acting
alpha-2 agonist for sedation, provides analgesic effects. We
present our experiences of thoracoscopic surgery performed
under sedation with Dex and with lidocaine for local anaesthesia.
Methods Patients with acute empyema underwent thoracoscopic surgery under sedation with Dex and with lidocaine
for local anaesthesia. Under continuous medication by Dex,
operation was performed in lateral position. Flexible port (8
mm) was typically located between 5th and 8th intercostal
spaces. Pleural effusion was aspirated and thoracoscope was
introduced through the port. Fibrin net and pus were evacuated. After lavage, two or three chest tubes were locateded
and fixed. We compared the cases of Dex with the cases
without using Dex.
Results During the operation, pain control was well in all patients using Dex. The amount of lidcaine was lesser in Dex
using group. Dex also provides analgesic effects without attenuating respiratory drive.
Conclusions Dex is useful as the primary sedative for thoracoscopic procedures under local anesthesia.
No funding was used for this paper. The authors report no
relevant conflict of interests. None of this paper or any portion thereof has previously been presented or published.
248
Department of Surgery, Yaizu City Hospital, Japan1), Suzukake Central Hospital, Japan2)
Yusuke Kita1), Ryo Kobayashi1), Hiroshi Nogimura1),
Ryohei Koreyasu1), Chieko Kitamura1), Ayaka Tsuboi1),
Yoshihumi Nishino1), Kazuki Yakuwa1),
Natsumi Fukuhara1), Kumiko Hongo1), Hideyo Miyato1),
Yukio Ishihara1), Naoki Takabayashi1),
Takeyuki Hiramatsu1), Kazuya Suzuki2)
Introduction Dexmedetomidine is a centrally acting alpha-2
agonist for sedation. It provides analgesic effects without attenuating respiratory drive. We present a case of bronchoscopic examination performed under sedation with
dexmedetomidine and with lidocaine for local anaesthesia.
Case An 88-year-old male presented to our hospital for back
pain. His past medical history included hypertension, history
of smoking and abdominal aortic aneurysm. Chest CT revealed lung shadow in right upper lobe. Lung cancer was
suspected. After confirming informed consent for bronchoscopic examination, intravenous infusion of dexmedetomidine is initiated with 1μg!
kg loading dose, administered
over 10 minutes, followed by a maintenance infusion of 0.2∼
1.0μg!
kg!
hour. Local anaesthesia with 2% lidocaine was also
administered. A video bronchoscope was inserted into the
airway. The hemodynamic measurements were monitored.
There were no episodes of oxygen desaturation. After the
procedure, he did not recall any discomfort.
Conclusion Dexmedetomidine is useful as the primary sedative for bronchoscopic procedures in patients of higher risk.
Poster Presentation
IP-P4-7
IP-P5-1
Safety of muscle paralysis during anesthesia for therapeutic bronchoscopy in patients with anterior mediastinal masses
A new retrograde bronchial embolization approach
utilizing Endobronchial Watanabe Spigot
Anesthesiology and Perioperative Medicine, Department of
Pulmonary Medicine, University of Texas MD Anderson Cancer Center, USA1), Baylor College of Medicine. Section of Pulmonary, Critical Care, and sleep Medicine2), University of
Texas MD Anderson Cancer Center. Department of Pulmonary Medicine3)
Mona G. Sarkiss1), Donald Lazarus, jr.2), Roberto Casal2),
David Ost3), Rodolfo Morice3), Carlos Jimenez3),
Georgie Eapen3)
Anesthetic management of patients with an anterior mediastinal mass is considered extremely challenging among anesthesiologists, thoracic surgeons and interventional pulmonologists. The prevalent belief is that an anterior mediastinal mass causing more than 50% narrowing of the trachea and compressing the great vessels is likely to cause further narrowing of the airway and cardiovascular collapse
once spontaneous negative pressure ventilation is abolished
by the administration of muscle relaxants. Several case reports in the literature have contributed to this perception.
However in most of these case reports an attempt to administer a muscle relaxant and provide positive pressure ventilation using a well suited specific ventilatory setting for the altered airway anatomy was not described.
In the following case reports we describe the safe anesthetic
management of two patients with anterior mediastinal
masses using muscle relaxant as part of the anesthesia induction and maintenance.
The first case describes a patient with a subacute growth of
a solid tumor (lymphoma) that gradually compressed the airway and encased the great vessels over an estimated period
of 3 months. The second case describes an acute airway and
large vessels compression by a rapidly growing hematoma!
mediastinal abscess over an estimated period of 3 days. In
both cases the trachea lumen was reduced by 80%. In the
first case the tracheal lumen was mainly compressed in the
anterior-posterior dimension and in the second case the lumen was compressed from the lateral aspect in addition to
an anterior component of the mass. Both patients were
markedly symptomatic and in respiratory distress as classically described for a patients with anterior mediastinal mass.
Department of Thoracic Surgery, Ayabe City Hospital, Japan
Masashi Yanada
The Endobronchial Watanabe Spigot (EWS) is a silicon implant plug used to treat bronchopleural fistula (BPF), hemoptysis, and intractable pneumothorax. Embolization with EWS
is an option for managing empyema with BPF. We often fail
in our efforts to treat empyema with BPF due to lack of sufficient sealing of the BPF. We present herein an empyema
case successfully treated with EWS using a new retrograde
approach.
A 77-year-old female in previously good health came to our
emergency department in severe respiratory distress. Chest
auscultation revealed diminished breath sounds over the left
lung. Chest computed tomography (CT) revealed a left pneumothorax and multiple cavitary nodules in both lungs. She
was hospitalized with a diagnosis of left spontaneous pneumothorax and lung abscesses. A chest tube was inserted into
the left thoracic cavity and the lung was drained of -10 cm
H2O. On day 7, Mycobacterium avium complex was isolated
from sputum and pleural effusion. Antibiotics, rifampicin,
ethambuthol, clarithromycin, and streptomycin, were then
initiated. The air leakage from the left lung did not resolve;
hence, surgery was considered to be necessary. First, a fenestration operation was performed to clean and sterilize the
empyema cavity. Then, surgery was performed to seal the
BPF. A retrograde approach utilizing EWS was applied in
combination with surgery to seal the BPF using an absorbable fibrin sealant patch. This operation achieved complete
resolution of the air leakage without thoracoplasty or omentopexy. She had no complications and the postoperative
course was uneventful. Three months after discharge, chest
CT examination revealed the patient s left lung to show almost full expansion.
A combination surgery utilizing the retrograde EWS technique and flaps is more effective than using only flaps plus
EWS. When performing this combination surgery, we have
found the retrograde EWS technique to be the superior option for the treatment of empyema with BPF.
249
Poster Presentation
IP-P5-2
IP-P5-3
New plug technique for Endobronchial Watanabe
Spigot (EWS): Side heel kick method
Novel bronchial occlusion method using an Endobronchial Watanabe Spigot for empyema with bronchopleural fistula
Department of Internal Medicine, St. Marianna University
School of Medicine, Japan
Hirotaka Kida, Hiromi Muraoka, Mariko Okamoto,
Teppei Inoue, Naoki Furuya, Hiroshi Handa,
Hiroki Nishine, Seiichi Nobuyama, Takeo Inoue,
Masamichi Mineshita, Teruomi Miyazawa
Background:
Bronchial occlusion using Endobronchial Watanabe Spigot
(EWS) is reported to be useful for the management of persistent pulmonary air leaks.
Many patients with persistent pulmonary air leaks have respiratory disability and poor general condition.
These patients need minimally invasive therapies, such as
bronchial occlusion, however, difficulties in plugging EWS at
target bronchus is still debated.
Recently, grasping forceps (FG-14P-1 OLYMPUS) have been
recommended for controlling EWS. However, we found that
by grasping the edge of EWS then using rotational forceps
(FB-19CR-1, OLYMPUS) to maneuver the spigot make it simple to plug the EWS into the target bronchus. Since this
method increases the variable angle making it possible to fix
and rotate using a large angle, we have named this method
the Side heel kick .
Objective:
The aim of this study is to evaluate the effectiveness of this
method for easy plugging EWS.
Methods:
First, on the tabletop, we measured the variable angle of
EWS by conventional method, then by side heel kick method.
Next, we measured the time to plug the EWS for the conventional and side heel kick methods using a lung model (LM-092
KOKEN).
Results:
The variable angle in the conventional method was 45 degrees and that in the side heel kick method was 90 degrees.
The time to plug the EWS using the side heel kick method
was significantly shorter than the conventional method.
Conclusion:
Side heel kick method significantly reduced the time in plugging EWS.
The superior lobe bronchus is notoriously difficult to plug,
however, the side heel kick method was easily able to plug
the target bronchus.
250
Department of Genaral Thoracic Surgery, Graduate School of
Medical and Dental Sciences Kagoshima University, Japan
Yoshihiro Nakamura, Kota Kariatsumari,
Naoya Yokomakura, Tsunayuki Ohtsuka,
Toshiyuki Nagata, Masaya Aoki, Yui Watanabe,
Kazuhiro Wakida, Aya Harada, Tadashi Umehara,
Soichi Suzuki, Masami Sato
Background: Bronchial occlusion is an endoscopic treatment
that uses a bronchial plug to block airflow and improve various clinical conditions. Various methods (eg, heel kick
method, method with a curette, Push & Slide method with a
guidewire) to place Endobronchial Watanabe Spigot (EWS)
into the target bronchus were reported. We improved the
original Push and & slide method with a guide wire. Methods: At present, EWS placement is performed with an improved technique using a guide wire in our institution. Here,
we describe our novel target bronchus determination
method and modified Push and Slide method with a guide
wire for treating empyema with bronchopleural fistula. The
procedures and characteristics for this technique are as follows:
1) Indigo carmine is injected into the thoracic cavity to help
identify the target bronchus. If this is difficult, thoracography and a Fogarty balloon catheter are useful for identifying
the target bronchus by reduced air leakage.
2) Choose an appropriately sized EWS with balloon sheath
based on endobronchial ultrasound (EBUS) imaging.
3) Insert a guidewire to the target bronchus with a flexible
bronchoscope under fluoroscopic image.
4) Insert an injection needle in the center of the EWS, then
pass the guide wire through it and remove it. Grasp the top
of the guide wire with biopsy forceps and lead the guide wire
into the bronchoscope retrogradely to prevent damage to
the bronchoscope channel.
5) Wide-range fluoroscopy is important to prevent the prolapse of the guide wire.
6) Combination method for adequate positioning with fluoroscopy and bronchoscopy. Firstly, EWS is guided under fluoroscopy, and then under bronchoscopy to help provide the
best positioning.
Results: Using the above steps, EWS can be placed smoothly
without bronchoscope damage. Conclusion: Our novel target
bronchus determination method and modified Push and
Slide method with a guide wire are considered to be safe
and reliable.
Poster Presentation
IP-P5-4
IP-P5-5
Bronchial occlusion with silicone spigots in the management of acute empyema with bronchial fistula: 2
case reports
Clinical impact of Endobronchial Watanabe Spigot
treatment for prolonged air leaks of the severe lung
diseases
Department of Pulmonarly Disease, Japanese Red Cross
Okayama Hospital, Japan
Department of Pulmonary Medicine and Oncology, Graduate
School of Medicine, Nippon Medical School, Japan
Yosuke Toyota, Makoto Sakugawa, Shinobu Hosokawa,
Naohiro Oda, Kazuya Nishii, Nobuaki Fukamatsu,
Takeshi Horiuchi, Akihiro Bessho, Yoichi Watanabe
Toru Tanaka, Hiroki Hayashi, Kazue Fujita,
Minoru Inomata, Kenichiro Atumi, Nariaki Kokuho,
Akihiko Miyanaga, Yoshinobu Saito, Masahiro Seike,
Akihiko Gemma
Introduction: Empyema with bronchial fistula is an intractable respiratory disease of which treatment methods are not
established. Streptococcus anginosus group is the most common pathogen that causes community acquired empyema.
We developed a silicone spigot, named as EWS (Endobronchial Watanabe Spigot), to obtain surer and longer bronchial
blockade than conventional methods such as bronchial occlusion using fibrin glue. We present two cases of acute empyema with bronchial fistula due to Streptococcus anginosus
group cured conservatively by bronchial occlusion using
EWS.
Case series: Patient 1: An 80-year-old man who had been
taken polysurgery including total gastrectomy for gastric
cancer, presented with fever and massive purulent sputum.
His chest CT revealed moderate collapse of left lung and ipsilateral pleural effusion with niveau formation. Gram stain
and culture from the samples of both sputum and pleural effusion identified the pathogen as Streptococcus constellatus .
Chest tube drainage and antibiotic treatment were started,
and bronchial occlusion using EWS was performed on 16th
hospitalized day. Left B4a, B4b, and B5 were occluded with
spigots, and then air leaks from drainage tube immediately
ceased. His collapsed lung re-expanded completely. No recurrence was observed over 3 years.
Patient 2: A 77-year-old man visited at our emergency room
with acute respiratory failure. He complained of high fever
few days ago, and he developed massive purulent sputum
and dyspnea immediately before visiting hospital. He was diagnosed as left sided empyema with bronchial fistula. Chest
tube drainage and antibiotic treatment were immediately
started. Gram stain and culture from the sample of pleural effusion identified the pathogen as Streptococcus anginosus .
Bronchial occlusion using EWS was performed at 31st hospitalized day. Left B1+2c and B4a were occluded with spigots,
and then air leaks gradually decreased and finally ceased.
The closure of bronchial fistula enabled us to perform thoracic lavage, and drainage tube could be removed. He was diagnosed as advanced pharyngeal cancer during the course
of the therapy and died from rapid growth of cancer 116
days after the diagnosis of empyema with bronchial fistula;
however, he could live on drainage tube-free condition without the recurrence of empyema until his death.
Conclusion: Bronchial occlusion with EWS can be a useful
and less invasive treatment method for the blockade of peripheral bronchus-derived fistula concomitant with empyema.
Background and Aim of Study: Prolonged pulmonary air
leaks are an important clinical problem associated with significant morbidity and mortality. The usual approaches to
persistent air leaks include prolonged thoracostomy tube
drainage, pleurodesis, and attempts at thorascopic or open
surgical repair. However, some of these patients may be at
high risk for surgery, particularly those with severe lung diseases such as severe COPD and interstitial pneumonia; for
this group there is a need for less invasive methods of stopping or reducing air leaks. A bronchoscopic technique using
endobronchial Watanabe spigot (EWS) is a novel option for
this indication, but few studies have reported EWS treatment in patients with severe lung diseases. We present the
results of a consecutive case series of patients treated for
complex alveolopleural fistula with EWS.
Patients and Methods: Patients with air leaks that persisted
after treatment gave consent for the use of EWS and compassionate use approval was obtained. Bronchoscopy with
balloon occlusion was used to identify the airways to be
treated. EWSs (Watanabe Spigots, Novatech, Cedex, France)
were placed after airway measurement.
Results: Between April and December 2013, EWSs placement procedures were performed in 6 patients. The median
age of the 6 patients (5 men, 1 woman) who received EWSs
was 69.1 years (range, 60 to 79 years). All had underlying diseases. These included emphysema, COPD, idiopathic pulmonary pneumonia and neoplasm. All patients had undergone
previous pleural procedures. A median of 4 EWSs (range, 1
to 7) were used during procedures. All patients needed 1 to 3
procedures because of multiple air leaks. The median duration of air leakage was 15 days before treatment. Three patients (50.0%) had complete resolution of the air leaks, 1
(16.7%) had a reduction in air leaks, and 2 (33.3%) showed no
improvement. Chest tube removal was a median of 12 days
after valve treatment (range, 4 to 14 days). There were no
procedural or EWS related complications.
Conclusions: EWS treatment appears to be a safe and effective intervention for prolonged air leaks in patients with severe lung diseases. With further careful study, the risk!
benefit profile of these procedures will be determined, allowing
patients with severe lung diseases and their physicians to
choose among a number of viable options for prolonged air
leaks.
251
Poster Presentation
IP-P5-6
IP-P5-7
Bronchial occlusion with silicone spigots in the management of secondary spontaneous pneumothorax
Bronchial occlusion with silicone spigots in the management of hemoptysis due to pulmonary aspergilloma: 2 cases report
Department of Pulmonary Disease, Japanese Red Cross
Okayama Hospital, Japan
Makoto Sakugawa, Shinobu Hosokawa, Naohiro Oda,
Yosuke Toyota, Nobuaki Fukamatsu, Kazuya Nishii,
Takeshi Horiuchi, Akihiro Bessho, Yoichi Watanabe
Background: Secondary spontaneous pneumothorax due to
pulmonary emphysema, interstitial pneumonia, and other
pulmonary diseases is associated with significant morbidity
and increased risk of mortality. The management of prolonged air leaks is often difficult because of the severity of
their underlying diseases. Treatment options are limited for
patients who are not good candidates for surgery. We developed a silicone spigot, named as EWS (Endobronchial Watanabe Spigot), to obtain surer and longer bronchial blockade
than conventional methods such as bronchial occlusion using
fibrin glue.
Purpose: The aim of this study is to evaluate the clinical effectiveness and the safety of endoscopic bronchial occlusion
with silicone spigot (EWS) for the management of secondary
spontaneous pneumothorax with prolonged air leaks.
Methods: Retrospective analysis was performed in 84 cases
with secondary spontaneous pneumothorax who underwent
bronchial occlusion with EWS between April 2000 and September 2012. Patients with prolonged air leaks who were unfit or unwilling for surgery underwent this procedure. The
procedure was performed with fiberoptic bronchoscope under local anesthesia.
Results: Drainage tube could be removed in 54!
79 cases
(68.3%). With this procedure, air leak was stopped in 25!
79
cases (31.6%), and was reduced in 35!
79 cases (44.3%). The
procedure-related complication was observed in 6 cases of
obstructive pneumonia, one case of lower respiratory infection, one case of re-expansion pulmonary edema, one case of
acute exacerbation of interstitial pneumonia, and one case of
lobar atelectasis.
Conclusion; Bronchial occlusion with EWS is thought to be
useful and relatively safe bronchoscopic management
method of prolonged air leaks due to spontaneous pneumothorax.
252
Department of Pulmonary Disease, Japanese Red Cross
Okayama Hospital, Japan
Naohiro Oda, Makoto Sakugawa, Shinobu Hosokawa,
Yosuke Toyota, Kazuya Nishii, Nobuaki Fukamatsu,
Takeshi Horiuchi, Akihiro Bessho, Yoichi Watanabe
Introduction: Pulmonary aspergilloma is one of the major
causes of life-threatening hemoptysis. Surgical resection is
the only radical treatment; however, surgical intervention is
often difficult for patients with pulmonary aspergilloma because of their poor cardiopulmonary reserve due to underlying disease. We developed a silicone spigot, named as EWS
(Endobronchial Watanabe Spigot), to obtain surer and longer
bronchial brockade than conventional methods. We present
two cases of persistent moderate hemoptysis due to pulmonary aspergilloma who are unfit for surgery, managed successfully by bronchial occlusion with EWS.
Case series: Patient 1: A 62-year-old man with a past history
of coronary bypass surgery for myocardial infarction was referred to our hospital for persistent hemoptysis. Chest CT
revealed fluid retention in the bullous cavity of the right lung
apex that was seeed to be amorphous matter and blood. A
tentative diagnosis of pulmonary aspergilloma was made.
Surgical resection was thought to be difficult due to severe
emphysema and reduced cardiac function with an EF of 30%.
Hemoptysis persisted despite administration of a hemostatic
agent and the patient s general condition deteriorated. On
day 7 of hospitalization, bronchoscopy was performed, revealing active bleeding from the right B3b and middle lobar
bronchus. Hemoptysis disappeared immediately after spigots were occluded in each bronchus. Aspergillus fumigatus
was detected from a sputum culture and pulmonary aspergilloma was diagnosed. Although radical treatment such as
surgical resection was not performed for pulmonary aspergilloma, hemoptysis did not recur 2 years after placement of
spigots.
Patient 2: A 66-year-old man who was hospitalized in another
hospital for treatment of a femoral fracture was transferred
to our hospital as hemoptysis persisted for more than 1
month despite administration of a hemostatic agent. Chest
CT revealed spheroidal matter in the cavity of the right lung
apex. He had a past history of pulmonary tuberculosis. The
patient had also severe emphysema and hemiplegia due to
thoracic cord injury, and thus, surgery was thought to be difficult because of his poor pulmonary function. Bronchoscopy
revealed active bleeding from the right B1a and B1b, and hemoptysis disappeared immediately after spigots were occluded in each bronchus. Aspergillus fumigatus was detected from a sputum culture and pulmonary aspergilloma
was diagnosed. Hemoptysis did not recur 10 months after
placement of spigots.
Conclusion: Bronchial occlusion with EWS can be a rapid and
sustained hemostasis method for moderate hemoptysis due
to pulmonary aspergilloma who may not tolerate surgery.
Poster Presentation
IP-P6-1
A web based multicenter and prospective EBUSTBNA registry: A european experience
Pulmonology Unit, Sainte Anne Military Hospital, France1),
Pulmonology and Bronchoscopy Unit, Fundacion Jimenez
Diaz Hospital, Madrid, Spain2), Pulmonology and Bronchoscopy
Unit, North Hospital, Saint Etienne, France3), Pulmonology and
Bronchoscopy Unit, Saint Joseph Hospital, Marseille4)
Julien Legodec1), Javier Flandes2), Jean Michel Vergnon3),
Bruno Escarguel4)
Backgroud: In France, there is no prospective registry to
document national activity and outcomes of EBUS-TBNA
procedures as well as for new diagnostic and therapeutic advanced bronchoscopic procedure. EBUS-TBNA becomes a
standard for diagnostic or re-diagnostic strategy in oncology.
In this paper we assessed the feasibility of a web based prospective multi-institutional outcomes database of EBUSTBNA procedures.
Methodes: We built a web site, called EBUS-DB.com. You
need a login and a password to report prospectively all of
your EBUS-TBNA procedures, thanks to 3 different stages.
Stage 1: you should complete general information of your
procedure and specific information of each lymph node puncture. Stage 2: as soon as reception of cytology results, you
should complete diagnostic and rentability of your procedure
for staging and!
or for molecular tumor profile determination. Stage 3: you still have all the time a free access to your
personal outcomes database. This web based EBUS-TBNA
registry was tested in 3 no academicals institutions in
France and Spain, since January the 1st in 2012.
Results: A total of 427 procedures were reported over the 22month period in three institutions (291 from St Joseph Hospital of Marseille, 26 from Ste Musse Hospital of Toulon and
110 from Fundacion Jimenez Diaz in Madrid). That corresponds to 802 lymph node punctures, majority under general
sedation (62% vs 38%), witch 30% in the 7 station, 38% in the
4 right (R) and left (L) stations, 12% in the 10 (R-L) station,
15% in the 11 and 12 (R-L) station, and 4% in the 2 (R-L) station. EBUS-TBNA confirms diagnostic in 90%, with specificity and sensibility respectively at 100% and 64% for extrathoracic diagnosis, and a specificity and sensibility respectively at 100% and 82% for stanging. EBUS-TBNA could determinate molecular statut in 82% of malignancy diagnostic.
We report a 2% of complication rate.
Conclusion: This web based prospective data analysis of
EBUS-TBNA procedures is completely innovating in France.
Unisness is very simple and short for endoscopists. We confirm that EBUS-TBNA still be recommended for diagnostic
oncology strategies. We believe that kind of multiinstitutional registry, which minimise the percentage of missing data fields, can potentially be utilised for database collection, bench marking and quality improvement initiatives and
for training purposes in the French fellowship programs. We
plan to extend this database to other French or European
EBUS-TBNA centres, and maybe extend to other advanced
bronchoscopic procedures.
253
Poster Presentation
IP-P6-2
IP-P6-2
EBUS-TBNA in thoracic oncology: Much more than
mediastinal staging
EBUS-TBNA in thoracic oncology: much more than
mediastinal staging
Division of Thoracic Surgery, European Institute of Oncology,
Italy1), Division of Pathology, European Institute of Oncology2)
Juliana Guarize1), Stefano Donghi1), Chiara Casadio2),
Massimo Barberis2), Monica Casiraghi1),
Lorenzo Spaggiari1)
Background
Endobronchial ultrasound guided transbronchial needle aspiration (EBUSTBNA) have changed the way to perform mediastinal staging in lung cancer
patients.
In a short period of time, EBUS-TBNA improved its value with new indications
in lung cancer diagnosis and treatment.
This study presents the experience in the use of EBUS-TBNA in a large cancer
center with particular attention to the oncological applications and its results.
Methods
We retrospective reviewed all EBUS performed from December 2011 to July
2013 and subdivided in 5 groups according to main indications and subsequently analyzed sensitivity, specificity and negative predicted value in each
group.
EBUS specimens were collected with a 22 gauge needle and a small part was
air dried and stained immediately using Diff-Quick for ROSE (Rapid On Site
Evaluation) by a cytopathologist.
Results
Five hundred and seventeen (517) cases were included.
1) Mediastinal staging in lung cancer patients: 195 patients were included. Sensitivity, specificity and negative predictive value were respectively 97%, 100%
and 95%. In nine cases (4.6%) the specimen was inadequate and patients underwent mediastinoscopy.
2) PET-FDG positive lymph node enlargement of unknown etiology: 61 patients
were enrolled. Most common diagnoses were: sarcoidosis, reactive!inflammatory lympnodes and tuberculosis. Sensitivity, specificity and negative predictive value were 82%, 100% and 87.5% respectively. False negative cases were
related to tuberculosis and lymphoma.
3) PET-FDG positive lymph node enlargement in patients with previous neoplasm (thoracic and extra-thoracic tumors): 70 patients.
Sensitivity, specificity and negative predictive value of 96%, 100% and 89% respectively.
4) Mediastinal masses, hylar masses and Stage IV lung cancer: 190 patients
were evaluated. Overall sensitivity in this group was 94%. All cases were tumor
cases.
In 7 cases of lymph proliferative disorders EBUS-TBNA was conclusive in only
2 cases (Large B cell Lymphoma).
5) Mutational analyses: 124 cases of adenocarcinoma underwent EGFR, K-Ras
and ALK mutational study. Molecular testing was possible in 110 cases (88.7%).
Fourteen (12.7%) EGFR mutations, 28 (25.6%) mutations of the KRAS gene and
4 (3.6%) ALK rearrangement by FISH were detected.
Conclusions
EBUS-TBNA is a safe procedure with a very high sensitivity and specificity for
mediastinal lymph node sampling in lung cancer and other chest neoplasms.
Mediastinal staging is paramount in lung cancer and can be safely performed
with EBUS-TBNA instead of mediastinoscopy.
In advanced NSCLC, EBUS-TBNA is the procedure of choice to achieve specimens for molecular analyses.
Further analyses are required to improve sensitivity in benign and lymph proliferative disorders.
254
Poster Presentation
IP-P6-3
IP-P6-4
EBUS!
TBNA minimally invasive and highly effective
diagnostic procedure for lung cancer a single center
experience
Diagnostic results of tissue sample processing methods for EBUS (EUS-B)-FNA: Results of 211 consecutive procedures
Thoracic Surgery, Centre Chirurgical Marie Lannelongue,
France1), Anatomopathology, Centre Chirurgical Marie Lannelongue, France2), Thoracic Oncology, Institut Gustave
Roussy, France3)
Adrian Crutu , Pierre Baldeyrou , Maria rosa Ghigna ,
Thierry Le chevalier3), Philippe Dartevelle1)
1)
1)
2)
Introduction: the echoendoscopy or EBUS (for endobronchial
ultrasound) is an exploration of the tracheo-bronchial tree
that combines endoscopy and ultrasound. It allows identifying structures located inside and behind bronchial walls and
non-visible in conventional endoscopy. Under ultrasound
guidance, it is then possible to safely puncture the discovered anomalies. The primary indication is the diagnosis of
lymph node invasion.
Method: we present the retrospective analysis of the 405
EBUS!
TBNA performed under local anaesthesia and conscious sedation, at the Centre Chirurgical Marie Lannelongue (CCML), between February 2011 and May 2013.
Results: our serie features 326 EBUS!
TBNA (80.49%) for
lung cancer with a positive predictive value (PPV) of 100%
and a negative predictive value (NPV) of 69%. Out of 326 patients, 79 patients had a diagnosis of adenocarcinoma warranting molecular analysis. A total of 62 of 79 (78.48%) patients had sufficient cytologic material for molecular testing
(5 molecules). A complete lymph node mapping was carried
out for 88 patients (26.99%) with a PPV of 100% and a NPV
by 55%. A rapid-on-site cytological examination (ROSE) was
conducted in 99% of cases. Complications throughout the serie were: 2 cases of pneumothorax (0.49%) and 1 case of acute
respiratory failure (0.24%). EBUS!
TBNA permitted us to decrease the number of mediastinoscopies from 103 in 2010 to
38 in 2012 (63%).
Conclusions: EBUS!
TBNA is a safe, effective and minimally
invasive tool for the diagnosis of lung cancer and mediastinal
lymph node staging. It can yield sufficient tissue for molecular analysis. This procedure is the natural complement to
standard endoscopy for the diagnosis of lung cancer. It also
allows to significantly reduce the indications for mediastinoscopy.
Department of Thoracic Surgery, North Estonia Medical Centre, Estonia1), Department of Endoscopy, North Estonia Medical Centre, Estonia2)
Ingemar Almre1), Sirje Marran2), Tonu Vanakesa1)
Background. The role of endobronchial ultrasound (EBUS)
and transesophageal bronchoscopic ultrasound (EUS-B)guided fine-needle aspiration (FNA) of intrathoracic
lymphnodes has aquired paramount importance in obtaining
definitive diagnosis in malignant and benign diseases. Recently, the value of cell block processing of EBUS-FNA samples has been studied, but the diagnostic yield of tissue sample
processing methods within different disease categories have
been marginally investigated in a larger cohort of patients.
Objective.The objective of this study is to review tertiary hospital experience with EBUS-FNA and EUS-B-FNA in obtaining tissue diagnosis of intrathoracic lymph nodes and evaluate
the value of different tissue sample preparation techniques for
all consecutive procedures performed within a calendar year.
Methods.The pathological examination was based on smear
cytology (SC) and cell block preparation (CBP) routinely obtained during EBUS (EUS-B)-FNA. We evaluated diagnostic
rates of the techniques, separately and combined, within malignant and benign group of diseases. Benign diseases were
subcategorized, as sarcoidosis and non-specific reactive lymphadenopathy.
Results. From January 2012 to December 2012, 209 patients
(211 procedures) with mediastinal and hilar lymph nodes pathology underwent EBUS-FNA or simultaneous EUS-B-FNA
in North Estonia Medical Center. Cytological assessment of
smears from aspiration samples was performed in all cases.
Formalin fixed paraffin-embedded cell block for histopathological examination was available in 195 (93.3%) cases. The
overall diagnostic rate was 78.2% for SC and 76.4% for CBP.
The combination of smears with cell block significantly increased diagnostic yield: up to 91.9%. The overall diagnostic
rate for malignant diseases was 92.9% and for benign diseases
91.3% using both methods simultaneously. The diagnostic accuracy for malignant diseases was 84.3% in cytologic examination and 79.2% in histology. The diagnostic results for benign
diseases were similar for SC and CBP, 74.2% and 73.7% respectively. SC and CBP, separately and combined, did not reveal
differences in diagnostic results within subcategory of benign
diseases. CBP provided clinically significant information for
accurate subtyping of lung cancer in 26 (31.3%) cases.
Conclusions. EBUS (EUS-B)-FNA can provide accurate diagnosis, but the diagnostic yield is suboptimal in using conventional cytological examination or cell block preparation alone.
Regardless of disease under the evaluation, benign or malignant, both tissue processing techniques should be routinely
applied whenever possible. Although the diagnostic accuracy
of cytology and histology in benign and malignant diseases are
comparable, cell block preparation is superior tissue processing method in subtyping of lung cancer histology.
255
Poster Presentation
IP-P6-5
IP-P6-6
Impact of rose in linear EBUS TBNA: The austin hospital experience
Utility of rapid on site evaluation (ROSE) during bronchoscopic examination for malignant disease
Department of Respiratory and Sleep Medicine, Austin
Health, Victoria, Australia1), Department of Pathology, Austin
Health, Australia2)
Raymond Wong1), Alesha Thai1), Celia Lanteri1),
Yet Hong Khor1), Kerryn Ireland-jenkin2),
Gerardine Mitchell2), Barton Jennings1)
Background
Linear endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is widely used for tissue sampling of mediastinal and hilar lesions. Rapid On-Site Evaluation (ROSE) allowed samples taken during bronchoscopies to be assessed on site by a pathologist. The bronchoscopist is then able to stop sampling if a diagnostic sample had been taken or to continue sampling as needed.
Until recently, at Austin Health, EBUS TBNA samples were prepared in the endoscopy room and evaluated off-site in the pathology
department, leading to a delay in conveying the results to the bronchoscopist.
We propose that the implementation of ROSE to assist EBUSTBNA procedures will reduce the number of lymph node aspirates
performed without reducing diagnostic yield.
Methods
Consecutive EBUS-TBNA cases were prospectively evaluated following institution of ROSE. The number of lymph node stations
sampled and the number of aspirations per lymph node station
were recorded. This was compared to a retrospective dataset of 69
consecutive cases preceding the commencement of ROSE.
Specimen Preparation
Material obtained from TBNA was transferred onto numbered
slides with at least one air-dried smear and one 95% alcohol fixed
smear prepared per puncture. Remaining material was put into a
saline pot for cell block preparation. A cytologist s assessment of
specimen adequacy and presence of diagnostic material was performed on-site after a rapid H&E stain. Lymph node stations sampled and number of aspirations performed was recorded.
Results
refer to table
Conclusion
ROSE led to a significant reduction in the number of TBNA samples performed per case. There was also a reduction in the number
of sites sampled. ROSE allowed for rapid assessment of samples allowing the bronchoscopist to alter the way in which tissue sampling
was performed to maximize benefit with minimal number of lesions
targeted. Off-site assessment of TBNA samples during linear EBUS
was an inadequate substitute for ROSE. Diagnostic concordance
was high in keeping with published data.
ROSE was superior to off-site cytological assessment of bronchoscopy specimens.
256
Department of Internal medicine, Kinki-chuo chest medical
center, Japan
Naoki Omachi, Chikatoshi Sugimoto, Kazuhiro Asami,
Kazunobu Tachibana, Toru Arai, Kyoichi Okishio,
Tomoya Kawaguchi, Shinji Atagi, Yoshikazu Inoue,
Seiji Hayashi
Objective: To evaluate the efficacy of on rapid site evaluation
(ROSE) during bronchoscopy improve diagnostic yield.
Design: retrospective study
Setting: Kinki-chuo chest medical center
Patients and methods: We retrospectively studied the utility
of ROSE during bronchoscopy to examine lung nodule or
mass (es) and!
or lymphadenopathy at Kinki-chuo chest
medical center between April 2012 and November 2012.
Results: 254 cases of bronchoscopic examination with rapid
on site evaluation were performed. 177cases were malignant
disease (lung adenocarcinoma 79cases, lung squamous carcinoma47cases, non-small cell lung cancer 24cases, small cell
lung cancer18cases, pleomorphic carcinoma1cases, metastatic lung tumor4cases, and unclassified malignant disease4
cases). The diagnostic yield was 86%, Positive predictive
value was 100%, negative predictive value was 77%, and
specificity was 100%. Diagnostic yield of bronchoscopy for
malignant disease without ROSE performed in the same period was 71%.
Conclusion: Diagnostic yield was greater when ROSE was
used. Positive predictive value and negative predictive value
were high. ROSE is useful tool during bronchoscopy.
Poster Presentation
IP-P6-7
IP-P7-1
Adequacy criteria of rapid on-site evaluation in endobronchial ultrasound-guided transbronchial needle
aspiration
Feasibility of EGFR testing using endobronchial
ultrasound-guided transbronchial needle aspiration
(EBUS-TBNA) specimens
Department of Internal Medicine, Seoul National University
Hospital, Korea1), Department of Pathology, Seoul National
University College of Medicine, Seoul, Korea2)
Young Sik Park1), Ae-ra Lee1), Ji-young Choe2),
Soo jeong Nam2), Doo-hyun Chung2), Sun mi Choi1),
Jinwoo Lee1), Chang-hoon Lee1), Sang-min Lee1),
Jae-joon Yim1), Chul-gyu Yoo1), Young whan Kim1),
Sung koo Han1)
Introduction: Rapid on-site evaluation (ROSE) during Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) has been advocated for qualitative diagnosis. But the adequacy criteria of ROSE in EBUS-TBNA
is unclear. The aim of this study is to elucidate on-site adequacy criteria for EBUS-TBNA samples and suggest an algorithm to define adequacy. Methods: Patients, who were underwent EBUS-TBNA for nodal evaluation between March
and July, 2013 in Seoul National University Hospital, were included in this prospective study. The archived ROSE slides
were reviewed by two independent pathologists. Results:
EBUS-TBNA was performed in 133 patients on 300 lymph
nodes. The frequency of non-diagnostic samples in the cytologic, histologic, and overall pathologic results were 7.7%,
6.3%, and 1.7%, respectively. Large tissue core size (>2cm),
presence of microscopic anthracotic pigment (MAP), and increased lymphocyte density (LD, >40!
x40) in ROSE slides
were significantly associated with adequacy in the cytological or histological results. According to the following sequential four steps: tissue core size, presence of malignant cells,
MAP, and LD, the sensitivity and accuracy rate of ROSE
were increased 98.0% and 97.0%, respectively. Conclusions:
The high adequacy rate of ROSE in EBUS-TBNA can be
achieved by sequential application of 4 criteria including tissue core size, malignant cell, MAP, and LD.
Faculty of Medicine, Prince of Songkla University, Canada1),
Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Quebec, Canada2), Department
of Pathology, McGill University Health Centre, Montreal, Quebec, Canada3)
Asma Navasakulpong1), Anne Gonzalez2), Sungmi Jung3)
Introduction: Advances in molecular biology are improving
the understanding of non-small cell lung cancer (NSCLC) and
changing the approach to treatment. Targeted therapy is
available for the subgroup of NSCLC patients with specific
mutations of the Epidermal Growth Factor Receptor (EGFR)
tyrosine kinase domain. EBUS-TBNA is increasingly used
for diagnosis and staging of NSCLC. The reported feasibility
of molecular testing using EBUS-TBNA specimens has varied from 70 to 100%, when specimens are acquired with
rapid on-site evaluation (ROSE) by a cytopathologist. The
minimum number of tumor cells required for successful mutation testing, and procedural factors that may affect specimen quality, remain unclear. The aim of this study was to assess the feasibility of EGFR testing using EBUS-TBNA samples acquired in the absence of ROSE.
Methods: This was a prospective observational study. Demographic and procedural data was collected from consecutive
patients who underwent EBUS-TBNA for diagnosis and!
or
staging of lung cancer from September 2012 to September
2013. Specimens were processed using liquid cytology, with
cell block preparation in the presence of a visible cell pellet
after centrifugation. EGFR mutation analysis was performed
at the request of the treating physician, using Taqman quantitative PCR following cell block macrodissection. Tumor cell
count, percentage of tumor cells and tumor cell volume were
examined in each specimen. The final result of EGFR mutation analysis was recorded.
Results: 193 patients underwent EBUS-TBNA for diagnosis
and!
or staging of lung cancer (22G needle); 29 patients were
diagnosed with adenocarcinoma and 2 patients were diagnosed NSCLC not otherwise specified. EGFR testing was requested in 16 of 31 patients. In 15 of 16 patients (93.7%)
EBUS-TBNA specimens from a single lymph node station
were found to be adequate for EGFR testing. A median of 3.5
needle passes per lymph node station tested (range 2-5) had
been performed. In 13 of the 16 EBUS-TBNA specimens
used for molecular analysis, tumor cell counts were above
400 cells. The minimum tumor cell count that allowed successful EGFR testing was 100 cells. Average tumor cell
population among nucleated cell was 63%. The median tumor volume over the entire cut surface area of the cell block
was 45%. In 2 of 16 patients (12.5%), EGFR mutations were
detected (exon 19 in one and exon 21 in the other).
Conclusion: When performed in the absence of ROSE, EBUSTBNA provides an adequate specimen for EGFR mutation
testing in a majority of patients in whom it is requested.
257
Poster Presentation
IP-P7-2
IP-P7-3
EGFR and K-ras mutations in cytologic samples from
EBUS-TBNA in NSCLC patients
Diagnostic value of endobronchial ultrasound-guided
transbronchial needle aspiration in pulmonary sarcoidosis
pneumology, Asl Ravenna, Italy
Alessandro Messi, Piero Candoli
EGFR mutations in patients with non small cell lung cancer
(NSCLC) have been associated with response to anti-EGFR
therapy, whereas k-ras mutations seem to indicate resistance to treatment. The paucity of biologic samples often
hinders histologic diagnosis and cytologic material could be a
valid alternative. We evaluated the reliability of cytologically
determined EGFR and k-ras mutations against histologic
samples.
Sixty NSCLC patients were prospectively analyzed. Cytologic specimens from bronchoscopy were fixed and
stained. Non-tumour cells were macroscopically removed
and EGFR and k-ras mutation status was determined. For 26
patients, results obtained from cytologic smears were compared to those from histologic specimens and!
or cell blocks.
Both mutations were only detected in adenocarcinomas. Specifically, 7 (14%) and 13 (25%) cases of adenocarcinomas
showed EGFR and k-ras mutations, respectively. EGFR mutations comprised 4 exon 19 deletions, 2 exon 21 and 1 exon
18 point mutations, whereas k-ras mutations were all on codon 12. The results from cytologic and histologic samples
were superimposable. In a small tumour subgroup, mutations were detected in as few as 20 cells.
EGFR and k-ras analyses performed in cytologic specimens
were technically feasible, giving reliable results and providing a potentially valid diagnostic alternative to histologic
evaluation.
258
Department of respiratory and critical care medicine, Peking
Universith First Hospital, China1), Department of Pathology,
Peking University First Hospital, China2)
Hong Zhang1), Guangfa Wang1), Wei Zhang1), Nan Li1),
Yunhong Wang2), Yuhong Gong1)
Objective: Bronchoscopy is the most common used method to obtain lung samples in
diagnosing sarcoidosis with unsatisfied yielding. The aim of this study is to observe the
diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration
(EBUS-TBNA) in sarcoidosis in Chinese people.
Methods: Retrospectively analyzed the diagnostic efficiency of standard bronchoscopy
and EBUS-TBNA in all patients diagnosed as sarcoidosis and underwent EBUS-TBNA
in Peking University First Hospitals between August 2010 and October 2011.
Results: There were 17 patients diagnosed as sarcoidosis during this period. 65% of
them were in phase I and 35% in phase II. EBUS showed there was no difference
among the involving rate of the sites of lymph nodes (χ2=4.58, P>0.05). The short diameter of the subcarinal lymph nodes were 2.69 0.96cm, significant larger than hilar (1.99
0.44cm) and paratracheal lymph nodes (1.93 0.24cm), F=4.99, P=0.01.
Groups of epithelioid histiocytes and!or multinucleated giant cells with or without minimal necrosis were found in 14 patients TBNA samples which support the diagnosis of
sarcoidosis. Positive rate was 82.4%.
1-3 lymph nodes were aspirated in each patient and totally 31 lymph nodes were punctured. Positive rate was different (χ2=6.78, P<0.05) among different locations and highest positive rate was achieved in subcarinal lymph nodes (82%). The positive rate was
79% in lymph nodes with short diameter>2cm, while only 25% in lymph nodes with
short diameter <2cm, χ2=8.79, P<0.01.
In order to find the suitable numbers of puncture passes, which provides better yield
while saving procedures and times, we analyzed the positive and negative lymph nodes
separately. As shown in Fig., among 18 positive lymph nodes the positive rate of the
first pass was 61%. The accumulated positive rate reached 100% in the fourth pass.
There are 13 negative lymph nodes with highest passes numbers of 6. To sum them up,
four passes provided 100% consistency with the final results.
9 patients could get pathologic diagnosis through conventional bronchoscopy, positive
rate was 53%. When combined with EBUS-TBNA, pathologic diagnosis rate increased
to 88% (15!17).
No severe complications were found in these patients.
Conclusions: EBUS-TBNA is a safe and effective method in diagnosing pulmonary sarcoidosis. For patients with suspected sarcoidosis, EBUS-TBNA should aim at the largest lymph nodes with four passes.
Poster Presentation
IP-P7-4
IP-P7-5
Efficacy of endobronchial ultrasonography-guided
transbronchial needle aspiration in patients with suspected sarcoidosis
Complications related to EBUS-TBNA in patients with
tuberculous lymphadenopathy
Second department of internal medicine, Nara Medical University, Japan1), Center for infection disease, Nara Medical University, Japan2)
Nobuhiro Fujioka1), Yoshifumi Yamamoto1),
Kanako Harunari1), Kanako Teramoto1),
Makiko Kumamoto1), Masato Tasaki1), Yukio Fujita1),
Shigeto Hontsu1), Noriko Koyama1), Koichi Tomoda1),
Koichi Maeda2), Masanori Yoshikawa1), Kaoru Hamada1),
Hiroshi Kimura1)
Background: Endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA) had been depeloped as a novel diagnostic procedure for mediastinal lymphadenopathy. We began to perform this procedure at our
hospital in April 2012.
This study was carried out to evaluate the diagnostic yield of
EBUS-TBNA, and transbronchial lung biopsy (TBLB).
Methods: We analyzed patients who underwent diagnostic
bronchoscopy for pathological diagnosis of sarcoidosis from
September 2010 to October 2013 at our hospital.
Result: Eighteen patients were clinically and histologically
diagnosed sarcoidosis. Ten cases were categorized as Stages
I, 7 cases were categorized as Stage II, and 1 case was categorized as Stage III. Since April 2012, 4 cases were categorized as stage I, 2 cases were categorized as Stage II, and 1
case was categorized as Stage III. Nine cases were histologically diagnosed by EBUS-TBNA or TBLB, and 5 cases were
categorized as Stage I, 3 cases were categorized as Stage II,
and 1 case was categorized as Stage III. EBUS-TBNA was
performed in 3 cases (all cases are Stage I), and histologically
diagnosed in 2 cases (66.7%). TBLB was performed in 6 cases
of Stage I, and histologically in diagnosed 2 cases (33.3%). The
diagnostic yield of EBUS-TBNA showed no significant difference statistically in comparison with TBLB.
Conclusion: In our study, we could not make sure the advantage of EBUS-TBNA, but tendency to be superior to TBLB
in patients with clinical suspicion of sarcoidosis.
Division of Chest Surgery, Toho University School of Medicine, Japan1), Division of Pumonary Medicine, Toho University
School of Medicine, Japan2), Department of Radiology, Toho
University School of Medicine, Japan3), Department of Surgical
Pathology, Toho University School of Medicine, Japan4)
Yoshinobu Hata1), Susumu Sakamoto2), Hajime Otsuka1),
Keita Sato2), Fumitomo Sato1), Takashi Makino1),
Keishi Sugino2), Kazutoshi Isobe2), Nobuyuki Shiraga3),
Naobumi Tochigi4), Kazutoshi Shibuya4), Sakae Homma2),
Akira Iyoda1)
Background
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUSTBNA) is safe and effective for diagnosing intrathoracic lymphadenopathy, including tuberculous lymphadenopathy. Nevertheless, as we document here, it
is necessary to consider other probable EBUS-TBNA related complications associated with tuberculous lymphadenopathy. Our first patient was a 26-yearold woman who, 2 months after undergoing EBUS-TBNA, developed intrabronchial polypoid granulomas exclusively at puncture sites. The second patient was a 39-year-old woman with transient smear-positive bloody sputum,
which developed immediately after EBUS-TBNA and persisted for 3 days.
Case 1
A 26-year-old woman presented with mediastinal and hilar lymphadenopathy
and reported transient low-grade fever. Brain magnetic resonance imaging revealed multiple nodular lesions that increased in number over a period of 3
weeks. Although metastatic lung cancer was suspected, EBUS-TBNA revealed caseous necrosis. An aspirate smear was negative for acid-fast bacilli,
and a subsequent scalene lymph node biopsy revealed tuberculosis. Two
months after initiating antitubercular chemotherapy, a chest CT scan showed
intrabronchial polypoid lesions exclusively at the puncture sites. A transbronchial biopsy revealed granulomas compatible with a diagnosis of bronchial tuberculosis. Steroid inhalation was initiated to prevent bronchial stenosis. The
patient recovered completely, without stenosis, and her intracranial tuberculomas disappeared.
Case 2
A 39-year-old woman with a history of untreated mixed connective tissue disease presented with fever and intrathoracic lymphadenopathy with small nodules in the right lung field. She had been taking oral steroids for 3 weeks. Repeated microbiological examinations showed no evidence of tuberculosis.
Fluorodeoxyglucose-positron-emission tomography revealed abnormal accumulation in the cervical, mediastinal, and abdominal lymph nodes. An
interferon-γ-release assay was uninformative due to the patient s low response
to mitogen control. Although malignant lymphoma associated with infection
was expected, the EBUS-TBNA aspirate was smear-positive, and PCR assays
identified tuberculosis. The patient was isolated, and antitubercular therapy
was initiated. She developed smear-positive bloody sputum immediately after
the EBUS-TBNA procedure, which persisted for another 2 days, but reverted
to smear-negativity 3 days later.
Conclusion
Although EBUS-TBNA is useful for excluding malignancy and obtaining drug
sensitivity results for patients with probable tuberculous lymphadenopathy,
potential complications peculiar to tuberculosis should be considered, eg, progression to bronchial tuberculosis and development of smear-positive bloody
sputum immediately after the procedure. Temporary isolation after EBUSTBNA might be desirable in cases of possible tuberculous lymphadenopathy.
Indications for EBUS-TBNA in patients with tuberculous lymphadenopathy
should be carefully considered.
259
Poster Presentation
IP-P7-6
IP-P7-7
Endobronchial ultrasound differential diagnosis between lymph node tuberculosis and pulmonary sarcoidosis
Usefulness of high suction pressure for sufficient tissue collection during EBUS-TBNA
Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, China1), The first affiliated hospital of
Guangzhou medical university2)
Wz Luo1), Yu Chen2), Ch Zhong2), Shiyue Li2)
Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has used to diagnostic
lymph node tuberculosis and pulmonary sarcoidosis. However, the pathological biopsy of lymph node tuberculosis and
pulmonary sarcoidosis is similar. In this study, we compared
the characteristics of endobronchial ultrasound lymph nodes
with tuberculosis to those with sarcoidosis.
Methods: The characteristics of 29 patients were enrolled.
They were confirmed by pathologic diagnosis or on results
of clinical follow-up for at least 6 months. The endobronchial
ultrasound characteristics and pathologic features of 35
cases with lymph node tuberculosis and 25 cases with pulmonary sarcoidos were analyzed. Statistical significance between the two groups was evaluated with the Chi-square
test and t test by SPSS13.0. A P value of <0.05 was considered statistically significant.
The lymph node of tuberculosis and pulmonary sarcoidosis
showed significant differences (P<0.05) in margin, echogenicity, liquefied, calcified, coalesced into masses. In patients with
pulmonary sarcoidosis, 68.00% of the lymph nodes had a distinct margin, 53.85% had a low echogenicity, 3.84% had liquefaction, 11.54% had calcification, 3.84% had coalesced into
masses. However, in patients with lymph node tuberculosis,
65.71% had indistinct margin, 71.43% had a middle echogenicity, 61.76% had liquefaction, 35.29% had calcification, 17.65%
had coalesced into masses.
Conclusion: There are some different endobronchial ultrasound characteristics between lymph node tuberculosis and
pulmonary sarcoidosis. Analyzing the endobronchial ultrasound characteristics of the lymph nodes may be helpful to
differential diagnosis between lymph node tuberculosis and
pulmonary sarcoidosis.
260
Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Japan1), Department of Bronchology, Osaka Prefectural Medical Center
for Respiratory and Allergic Diseases, Japan2), Department of
Pathology, Osaka Prefectural Medical Center for Respiratory
and Allergic Diseases, Japan3), Department of Endoscopy, Respiratory Endoscopy Division, National Cancer Center Hospital,
Japan4)
Takayuki Shiroyama1), Norio Okamoto2),
Hidekazu Suzuki1), Yuichiro Azuma1), Sawa Takeoka1),
Akio Osa1), Satomu Morita1), Motohiro Tamiya1),
Naoko Morishita1), Yoko Uehara1), Tomonori Hirashima1),
Kunimitsu Kawahara3), Shinji Sasada4), Ichiro Kawase1)
Introduction: The optimal suction pressure during endobronchial ultrasound guided transbronchial needle aspiration
(EBUS-TBNA) remains to be determined. The aim of this
study was to compare suction pressures for performance in
collecting sufficient tissue specimens from mediastinal and
hilar lymph nodes during EBUS-TBNA.
Methods: Retrospective analysis of consecutive patients with
mediastinal and hilar lymphadenopathy who underwent
EBUS-TBNA over a 3-year period. Results from patients
who underwent EBUS-TBNA using a dedicated 20-mL
VacLoc (Merit Medical Systems, Inc, South Jordan, UT) syringe (conventional method, group C) were compared with results from patients in whom a disposable 30-mL syringe (high
pressure group, group H) was used. The yield for sufficient
histologic specimen retrieval and amount of tissue obtained
were compared between the 2 groups.
Results: Of 178 patients who underwent EBUS-TBNA, 131
had lung cancer confirmed by EBUS-TBNA: 35 in group C
and 96 in group H. There were 7 patients in group C and 6 in
group H who received final diagnoses by cytology alone.
There were 28 in group C and 90 in group H who were diagnosed by both cytology and histology. There was a statistically significant difference between the groups in terms of
the rate of sufficient sampling for histological specimens (p=
0.04). The H group revealed a tissue area approximately
twice that of the C group (p=0.003). There were no major
procedure-related complications in either group.
Conclusion: Higher suction pressures with larger syringe volumes during EBUS-TBNA may be useful for safely collecting sufficient tissue specimens.
Poster Presentation
IP-P7-8
IP-P8-1
Is there any difference between the order of obtaining
cell blocks and smears through EBUS-TBNA? A comparative study
Diagnostic accuracy of EBUS-GS for peripheral lung
cancer with ground-glass opacity
Thoracic Surgery, Izmir Dr. Suat Seren Chest Disease and
Thoracic Surgery Training and Research Hospital, Turkey1),
Chest Disease, Izmir Dr Suat Seren Chest Disease and Thoracic Surgery Training and Research Hospital, Turkey2)
Ozan Usluer , Soner Gursoy , Ahmet Ucvet ,
Ahmet Emin Erbaycu2)
1)
1)
1)
Background: Endobronchial ultrasound with real-time transbronchial needle aspiration (EBUS-TBNA) samples are
evaluated with standard conventional smears and cell block
processings. The aim of this study is the contribution and
comparison of conventional smears and cell block analysis to
the diagnostic yield into two different techniques.
Methods: In this study we evaluated the diagnostic value
and validity of preparing smear and cell blocks from EBUSTBNA cytology specimens in different orders. The patients
were divided into two groups. Group A consisted of patients
of which a cell block was prepared firstly and a smear after
where group B consisted of patients of which a smear was
prepared firstly and cell block after. The procedures were
performed under intravenous sedation. Confirmation of the
lymph node sampling was obtained by cytology, surgical procedures, and clinical follow-up for at least 6 months.
Results: Two-hundred consecutive cases (151 men, 49
women) who were performed EBUS-TBNA between 2012
and 2013. A hundred EBUS procedures; 715 biopsies (average 7.15 for each patient, in 3-12 range) were applied to 274
lymph nodes (average 2.74 for each patient, in 1-5 range) in
Group A, 100 procedures and 635 biopsies (average 6.35 for
each patient, in 1-12 range) were applied to 261 lymph nodes
(average 2.61 for each patient, in 1-4 range) in Group B. In
group A; 4!
100 of the patients were evaluated as histopathologically false negative after surgical confirmation,
against 5!
100 of patients in group B. In the histopathological
examination revealed a reactive hyperplasia in 47 and 38,
neoplastic disease in 34 and 36, granulomatous diseases in 14
and 20 (tuberculosis compatible in 3 and 1 cases) and a suspicious malignant disease in groups A and B, respectively. The
pathologists evaluated diagnostic value of the cytologic
specimens as the presence of lymphocytes, pigmented
macrophages, histiocytes clusters, and neoplastic cells.
There were no deaths or any major complications.
Conclusions: The results of this study demonstrate that the
order of obtaining smears and cell blocks during EBUSTBNA does not result any difference in the diagnostic accuracy of the procedure. Both of these two techniques are feasible and useful for cytologic smear and cell block preparation and examination.
Keywords: Endobronchial ultrasound, mediastinal lymph
node, smear, cell block, diagnostic value.
Division of Respiratory and Infectious Diseases, Department
of Internal medicine, St. Marianna University School of Medicine, Japan1), Department of Surgery, Division of Chest Surgery, St. Marianna University School of Medicine, Japan2)
Mariko Okamoto1), Noriaki Kurimoto2), Hiromi Muraoka1),
Ayano Usuba1), Teppei Inoue1), Kei Morikawa1),
Naoki Furuya1), Hiroshi Handa1), Hirotaka Kida1),
Hiroki Nishine1), Atsuko Ishida1), Seiichi Nobuyama1),
Takeo Inoue1), Masamichi Mineshita1),
Teruomi Miyazawa1)
Background: Endobronchial ultrasonography using a guide
sheath (GS) is a method established for pulmonary lesions
however, there are only few reports regarding lesions with
ground glass opacity (GGO).
Methods: To assess the diagnostic accuracy of GS for lesions
with GGO. Between January 2010 and November 2013, 58 patients with a confirmed diagnosis of lung cancer underwent
either surgery or GS. GS was performed using an endoscopic
ultrasound system, which was equipped with a 20-MHz mechanical radial-type probe with an external diameter of 1.4
mm with GS. Bronchoscope with a working channel diameter of 2.0 mm was used. Three to 5 biopsy and brushing samples were taken for all patients. Subjects were then categorized by the ratio of solid area and GGO (longest diameter of
tumor with lung window!
longest diameter of tumor with
lung window 100) on CT as pure GGO or mixed GGO
(<25%, 25-50%, >50%).
Result: The total diagnostic yield of GS in patients with GGO
was 76%. Cytological diagnosis was 48.2%, and histopathological diagnosis was 70.6%. The diagnostic accuracy
when the position of the probe was outside the lesion was
0%, adjacent to the lesion was 76.5%, and within the lesion
was 83.8%. The diagnostic accuracy visualized as typeIIa
(hyperechoic points without open vessels) was 72.0%, typeIIb
(hyperechoic points with open vessels) was 86.2%.
Conclusion: The diagnostic yield of pure GGO was 50.0% using GS. When the rate of solid portions increased, cases of
type II b, within, and the diagnostic yield were increased.
261
Poster Presentation
IP-P8-2
IP-P8-3
Image-guided bronchoscopy for histopathologic diagnosis of pure ground glass opacity
Diagnostic value of aspergillus galactomannan antigen from EBUS guided bal fluid for diagnosis pulmonary aspergillosis
Respiratory Endoscopy, National Cancer Center Hospital, Tokyo, Japan
Christine Laoang Chavez, Shinji Sasada,
Takehiro Izumo, Yukiko Nakamura, Takaaki Tsuchida
Background.
Guided bronchoscopy has been found to be useful for the diagnosis of solid peripheral pulmonary lesions (PPLs) but
more evidence on peripheral pulmonary ground glass opacities (GGO), especially those without a solid component, are
lacking.
Case Presentation.
To describe how we successfully obtained diagnostic transbronchial biopsy (TBB) samples from a PPL with pure GGO,
we present a case of a 69 year old male with an incidental
finding of a focal pure GGO in the posterior segment of the
right upper lobe on computed tomography scan (Fig. 1A).
Bronchoscopy with the use of virtual bronchoscopic navigation (Fig. 1B), endobronchial ultrasound with a guide sheath
(Fig. 1C), and fluoroscopy guidance (Fig. 1D) was performed
for diagnosis. Cytology specimen that was collected by brush
was negative for malignant cells. Five consecutive TBB
specimens were obtained and histopathology examination
revealed adenocarcinoma on the fourth and fifth specimens.
There were no complications after the procedure. The diagnosis was confirmed on the surgical specimen to be minimally invasive adenocarcinoma (Fig. 1E).
Conclusion.
Image-guided bronchoscopy with transbronchial biopsy was
successful for the diagnosis of a patient with pure GGO. Use
of a larger biopsy device may be helpful for the histopathologic diagnosis of lung adenocarcinoma with lepidic
growth.
262
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital,
Taiwan
Wen Chien Cheng, Chih-yen Tu, Chia-hung Chen,
Wei-chih Liao, Biing-ru Wu, Te-chun Hsia, Wu-huei Hsu
Background:
Invasive Pulmonary Aspergillosis (IPA) is a frequent and increasing cause of morbidity and mortality in immunocompromised patients. To improve the outcome of these often fatal infections, early diagnosis of IPA is of utmost importance.
The primary aim of this study was to establish the diagnostic value of Aspergillus galactomannan antigen assay from
endobronchial ultrasonography (EBUS) guided bronchoalveolar lavage (BAL) fluid for diagnosis of IPA.
Design:
Retrospective analysis.
Methods:
The diagnostic yields of EBUS for patients with suspicion of
pulmonary aspergillus between December 2008 and March
2013 were analyzed.
Results:
A total of 106 patients with suspicion of pulmonary aspergillus were enrolled in the study. The mean age was 52.9 17.1
years old and the most underlying disease was hematological
malignancy (n=36, 34%). Among these patients, 29 patients
were diagnosed as proven aspergilosis and 6 patients as possible aspergilosis. At a cut-off index value of 0.5, GM detection in BALF had a sensitivity of 97.14% and specificity of
78.57%. PPV and NPV were 69.39% and 98.21%. Applying a
cut-off index of 1.0 as is proposed in adults resulted in a sensitivity, specificity, PPV and NPV of respectively 96.97%,
95.89%, 91.43% and 98.59%.
Conclusion: Aspergillus galactomannan antigen assay from
EBUS guided BAL fluid is a useful diagnostic tool for pulmonary aspergillus. It offered a high sensitivity, specificity, positive predictive value and negative predictive value at a cutoff index value of 1.0. This technique can be particular helpful in immunocompromised patients who suspicion of pulmonary aspergillus to avoid delay treatment.
Poster Presentation
IP-P8-4
IP-P8-5
Radial probe endobronchial ultrasound (EBUS) in diagnosing atypical pulmonary infection
Validation of combined radial endobronchial ultrasound with navigational bronchoscopy for peripheral
pulmonary lesion
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital,
Taiwan
Wei Chih Liao, Tu Chih-yen, Chen Chia-hung,
Hsia Te-chun, Wu Biing-ru, Chen Hung-jen, Hsu Wu-huei
Background:
The unknown pathogens responsible for non-bacterial pulmonary infection remain a diagnostic challenge. The usefulness of bronchoscopy with radial probe endobronchial ultrasound (EBUS) in the diagnosis and management of patients
with atypical pulmonary infection was investigated.
Design:
Retrospective analysis.
Methods:
The diagnostic yields of EBUS for patients with atypical pulmonary infection treated in a tertiary university hospital between December 2007 and December 2010 were analyzed.
Results:
A total of 78 patients with atypical pulmonary infection were
enrolled in the study. The majority of those patients (n=57,
73%) also had underlying disease, such as diabetes mellitus
(n=26) or malignancy (n=12). A total of 78 microorganisms
were isolated or identified by histopathology, including Mycobacterium tuberculosis (n=59), Aspergillus (n=8), Cryptococcus (n=6), Pneumocystis jiroveci (n=3), and mucormycosis
(n=2). The definitive diagnostic rate by EBUS was 82.1% (n=
64), including 86.4% of Mycobacterium tuberculosis (51!
59),
87.5% of Aspergillus (7!
8), 100% of Pneumocystis jiroveci (3!
3) and mucormycosis (2!
2), and 16.7% of Cryptococcus (1!
6).
EBUS examination assists in both the diagnosis (80.1%) and
management (78.2%) of patients. Pneumothorax was the only
complication, which occurred in two patients (3%).
Conclusion:
Bronchoscopy with EBUS is a useful diagnostic tool for atypical pneumonia. This technique can be particular helpful in
critically ill patients who cannot tolerate surgical intervention.
Interventional Pulmonology, University of Louisville, USA1),
Pulmonary Medicine, University of louisville, United States2)
Tanya Wiese1), Mostafa Tabassomi1), Karim El-kersh2),
Rodrigo Cavallazzi2)
Background:
Solitary pulmonary nodules are common findings occurring in
26% of high risk individuals. However, even in these high risk
individuals the majority of solitary nodules are benign. In order to avoid unnecessary surgery or to offer a diagnosis in
those who are not surgical candidates, less invasive technologies have emerged.
In the past, if surgery was not an option, individuals would
either undergo CT guided fine needle aspiration or traditional
transbronchial biopsy. Each of these procedures has its own
limitations and risks. Studies have shown that bronchoscopy
with combined use of navigational technology and radial endobronchial ultrasound will increase diagnostic yields with
minimal risk. We did a retrospective analysis of 39 patients
with solitary pulmonary nodules to validate the combination
of these therapies.
Methods:
This is a retrospective review of 39 patients who underwent
navigational and radial ultrasound assisted biopsies of a solitary pulmonary nodule. For radial ultrasound we scored static
images based on three malignant characteristics: presence of
continuous hyperechoic margins, hyperechoic dots, and heterogeneity. The diagnosis was based on histopathologic findings confirmed by a pathologist. Non-diagnostic results were
confirmed by radiologic stability per American College of
Chest Physician guidelines or by surgical intervention.
Results:
Overall the combined diagnostic yield of navigational and radial ultrasound for solitary pulmonary nodules was 73.1% with
confidence interval of 95%. In patients who had at least 1 out
of the 3 described radial ultrasound characteristics, the sensitivity for malignancy was 100% and the specificity was 35.7%
with confidence interval of 95%. Five out of six patients with
false negative results by navigational biopsy had at least 2 of
the described malignant characteristics on radial ultrasound.
Pneumothorax was the only complication with risk of 4.34%.
Conclusion:
Diagnostic yields for solitary pulmonary nodule by traditional
transbronchial biopsies are reported to be around 40%. Addition of navigational guidance increases this yield to about 70%
and up to 90% by combining this with radial endobronchial ultrasound. Despite using both modalities our diagnostic yields
were similar to those published for navigational guidance
alone. We suspect this is due to factors such as the lesion size,
location and the operator skills.
Notably, our study did show that a negative biopsy with a suspicious radial ultrasound image for cancer should prompt further investigation instead of surveillance computed tomography.
263
Poster Presentation
IP-P8-6
VBN combined with ultrathin bronchoscopy or RPEBUS to diagnose peripheral pulmonary lesions.
Cases report
Department of Respiratory Medicine, Guangdong General
Hospital!Guangdong Academy of Medical Science, China
Jing Li, Huang Yongjun, Gao Xinglin, Yang Shifang,
Chen Zixing, Chen Jingjing, He Bifang, Li Xiuyu,
Yang Weiguo, Chen Pingping
Background
Pathological findings are the benchmark for a diagnosis of
peripheral pulmonary lesions (PPL). Sometimes surgical operation is over treated for benign lesions. Transthoracic needle aspiration (TTNA) brings high incidence of complications
despite of high diagnostic accuracy(1). Bronchoscopy with radial type probe endobronchial ultrasonograph (RP-EBUS)
and ultrathin bronchoscopes (outer diameter<3 mm) can
help to diagnose PPL(2-3). Virtual bronchoscopic navigation
(VBN) can guide a bronchoscope and EBUS to the target(4).
We explored whether VBN-assisted ultrathin bronchoscopy
or EBUS-guided conventional bronchoscopy can help to improve the diagnostic yield of transbronchial lung biopsy. We
began the study recently and here we report three typical
cases.
Case report
Participants: Three patients with PPL were examined in November 2013 in our department.
Method: Multidetector chest CT (16-row or 64-row; slice
width, 1.25mm)-CD-workstation of VBN software (Cybernet
Systems, Direct Path V1.0)-select a target lesion-Navigation
route-Assistant controlled the virtual bronchoscopic images
during bronchoscopy and a bronchoscopist steer the bronchoscope according to the instruction-An ultrathin bronchoscope (type XP260; outer diameter, 2.8 mm; working channel
diameter, 1.2 mm; Olympus, Tokyo, Japan) was navigated to
the target bronchus-biopsy or brush if we find the neoplasm
or abnormal bronchial mucosa-Alternatively use conventional video-bronchoscope (type BF260; outer diameter, 4.9
mm; Olympus) guiding by VBN system if we could not have
an euthyphoria about the lesion while arriving to the target
bronchus-Lesions were anchored by radial-type EBUS probe
(external diameter, 1.4 mm; Olympus) through the bronchoscopic working channel-Withdrew the probe as the lesion
was visualized and conducted biopsy or brush. All procedure
were operated without X-ray fluoroscopy or CT guidance.
Results: In these three patients, the navigational pathway
was exactly in consistent with the actual pathway. Conventional bronchoscopy did not find any lesion or abnormal mucosa change. The target lesions of these three cases located
in the 4th to 6th generation bronchus. The mean searching
time with help of VBN was shorter than that without VBNassisted according to our record in the past. VBN parameters and the biopsy results were shown in table 1 below.
Conclusion:
VBN-assisted ultrathin bronchoscopy or EBUS with conventional bronchoscopy may play a role in diagnosing PPL and
need further study to prove.
264
IP-P8-6
Poster Presentation
IP-P8-7
IP-P8-8
Bronchoscopy for pulmonary peripheral lesions with
virtual fluoroscopic preprocedural planning combinated with EBUS-GS
Virtual bronchoscopy using OsiriX
Department of Pulmonary Medicine, National Hospital Organization Disaster Medical Center, Japan1), Department of Radiology, National Hospital Organization Disaster Medical Center,
Japan2), Department of Thoracic Surgery, National Hospital
Organization Disaster Medical Center, Japan3), Department of
Emergency and Critical Care Medicine, St. Marianna University School of Medicine4)
Munehisa Fukusumi1), Yoshiaki Ichinose2),
Yoshihito Arimoto1), Shinjiro Takeoka1), Chie Homma1),
Hiroyasu Matsuoka3), Atsuto Mouri1),
Yoichiro Hamamoto1), Junichi Matsumoto4),
Mitsuhiro Kamimura1)
Background: Virtual Fluoroscopic Preprocedural Planning, which
was firstly initiated by one of our co-authors, is the figure that the
trace lines are drawn along ductal structures such as vessels or biliary ducts related to target lesions on Ray Summation image similar
to fluoroscopy. The lines can be displayed by any angle with 3
Dimage, and allow us to search the responsible vessels more easily
during angiography or the responsible biliary ducts during the settlement of stent, for example. Virtual Fluoroscopic Preprocedural
Planning is easy to prepare by volume data from MDCT and workstation, and might make vessel structure-related procedure more
accurate.
This time, we applied this system to bronchoscopic procedure. The
trace lines between the trachea and the target lesions were constructed along the responsible bronchus and made reference to
during the procedure, as a new type of navigation system. We report the feasibility of Virtual Fluoroscopic Preprocedural Planning
on bronchoscopy, that has never been tried before.
Methods: The peripheral lung lesions less than 30mm in longer axis
were selected for the study. Bronchoscopy was performed by simultaneous display of Virtual Fluoroscopic Preprocedural Planning.
Results: For twenty seven patients with 27 lesions, bronchoscopy
with simultaneous display of Virtual Fluoroscopic Preprocedural
Planning was performed safely without major complications. The
median lesion size was 20.2 mm (10 to 30 mm). The lesion size was
≦20mm in 12 lesions, >20mm in 15 lesions. Five lesions couldn t be
visualized by radiographic fluoroscopy. The median examination
time was 24.5 min (range, 12 to 50 min). 18 lesions were visualized
by EBUS and diagnosis was made for 17 lesions of the 27 lesions.
Lung cancer was diagnosed in 12 lesions, nontuberculous mycobacterial disease in 1 lesion, lymphoid hyperplasia in 1 lesion, and inflammation in 3 lesions.
A diagnosis was not made in 10 lesions. Four lesions are diagnosed
as adenocarcinoma by operation or transthoracic biopsy. Two lesions consistent with the clinical characteristics of cancer were performed radio-surgery without definitive diagnosis. And the other lesions are still under observation without diagnosis.
The diagnostic rate of this procedure was 63.0%. The sensitivity,
specificity, negative predictive value, positive predictive value, and
accuracy for malignant disease were 66.7%, 100%, 45.5%, 100%, and
73.9%, respectively.
Conclusions: Virtual Fluoroscopic Preprocedural Planning was easy
to prepare and useful for selecting target bronchus. It might contribute to better diagnostic rates.
Department of Thoracic Surgery, Chigasaki Municipal Hospital, Japan1), Department of Respiratory Medicine, Chigasaki
Municipal Hospital, Japan2)
Atsushi Sano1), Takehiro Tsuchiya1),
Mitsuaki Kawashima1), Ken Tashiro2), Masako Hoshino2),
Haruyuki Hara2), Tsutomu Fukuda2)
Background:
Although the utility of virtual bronchoscopy has been reported,
the software for virtual bronchoscopy has not been popular due
to the high cost. OsiriX(R) is a reasonably priced software that is
available to reconstruct virtual endoscopic images. Herein, we
present the ability of OsiriX to enable virtual bronchoscopy.
Methods:
Computed tomography (CT) of the chest was performed without
contrast using a 16-row multidetector. Data in 2 mm slices from
one lung were obtained in 10 patients with a lung nodule. Virtual
bronchoscopic images were established by OsiriX version 5.5 (32bit). To examine the ability to visualize small bronchi, we tried to
visualize the distal bronchus possible. We selected B1a and B10c
for the right lung and B1+2a and B10c for the left lung.
Results:
Bronchoscopic images were successfully reconstructed for all patients. It takes less than 30 seconds to convert CT images into
bronchoscopic images. The third to the seventh bronchi were
visualized, except in one patient whose right B10 was occluded
by a tumor. The smallest bronchial diameter visualized was 1.0 to
2.1 mm. For all cases, the second-order bronchus, such as B1 and
B10, were easily visualized. To visualize the third and higherorder bronchi, it was sometimes necessary to manually adjust
brightness and contrast. The pathway can be recorded and retrieved using the Fly Through function. The pathway of the
virtual bronchoscopy was reconstructed in only 5 to 10 minutes.
Conclusion:
We demonstrated that OsiriX has enough functionality to reconstruct virtual bronchoscopic images. OsiriX 32-bit is a free software for Mac. Even the 64-bit version cleared by the Food and
Drug Administration costs only 599 US dollars. With OsiriX, virtual bronchoscopy can become popular at a relatively low cost.
265
Poster Presentation
IP-P9-1
IP-P9-2
First use of a helicoidal core biopsy needle guided by
transthoracic ultrasound for the diagnosis of lung cancer
Small peripheral pulmonary nodules and ultrasound
guided aspiration biopsy (UGAB)
Pneumology, CHU de Liege, Belgium
Vincent Heinen, Bernard Duysinx, Jean-louis Corhay,
Andreea Petrovici, Monique Henket, Renaud Louis
Background:
The complete diagnosis of lung cancer doesn t actually rely on the sole
pathologic identification of the tumor. Immunohistochemistry and molecular analyses are needed to provide targeted treatments. Research
requires even much more preserved samples to analyze fragile marcomolecules such as mRNA. Untill this day, only surgery provided high
quality tumor tissue in sufficient quantity. Guided microbiopsies often
provide poor quality samples, especially concerning RNA quality. Data
concerning noninvasive RNA harvesting in the lung is rare.
Objective:
We evaluated a frontal core macrobiopsy system (Spirotome, Cooks
Medicals) for the diagnosis of lung masses suspected of malignancy. The
objective was the evaluation of the diagnostic performance, the quality
and quantity of the samples (including RNA quality index) and complications.
Methods:
Twenty-three consecutive patients referred to the department of Interventional Pneumology of the CHU de Liege for the diagnostic of lung
nodules abutting the pleura were included. All gave informed consent.
The study was approved by the local Ethic Committee. The biopsies
were harvested using the Spirotome device; which consists of a helicoidal cutting needle system (see figure). The biopsy was guided with
transthoracic ultrasound. All required pathological and molecular analyses were performed. Additionally, the quantities and qualities of DNA
and RNA were evaluated for 12 cases. A visual pain score was used, and
complications were looked after with low dose chest CT.
Results:
The sensibility and specificity of the technique were respectively 85
and 100%. The negative predictive value was 40%. All samples positive
for the diagnosis of lung cancer allowed a comprehensive pathological
workup including analyses for targeted therapies. The evaluation of the
RNA quality showed 7!12 samples suitable for microarrays analyses
(RQI>7). The mean pain scale was 1.43!10 Complications included pneumothorax (2 required chest tube), 1 local infection and 1 case of fistulization to the pleura.
Conclusion:
The Spirotome system under ultrasound guidance for the diagnosis of
peripheral lung masses is an efficient and safe procedure. The possibility to harvest marcobiopsies without surgical procedure is important in
an era of personalized medicine, demanding larger biopsy samples to
process a complete workup or research. Comparative studies are
needed to confirm the superiority of the device over the standard microbiopsy systems.
266
Clinic of Pulmonology and Allergy, Medical Faculty, Skopje,
Macedonia1), Clinic of Cardiology, Medical Faculty, Skopje,
Macedonia2)
Biserka Jovkovska Kjaeva1), Zoran Spiridon Arsovski1),
Sasha Mitko Kjaeva2)
It is difficult to obtain the accurate etiologic diagnosis of
small peripheral pulmonary nodules, which is important for
the subsequent management. The aim of this study was to
assess the diagnostic value of UGAB in patients (pts) with
small peripheral pulmonary nodules and to compare the diagnostic yield of UGAP and fiberoptic broncoscopy with biopsy. During the period of 5 years we have analyzed 17 pts
with small peripheral pulmonary nodules smaller than 4 cm
in diameter. All 17 pts received ultrasound-guided aspiration
biopsy.(an average of two aspirations were conducted in
each patient) and 10 underwent fiberoptic brochoscopy with
biopsy. The ultrasound examinations were performed with a
real-time convex unit with 3.5MHz and 5MHz transduser.
Confirmative diagnoses were obtained in 13pts (76%). Eleven
(78%) of 14 pts with malignant nodules had positive cytology
for malignancy and 2(66%) of 3 pts with benign lesions had diagnosis made by cytological and microbiologic examination.
In only two pts the diagnose was obtained by fiberoptic
bronchoscope with biopsy(2 of 10)-20%. The final diagnoses
were confirmed by surgical resection or biopsy in 5pts, clinical evidence of strongly suggestive of the disease entity with
compatibile cytological results in 9pts, and microbiologic examination of the aspirates and clinical follow-up in 3pts. CONCLUSION: The UGAB is a simple, safe and accurate diagnostic method for peripheral pulmonary nodules even when the
size of the module is smaller than 4 cm in diameter. The diagnostic yield of UGAB exceeds the one that can be obtained
by fiberoptic bronchoscopy with biopsy.
Poster Presentation
IP-P9-3
IP-P9-4
Fiberoptic bronchoscopy with CT guided transbronchial biopsy: Initial experience
Diagnostic yield of bronchoscopic biopsy in the diagnosis of peripheral cancers in the lung
Department of Pulmonology, Guillermo Almenara HospitalPeruvian Social Security, Peru1), Department of Medicine, Daniel Alcides Carrion Hospital, Peruvian Social Security, TacnaPeru2)
Pedro Francisco Garcia-Mantilla1), Nora Fuentes2),
Pedro Garcia-Mantilla1)
Background: This study was conducted at the Department of Pulmonology, Guillermo Almenara Hospital in Lima- Peru. Since March 2009 we have included Bronchoscopy with CT
guided transbronchial biopsy(TBBx) for peripheral lesions in patients who had undergone
conventional FB without evidence of endobronchial lesions.
Methods:We conduct a case series; retrospective, descriptive study, to evaluate the diagnostic yield of CT guided TBBx. The study population consisted of all patients undergoing bronchoscopy with CT guided biopsy, a total of 14, performed in 2009 and 2010.
Prior to the CT guided bronchoscopy, imaging tests and conventional FB was performed.
All bronchoscopies were performed by the same physician. In all cases (14 cases) studied, we
used the same protocol of diagnostic techniques: bronchial washings, brushings and TTBx to
evaluate the performance of these procedures.
Bronchoscopic reports, and pathology and cytology results were reviewed.
Results: In our study 14 procedures were performed during 2009 and 2010, 6 had positive results, obtaining 42.80% of sensitivity. The anatomopathological diagnoses were a carcinoma,
adenocarcinoma and tuberculosis. The average of size of the lesion found in the tomography
of thorax was 2.3 cm. A surgical follow-up was realized in 3 of 8 patients with negative results.
Of 14 patients who entered the study, 6 had pulmonary lesions less than 2cm and the yield
was 0%. In the range of 2- 2.4 cm, the yield was 50% (2 of 4 patients), in the range of 2.5 to 2.9
cm, the yield was 100% (3 of 3) and the same result for lesions larger than 3 cm (1 of 1).
In smaller pulmonary nodules the diagnostic yield was zero while the yield rises with increasing size of the lesion.
It was found that only the transbronchial biopsies had a yield of 42.80%. Bronchial brushings
and washings had zero yields.
Conclusions: Bronchoscopy with CT Guide lung biopsy increases the diagnostic yield in peripheral lesions (greater than or equal 2cm) so this procedure could be implemented routinely.
Bronchoscopy remains the primary diagnostic method in nodular lesions and lung cancer,
that are visible, but has a poor performance when there is no visible injury. Therefore the
CT guided biopsy increases positive results in peripheral lesions and avoid performing more
invasive procedures. The yield of this procedure has been high in other international series
in which this procedure has been conducted for several years now.
Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
Marianne Anastasia De Roza,
Ganesh Kalyanasundaram, Anantham Devanand,
Chian Min Loo, Chwee Bee Yap, Hua Hui
AIM: The incidence of cancers presenting as peripheral lung lesions is increasing. Flexible
bronchoscopy is an outpatient diagnostic modality, but biopsies are performed blind . Aim
to evaluate the diagnostic yield and safety of trans-bronchial lung biopsy (TBLB) in the histological diagnosis of patients with suspected peripheral lung malignancy.
METHODS: Prospective database of all cases undergoing flexible bronchoscopy at the SGH
Endoscopy Centre over 12 months (April 2011-March 2012). Inclusion criteria: patients with
suspected cancer based on CT Thorax and clinical history (e.g. smokers, haemoptysis, and
weight loss). Those who had endoscopic or radiological evidence of central thoracic malignancy were excluded. Patients with negative results underwent transthoracic needle aspiration, surgical biopsy or had clinic-radiological surveillance for 12 months to establish the
final diagnosis.
RESULTS: 121 patients met inclusion criteria: 79 (65%) male and mean age of 63 11.3 years.
Mean lesion size: 45 23 mm. Median duration of the procedure: 20 minutes (range 5-75).
TBLB successfully diagnosed lung cancer in 90 patients (74.4%) of which 80 (77.7%) were
positive for bronchus sign and 59 (78.7%) were positive for pleural apposition seen on CT
scan. 32 patients (26%) had procedure related complications: 26 (21%) bleeding, 3(2.5%) significant hypoxia and 2 (1.7%) pneumothorax. Logistic regression showed that patients>65
years of age had a higher risk of complications (OR=2.34, 95% CI=1.02, 5.37; p=0.045), while
patients with middle!lower lobes lesions had a lower risk (OR=0.31, 95% CI=0.13, 0.77; p=
0.011).
CONCLUSION: TBLB is efficacious in obtaining a histological diagnosis of cancer in peripheral lung lesions. Older patients and those with upper lobe lesions had a higher risk of complications.
References:
1) ClinicalTrials.gov Identifier: NCT01374542
267
Poster Presentation
IP-P9-5
IP-P9-6
Predicting histology of transbronchially biopsied but
undifferentiated non-small cell lung cancer
Flexible bronchoscopy in the diagnosis of lung cancer
in a peruvian teaching hospital
Department of Thoracic and Cardiovascular Surgery, Kansai
Medical University, Japan1), First Department of Internal
Medicine, Kansai Medical University, Japan2), Department of
Clinical Sciences and Laboratory Medicine, Kansai Medical
University, Japan3)
Department of Pulmonology, Guillermo Almenara HospitalPeruvian Social Security, Peru1), Department of Medicine, Huanuco Hospital, Peruvian Social Security, Peru2), Department
of Critical Medicine, Guillermo Almenara Hospital, Peruvian
Social Security, Peru3)
Takahito Nakano1), Yohei Taniguchi1), Tomohito Saito1),
Hiroyuki Kaneda1), Toshihumi Konobu1), Maiko Niki2),
Yuta Yamanaka2), Yousuke Sawai2), Makoto Ogata2),
Yorika Nakano2), Chika Miyasaka3), Chisato Ohe3),
Noriko Sakaida3), Yosiko Uemura3), Yukihito Saito1)
Pedro Francisco Garcia-Mantilla1),
Pedro Garcia-mantilla1), Hugo Sanchez2), Miriam Latorre1),
Victor Flores1), Nancy Alvarez1), Jorge Delgado3)
【Background】Histologic subtyping of non-small cell lung cancer
(NSCLC) has become essential to determine suitable chemotherapeutic agent. However, histologic subtyping by using transbronchially
biopsied samples would be difficult because only limited tissue is
available to determine either adenocarcinoma(ADC) or squamous
cell carcinoma(SQCC), leading diagnosis of NSCLC not otherwise
specified(NSCLC-NOS) in some cases. Our primary aim is to investigate usefulness of immunostaining to refine the diagnosis of NSCLCNOS. The secondary aim is to identify clinical factors predicting the
presence of SQCC component.
【Methods】Chart review was carried out on consecutive 159 patients
who were preoperatively diagnosed as NSCLC based on transbronchially biopsied samples and subsequently underwent surgical resection without preoperative chemotherapy at our hospital. Among the
159 patients, preoperative diagnosis of light microscopically NSCLCNOS were made in 18 patients. First, we investigated the diagnostic
accuracy of immunostaining in the 18 cases with NSCLC-NOS by
comparing with cases with light microscopic diagnosis of ADC(n=
121) and SQCC(n=16). Second, two cases with preoperative diagnosis
of possible LCNEC were excluded from the 18 cases, and the remaining 16 NSCLC-NOS cases were divided into two subgroups based on
whether or not a case contained SQCC component in surgically resected specimens(surgical SQCC group and surgical non-SQCC
group, respectively). Next, we analyzed the difference in clinical
characteristics between the two subgroups. Analyzed factors included age, sex, smoking history, positron-emission tomography
maximum standard uptake value, radiological tumor position(central
or peripheral), and serum tumor marker levels.
【Results】Of the 18 cases with NSCLC-NOS, immunostaining were
performed in 14 cases(77.8%), leading in following diagnosis; favor
ADC in five, favor SQCC in three, possible LCNEC in two, possible
adenosquamous carcinoma in one, and miscellaneous in three. None
of the five cases with the preoperative diagnosis of favor ADC
showed SQCC component in surgical specimens. On the other hand,
one of the three cases with preoperative diagnosis of favor SQCC did
not showed SQCC component in surgical specimens, whereas all of
the 16 cases with preoperative diagnosis of SQCC by light microscopy showed SQCC component in postoperative specimens(p=0.018).
Additionally, serum SCC levels were significantly higher in the surgical SQCC group than surgical non-SQCC group(p=0.019).
【Conclusion】Our results suggest that preoperative diagnosis of favor ADC by immunostaining could be compatible with postoperative diagnosis of ADC, whereas preoperative daignosis of favor
SQCC may not necessarily predict postoperative diagnosis of SQCC.
Additionally, serum SCC levels would be useful to predict the presence of SQCC component.
268
Background
Fiberoptic bronchoscopy (FB) is the most important method used in patients with potential lung cancer.
Guillermo Almenara Hospital is a teaching hospital with pulmonology residency program.The diagnostic yield
from FB in patients with potential lung cancer at our Hospital hasńt been evaluated previously.
Methods
A retrospective study was performed to evaluate the diagnostic yield of FB in lung cancer.
All bronchoscopies, a total of 495, performed in 2009 were reviewed, and 84 patients with direct findings (endobronchial tumor) or indirect findings (obstruction, stenosis, extrinsic compression) of lung cancer in bronchoscopic inspection were included in the study.
Sampling techniques performed were biopsy, brushing and aspiration of fluid from the entire procedure.
Bronchoscopies were performed by different physicians. The number of biopsy specimens in cases of visible tumor was not registered in the bronchoscopic report.
Results
Of 84 bronchoscopics reports with direct findings and indirect findings of lung cancer, 36% had visible tumors
(Group 1) and 64% had indirect findings of lung cancer (Group 2).
In Group 1 biopsy specimens gave a diagnosis of malignancy in 37% of cases. The remaining diagnoses were
chronic bronchitis in 23%, TB in 3%, normal tissue in 7%, metaplasia in 13%, and unspecified diagnosis in 17% of
cases. Bronchial brushing was positive in 37% of cases and bronchial aspiration in 23% of cases.
In Group 2 biopsy specimens were positive in 24%. The remaining diagnoses were chronic bronchitis in 20%, insufficient sample in 9%, normal tissue in 11%, metaplasia in 2%, necrotic tissue in 2%, and unspecified diagnosis
in 32% of cases. Bronchial brushing was positive in 24% of cases and bronchial aspiration in 16% of cases. The diagnostic yield from combined techniques increased to 50% for visible lesions (Group 1) and to 35% when the tumor was not visible (Group 2).
Conclusions
Biopsy yield and the combined yield of bronchoscopic techniques were below the international standards for
visible and non visible lesions.
Of particular concern is the low diagnostic yield from biopsy in our study.
BTS Guideline for diagnostic FB cited that in patients with visible tumor a diagnostic yield of at least 85% is
achievable.
We need to standardize our bronchoscopic procedures and must design an educational intervention to improve
the teaching and learning of bronchoscopy.
Simulation-based bronchoscopy training is increasingly used and is effective in comparison with no intervention. Simulation based education can improve quality of care at a teaching hospital.
Poster Presentation
IP-P9-7
IP-P9-8
Added value of 18F-FDG-PET!
CT in addition to fiberoptic bronchoscopy in differentiation of solitary
pulmonary nodules
Role of endobronchial ultrasound in the diagnosis of
bronchogenic cysts
Emergency, Pneumology Unit, University Hospital Arcispedale S. Anna of Ferrara, Italy1), Nuclear Medicine Unit, University Hospital Arcispedale S.Anna of Ferrara, Italy2), Pathology
Unit, University Hospital Arcispedale S.Anna of Ferrara, Italy3)
Valentina Conti1), Martina Marchi1), Ivan Santi2),
Chiara Peterle2), Corrado Cittanti2), Rosa Rinaldi3),
Nunzio Calia1), Luciano Feggi2), Franco Ravenna1)
Aim: to evaluate the diagnostic performance of 18F-FDGPET!
CT (PET) combined with fiberoptic bronchoscopy
(FOB) compared to the single techniques in solitary pulmonary nodule (SPN) differentiation.
Materials and Methods: we retrospectively evaluated 42 consecutive patients presenting with SPN (1-3 cm) identified by
CT scans who underwent both PET and FOB for lesion differentiation. FOB included Trans-Bronchial Pulmonary Biopsy (TBB), Trans-Bronchial Pulmonary Needle Aspiration
(TBNA) and bronchial washing (BW). Findings were considered positive as follows: PET, when maximum Standardized
Uptake Value of FDG uptake in the lesion was>=2.5; FOB, in
case either TBB, TBNA or BW was positive for malignancy;
PET and FOB combined, when at least one was positive. Results were confirmed through histology after surgery or
follow-up, as reference standard. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive
value (NPV) of PET, FOB and the 2 techniques combined
were respectively calculated.
Results: out of the 42 patients PET, FOB and the combined
procedures respectively resulted true positive (TP) in 33, 23
and 38 cases, true negative (TN) in 1, 4 and 1, false positive
(FP) in 3, 0 and 2, false negative (FN) in 5, 15 and 0. PET was
FP in 2 TN FOB case (inflammatory lesion), and FN in 4 TP
FOB case (2 bronchiolo-alveolar carcinoma, 2 lung adenocarcinoma). FOB was FN in 16 TP PET cases.
The diagnostic performance of PET, FOB and the combined
procedures respectively resulted in: sensitivity 87, 61 and
97%; specificity 25, 100 and 33%; accuracy 81, 64 and 92%;
PPV 95, 100 and 92%; NPV 16, 21 and 50%.
Conclusions: PET showed high sensitivity and accuracy
playing an important diagnostic role especially in cases of FN
FOB. The addition of PET to FOB resulted in an improved
diagnostic accuracy that may lead to a better selection of patients with SPN addressed to surgery, and strengthens the
value of multimodal patient management.
Department of Thoracic Surgery, Dr. Suat Seren Chest Diseases and Thoracic Surgery Training Hospital, Turkey1), Department of Pulmonary Diseases, Dr Suat Seren Chest Diseases and Thoracic Surgery Training Hospital, Turkey2), Department of Pathology, Dr Suat Seren Chest Diseases and
Thoracic Surgery Training Hospital, Turkey3)
Esra Yamansavci Sirzai1), Ozan Usluer1), Soner Gursoy1),
Onur fevzi Erer2), Ahmet Ucvet1), Alev gulsah Hacar3)
Bronchogenic cysts arise from abnormal budding of the
primitive tracheobronchial tube. Most of the bronchogenic
cysts are diagnosed during in adulthood. EBUS can evaluate
the cystic nature of the lesion. EBUS-TBNA can be performed on these patients to aspirate the fluid for cytological
analysis, and confirm the diagnosis.
A 48-year-old woman presented with progressive cough. She
had an unremarkable physical examination. CT scan revealed a well-circumscribed mass lesion in the right hilum.
PET!
CT did not reveal any abnormal FDG uptake. EBUS
was performed and ultrasound identified a round lesion with
an echogenic centre and calcified, thickened, and hyperechoic wall. These findings were considered as a brochogenic
cyst. The aspitarion biopsy could not be performed because
the cyst was too close to the pulmonary vessels.
Right-sided thoracotomy was performed for the definite diagnosis and treatment. A calcified lesion with a cystic cavity
at the root of the right upper lobe bronchus was found and a
right upper lobectomy was performed.
Histopathological examination revealed a well-defined cystic
space lined by inflamed respiratory epithelium, cartilage,
muscle and mucous gland consistent with the histopathological diagnosis of a bronchogenic cyst (Hex40).
Surgical resection is still the best treatment option for bronchogenic cysts. EBUS can be used to confirm the definitive
diagnosis especially for hilar lesions. EBUS-TBNA can be
performed as a treatment method for patients who are not
suitable for an open surgical procedure.
269
Poster Presentation
IP-P10-1
IP-P10-2
Assessment of tracheobronchial stenosis using a
novel stereoscopic bronchoscope for airway measurement
Ultrasonic balloon measurement and suitable stenting
for air way stenosis
Department of Internal Medicine, St. Marianna University
School of Medicine, Japan
Seiichi Nobuyama, Hiromi Muraoka, Mariko Okamoto,
Teppei Inoue, Naoki Furuya, Hirosi Handa,
Hirotaka Kida, Miwa Fujiwara, Hiroki Nishine,
Atsuko Ishida, Takeo Inoue, Masamichi Mineshita,
Teruomi Miyazawa
BACKGROUND: Stereoscopic bronchoscope (BF-Y0006,
OLMPUS, TOKYO) is a new diagnostic tool to measure the
diameter and cross-sectional area of the airway. The bronchoscope, which operates the same as a normal bronchoscope, utilizes two lenses to measure the airway using the
principles of triangulation. To assess the accuracy of stereoscopic bronchoscope measurements, we compared stereoscopic bronchoscopy images with multi-detector computed
tomography (MDCT).
METHODS: Between February 2009 and February 2013, we
performed airway stenting on 21 patients, 15 malignant and
6 benign cases. We then compared pre-operative stereoscopic bronchoscope images and MDCT to assess narrowing
areas in the airway at 165 points. Of these, 134 were considered normal and 31 were deemed abnormal. Stereoscopic
bronchoscope also has the capability to measure the size of
the airway during intervention in real time.
RESULTS: Diameter and length measurements at all areas
taken by stereoscopic bronchoscope and MDCT were near
equal in all patients. Significant correlations were seen at all
165 sites (r=0.7944, p<0.0001), and for 134 normal (r=0.849, p<
0.0001) and 31 abnormal sites (r=0.785, p<0.0001). Stereoscopic bronchoscope is also useful to assess improvements in
airway stenosis post operation, such as laser ablation or ballooning, and for observing the sequence of changes in airway
diameters.
CONCLUSIONS: Stereoscopic bronchoscopy was able to
measure the size of the airway during intervention, making
it possible to choose the appropriate size of the stent.
270
Department of General Thoracic Surgery, Graduate School of
Medical and Dental Sciences Kagoshima University, Japan1),
Department of General Thoracic Surgery, Kagoshima City
Hospital, Japan2)
Tsunayuki Otsuka1), Masakazu Yanagi2),
Naoya Yokomakura1), Masaya Aoki1), Aya Harada1),
Kazuhiro Wakida1), Toshiyuki Nagata1),
Koichi Sakasegawa1), Yoshihiro Nakamura1),
Souichi Suzuki1), Tadashi Umehara1), Go Kamimura1),
Koki Maeda1), Yui Watanabe1), Kota Kariatsumari1),
Masami Sato1)
Central airway stenosis becomes the cause of dyspnea and
obstructive pneumonia, so notably affect patients QOL. In
addition, esophagobronchial fistula by esophageal cancer
causes repeated pneumonia, and patients experience difficulty of eating by oral. Airway stent is highly useful to solve
these problems with airway stenosis and esophagobronchial
fistula, but migration, pressure of stent cause ischemia on the
wall of airway leads to fistula, and some complications such
as penetrating major blood vessels are reported. It have
been reported that improper size could cause such complications. In order to determine proper size of stent, we measure
the airway by ultrasonic balloon. We take HRCT and prepare several size of stent by measuring proximal and distal
part of stenosis before airway stenting. Rigid bronchoscopy
is performed under general anesthesia. In case of stenosis
caused by tumor, we excise or cauterize the tumor. Also, in
case of stenosis caused by scar, balloon dilatation would be
done in airway after resection. After such treatment, we
measure the internal diameter of airway by inserting flexible
bronchoscopy into rigid bronchoscopy tube and using ultrasonic balloon. We measure minor radius and major radius at
right angles, and chose stents that are one size bigger than
its average radius. For Y shaped stent, we determine the
size of stent based on the narrowest parts of trachea and
both bronchi. We performed 34 airway stenting out of 29
cases from July 2007 through December 2011. The leading
cause was 13 cases of invasive esophageal cancer. We have
used 11 cases of Y shaped silicon stent, 10 cases of I shaped
silicon stent, and 13 cases of Expandable metallic stent
(EMS). We found 3 complications; 2 cases (5.8%, 1 I shaped
silicon stent and 1 EMS) of granulation, and 1 migration
(2.9%, I silicon stent). We found no critical complication such
as ischemia of the wall of airway and!
or penetrating major
blood vessels caused by stent pressure. According to Dr.
Chung report, they found 7.6% of migration and 15.2% of
granulation tissue formation within EMS cases. Also, according to Dr. Ryu report, they found 48% of migration and 44%
of granulation tissue formation within silicon stenting. We
found 5.8%of migration and 2.9% of granulation tissue formation from our experience. We could decrease the number of
complication by using ultrasonic balloon measurement although it is difficult to compare as less case reports and
short observation period.
Poster Presentation
IP-P10-3
IP-P10-4
Successful treatment of severe tracheal stenosis due
to mediastinal tumor with a dumon stent and chemoradiotherapy
Stent and freeze. Bronchoscopic spray cryotherapy in
palliative airway interventions
Department of Respiratory Medicine, Fukuyama Medical
Center, Japan
Masaomi Marukawa, Yuka Beika, Masayuki Yasugi,
Kenichi Genba
Background: Malignant tumors are sometimes complicated
by oncological emergencies, even at the onset of the disease.
Progressive tracheal stenosis is one of the most complex situations encountered when treating patients with advanced
malignant diseases in the thorax. A case of severe tracheal
stenosis caused by poorly differentiated carcinoma in the
retrotracheal mediastinum is described.
Case report: A 52-year-old-man was referred to our hospital
due to progressive dyspnea and an abnormal mediastinal
shadow on his chest radiograph. Chest computed tomography (CT) revealed a giant tumor in the upper, retrotracheal,
mediastinal position compressing the trachea. A Dumon
stent (straight type) was first inserted to the stenotic portion
of the trachea to prevent airway obstruction and palliate his
symptoms of distress. No diagnostic clue was obtained by
percutaneous needle biopsy, which was done on the day after stenting; therefore, video-assisted thoracic surgery
(VATS) was performed as the second diagnostic procedure.
Specimens obtained through the VATS procedure revealed
a poorly differentiated carcinoma. Based on the location of
the tumor, histological findings, and other whole-body examinations, the tumor was finally diagnosed as a primary unknown, poorly differentiated carcinoma in the retrotracheal
mediastinal position. Because the giant tumor was localized
to the mediastinum alone, the patient underwent concurrent
chemoradiotherapy comprising cisplatin and docetaxel. After the tumor-specific therapy, the tumor regressed prominently on chest CT, and his distress disappeared. Furthermore, the stent was able to be removed due to migration to
the lower portion of the trachea four months after therapy.
The patient survived for two years after therapy without recurrence of tracheal stenosis.
Conclusion: A case of severe tracheal stenosis caused by
poorly differentiated carcinoma in the mediastinum was reported. Combined treatment including Dumon stent placement and cisplatin-based chemoradiotherapy not only overcame the oncological emergency, it also achieved an excellent anti-tumor effect. As in the present case, temporary
stenting using a Dumon stent is very useful in the treatment
of malignant airway stenosis when tumor-specific therapy
can be expected to have an effect.
Pulmonary Medicine, Walter Reed National Military Medical
Center, USA1), Thoracic Oncology, Walter Reed National Military Medical Center, USA2), Interventional Pulmonary and
Critical Care Medicine, Cancer Treatment Centers of America, USA3)
Scott Charles Parrish1), Robert Browning1),
Corey Carter2), J. Francis Turner3)
Background:
Endoscopic spray cryotherapy (SCT) is a novel method of using liquid nitrogen to treat a wide variety of endobronchial
disease. In 2012, a new non-contact device to deliver liquid nitrogen through a flexible catheter to flash freeze unwanted
tissue (TruFreeze spray cryotherapy system, CSA Medical,
Boston, USA) was made available for use in the USA. This
technology has unique advantages over other bronchoscopic
tools currently available. The case presented illustrates
many of these applications.
Case Report:
71 year old female was diagnosed in November 2011 with
Stage IV Non Small Cell Lung Cancer (adenocarcinoma,
KRAS positive, and HER2 over expressed by FISH) with metastatic disease to T12, femur and sacrum. Over the course
of the next 12 months, she received multiple chemotherapeutic agents and radiation but progressed through all of them.
In November of 2012, with worsening dyspnea and an increasing oxygen requirement, she was referred to interventional Pulmonology for evaluation. Initial bronchoscopy
showed a complete obstruction of the right main bronchus
due to tumor extending from the right upper lobe. A 12
mm 3 mm self-expanding hybrid nitinol silicone stent was
placed in the right main bronchus extending to the distal
bronchus intermedius successfully restoring 70% of the lumen. Spray cryotherapy was used to treat the tumor compressing the stent. The patient underwent 5 subsequent serial bronchoscopies with spray cryotherapy treatments at
30-90 day intervals to manage tumor obstruction of stent,
granulation tissue formation threatening stent patency and
bleeding from extremely friable tissue in the area of the tumor and stent. Throughout this course she presented many
challenges to therapy due to her hypoxia and performance
status. In June of 2013, the endobronchial tissue was no
longer friable; the tumor appeared to have regressed and the
stent was removed. The airways in the proximal right upper
lobe were scarred but without evidence of tumor. The patient was able to wean off her supplemental oxygen as an
outpatient and her performance status had markedly improved from presentation. To date she has not required any
further intervention for respiratory symptoms for over 6
months.
Conclusion: SCT is a unique bronchsocopic tool that can be
used to safely preserve central airway patency in the setting
of existing silicone!
nitinol stents through concurrent chemotherapy and radiation.
271
Poster Presentation
IP-P10-5
Self-expending metallic Y-stent for complex malignant
lesions of the main carina
Pneumology, Rouen University Hospital, France
Samy Lachkar, Mathieu Salaun, Suzanna Bota,
Luc Thiberville
Introduction: Silicon Y-stents are commonly used to manage
malignant disease of the carina, but remains often inadequate to address complex stenosis or tracheo-oesophageal
fistula.
Objective: To assess the use of self-expending metallic Ystent (Micro-Tech Carina Y-Stents), and to evaluate symptoms relief and tolerance in patients with malignant tumors
of the main carina, not suitable for surgical curative treatment or silicon stenting.
Methods: 8 patients with complex stenosis due to lung cancer received metallic Y tracheal stents, and 7 patients with
complex fistula involving the carina and left main bronchus
had both metallic oesophageal and Y tracheal stents (oesophageal cancer, n=5), or tracheal stent alone (mediastinal invasion of metastastic nodes from extra-thoracic cancer, n=2).
Stents were placed under general anaesthesia using rigidbronchoscopy with guide-wire fluoroscopy guidance. Respiratory symptoms, symptom-free and overall survival were
recorded.
Results: Self-expending metallic Y-stent were easily placed in
each case, with a procedure median duration of 30 min. All
patients experienced symptoms improvement, with a median symptom-free survival of 35 days (1 to 273 d.). Among
patients with oesophago-tracheal fistula, only one had a fistula extension on follow-up needing re-stenting, while 4 patients reported symptom resolution until death (at 1, 3, 6 and
9 months). Two patients are symptom-free at 1 and 3
months, allowing oral nutrition. In lung cancer-related stenosis patients, the median symptom-free survival was 28 d. (interquartile range (IQR): 17-56 d.), and median survival 30 d.
(IQR: 17-57 d.).
Conclusion: Self-expanding metallic Y-stents appear easy to
use and provide symptoms improvement in patients with
complex malignant diseases of the main carina, who are not
suitable for curative treatment or silicon stenting.
272
Poster Presentation
IP-P10-6
IP-P10-6
Non-surgical management of a large iatrogenic tracheal tear with silicone airway Y stent
Department of Pulmonary, Critical Care & Sleep Services,
Yashoda Hospitals, Malakpet, Hyderabad, India1), Department
of Cardiology, Yashoda Hospitals, Hyderabad2), Department of
Cardiothoracic Surgery, Yashoda Hospitals, Hyderabad3), Department of Cardiothoracic Surgery, Care Hospitals, Hyderabad4)
Vijay Kumar Chennamchetty1), Jayachandra A1),
Aparna Maramreddy1), Mukesh Rao2), Nageswara Rao3),
Hemanth Kumar4)
Background:
Iatrogenic tracheal injury following endo-tracheal intubation
is a rare but devastating complication. Traditional management of tracheal tear involves primary surgical repair. Nonoperative management of such traceal injury by silicone airway stent is described. The clinical scenario for which nonoperative treatment considered in this case is described.
Case report:
A 58 year old male referred from a nursing home for management of post (cardiac arrest) CPCR status, resulting from
a massive MI leading to shock state requiring moderate
doses of dopamine infusion. In ER, patient has low GCS, low
blood pressure & small but significant subcutaneous emphysema in neck. Subsequently, patient got shifted to ICCU &
appropriate treatment given including mechanical ventilatory support. On positive pressure ventilation, subcutaneous
emphysema progressed gradually, for which subcutaneous
incisions and bilateral ICD s were placed. In due course, cardiac condition stabilised and weaned off from ventilation.
Post extubation, patient developed severe ineffective cough.
Bronchoscopy done under sedation revealed a full thickness
tear in the right side of tracheal wall in the lower 5cm, extending upto origin of right main bronchus. Thoracic surgeon consult obtained. Thoracic surgeon denies for offering
surgical repair.
Airway stenting using a silicone (DUMON-Y) has planned
and placed in operation theatre using rigid bronchoscpy. Patient could tolerate procedure well. He was managed with intravenous broad spectrum antibiotics to prevent mediastinitis.
Post-stenting, CT thorax done on the day of discharge revealed attempted approximation of both lacerated margins
and silicone stent insitu. 6 weeks later, patient underwent
virtual bronchoscopy, revealed full thickness approximation
of tracheal tear. Patient subsequently operated for CABG &
got discharged to home.
Conclusion:
In management of large iatrogenic tracheal tear, where primary surgical repair is not feasible, airway stenting using
Silicone stents is an effective & safer alternative with a reasonable good outcome.
273
Poster Presentation
IP-P10-7
IP-P11-1
Silicone Y-stent placement for severe airway stenosis
due to primary mediastinal large B-cell lymphoma in
late pregnancy
Hemoptysis after therapeutic intervention for a pneumothorax
Department of Respiratory Medicine, National Hospital Organization, Nagoya Medical Center, Japan
Masatoshi Tokojima, Masahide Oki, Hideo Saka,
Yuko Ise, Yasushi Murakami, Kazumi Hori,
Masashi Nakahata, Saori Oka, Misaki Ryuge,
Yoshihito Kogure, Chiyoe Kitagawa
<BACKGROUND>
Although severe airway stenosis is life-threatening, stent insertion re-establishes the airway patency. Airway stent
placement for a pregnant woman is a rare situation.
<CASE REPORT>
A 32-year-old female patient at 36 weeks of pregnancy was
referred to our hospital because of severe acute respiratory
failure. The fetus was alive but weakening. Chest X-ray and
computed tomography demonstrated a large anterior mediastinal mass, which caused severe extrinsic airway stenosis.
After resolving airway patency by rigid and flexible bronchoscopy under general anesthesia, the baby was delivered
by caesarean section. A Dumon silicone Y-stent was deployed on the main carina to maintain the airway. She was
diagnosed with primary mediastinal large B-cell lymphoma.
Systemic chemotherapy was started under anesthetized
condition on artificial ventilation from the second postoperative day.
<CONCLUSION>
Silicone Y-stent placement was effective and performed
safely under general anesthesia for severe airway stenosis
even in a woman with late pregnancy.
274
Weill Medical College of Cornell University, USA1), Division of
Pulmonary and Critical Care Medicine, New York Hospital
Queens, USA2)
Jack Michael Mann1,2), Divyajot Sohal1,2)
We were called to the MICU to help evaluate the etiology of
hemoptysis in an 84 year old female who had required mechanical ventilation for acute respiratory failure as a consequence of community acquired pneumonia. She had multiple
comorbid conditions including CAD and COPD.
Several hours prior to the frank blood form the endotracheal
tube a chest tube had been placed into the right pleural
space for a pneumothorax.
Bronchoscopic examination of the airways revealed a clot
emanating form the right airway. The clot was successfully
removed revealing a light blue object arising in the airway
Figure 1.
A large bore chest tube was inserted into the right pleural
space via a chest wall incision. The previously place percutaneous chest tube was removed. The bronchopleural fistula
eventually healed and the patient was successfully weaned
form the ventilator.
A discussion regarding the photos as well as the technique
and complications of percutaneous catheter placement via
the Seldinger technique will follow.
Poster Presentation
IP-P11-2
IP-P11-3
Treatment of central airway tumor by combination of
flexible bronchoscope with endotracheal intubation:
Two cases report
Efficacy of bronchoscopic microwave coagulation
therapy for endobronchial malignancies
Department of Respiratory Medicine, Tangdu Hospital,
Fourth Military Medical University, China
Faguang Jin, Deguang Mu, Xin Li
Tumor caused central airway obstruction often causes fatal
complications to patients, such as severe dyspnea and the patient is often in a critical condition. During the treatment of
tumor located at the central airway by the flexible bronchoscope, the patients may be subject to suffocation at any
times, so this operation is at very high risks. Our treatment
obtained success in two cases who had been diagnosed the
central airway obstruction caused by tumor by flexible bronchoscope combined with endotracheal intubation.
Department of Thoracic and Cardiovascular Surgery,
Wakayama Medical University, Japan
Takuya Ohashi, Tatsuya Yoshimasu, Shoji Oura,
Yozo Kokawa, Mitsumasa Kawago, Yoshimitsu Hirai,
Megumi Kiyoi, Haruka Nisiguchi, Masako Matsutani,
Yoshitaka Okamura
Background
Bronchoscopic microwave coagulation therapy (BMCT) has
several advantage compared to LASER treatment. First,
BMCT is able to coagulate an extensive longitudinal airway
area. Second, BMCT is a less bleeding procedure and produce no smoke. Third, BMCT is low-cost.
Patients and Methods
BMCT was performed 21 endobronchial malignancies in our
hospital between 2005 and 2013. The patients included 9
cases of small airway lesions, 11 cases of airway stenosis due
to endobronchial malignant lesions and 1 case of bleeding
due to endobronchial malignant lesion.
Small airway lesions were consist of carcinoma in situ (7
cases), and thyroid cancer (2 cases).Airway stenosis was
caused by lung cancer (6 cases), colon cancer (2 cases), thyroid cancer (2 cases), and esophageal cancer (2 cases).
Bronchoscopy was performed under modified neurolepitic
analgesia with 15 mg of pentazocine, 5mg of midazolam and
topical administration of 2% lidcaine. Patients breathed spontaneously during the procedure. Microwave coagulation was
performed with 50-100 watts intensity.
Results
There was no complication in all patients in BMCT. In patients of small airway lesions, the mean follow-up period was
25 19 months. Only 1 local recurrence was observed. In all
patients with airway stenosis, sufficient dilatation was obtained after BMCT. However, 9 patients needed to additional
therapies such as LASER coagulation therapy, chemotherapy, radiotherapy, and airway stent, during follow-up.
Conclusion
BMCT seems to be a safe and useful option for small endobronchial malignant lesion and malignant air way stenosis.
275
Poster Presentation
IP-P11-4
IP-P11-5
Interventional bronchoscopy before definitive
chemoradiotherapy to avoid interruptions of planned
radiation therapy
Combined argon plasma coagulation and cryotherapy
for solitary endobronchial metastasis from colorectal
cancer
Department of Internal Medicine, Tottori Prefectural Central
Hospital, Japan1), Department of Radiology, Tottori Prefectural
Central Hospital, Japan2)
Hisashi Suyama1), Takashi Sumikawa1),
Natsumi Tanaka1), Satoshi Urakawa1), Yuji Sugimigo1),
Kazuhiko Nakamura2), Nobue Uchida2), Norihiko Hino1)
<Background>In case with intraluminal tumor in the main
bronchus caused by lung cancer, definitive chemoradiotherapy would sometimes be discontinued because of complete
occlusion and subsequent unilateral atelectasis. These patients would not gain an expected anticancer effects, and
would have markedly adverse influence on long-term survival. Therefore, it is essential to avoid complete atelectasis
in such lung cancer patients with intraluminal tumorous invasion. We treated two cases of non-small cell lung cancer
treated with interventional bronchoscopy before definitive
chemoradiotherapy. <Case report>A 63-year-old man suffering dyspnea visited our hospital. He was suffering from intraluminal occlusion caused by squamous cell lung cancer.
After systematic work-up, he was diagnosed as stage IIIB
squamous cell carcinoma of the lung. There was a concern
that if obstructive atelectasis developed in his whole right
lung, the definitive chemoradiotherapy would be interrupted
and resulted in poor clinical outcome. Almost of his right
main bronchus had already been plugged by the cancerous
lesion. Then, we planned tumor removal to avoid cessation of
definitive chemoradiotherapy. The tumor removal was performed safely using the rigid bronchoscope and the argon
plasma coagulator under general anesthesia. Docetaxel and
cisplatin with concomitant thoracic radiotherapy was given
to the patient and planned chemoradiotherapy was completed without any interruption. We treated another case in
the same strategy. <Conclusion>The addition of interventional bronchoscopy before definitive chemoradiotherapy
should be considered a treatment option in patients suffering
from airway obstructions.
276
Internal Medicine, Chonbuk National University Hospital, Korea1), Department of Critical Care Medicine, Samsung Medical
center, Korea2), Department of Internal Medicine, Korea University College of Medicine, Korea3)
Seungyong Park1), Chi Ryang Chung2),
Kyoung Hoon Min3), Yeoung Hun Choe1), So Ri Kim1),
Seoung Ju Park1), Yong Chul Lee1), Heung Bum Lee1)
Colorectal cancer is common and the liver and lung are frequent metastatic sites. But single metastasis from colorectal
cancer to the central airway is extremely rare.
In a fatal central airway obstruction, generally, the rigid
bronchoscopic interventions or surgical procedures under
general anesthesia were the preferred management. However in patients who are not candidates for surgical resection, bronchoscope-guided multidisciplinary approaches offered a safe and effective alternative in the palliative management of respiratory symptoms related with airway obstruction. Of these, argon plasma coagulation (APC) is a valuable tool in treating superficial bleeding and debulking
granulation tissue and tumors. In addition cryotherapy relies
on repeated freeze!
thaw cycles for tissue destruction, and
spares cartilaginous structures due to their poor vascularity.
Herein, we report an interesting case of the successful debulking management with combined APC and cryotherapy
guided by flexible bronchoscopy under the simple sedation
in a patient with impending total airway obstruction from
colorectal cancer.
Poster Presentation
IP-P11-6
IP-P11-7
Usefulness of argon-plasma coagulation for the management of central airway tumors
Laser application for obstructive left main bronchus tumour in a patient with metastatic cervical cancer
Department of Internal Medicine, Chonnam National University Medical School, Korea
Yong Soo Kwon, In-Jae Oh, Kyu-Sik Kim, Sung-Chul Lim,
Kim Young-Chul
Background: To evaluate the usefulness of argon plasma coagulation (APC) for the management of central airway obstruction due to central airway tumors.
Methods: We retrospectively evaluated patients with central
airway obstruction due to benign or malignant tumors from
February 2008 to February 2013 at Chonnam National University Hospital were retrospectively reviewed. All patients
were received a rigid bronchoscopic tumor removal under
general anesthesia and APC was applied before and after tumor removal.
Results: The median age of all patients were 58 (interquartile
[IQR] range, 53-67) and 60% were female. The causes of airway obstruction include malignancy (n=8) and benign (n=12).
According to types of airway tumors, intra-luminal lesions
were 7 (55%) and mixed lesions were 9 (45%). The median
size of tumor was 15 mm (IQR 10-18) and median degree of
airway obstruction was 90% (IQR 85-95). All patients except
3 who had no dyspnea before procedure showed improvement in dyspnea and 10 of 11 who performed pulmonary
function tests before and after bronchoscopy showed improvement in FEV1 (46 [IQR 30-74] vs 91 [IQR 80-107], % predicted, p=0.003). There were no procedure related acute
complications and mortality.
Conclusions: APC combined with rigid bronchoscopy was an
effective and safe procedure to alleviate central airway tumors.
Respiratory Medicine, Tan Tock Seng Hospital, Singapore
Pee Hwee Pang, Alan Ng, Wee See Yap
INTRODUCTION
Cervical cancer typically spreads to the pelvic and paraaortic lymph
nodes by lymphatic drainage. The common sites of haematogenous
spread are lungs, liver and brain. This is a case report on laser application to the left main bronchus tumour in a patient with metastatic cervical cancer.
CASE REPORT
A 36 year old Indonesian female, an ex-smoker with a history of stage
IIB cervical cancer, presented with shortness of breath and productive
cough of 3 months duration. She had previous chemotherapy and radiotherapy in 2011. On examination, there were absent breath sounds with
dull percussion note and reduced vocal resonance on the left hemithorax. Chest radiograph showed near complete opacification of the left
hemithorax with partial aeration of left upper zone and mediastinal shift
to the left. Computed tomography scan of the thorax revealed multiple
enlarged necrotic mediastinal lymph nodes, in particular a large subcarinal node measuring 3.5 4 cm with extrinsic compression on the left
main bronchus. A left hilar heterogeneous mass was associated with
collapse of the left lower lobe. There were multiple bilateral pulmonary
nodules of varying sizes. Flexible bronchoscopy revealed an infiltrative
tumour causing complete obstruction in the left main bronchus, with extension to the right main bronchus, but without causing obstruction.
Bronchial washings and biopsy demonstrated squamous cell carcinoma,
likely metastatic disease from the cervical cancer. Rigid bronchoscopy
with laser application was subsequently performed 4 days later. NdYAG laser therapy to the left main bronchus tumour was applied with
establishment of the patency of left upper bronchus. Repeat chest radiograph showed improved aeration of left upper and mid zones, with residual left lower zone opacification. She subsequently underwent palliative radiotherapy to the mediastinum.
CONCLUSION
This was an unusual case of recurrence of cervical cancer in the mediastinal lymph nodes and lungs without intra-abdominal disease. As an
interim measure before the patient receive palliative radiotherapy to
the mediastinum, we proceeded with interventional bronchoscopy. In
this case, we managed to apply laser therapy to the left main bronchus
tumour successfully, so as to establish airway patency.
277
Poster Presentation
IP-P12-1
IP-P12-2
Endoscopic treatment of pulmonary alveolar proteinosis with whole lung lavage. The forlanini hospital experience
Endoscopic management of lung abscess: Prelim report
Servizio di Endoscopia Toracica, Ospedale San CamilloForlanini, Roma, Italy1), Unita Operativa di Chirurgia Generale
ad Indirizzo Toracico, Policlinico Paolo Giaccone, Palermo, Italy2)
Gabriele Lucantoni1), Giovanni Galluccio1),
Manuela Palazzolo2)
BACKGROUND:Pulmonary Alveolar Proteinosis (PAP) is a rare lung disease
characterised by abnormal intra-alveolar accumulation of surfactant-like lipoproteinaceous material. Clinical presentation is usually with non specific respiratory
symptoms such as dyspnoea or minimally productive cough. The clinical course
can be variable, ranging from spontaneous resolution to respiratory failure and
death. The appearance on HRCT is characterised by the typical crazy paving
pattern (FIGURE 1A). Recent advances now allow diagnosis by examination of
the milky fluid obtained by Bronchoalveolar Lavage (BAL) fluid. Although there
are no randomised controlled studies Whole Lung Lavage (WLL) is actually considered the most effective form of treatment. Our expericed would contribute to
confirm the efficacy and safety of this therapeutical approach.
METHODS:From 2001 to 2011 n̊ 10 subjects (6 male and 4 female; median age
35 5) were referred to our Endoscopy Center for the diagnosis and tretment of
PAP. All subjects had the typical HRCT bilateral pattern, and showed slightmoderate dyspnea (Borg Scale 3 1).Patiens were subjected to serial monthly
WLL alternating the lung. Under general anesthesia they were intubated by
Harrel-Dumon rigid bronchoscope and serial aliquots (50 ml each) of warm (36-37
̊C) neutral sterile saline solution were instilled into the whole bronchial segments,
using a flexible instrument, and draining the milky fluid from the selected lung.
The number of WLL for each patients was decided on the basis of clinicalradiological improvement and progressive clarification of BAL.
RESULTS: A median of 19 5 WLL were performed for each patients. All subjects had improvement of dyspnea, a progressive pulmonary clarification was
showed at HRCT (FIGURE 1B). No significant post-operative complications occurred during these procedures.
CONCLUSIONS:Our experience confirms the WLL could be considered the treatment of choice for PAP.
278
Dept of Internal Medicine, University of South Carolina, USA
Franklin Riley McGuire, Mohammed Moizuddin,
Alexis Stroman, Maria Cirino-Marcano
Background
Management of lung abscess is perplexing when patients do nott respond to antibiotic therapy. Transthoracic drainage techniques carry
high risk of complications and surgical resection is only plausible for
contained lobar infection. Unfortunately these patients are often poor
surgical candidates. given the challenges we designed an innovative endoscopic approach and treatment protocol for management of these patients. As part of a quality assurance review we report safety data on
the first five patients treated.
Methods
The setting is a single center 650 bed community hospital with an interventional pulmonary (IP) program. Failure of medical therapy was documented as persisting or deterioration of clinical symptoms and!or enlarging cavity size. We have reviewed the safety of patients with their
demographics, procedural and clinical management details. Outcomes
to report are catheter placement success, length of stay (LOS) in hospital and!or Medical intensive care unit, bacterial cultures within the cavity, complications associated with procedure, readmission rate and duration of antibiotic therapy. Patients had standard flexible bronchoscopy
with washout of their abscess cavity and under fluoroscopic guidance
with endoscopic catheter placement under fluoroscopic guidance to
flush the cavity.
Results
Five patients with lung abscess were identified as appropriate candidates for endoscopic management. Mean age was 57.8years, three of
them were males, upper lobe cavity was noted to be the affected site in
all patients (Right 40%, Left 60%). Successful endoscopic 5 French catheter placements were confirmed by fluoroscopic contrast in all patients.
No complications were noted except two endoscopic catheter dislodgements. Mean white cell count on admission was 14.5 billion cells!L. 80%
patients had positive broncheoalveolar lavage cultures and mean duration of intravenous antibiotic therapy was 14.6 days. One patient received installation of gentamycin therapy into the cavity through endobronchial catheter. Mean LOS was 14.4 days in hospital with all patient survival to discharge mean of 8.6 days. Twenty percent readmission was observed after 51 days.
Conclusion
Endoscopic drainage has been described but no studies have evaluated
the results of this approach. We are compiling a data on our endoscopic
management protocol and hope to provide an answer to the safety and
efficacy of this approach.
Poster Presentation
IP-P12-3
IP-P12-4
Air embolism following plasma coagulation, endobronchial stenting, and air insufflation for malignant airway
obstruction
Recurrent bronchogenic cyst after surgical resection
Dept of Internal Medicine, University of South Carolina, USA1),
Undersea and Hyperbaric Medicine, University of South Carolina School of Medicine, USA2)
Franklin Riley McGuire1), Erin R Hays1),
Matthew D Kolok1), Lindsie Cone2)
Background
Air embolism is a rare complication of interventional bronchoscopy.
There have been case reports of an air embolism occurring during:
transthoracic lung biopsy, endobronchial biopsy, use of a neodymium:
yttrium-aluminum-garnet (Nd-YAG) laser, and use of argon plasma coagulation (APC). We have used air insufflation as well as contrast media
to assess the potential of the lower lobe to re-expand. This is a case report of an air embolism following APC, endobronchial stenting, and use
of air insufflation for a malignant left lower lobe neoplasm.
Case Report
A 55 yo CM with a smoking history of 30 pack!years, was referred to
our pulmonary clinic due to hemoptysis and an atelectatic LLL on chest
x-ray. Bronchoscopy was performed with diagnostic and therapeutic intent. Transbronchial biopsies then APC was performed in the LLL.
Touch prep was positive for malignancy. An uncovered 3cm metal
stent was placed in the LLL, with subsequent air insufflation performed
under fluoroscopy showing intact airways and partial re-expansion of
the LLL (see Figure 1). Approximately 150 cc s of air was rapidly infused. Shortly after the procedure, the patient developed a perioral cyanosis followed by a bradycardia. He was given 1.5 amps of atropine and
a 1 liter bolus of normal saline and eventually required transcutaneous
pacing. No pneumothorax was noted on CXR, an EKG showed STelevation. The patient then had VF requiring defibrillation. The patient
was rushed to the cardiac catheterization lab, where imaging revealed a
mobile filling defect in the left ventricle suggestive of an air embolus.
After catheterization the patient was found to be neurologically intact.
Given his significant cardiovascular deterioration and the possibility of a
cerebral arterial gas embolism, the decision was made to perform hyperbaric oxygen (HBO) therapy. The patient had a full cardiovascular
and neurologic recovery following a single treatment.
Conclusion
Prior to the case described, no adverse events had been noted during
air insufflation in our practice. Following the complications associated
with this case, we have reevaluated the use of air insufflation and we
feel it can still remain a useful tool particularly in patients with contrast
sensitivity. Use should be limited to gradual, low pressure only techniques, with contrast bronchography being considered the modality of
choice.
Respiratory Institute, Cleveland Clinic Foundation, USA
Abdul Hamid Alraiyes, Michael Machuzak
Background: Bronchogenic cysts (BCs) are rare congenital
anomalies that arise early in gestation from abnormal budding of the developing respiratory system. Abnormal bronchi or bronchioles may form large saccular structures, which
may later form cystic lesions. Typically, bronchogenic cysts
do not have alveolar structures but have ciliated epithelium
with cartilage, smooth muscles and mucus producing bronchial glands similar to bronchial walls. BCs usually take time,,
often more than 10 years to appear. There are reports of recurrence of BC after resection including the need for a reoperation. We report a case of a recurrent BC 8 years after
resection treated with drainage using Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA).
Case report: A 67-year-old male patient presented with exertional dyspnea for 1 month. He denied chest pain, cough or
hemoptysis. His past history was significant for hypertension, atrial fibrillation and a bronchogenic cyst. The BC was
diagnosed 20 years ago followed by surgical resection 8
years ago. His follow-up included periodic surveillance computed tomography of the chest, which revealed recurrence
of the bronchogenic cyst. On examination, vital signs were
normal. He was not in respiratory distress. Chest exam
showed relatively good air entry to both sides with no added
sounds. Other systemic examination was unremarkable.
Laboratory findings were within normal values. CT- chest
showed a large recurrent bronchogenic cyst. There was increasing mass effect from the lesion with severe narrowing
of the left main pulmonary artery. EBUS-TBNA was performed (Figure) and 56 ml of white cloudy fluid was drained
from bronchogenic cyst. Fluid culture showed no growth
and cytology was negative for malignant cells. Post intervention the patient was discharged home with improvement in
his exertional dyspnea and will follow up in pulmonary clinic
with a CT chest in 6 months.
Conclusion: Recurrent BCs have been reported with caes of
incomplete surgical excision. These BCs usually take many
years to appear. Our case describes a successfully drained
BCs following resection 8 years prior to presentation.
279
Poster Presentation
IP-P12-5
IP-P12-6
Seven cases of endobronchial tumor diagnosed with
brochoscopic examination
A pilot study for intractable benign central airway
stenosis: Surgical treatment combined with interventional therapy
Division of Respiratory diseases, Department of Internal medicine, Jikei University School of Medicine, Japan
Takanori Numata, Yusuke Hosaka, Hiroshi Wakui,
Yutaka Yoshii, Naoki Takasaka, Jun Kojima,
Hiromichi Hara, Kenichiro Shimizu, Makoto Kawaishi,
Jun Araya, Yumi Kaneko, Katsutoshi Nakayama,
Kazuyoshi Kuwano
Background:
Endobronchial tumors are a relatively rare clinical condition.
The paucity of related abnormal findings in chest X-ray images can lead to delays in ordering diagnostic tests, including
CT scan and bronchoscopic examination. To elucidate the
clinical manifestations of endobronchial tumors and thus
avoid a delay in diagnosis, we conducted retrospective evaluations of the clinical characteristics of seven cases diagnosed
as endobronchial tumor upon bronchoscopic examination.
Subjects and methods:
Of the 873 patients that underwent flexible bronchoscopy
(FBS) from April 2008 to March 2013 in our hospital, seven
patients were diagnosed with endobronchial tumors (0.8%).
We performed retrospective examinations of their clinical
features, radiological findings, histopathological diagnoses,
and treatment modalities.
Results:
Seven patients were included in this study (4 male and 3 female; mean age, 49.1 years.). Mean duration from the onset of
symptoms to diagnosis was 4.4 months (0.25-18 months). One
patient was treated as refractory bronchial asthma for 18
months. The major symptoms were cough (n=7), dyspnea
(n=3), and hemosputum (n=3). Endobronchial tumors were
located in the right bronchus in one patient (intermediate
bronchus) and the other six patients had tumors localized in
the left main bronchus (n=2), left upper bronchus (n=2), and
left lower bronchus (n=2), respectively. All patients demonstrated endobronchial lesions on chest CT scan examination,
but four patients had the chest X-ray abnormalities which
were very difficult to point out. Pathological diagnosis were
squamous cell carcinoma (n=2), mucoepidermoid carcinoma
(MEC) (n=2), adenocarcinoma (n=1), atypical carcinoid (n=1),
and lipoma (n=1). The adenocarcinoma patient was treated
with conccurent chemoradiotherapy and snare resection
was performed for the lipoma patient. Surgical resections
were performed for the rest of the patients.
Conclusions:
Endobronchial tumors should be considered in patients complaining of refractory cough without abnormal findings in radiological examinations. Hence, FBS examination should be
performed to avoid a delay in diagnosis.
280
Department of Interventional Pulmonlogy, The First Affiliated Hospital of Guangzhou Medical University, China
Yu Chen, Li Shi Yue, Chen Hanzhang, Wang Jun
Objectives: To evaluate the efficacy and security of surgical
treatment combined with Interventional therapy for benign
central airway stenosis(BAS).
Methods: Seven intractable BAS patients were selected into
treatment group from Oct. 2011 to Oct. 2013. Stenosis causes,
types, position, degree and duration were evaluated. Surgical
treatment including: resection of tracheal stenosis segment,
end-to-end anastomosis, and silicone tube implant in the trachea, external fixation with nylon line. Schedule postoperative bronchoscopy procedures were operated and the corresponding complications were solved. After a 12 months
follow-up, compared the airway diameter, airway stricture
rate, dyspnea score, clinical stationary time before and after
the therapy to evaluate its curative effect and side effect.
Tracheal stenosis segments were sent to histopathologic examination, including observation at high magnification, special staining test, immunohistochemical test, analysis of the
cause of the refractory.
Results:Seven patients with intractable benign central airway stenosis were treated. Stenosis segments located in the
subglottic (1.86 0.62) cm, (2.87 0.48) cm in length, preoperative interventional treatment for an average of 8.8 (5∼22)
times. The recent effective rate was 100%.(Table 1)
A 12 months follow-up, 6 patients, did not appear restenosis;
1 patients appear restenosis and received balloon dilation
and metal stent. Clinical stationary time was increased from
(8.72 4.86) days before the therapy to (188.83 87.30) days after therapy (P<0.01).
Tracheal stenosis segment pathology: cartilage lesions 71.4%
(5!
7), granuloma formation 57.1% (4!
7), submucosal fibrous
tissue hyperplasia 57.1% (4!
7), bronchial epithelial squamous
metaplasia 42.8% (3!
7).
Conclusion: Surgical treatment combined with Interventional therapy for BAS has good curative effect. The tracheal
cartilage lesion, granuloma hyperplasia may be the important factors of intractable stenosis.
Poster Presentation
IP-P12-7
IP-P12-8
Not all who wheezes are asthmatics
Esophageal perforation with esophago-pleural fistula
< empyema sinistra complications in diabetic adult
man
Department of Internal Medicine, Universiti Putra Malaysia,
Malaysia1), Department of Internal Medicine, Serdang Hospital2)
Liza Ahmad Fisal , Azlina Samsudin ,
Jamalul Azizi Abdul Rahaman2)
1)
2)
Background: Malignant central airway obstruction usually
develop gradually resulting in patients incorrectly diagnosed
as asthma or chronic obstructive pulmonary disease leading
to delayed diagnosis and treatment. In our clinical case series
with present two patients with malignant endobronchial lesions masquerading as asthma who had undergone curative
endoscopic therapy.
Case report: The first patient was a 38-year-old gentleman
who presented with a chronic cough associated with breathlessness. He was empirically treated as asthma but did not
respond to standard treatment. Eight years prior, he had a
curative lobectomy (right middle lobe and right lower lobe)
for mucoepidermoid carcinoma. Given the previous history
of malignancy, a flexible bronchoscopy was performed and
revealed a stalked lesion in the left main bronchus which
was successfully snared and removed during rigid bronchoscopy under general anaesthesia. Histopathological examination revealed recurrent mucoepidermoid carcinoma. Residual nodules were removed using cryoablation & argon
plasma coagulation. Since computed tomography of the thorax showed localised disease and surgical intervention was
not advisable considering his previous lobectomy, he was
closely monitored by surveillance bronchoscopy which had
not shown disease recurrence.
The second patient was a 30-year-old lady who presented
with increasing shortness of breath at 12 weeks of gestation.
She too was empirically treated as asthma but then developed haemoptysis. Chest radiography revealed a collapsed
right upper lobe where computed tomography of the thorax
confirmed an obstructing lesion originating from the right
upper lobe bronchus. Flexible bronchoscopy demonstrated a
cherry-red mass in right main bronchus. Shortly after she
delivered, we performed a diagnostic cryoprobe biopsy during rigid bronchoscopy under general anaesthesia and histopathological examination revealed typical carcinoid. Unfortunately, the base of the tumour was located at the proximal
end of the right upper lobe bronchus thus prohibiting curative lobectomy. Consequently, she had 4 therapeutic rigid
bronchoscopies utilising a combination of cryoablation and
argon plasma coagulation where the tumour has been successfully removed. Surveillance bronchoscopy had shown
complete resolution of the tumour.
Conclusions: The therapeutic approach for malignant central
airway obstruction utilises several treatment modalities
which may preserve healthy lung which would otherwise be
resected. Patient selection is vital and close monitoring is
necessary in order to identify any complications and recurrences early and intervene accordingly.
Pulmonology and Respiratory Medicine, Brawijaya University
Indonesia1), Surgery Departement, Brawijaya University, Indonesia2), Internal Departement, Brawijaya University, Indonesia3), Radiology Departement, Brawijaya University, Indonesia4)
Sri Handayani Rahayu1), Susanthy Djajalaksana1),
Setyo Sugiharto2), Rulli Rosandi3), Islana Gadis Yulidani4)
Background Esophageal perforation is a rare condition. Its
clinical presentation can mimic other diseases < it can be
easily misdiagnosed. Late diagnosis < management can lead
to poor results < increase the risk of complications as
esophago-pleural fistula < empyema. The presence of Candida in pleural fluid < the absence of other sources of infection may be the cause of esophageal perforation < esophagopleural fistula formation. The main purpose of esophageal
perforation treatment to prevent further contamination <
eliminate the infection it causes, restore the integrity of the
gastrointestinal tract, maintain the patient s nutritional intake.
Case Illustration A thirty-two-years-old male with severe
vomiting < history of severe retrosternal pain < shortness of
breath came to our hospital. Blood examination showed diabetic ketoacidosis. Chest x-ray shows left pleural effusion <
two days later the Chest X-ray shows pneumothorax < suspected malposition of nasogastric tube. We found empyema
from thoracocentesis < Candida in cytology examination. Upper Gastro Intestinal radiologic examination shows suspected gastro-pleural fistula, but follow up esophagogastroduodenoscopy showed two fistulas in esophagus. There was
no sign of mediastinitis. Our final diagnosis was diabetes mellitus with esophageal perforation with esophago-pleural fistula < empyema sinistra complications. The patient was then
managed conservatively by keeping the chest tube drainage
< had gastrostomy surgery to avoid peroral intake. During
the period of treatment, we found pus from naso gastric tube
< chest tube. We recheck the pus culture < found secondary
infection by Acinotebacter baumanii. After the patient was
treated according to the drug sensitivity test result, the pus
production decreased significantly < then the patient was
discharged with gastrostomy.
Conclusion Holistic examination plays an important role in
diagnosis < management of esophageal perforation. Conservative therapy should be followed by definitive therapy.
281
Poster Presentation
IP-P13-1
IP-P13-2
Do antidepressants increase the risk of bleeding during percutaneous tracheostomy?
Bronchoscopic and angiographic comparison of endobronchial vascular lesions in patients with hemoptysis
Department of Internal Medicine, The Ohio State University
Wexner Medical Center, USA1), Department of Internal Medicine, University of Louisville, United Sates2)
Muralidhar Kondapaneni1), Adam Abdulgadir1),
Umair Gauhar2), Rebecca Cloyes1), Rakin Hoq1),
David Chambers1), Timothy Udoji1), Shaheen Islam1)
INTRODUCTION: Bedside percutaneous tracheostomy (PT) is now routinely performed in the intensive care units. A recent large observational
study has shown that selective serotonin reuptake inhibitors (SSRI) are associated with increased risk of bleeding and transfusion in surgical patients.
SSRIs were known to cause increased upper gastrointestinal bleeding.
SSRIs affect coagulation cascade and platelet function and may result in
bleeding complications during PT. A thorough literature review did not reveal any studies that evaluated the association of bleeding complications of
these agents with PT. We present our experience of PT in patients on SSRIs
and selective nor-epinephrine reuptake inhibitors (SNRI) at a tertiary university hospital.
METHODS: Retrospective chart review was performed on patients who underwent PT between December 2008 and June 2013. All patients that underwent PT were identified from our procedure database. We collected information regarding demographics, use of SSRI!SNRI, complications and
procedural details. Risk factors of patients on SSRI!SNRI (Group A) were
compared to those who were not on these medications (Group B). Bleeding
of 5 mL or more was considered significant. We classified 5 to 19 ml as minor
bleed and any bleeding of 20ml or more as major. Two tailed p value with
95% confidence interval was used for analysis. Student s t-test was used for
continuous variables and chi-square was used for categorical variables.
RESULTS: 199 records were available for review. 26 patients were on SSRIs
(Table 1A). There was no statistically significant difference on baseline characteristics between the two groups. 11.5% patients in group A (3 out of 26)
had bleeding compared to 13.9% in group B (24 out of 173), which was not
statistically significant (p=0.86). Although all patients in group A had major
bleeding it was not statistically significant (p=0.15) compared to group B.
Overall, 13.2% of patients had bleeding of 5ml or more. There was no significant correlation between the dose of SSRI!SNRI and bleeding. There was
no statistically significant difference in the use of electrocautery, procedural
hypotension and pressor requirement between the two groups (Table 1B).
CONCLUSION: PT can be safely performed on patients on SSRI or SNRI
without any increased risk of bleeding.
CLINICAL IMPLICATIONS: Although limited by retrospective nature and
small sample size, this study reports the safety of PT in patients on SSRI or
SNRI and the importance of close monitoring for major bleeding.
282
First Department of Respiratory Medicine, Yanan Hospital
Affiliated to Kunming Medical University, China1), First Department of Respiratory Medicine, First Affiliated Hospital of
Kunming Medical University, China2)
Xi-Qian Xing1), Jiao Yang2), Yan-hong Liu1), Ze-ming Yu2),
Xu-wei Wu1)
Background In order to study the bronchoscopic and angiographic findings of endobronchial vascular lesions in patients with hemoptysis and to observe changes of the lesions after bronchial artery embolization.
Methods We retrospectively analyzed the bronchoscopic and angiographic data of patients with hemoptysis and endobronchial vascular lesions in two affiliated hospitals of
Kunming Medical University from January 2008 to December 2012.
Results There were 7 patients (3 men and 4 women; age range, 18-46) with endobronchial
vascular lesions and with hemoptysis duration 4 days to 1 year. The vascular lesions were
all located in the third-order and were divided into three types according to the lesion
morphology, tubular bulging type, mass-like type and haemangioma type. There were 6
cases located in the right bronchus and one case located the left bronchus. There were 2
cases located in the right B10, 2 cases located in the right B6, 1 case located in the right B7,
1 case located in the right B5, 1 case located in the left lingular bronchus. According to the
lesion morphology, 5 lesions were the tubular bulging type, 1 lesion was the mass-like type
and 1 lesion was the haemangioma type. All the patients underwent a bronchial arteriography. Bronchial angiographic findings revealed hypervascularity, dilatation, and tortuosity of bronchial arteries which corresponds with the location of the endobronchial lesions.
4 of the 7 cases showed the bronchial artery-pulmonary artery fistula, 1 case showed the
bronchial artery-pulmonary venous fistula, 2 cases showed the bronchial artery rupture.
All the patients were treated with bronchial arterial embolization, and 1 patient were
treated with surgical resection of lung segment after bronchial artery embolization. The
follow-up period was 3 months to 5 years. There were no further hemoptysis in 6 patients,
one patient had a small amount of hemoptysis again. Bronchoscopy showed disappearance
or diminution of the endobronchial vascular lesions observed before treatment.
Conclusions Endobronchial vascular lesions were mainly located in the right lower lobe
bronchus. When bronchoscopy showed vascular lesions protruding into the lumen, biopsies should be cautious, bronchial arteriography should be considered in order to exclude
the possibility of bronchial artery disease and avoid potential bleeding risks. These implications of the correspondence between the bronchoscopic findings and the angiograms
should be most useful when using bronchoscopy in the management and treatment of endobronchial.
Poster Presentation
IP-P13-3
IP-P13-4
Massive bleeding as severe complication during flexible bronchoscopy: 5 cases with literature review
Hemoptysis in lung cancer patient in Persahabatan
Hospital Jakarta Indonesia: Outcome and prognosis
Department of Respiratory Medicine, The Second Xiangya
Hospital, Central South University, China1), Department of
Respiratory Medicine, Changsha Central Hospital, Changsha,
China2)
Kui Xiao1), Jiehan Jiang2), Shan Cai1), Lanyan Zhu1),
Yingjiao Long1), Zhihui Shi1), Naixin Kang1),
Dongyuan Zheng1), Rui Zhou1), Ping Chen1)
Background: Flexible bronchoscopy is widely used for the diagnosis and therapy of various types of pulmonary diseases.
Concerns have been raised about its complications especially
massive bleeding.
Methods: We retrospectively analyzed the clinical features
and emergency treatments in the massive bleeding cases in
the past 7 years with literature review.
Results: From Aug 2006 to July 2013, 19078 cases were performed either diagnostic or therapeutic bronchoscopy in our
department. Among them, severe bleeding occurred in 5
cases. Table 1 shows the clinical features of these 5 cases.
During the emergency treatment, all cases had preestablished venous channel except case 1#, no patient got
suffocated, while case 1# and 2# had hemorrhagic shock and
case 1# died. When massive bleeding occurred, we laid the
patient on the side of bleeding and supplied with high flow
oxygen, we kept the bronchoscope vision clear and sustained
suction. The transbronchial hemostasis methods we applied
including locally spray 1: 10,000 noradrenaline, hemocoagulase, 4̊C normal saline. Other hemostasis treatments were
normal saline and pituitrin intravenous infusion, hemocoagulase intravenous injection, pituitrin intramuscular injection
and emergency transfusion.
Conclusion: Though flexible bronchoscopy is a comparatively safe process for pulmonary diseases patients, massive
bleeding should always be on high alert. Five key points that
may save patients lives when the massive bleeding occurs
are: pre-established venous channel, laid the patient on the
side of bleeding, kept the bronchoscope vision clear and sustained suction, comprehensive treatment measures and
team work.
Pulmonology and Respiratory Medicine, Faculty of Medicine
University of Indonesia, Persahabatan Hospital, Jakarta, Indonesia
Wiendo Syah Putra, Sita laksmi Andarini,
Wahju Aniwidyaningsih, Faisal Yunus
Background
Hemoptysis is one of the respiratory emergency case and
sometimes fatal due to asphyxia. To evaluate the burden of
lung cancer patients with hemoptysis in our institution.
Materials and Methods
A cohort retrospective study on 1025 hospitalized lung cancer patients from January 1, 2012 until July 31, 2013. The total number of patients with hemoptysis was 15 patients
(1,4%).
Results
All patients were male and mostly (80%) aged over 40 years
old. The volume of hemoptysis at the hospital admission varied from blood streak to 250 mililitres (ml). Patients with hemoptysis for the first time nearly as much with recurrent hemoptysis in 7 patients (47%) versus 8 patients (53%). The histologic of lung cancer most commonly was adenocarcinoma
in 8 patients (53%), stage IV in 10 patients (67%), Performance Status 2 in 9 patients (60%), ex-smokers (80%) and
heavy smokers (40%) and hemoglobin concentration was>10
gr!
dl in 13 patients (87%). The thoracic CT-scan with contrast showed the number of locations in central lung tumors
and in the peripheral lung was comparable in 8 patients
(57%) versus 7 patients (47%). The fiber optic bronchoscopy
showed generally mucosal edema, infiltrative stenosis and
blunt karina. The treatment for hemoptysis were hemostatic
drugs in 13 patients (87%) and radiotherapy in 2 patients
(13%). No death case related to hemoptysis in this study. Further study should be done to evaluate impact of hemoptysis
in larger populations.
Conclusion
Lung cancer patients with hemoptysis had the most type of
adenocarcinoma, stage IV, no massive hemoptysis and the
bronchoscopy showed mucosal edema, infiltrative stenosis
and blunt karina. No death case related to hemoptysis.
283
Poster Presentation
IP-P13-5
IP-P13-6
Massive hemoptysis in patient with normal chest X-ray
using flexible bronchoscopy at Pelni Hospital, Jakarta,
Indonesia
Role of bronchoscopy in management of totally left
lung atelectasis due to massive hemoptysis
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Indonesia, Indonesia1), Division
of Pulmonology, Pelni Hospital, Jakarta, Indonesia2), Division of
Anesthesiology, Pelni Hospital, Jakarta, Indonesia3)
Prasenohadi Sabarto Pradono , Asep Deni Hamdani
1,2)
3)
Introduction. Hemoptysis is an expectoration blood from
lower respiratory tract and one of the alarming symptoms of
an underlying pulmonary problem. It may present as minimal blood-streaked sputum or a moderate to massive hemoptysis. A widely accepted definition of massive hemoptysis is
more than 600 ml of expectorated blood in 24 h. Chest X-ray
(CXR) can identify the site of bleeding (33-82%) of massive hemoptysis, while the yield for localization of bleeding site using computed tomography scan (CT scan) is up to 88%. It has
been a long debate whether CT should be done first before
bronchoscopy or the reverse. We reported a case of massive
hemoptysis with normal CXR.
Case Presentation. A 23 years-old man admitted with massive hemoptysis. No history of pulmonary tuberculosis,
smoking or chest trauma. In physical examination, patient
was alert with stabile hemodynamic, chest wall was symmetric in static and dynamic, percussion was resonance in both
lungs, and auscultation was crackles in base of both posterior
lungs. CXR was no significant abnormalities. We decided to
perform bronchoscopy and found active bleeding from both
right and left main bronchus. Later, CT-scan examination
found abnormalities in posterior of both lungs.
Discussion. Massive hemoptysis was an emergency and life
threatening. Even CXR can identify the site of bleeding, but
in our case CXR was normal. We performed flexible bronchoscopy (FB) and found a site of bleeding and treated using
adrenalin. In our case CXR had limitation because the site of
bleeding could not be identify due to posterior bilateral location. However, FB is more likely to reveal and localize the
site of bleeding. CXR and CT scan combined with FB is usually needed to reach a definitive diagnosis in majority of
cases. However, CT scan is superior in localizing pathology,
identifying the etiology, guiding definitive therapy and can
replace FB as a first-line investigational approach in patients
with massive hemoptysis.
Conclusion. Patients who suffer massive hemoptysis with bilateral abnormalities in lung and normal CXR, FB still a
choice for diagnostic tool. FB was useful in massive hemoptysis to find the site of bleeding and localization, even optimal
timing of FB (early vs. late) remains a controversial issue.
284
Departement of Pulmonology and Respirology medicine, University of Brawijaya, Indonesia1), Department of Radiology,
University of Brawijaya, Indonesia2), Department of Mikrobiology, University of Brawijaya, Indonesia3)
Normawati Darmawan1), Yani Jane Sugiri1),
Achmad Baihaqy2), Sumarno Sumarno3)
Backrground Atelectasis is caused by a blockage of the air
passages (bronchus or bronchioles) or by pressure on the
outside of the lung. Atelectasis is divided into obstructive <
non obstructive causes. Obstructive atelectasis is the most
common type < results from reabsorption of gas from the alveoli when communication between the alveoli < the trachea
is obstructed. Causes of obstructive atelectasis include foreign body, tumor, < mucous plugging. Fibreoptic bronchoscopy to aspirate secretions has been used in the management of proximal airway obstruction, < has been found to resolve atelectasis successfully in 26 of 35 (74%) paediatric intensive care patients.
Case Illustration A 21 years old male came to Emergency
Room with chief complaint hemoptysis. Physical examination, blood tests < chest x-rays showed normal results. Patients had massive hemoptysis again on the second day of
hospitalization. Evaluation of chest X-ray showed radioopaque shadow on the lower left lung with suspected
pleural effusion. Confirmation with ultrasound did not find
pleural effusion in both the right < left pleural space. Lung
physical examinations on the eight day of hospitalization
showed decreased breath sounds in all area of the left lung.
Chest X-ray evaluation showed total atelectasis of the left
lung. Bronchoscopy was performed to determine the cause
of atelectasis, the source of bleeding < for blood clot evacuation. The bronchoscopy was performed twice. The first
bronchoscopy found that blood clot totally obstruct the left
main bronchus. We performed blood clot aspiration, the result is not satisfying. After the second bronchoscopy < aspiration of blood clot, we found improvement on the CXR
evaluation. Sputum smear examination for Acid Fast Bacille
< culture of bronchial fluid on LJ media was negative. During hospitalization the patient received therapy: (1) Medication: Non specific antibiotics, first cathegory of antituberculosis drug, hemostatic drugs < symptomatic medications, (2)
Bronchoscopy to evacuate the blood clot and collect the
bronchial fluid, (3) Chest Physiotherapy.
Conclusion Tuberculosis infection is common in Indonesia <
the most frequent cause of hemoptysis in Indonesia is tuberculosis, we conclude that the patient suffered from tuberculosis. Patients were discharged with improved clinical symptoms confirmed by chest X-ray.
Poster Presentation
IP-P13-7
IP-P13-8
Assessment of pulmonary hemorrhage by bronchoscopy and CT findings in patients treated with bevacizumab
Spray cryotherapy for hemoptysis due to fibrosing mediastinitis
Division of Respiratory and Infectious Disease, Department of
Internal Medicine, St. Marianna University School of Medicine, Japan1), Department of Chest Surgery2)
Naoki Furuya1), Hiromi Muraoka1), Mariko Okamoto1),
Ayano Usuba1), Teppei Inoue1), Kei Morikawa1),
Hirotaka Kida1), Hiroshi Handa1), Miwa Fujiwara1),
Hiroki Nishine1), Atsuko Ishida1), Seiichi Nobuyama1),
Takeo Inoue1), Masamichi Mineshita1), Noriaki Kurimoto2),
Teruomi Miyazawa1)
Background
Pulmonary hemorrhage (PH) is a serious adverse event for
patients treated with bevacizumab (BV). Previous studies
have identified PH risk factors as tumor cavitation, location,
and endobronchial invasion confirmed by computed tomography (CT). However, for endobronchial invasion, we believe confirmation should be judged by bronchoscopy. The
aim of this study is to demonstrate the relevance of bronchoscopic findings for patients with PH and treated with BV.
Methods
Retrospective analysis of non-small cell lung cancer was performed on patients treated with combination therapy including BV, as a first line chemotherapy at St. Marianna University Hospital between April 2010 and November 2013. Clinical data were retrieved from medical records and criteria
from previous studies were used to identify tumor locations.
Bronchoscopic findings were classified as follows; epithelial,
subepithelial, extraluminal, and normal.
Results
Of the thirty-two patients analyzed in this study, 27 patents
underwent bronchoscopy before BV treatment. The median
age was 62 years (range 38-78), and adenocarcinoma was confirmed in all patients histologically. PH was present in 12.5%
patients (4!
32, all Grade1), and the location of tumors (central
vs. peripheral), was not a significant risk factor for PH. Bronchoscopic classification of patients for epithelial, subepithelial, extraluminal, normal were; 0, 20, 0, 7, respectively. Dilatation findings of subepithelial vessels were seen in 3 cases (3!
27). There was no significant difference for PH in bronchoscopic classifications (subepithelial vs. normal); however, patients with dilatation findings of subepithelial vessels were at
significantly higher risk for PH (p<0.01).
Conclusion
It might be possible that patients were safely treated with
BV in spite of central lesions confirmed by CT. However,
dilatation finding of subepithelial vessels should be observed
carefully under bronchoscopy, since these findings may predict PH risk factors for BV.
Interventional Pulmonary Program, Louisiana State University Health Sciences Center, USA1), Interventional Pulmonary
Program, Titus Regional Medical Center, USA2)
Adam Wellikoff1), Gordon Downie2)
Background
Fibrosing mediastinitis (FM) is an uncommon diagnosis that, in the United States, is
usually associated with previous Histoplasmosis capsulatum infection. It is estimated
that of the over 500,000 people per year in the US infected with Histoplasmosis , less
than 1% will develop FM. The natural history of FM is that of indolent progression
leading to compression of surrounding structures including the airways, esophagus
and vascular structures. Hemoptysis is a rare complication caused by various mechanisms including invasion of mucosa by fibrous tissue, post-obstructive necrotizing
pneumonia, pulmonary venous (PV) obstruction leading to PV hypertension, and pulmonary artery (PA) obstruction leading to functional anastomoses between the intercostal!bronchial arteries and the PA. Few techniques have been described to manage
FM-related hemoptysis including Nd:YAG laser and radiation therapy. We describe a
case of FM-related hemoptysis treated successfully with endobronchial spray cryotherapy (SCT).
Case Report
A 44-year-old man presented with previously diagnosed FM. His course was complicated by left PV obstruction requiring stenting. Patient presented with chronic cough
that later became notable for hemoptysis that eventually lead to hypoxemia and hospitalization. Initial flexible bronchoscopy revealed hyperemic mucosa that bled with the
slightest touch of the scope. Patient was then referred for SCT which he received over
the course of two separate treatments. The first treatment was directed at the left
mainstem bronchus and second to the carina. On follow-up 4 weeks later the patient
endorsed significant improvement in his cough. Repeat bronchoscopy showed complete resolution of the hyperemia and patient had no further episodes of hemoptysis at
six months post-treatment.
Conclusion
Spray cryotherapy is a non-contact mode of cryotherapy using a low-pressure delivery system allowing for treatment of wide areas. This modality has been used extensively in the GI tract with proven efficacy and safety. Several case reports and articles
have now demonstrated equal safety and efficacy in various structures of the pulmonary system including the airways and pleura. Histologically, SCT in the airway
causes necrosis limited to the mucosal and submucosal layers up to 1.5mm in depth including the underlying vasculature. Studies have shown no damage to the connective
tissue or extracellular matrix. Although cryotherapy via probe-device is well established as a means of managing endobronchial lesions, very little has been reported on
the use of cryospray. Reports of SCT for endobronchial disease exist, but very few describe benign disease. This is the first report of the use of this technology in FM.
285
Poster Presentation
IP-P14-1
IP-P14-2
Delayed mediastinal abscess after endobronchial
ultrasound-guided transbronchial needle aspiration for
sarcoidosis
Mediastinal abscess and tracheal granuloma formation complicating EBUS-TBNA due to tuberculosis: A
case report
Respiratory Medicine, University of Sherbrooke, Canada
Elaine Dumoulin, Brian Beaudoin,
Andree-anne Gagnon-audet, Yannick Poulin,
Robert Boileau
Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)
is a minimally invasive procedure. It is becoming a useful tool for diagnosis of benign diseases
including sarcoidosis. This technique has a low complication rate reported in the literature. To
our knowledge, no infectious complications of EBUS-TBNA in patients with sarcoidosis have
been published, although a case series has been reported with endoscopic ultrasound fine needle aspiration (EUS-FNA). We report a case of infectious complications one month following
EBUS-TBNA in a patient with sarcoidosis. It is possible that delayed complications are underreported. This could be of concern now that the technique is more widely used for benign condition.
Case report: We present a 42-year-old male having a suspected stage 2 sarcoidosis presenting
with increasing shortness of breath and thoracic chest pain. He underwent an EBUS-TBNA as
well as a flexible bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsies
(BTB). The results from cytology and pathology were consistent with sarcoidosis. Three weeks
after the procedure, the patient presented to a community hospital with increasing chest pain.
He had no infectious symptoms. He underwent a computed tomography (CT) angiography to
rule out a pulmonary embolism. No emboli were detected and the paratracheal region, although
enlarged, was not suspected of being infected. The patient had a short course of antibiotics
without improvement of his symptoms. A decision was made to stop the antibiotics and a
course of prednisone was given suspecting symptoms related to sarcoidosis. Three days after
the beginning of the therapy, the patient started having low-grade fever and coughed up smelly
thick secretions. A chest CT was repeated and showed an enlarged mediastinal abscess with
air-fluid levels in the paratracheal region (figure 1). The patient underwent an urgent mediastinoscopy for drainage and cleaning of the area. Thick pus was evacuated. The patient was then
treated with four weeks of moxifloxacin. Cultures obtained during surgery were negatives. A
repeat CT at one month showed complete regression of the mediastinal abscess.
Conclusion: Although EBUS-TBNA is a safe procedure, it is believed that the complication rate
is underreported. Our case shows an infectious complication requiring an invasive surgical
treatment in a patient with sardoidosis. The complication was diagnosed one month following
the procedure, which can explain initial misdiagnosis. When using a technique for a benign condition, it is important to know the real complication rate in regard of a risk-benefit evaluation.
286
Department of Medicine, Pamela Youde Nethersole Eastern
Hospital, Hong Kong
Yi-Tat Lo, Kwok-cheung Lung, Martin CW Tong,
Annie PH Chiu, Ho-yin Lo, Flora PL Miu, Loletta KY So
BACKGROUND: Endobronchial ultrasound guided- transbronchial needle aspiration (EBUS-TBNA) is increasingly applied in diagnosing mediastinal lesion as it is semi-invasive
and reported to be safe. We report complications after this
procedure.
CASE REPORT: A 60-year old man presented with one episode of blood streak sputum. Chest radiograph (CXR)
showed bilateral fine nodules. Sputum acid-fast bacilli (AFB)
smear and culture, and cytology were negative. Computed
tomography (CT) of thorax showed bilateral lung nodules
and multiple enlarged mediastinal lymph nodes.
He underwent EBUS-TBNA to stations 4R, 7 (both 3 passes
each) and 11R (2 passes). The procedure was smooth and uneventful. The TBNA specimens showed no malignancy, AFB
and fungal culture were negative. Three weeks after the
procedure, he was admitted for epigastric pain and fever.
CXR was similar and CT abdomen showed no evidence of
bowel perforation. His epigastric pain subsided spontaneously but fever persisted despite few weeks antibiotic and
clinically not septic. Microbiological work up was negative.
His Mantoux test (MT) 2 was strongly positive. Empirical
anti-tuberculous (TB) drugs (Isoniazid, Rifampicin, Ethambutol and Pyrazinamide) were started with good clinical response. Later CT thorax showed a larger mediastinal lesion
with central hypodensity likely lymph node necrosis or abscess; and thin rim of pericardial effusion. Repeated sputum
showed AFB smear positivity finally in one specimen and
culture confirmed Mycobacterium tuberculosis. Interval CT
thorax 2 months after anti-TB treatment showed reducing
mediastinal abscess size, similar thin rim of pericardial effusion, but there was a minute density within the trachea.
Bronchoscopy revealed 2 small tracheal nodules over previous EBUS-TBNA puncture sites at station 4R and biopsy
confirmed granulation tissue with negative MTB-PCR. The
patient was continued with anti-TB medications and monitored by interval CT.
CONCLUSION: Mediastinal abscess and tracheal granuloma
formation can be complicated after EBUS-TBNA in patient
with tuberculosis.
Poster Presentation
IP-P14-3
IP-P14-4
Microbial patterns of bronchial washing in patients
with lung cancer
Microbial analysis of transthoracic needle biopsy for
pulmonary nodules
Department of Pulmonology and Respiratory Medicine, University of Indonesia, Indonesia1), Departement of Clinical Microbiology, Persahabatan Hospital, Indonesia2)
Gatut Priyonugroho1), Cahyarini Dwiatmo2), Faisal Yunus1)
Introduction. Infections are considered to be a part of the
natural course of lung cancer. Infections can worsen the condition of the patients and can be fatal. Underlying diseases
and medical procedures may play role in the pathogenesis of
infections. The aim of this study is to analyze the pattern of
potentially pathogenic bacteria infecting or colonizing the
bronchial tree in patients with lung cancer. The microbial
pattern can be considered when administering empirical antibiotics treatment in lung cancer with bacterial infection.
Methods. Medical records of patients who undergone bronchial washing between November 2012 to December 2012
were reviewed. We analyzed patients with lung cancer
among them. Gram stains and identifications on specimens
collected bronchoscopically were performed. The number of
bacteria present in 1 ml of fluid was estimated by quantitative culture.
Results. The study included 32 patients (20 males and 12 females) with lung cancer aged from 35 to 74 (mean age of 56,9
years). In all patients, bronchial washing was performed during bronchoscopy from November 2012 to December 2012.
The types of lung cancer were adenocarcinoma (n=23),
squamous cell carcinoma (n=5), small cell (n=3), and large cell
(n=1). In three cases (9,4%), pathogenic bacteria was isolated
which was Gram-negative in all cases. Klebsiella pneumoniae
was isolated in three cases, Pseudomonas aeruginosa in one
case, and Stenotrophomonas maltophilia in one case. In one
case of small cell lung cancer, both K.pneumoniae and P.
aeruginosa were isolated. Two another cases of lung cancer
were adenocarcinoma. In one case, both extended-spectrum
β-lactamase K.pneumoniae and S.maltophilia were isolated.
Discussion. Gram-negative bacteria when infecting lower
respiratory tract is associated with higher morbidity and
mortality and is more common in nosocomial infection. K.
pneumoniae may present extended-spectrum β-lactamase
that mediate resistance to third- and forth-generation cephalosporins. P.aeruginosa is the most common cause of cavitary pneumonia, associated with very high mortality rate,
and should be treated with two synergistic antibiotic. S.maltophilia presents resistance to most of standard antibiotics.
TMP-SMX, fluoroquinolones, and ticarcillin-clavulanate have
activity.
Conclusion. Potentially pathogenic bacteria was identified in
9,4% patients with lung cancer. The isolated bacteria was
Gram-negative in all cases and may cause infection of lower
respiratory tract with higher morbidity and mortality. K.
pneumoniae , P.aeruginosa , and S.maltophilia were also potentially difficult to treat.
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine University of Indonesia, Indonesia1), Department of Clinical Microbiology, Persahabatan Hospital Jakarta
Indonesia2)
Nila Kartika Ratna1), Cahyarini Dwiatmo2),
Wahju Aniwidyaningsih1), Faisal Yunus1)
Background
Transthoracic needle biopsy (TTB) has been widely used as
diagnostic tools in pulmonary diseases especially to retrieve
sample for cytological examination of suspected malignant
lesions. However, its use in benign diseases is not very popular even though the American College of Chest Physicians
supports the use of transthoracic needle aspiration biopsy
(TNAB) as the procedure of choice in patients in whom the
benign nature of the solitary pulmonary nodule cannot be established by clinical criteria and in whom surgery (exploratory thoracotomy or video assisted thoracoscopic surgery)
cannot be undertaken. The aim of this study is to evaluate
the outcome of microbial analysis from sample, which was
obtained from TTB procedures.
Methods
The medical records from 618 patients whom underwent
computed tomography guided transthoracic needle biopsy
procedures during 2011-2013 were analyzed retrospectively.
Gram stain, Acid-fast bacilli smear, M. tuberculosis, fungal
and bacterial culture were performed from specimens obtained by TTB procedures. The results of TTB were classified into tuberculosis, fungal and bacterial infections.
Results
Only 180 samples out of 618 patients whom underwent TTB
procedures were sent for microbial analysis, 140 for tuberculosis, 75 for fungal and 21 for bacterial analysis. All of the
cases were suspected as malignant disease and all of the
specimens have negative results for microbial and fungal
analysis.
Conclusion
Benign disease, a lesion size, and morphology of the consolidation type were features which may correlated with negative results. The biopsy needle size and total numbers of procedures may also be put into consideration. The use of TTB
as diagnostic tool to obtain microbial and fungal analysis still
need further investigation.
287
Poster Presentation
IP-P14-5
IP-P14-6
Impact of prophylactic treatment of antibiotics on prevention of the fever and infectious complication after
EBUS-TBNA
Is prophylactic use of antibiotics effective in bronchoalveolar lavage with diagnostic bronchoscopy?
Division of Respiratory Medicine, Juntendo University Faculty of Medicine, Japan
Haruhi Takagi, Tetsutaro Nagaoka, Ryo Koyama,
Fumiko Kasuga, Takeo Tsutsumi, Sachiko Kuriyama,
Hidenori Takekawa, Masako Ichikawa, Naoko Shimada,
Yoshimi Kaku, Kazuhisa Takahashi
[Rationale] While EBUS-TBNA is useful in the pathological
diagnosis of mediastinal and hilar lymph nodes, a rare infectious complication due to puncture has been reported. However, the frequency and preventive measures of infectious
complication are still unclear. Thus, objective of this study
was to evaluate the usefulness of prophylactic treatment of
antibiotics to prevent the fever of short duration and the infectious complication in late phase after EBUS-TBNA,
prospectively.
[Methods] 92 patients who underwent EBUS-TBNA at Juntendo university hospital from January 2011 to September
2013 were enrolled in this study. Patients were randomly assigned to group with antibiotics (n=48) or control (n=44).
Characteristics of patients did not significantly differ between 2 groups. Antibiotics group was received drip infusion
of Sulbactam!
Ampicillin 30 min before the puncture, and
oral Amoxicillin!
Clavulanate was subsequently administrated for 7 days. Primary outcome was frequency of high fever within 5 days and infectious complication within 28 days
after EBUS-TBNA. Additionally, we assessed the clinical
background of group with high fever (≧37.6 degrees) or less
fever (<37.6 degrees) within 5 days.
[Results] Frequency of fever within 5 days in antibiotics
group did not differ from the control group. No infectious
complication due to EBUS-TBNA occurred within 28 days in
both groups. Treatment of antibiotics did not affect the value
of WBC and CRP before and after EBUS-TBNA. Value of
CRP before the EBUS-TBNA in high fever group was significantly higher than in less fever group (high vs. less: 3.04 4.24
vs. 0.55 1.06, p=0.029), whereas no significant differences
were seen in final pathological diagnosis, number of puncture, and presence of prophylactic antibiotics between the
high and less fever group. No severe adverse event of antibiotics was observed.
[Conclusion] Prophylactic treatment of antibiotics did not affect the fever of short duration after EBUS-TBNA. Further
investigation is needed to evaluate the preventive effect of
prophylactic antibiotics for infectious complication due to
EBUS-TBNA in late phase.
288
Clinical Research Center, National Hospital Organization
Kinki-Chuo Chest Medical Center, Japan1), National Hospital
Organization Kinki-Chuo Chest Medical Center, Japan2), Nagoya University, Japan3), National Hospital Organization Tokyo National Hospital4), National Hospital Organization Nagasaki Medical Center5), National Hospital Organization Nagoya Medical Center6), National Hospital Organization Kyushu
Cancer Center7), National Hospital Organization Shikoku Cancer Center8)
Chikatoshi Sugimoto1), Tomoya Kawaguchi2),
Masahiko Ando3), Shinobu Akagawa4),
Akitoshi Kinoshita5), Masahide Oki6), Takashi Seto7),
Naoyuki Nogami8), Hideo Saka6)
Background:
We previously reported that prophylactic use of antibiotics
in diagnostic flexible bronchoscopy did not have a significant
protective effect against following infection in the JBRONCHO study, a prospective observational cohort study
in Japan (H. Saka et al. ATS 2011). Given our experience that
high fever frequently happened after diagnostic bronchoalveloar lavage (BAL) in clinical setting, we conducted a
subset analysis in the study focusing on prophylactic antibiotics after the procedure.
Methods:
This study was conducted as a project of the Japanese National Hospital Organization Multi-Center Clinical Research
for Evidence-Based Medicine. From September 2007 to April
2009, at the 48 centers in Japan, we prospectively collected
the information of the 5,216 patients who received diagnostic
bronchoscopy. Among them, a total of 408 cases were examined with BAL. We calculated a propensity score to the cases
for prophylactic use of antibiotics and associations between
prophylactic antibiotics and clinical outcomes including infectious events in 1 week.
Results:
There were 212 patients in the prophylactic group and 196
patients in no prophylactic group. Nine patients (4.2%) received therapeutic antibiotics and 8 patients (3.8%) had documented infection in the prophylactic group, while 8 (4.1%) received therapeutic antibiotics and 5 (2.6%) had documented
infection in no prophylactic group. There was no significant
difference in using therapeutic antibiotics and documented
infection between the two groups (p=0.934, p=0.482, respectively). In propensity-matched cohort, odds ratio of prophylactic antibiotics was 1.243 (95%C.I 0.451-3.427) for therapeutic antibiotics, and odds ratio of prophylactic antibiotics was
1.734 (95%C.I 0.533-5.646).
Conclusion:
Prophylactic use of antibiotics was not effective to prevent
subsequent infection in BAL with diagnostic bronchoscopy.
Poster Presentation
IP-P14-7
IP-P15-1
An unusual case of a cavitary lung mass
Tracheal bronchus
Department of Respiratory Medicine and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
Carmen Pei Sze Tan, Chuen Peng Lee, Ai Ching Kor,
Wee See Yap, Wenyuan Sim
Pulmonary fungal infections are an important cause of morbidity and mortality in HIV-infected patients. Penicillium marneffei was first isolated from
the bamboo rat (Rhizomys sinensis) in Vietnam in 1956. Thereafter, P
marneffei infection was noted to be endemic in Southeast Asia & Southern
China. The first case of P. marneffei infection in an HIV-infected patient was
reported in 1989 from Bangkok, coinciding with the beginning of the AIDS
epidemic in the region. It is increasingly recognized as a threat to immunocompromised patients especially those infected with HIV.
Mr CSG is a 50 year old smoker who complained of chronic cough for one
year. He reported purulent sputum with occasional blood streaks, increasing
breathlessness & intermittent fever. He was single & unemployed but gave
a positive sexual history with commercial sex workers in Indonesia. He was
notably tested positive for HIV infection 2 weeks prior to admission. Physical examination revealed high spiking fever of 39.8C, cachexia & oral thrush.
There was no palpable lymphadenopathy, hepatosplenomegaly or skin lesions. The initial blood count was as follows: haemoglobin 10 g!dL (13-17);
white blood cells 6.7 109; platelets 269 109; & lymphocytes 0.34 109 (0.93.3 109). 2 sets of sputum acid fast bacilli (AFB) smear were negative &
aerobic culture grew pseudomonas aeruginosa. Blood & urine were negative
for bacterial culture. His Chest X-ray showed a right hilar mass with patchy
consolidation in bilateral upper lobes. The CT thorax demonstrated a large
ill-defined soft tissue mass with central area of necrosis and cavitation in the
right infrahilar region. Multiple nodules in both lung fields were in keeping
with metastases. Fibre-optic bronchoscopy was performed & results of
bronchial washing and endobronchial biopsy nailed the diagnosis of penicillium marneffei infection. His blood culture was also positive for the same organism. He was treated with IV amphotericin for 2 weeks followed by oral
itraconazole. His CD4 count was <20 at presentation.
P. marneffei is notorious for its propensity to infect the lungs and reticuloendothelial system. Although the clinical features of P. marneffei infection in
HIV infected patients are largely non-specific, the clinical combination of
HIV infection, fever, weight loss, lung disease, hepatosplenomegaly, cervical
lymphadenopathy & of note, characteristic skin lesions (molluscum
contagiosum-like lesion) should prompt a high index of suspicion. Early diagnosis is crucial as penicillosis is fatal if unrecognized.
Department of Thoracic Surgery, GMMA Haydarpasa Training Hospital, Turkey1), Department of Pulmonary Medicine,
GMMA Haydarpasa Training Hospital, Turkey.2)
Turgut Isitmangil1), Kunter Balkanli1), Mehmet Dakak1),
Haluk Sasmaz1), Mehmet Kutlu Celenk2)
Tracheal bronchus is a rare congenital anomaly of trachea. It
may occur as the upper position of normal bronchus, which
is called as displaced bronchus and also may be an additional
bronchus of trachea, which is called as supernumerary.
The patient was 21 year-old male patient with cough, expectoration, dyspnea, and recurrent respiratory system infection complaints. There was inspiratory crackle on the right
upper zone on physical examination and pneumonic consolidation was present in the right upper zone in the patient s
chest X-ray. Clinical and radiological response could not be
obtained by 2-month antituberculotic therapy. In the right
upper lobe at thorax CT, there were bronchiectasis and
pneumonic consolidation. Tracheal bronchus was diagnosed
by bronchoscopy. A right posterolateral thoracotomy was
performed to the patient. One cm far above the carina, one
ectopic bronchus was present from the trachea towards
right apical region. Tracheal bronchus excision and right apical segmentectomy were performed.
In conclusion, we suggest that in tracheal bronchus cases accompanied by recurrent pulmonary Infections, operation is
indicated.
289
Poster Presentation
IP-P15-2
IP-P15-3
Incdiental finding of tracheal bronchus in a young lady
suffering from lung abscess
Endobronchial metastatic cancer cases other than
lung cancer
Medicine, Tseung Kwan O Hospital, Hong Kong
Samuel Lee, Chi Fung Choy, Man Fung Cheng
Background: Tracheal bronchus is a rare congenital anomaly. We are reporting a case of incidental finding in a young lady suffering from aspergillosis lung
abscess.
Case History: Miss B was a healthy young lady. She presented with a week
history of fever and cough with blood stained and purulent sputum. Chest X
ray showed right upper lobe cavity with air-fluid level. Flexible bronchoscopic
examination revealed the presence of supernumerary type of tracheal bronchus with right upper lobe bronchus branching off from the lateral wall of trachea. Otherwise no other abnormality was seen. CAT scan thorax confirmed
the presence of the tracheal bronchus as well as right middle lobe abscess.
She was given a course of intravenous amoxillcin- clauvanate and she was discharged with improvement of the symptoms. However, Chest X ray during
follow-up showed progressive increase in size of the abscess and the symptom
of purulent and blood stained sputum persisted. Culture of bronchoscopic aspirate showed presence of asperigllosis. Itaconazole 400 mg daily was then
started and wedge resection of right middle lobe was also performed. Her condition improved after the surgery and the start of the antifungal agents.
Discussion: Tracheal bronchus is rare with reported incidence from 0.1-2%. A
true tracheal bronchus is any bronchus originating from trachea, usually
within 2 cm of carina.
Two main types are identified: displaced, which is more frequent,and supernumerary. In displaced type, one branch of the upper lobe bronchus is missing
while in supernumerary type, the normal branching is preserved as in our
case.
Most of the cases of tracheal bronchus are asymptomatic. There were reports
of its presentation with symptom of cough, wheezing, stridor and recurrent infection and haemoptysis. It may be also associated with other tracheobronchial
anomalies, congenital heart disease or Down syndrome. One of its main complications, especially in adults, is peri-operative hypoxiemia caused by occlusion
of the tracheal bronchus during endotracheal intubation resulting in atelactasis of the involved lobe.
Treatment of tracheal bronchus is usually conservative. Surgical removal of
the involved lobe is indicated when there is presence of complication for example, recurrent infection, bronchectasis or haemoptysis.
While pulmonary aspergillosis disease might be predisposed by underlying
lung diseases, we believe the tracheal bronchus in this case was only an incidental finding and unlikely to be related to the formation of the lung abscess. It
was the right middle lobe instead the right upper lobe which the tracheal
bronchus supplies.
290
Department of Pulmonary Medicine, GATA Haydarpasa
Training Hospital, Turkey1), Department of Pathology, GATA
Haydarpasa Training Hospital, Turkey2)
Ersin Demirer1), Dilaver Tas1), Omer Ayten1),
Dilaver Demirel2), Oguzhan Okutan1)
Background:
Metastasis to lungs can be observed in different cancer
cases. Endobronchial metastatic cancers which can be observed with fiberoptic bronchoscopy are very rare.
Methods:
Fiberoptic bronchoscopy (FOB) cases were retrospectively
reviwed and endobronchial metastasis other than lung cancer were analyzed.
Results:
Nine cases (3 female, 6 male) with endobronchial metastasis
other than lung cancer were reviewed. Median age was 69
years (age range 55-83 years). Eight cases were diagnosed
with endobronchial biopsy while one case with open lung biopsy.
Endobronchial metastasis was observed on the right lung in
4 cases and on the left lung in 4 cases while lower tracheal localization was observed in 1 case. The distribution of cancer
types were as follows; renal cell cancer in 2 cases, colorectal
cancer in 1 case, breast cancer in 1 case, malign melanoma in
1 case, larynx cancer in 2 cases, leiomyosarcoma in 1 case
and endometrial cancer in 1 case. Characteristics of cases
and endobronchial localization is summarized in Table 1.
Conclusion:
Different types of cancer can be observed in lungs. In this
study endobronchially observed cancer cases other than
lung cancer with metastasis diagnosed with FOB were reviwed.
Disclosure of funding: None
Poster Presentation
IP-P15-4
IP-P15-5
Diagnostic value of fiberoptic bronchoscopy in patients with endobronchially observed lung cancer
False positive derived from autofluorescence bronchoscopy: A case report
Department of Pulmonary Medicine, GATA Haydarpasa
Training Hospital, Turkey1), Department of Pathology, GATA
Haydarpasa Training Hospital, Turkey2)
Department of Pulmonary Medicine, Shanghai Chest Hospital,
Shanghai Jiao Tong University, China1), Department of Integrative Medicine, Huashan Hospital, Fudan University, China2)
Ersin Demirer1), Dilaver Tas1), Omer Ayten1),
Dilaver Demirel2), Oguzhan Okutan1)
Xiaoxuan Zheng1), Yubao Lv2), Jiayuan Sun1), Baohui Han1)
Background: Lung cancer is still one of the leading cause of
death in the World. Fiberoptic bronchoscopy (FOB) is a diagnostic and therapeutic tool used in patients with lung cancer.
In this study, the diagnostic value of FOB and further diagnostic procedures when FOB was nondiagnostic were investigated.
Methods: FOB results of a teaching hospital were reviwed.
Patients with endobronchial lesions were analyzed. Diagnostic value of FOB in lung cancer patients were evaluated.
Results: There were 172 patients with endobronchial lesions
diagnosed with lung cancer. Mean age was 64 11 years. 123
cases (71.5%) had non-small cell lung cancer, 41 cases (23.8%)
had small cell lung cancer and 8 cases (4.7%) had metastasis.
Bronchial biopsy, open lung biopsy, transthoracic needle biopsy and trucut needle biopsy were diagnostic procedures.
The diagnostic value of these procedures were summarized
at Table 1.
Conclusions: FOB has a high diagnostic value in lung cancer
patients with endobronchially observed lesions. Further invasive procedures may be requred in some patients.
Disclosure of funding source: None.
Background:Autofluorescence bronchoscopy (AFB) has exciting potential in detection of lung cancer & preneoplastic
lesions.Unfortunately, the average specificity of AFB is low
at around 60%, leading to many false positives.Case Report:
A 77 years old woman with hypertension coronary disease,
bladder cancer for several years. Continuous sputum cytology monitoring found epidermoid carcinoma. She was carried out four times diagnostic WLB followed by AFB in four
months. AFB showed abnormal fluorescence characteristics
in the dorsal segment of the right lower lobe bronchus. The
histopathology of the specimen from autofluorescence positive lesions revealed a small amount of bronchial mucosa tissue, and chronic inflammatory change. Conclusion: Abnormalities found on AFB were biopsies in our hospital, the
histopathological and cytological analysis of the samples
showed no elements of tumorous tissue and cell. The possibility of lung cancer owned to false positives of AFB could be
ruled out.
291
Poster Presentation
IP-P15-6
IP-P15-7
Optical imaging of subacute airway remodeling and
adipose stem cell engraftment after airway injury
Churg-strauss syndrome presenting with endobronchial masses
Department of Internal Medicine, Kosin University College of
Medicine, Korea1), Department of Biomedical Engineering and
Center for Marine-Integrated Biomedical Technology,
Pukyong National University2)
Chul Ho Oak1), Taewon Jang1), Maan Hong Jung1),
Yeh-Chan Ahn Ahn2), Sung Jin Nam1)
Acquired airway injury is frequently caused by endotracheal intubations, long-term tracheostomies, trauma, airway
burns, and some systemic diseases. An effective and less invasive technique for both the early assessment and the early
interventional treatment of acquired airway stenosis is
therefore needed. Optical coherence tomography (OCT) has
been proposed to have unique potential for early monitoring
from the proliferative epithelium to the cartilage in acute airway injury. Additionally, stem cell therapy using adipose
stem cells is generally recognized as an option for early interventional treatment in airway and lung injury. Over the
past decade, it has become possible to monitor the level of injury using OCT and to track the engraftment of stem cells
using stem cell imaging in regenerative tissue. The purpose
of this study was to assess the engraftment of exogenous adipose stem cells in injured tracheal epithelium with fluorescent microscopy and to detect and monitor the degree of airway injury in the same tracheal epithelium with OCT. OCT
detected thickening of both the epithelium and basement
membrane after tracheal scraping. The engraftment of adipose stem cells was successfully detected by fluorescent
staining in the regenerative epithelium of injured tracheas.
OCT has the potential to be a high-resolution imaging modality capable of detecting airway injury in combination with
stem cell imaging in the same tracheal mucosa.
292
Chest Disease, Edirne State Hospital, Turkey
Veli Cetinsu
Churg-Strausse syndrome is a condition with unknown etiology and asthma, allergic rhinitis, eosinophilic infiltration of
blood and tissues and transient infiltration of the lungs. It occurs mostly in 3rd-4th decades with an incidence of 2.4!
1000000. Presentation frequently involves nodular lung infiltrations, infiltrations with cavity, ground-glass appearance
and alveolar opacity. However, endobronchial mass is an unexpected presentation. In the current case report, we present a 45-year old male patient who was receiving asthma
therapy for 5 years. In the last follow-up visit, we identified a
mass in the right hilus on x-ray radiography and performed
fiberoptic bronchoscopy. Pathologic examination of biopsy
material verified the diagnosis of Churg-Strauss syndrome.
Bronchial mass is an unexpected presentation of ChurgStrauss syndrome and pathologic examination is essential to
distinguish from pulmonary malignancies.
Poster Presentation
IP-P16-1
IP-P16-2
Angiopoietin 2 levels of serum and bronchial lavage
fluids in non-small cell lung cancer
Napsin A levels in epithelial lining fluid in patients with
primary lung adenocarcinoma
Department of Pulmonary Medicine, GATA Haydarpasa
Training Hospital, Turkey1), Department of Biology, Erciyes
University, Turkey2), Department of Pulmonary Diseases,
Yedikule Hospital, Turkey3)
Ersin Demirer1), Omer Ayten1), Dilaver Tas1),
Oguzhan Okutan1), Faruk Ciftci1), Metin Aytekin2),
Atilla Uysal3), Zafer Kartaloglu1)
Background: Angiopoietin 2 (Ang-2) has an important role as
a growth factor in angiogenesis. We investigated serum and
bronchial lavage levels of Ang-2 (S-Ang 2, B-Ang 2 in patients with non-small cell lung cancer (NSCL).
Methods: Twenty nine cases with NSCL and 18 control were
evaluated. S-Ang 2, B-Ang 2 levels were measured. Laboratory results, metastasis and stage were analyzed.
Results: S-Ang 2 levels were (control: 1.61 0.4 ng!
ml, NSCL
group: 2.6 1.3 ng!
ml) while B-Ang 2 levels were (control:
0.82 0.08 ng!
ml, NSCL group: 0.65 0.4 ng!
ml). There was a
significant correlation between S-Ang 2 and B-Ang 2 levels
(r=-0.42, p=0.003). S-Ang 2 was correlated with stage of cancer (p=0.001).
Conclusion: S-Ang 2 and B-Ang 2 levels had a negative correlation. S-Ang 2 levels were correlated with NSCL cancer
stage.
Disclosure of funding source: None
Department of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Japan1), Department of General Thoracic Surgery, Graduate School of
Medical and Dental Sciences, Kagoshima University,
Kagoshima, Japan2)
Akifumi Uchida1), Takuya Samukawa1),
Tomohiro Kumamoto1), Tsutomu Hamada1),
Masahiro Ooshige1), Hironobu Kanazawa1),
Keiko Mizuno1), Ikkou Higashimoto1),
Yoshihiro Nakamura2), Masami Sato2), Hiromasa Inoue1)
Background: Napsin A, an aspartic protease, is mainly expressed in alveolar type-II cells. Immunohistochemical reactivity for napsin A is associated with most cases of primary
lung adenocarcinomas and is negative in most squamous cell
carcinomas and adenocarcinomas of other organs. Its local
expression is reported to be useful for identifying lung origin
in the setting of a metastatic adenocarcinoma. However, we
have previously shown that serum napsin A levels were not
elevated in patients with primary lung adenocarcinoma compared to healthy control subjects.
Aim: The aim of this study is to compare napsin A levels in
epithelial lining fluid (ELF) samples close to malignant nodules with the contralateral control site in patients with primary lung adenocarcinoma. We also measured carcinoembryonic antigen (CEA) levels in ELF.
Methods: Patients with indeterminate solitary pulmonary
nodules underwent diagnostic bronchoscopy. ELF samples
were obtained both from near the tumor and from the contralateral lung using a bronchoscopic microsampling (BMS)
technique before the transbronchial biopsy. Definitive histological diagnosis was established either by transbronchial biopsy or by subsequent surgical resection. Napsin A and CEA
were measured by ELISA.
Results: All patients underwent BMS without complications.
Napsin A in ELF samples from contralateral lung was under
detectable limit. In patients with primary lung adenocarcinoma, napsin A levels in ELF samples close to the nodule
were higher than those from contralateral lung. CEA levels
in ELF samples close to the nodule were similar to those
from contralateral site.
Conclusion: Our study suggests that napsin A in ELF collected by BMS could be a potentially useful adjunct to other
diagnostic methods for diagnosis of primary lung adenocarcinoma.
293
Poster Presentation
IP-P16-3
IP-P16-4
Cytology specimens vs biopsy are more than adequate for EGFR mutation analysis
A comparison of bronchofiberscopic washing cytology
and FFPE tissue in the analysis of EGFR mutations in
advanced NSCLC
Department of Medicine, Division of Respirology, University
of Calgary, Canada1), Alberta Health Services, Calgary, Canada2), University of Calgary, Calgary, Canada3)
Alex ChunMin Chee1), Laura Hampton2),
Doug Demetrick3), Don Morris3), Paul Maceachern1),
David Stather1), Alain Tremblay1)
Background: Testing for Epidermal Growth Factor Receptor (EGFR) mutations is an important step in the evaluation of patients with advanced nonsquamous, non-small cell lung cancer given the effectiveness of EGFR tyrosine kinase inhibitors in patients with such mutations. Tumor tissue samples
can be obtained from a variety of tissue sites using different sampling modalities. Selection of the optimal biopsy procedure for a given patient should include consideration of adequacy of specimens for such testing. Minimally invasive procedures often result in smaller sized tissue samples and could potentially affect the ability to detect EGFR mutations. We aimed to identify
sampling factors associated with EGFR mutation positivity.
Methods: We performed a retrospective analysis of a regional database (Alberta, Canada) of all EGFR mutation testing from January to June 2012 for
lung cancer. The Calgary Laboratory Services database, the regional testing
facility, was cross-referenced with electronic patient records to identify biopsy site and procurement method. Test positivity was used as a surrogate
for specimen adequacy. Tissue samples were analyzed with a PCR mutation
assay (Qiagen) for 28 known mutations.
Results: All samples had positive histology or cytology for non-squamous,
non-small cell lung carcinoma. A total of 289 biopsy samples were tested, with
77 tests on out of province patients excluded leaving 212 analyzed for this
study. Overall EGFR mutation positivity rate was 16%. Although biopsy samples were obtained from various metastatic sites, there was no significant
predilection for specific site positivity. EGFR mutation positivity according to
biopsy method was as follows: resection or mediastinoscopy (3!32, 9.4%), CT
guided or superficial aspirates (9!69, 13%); Endobronchial Ultrasound Transbronchial Needle Aspiration (EBUS: 13!57, 22.8%); Pleural!pericardial fluid
(5!13, 38.5%), (chi-square for differences between groups p=0.058).
Conclusion: Using test positivity as a surrogate marker of specimen adequacy, cytologic preparations appear at least as good as surgical specimens,
with EBUS and fluid specimens demonstrating highest positivity rates.
Minimally-invasive tissue acquisition techniques such as EBUS-TBNA and
fluid aspiration are suitable for EGFR mutation analysis in lung cancer.
294
Department of Respiratory Medicine, Yokohama Municipal
Citizen s Hospital, Japan1), Department of Medical Oncology
Yokohama Municipal Citizen s Hospital, Japan2)
Yoko Agemi1), Kazuhito Miyazaki1), Yuuki Misumi1),
Mari Ishii2), Yukiko Nakamura1), Tsuneo Shimokawa1),
Naoya Hida1), Hiroaki Okamoto1)
Background: In the treatment of advanced NSCLC, EGFR
mutation status is one of the most predictive factors for the
efficacy of EGFR tyrosine kinase inhibitors, and the evaluation of EGFR mutation status using the formalin-fixed
paraffin-embedded (FFPE) tissue has been widely used for
this analysis throughout the world. However, whether bronchofiberscopic brushing (BB) cytology samples can be used
as an alternative for FFPE samples in the analysis of EGFR
mutations is unknown. Therefore, in the current study, we
compared the freeze stock solution of BB cytology with
FFPE for the determination of EGFR mutation status in a
large sample set. Methods: In diagnostic BFS examinations,
after curetting or brushing and biopsy to target lesions, subsequent bronchial washing by saline was performed. Thereafter, the saline fluid in which the forceps were washed and
the bronchial washing fluid were mixed in a sterilized tube
and were immediately frozen in a "
20̊C freezer. EGFR mutation testing for both BB cytology and FFPE was performed
using high-sensitivity PCR (BML, PCR"
Invader). Results: A
total of 659 BFS examinations were performed from Aug
2010 to Aug 2012 in our hospital. The BB cytology samples of
437 suspected cases of lung cancer were successfully obtained. Of these, 68 cases that were pathologically confirmed
as adenocarcinoma based on both BB cytology and FFPE
samles were analyzed in this study. EGFR mutations were
identified in 32 cases, while the remaining 36 cases had wildtype EGFR. In 66 of 68 cases, the results of EGFR mutation
status were the same for BB cytology and FFPE samples,
and the kappa coefficient was 0.94. In one case, an exon"
18
mutation was detected only by BB cytology sample. In another case an exon"
21 mutation was detected only by FFPE
sample. In 29 of 30 cases of EGFR mutation, the mutation site
was the same in both samples. The kappa coefficient was
0.92. Conclusions: This is the largest genetic study to date
demonstrating a head-to-head comparison of BB cytology
and FFPE samples for the evaluation of EGFR mutations.
Both methods showed high reliability and concordance using
high-sensitivity PCR. BB cytology is considered a simple,
rapid method and represents an effective alternative for
FFPE in EGFR mutation testing.
Poster Presentation
IP-P16-5
IP-P16-6
The bronchoscopy-guided re-biopsy of non-small cell
lung cancer in patients who relapse after gefitinib therapy
Flipping the classroom: A paradigm shift in pulmonary
procedural education
Department of Bronchology, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Japan1), Department
of Thoracic Malignancy, Osaka Prefectural Medical Center for
Respiratory and Allergic Diseases, Japan2), Department of Pathology, Osaka Prefectural Medical Center for Respiratory
and Allergic Diseases, Japan3)
Norio Okamoto1), Takayuki Shiroyama2),
Motohiro Tamiya2), Hidekazu Suzuki2), Yuichiro Azuma2),
Akio Osa2), Sawa Takeoka2), Satomu Morita2),
Naoko Morishita2), Nobuko Uehara2),
Kunimitsu Kawahara3), Tomonori Hirashima2),
Ichiro Kawase2)
[Background] As knowledge regarding mechanisms of resistance to molecular targeted agents increases, re-biopsy of relapsed tumors has become a very important technique for
resolving drug resistance in non-small cell lung cancer
(NSCLC) patients. However, such examinations are rarely
performed in medical practice.
[Purpose] To retrospectively examine the technical problems
in tumor re-biopsy and to analyze histology and epidermal
growth factor receptor (EGFR) mutation status in re-biopsy
specimens from NSCLC patients harboring drug-sensitive
EGFR mutations who relapsed after EGFR-tyrosine kinase
inhibitor (TKI) therapy.
[Patients and Methods] We performed tumor re-biopsy for 8
NSCLC patients (male!
female, 2 patients!
6 patients; median
age [range], 63 years [43-67 years]; adenocarcinoma histology,
8 patients; exon 19 deletion!
L858R, 5 patients!
3 patients).
Initial diagnostic specimens were obtained by transbronchial biopsy (TBB) (n=4), endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA) (n=1),
medical thoracoscopy (n=1), or thoracic surgery (n=1). Rebiopsy specimens were obtained by TBB (n=6) or EBUSTBNA (n=2). Of the 8 re-biopsy specimens, 2 was obtained
from the same site as the initial biopsy and 6 were obtained
from different sites (pulmonary metastasis, 5 patients; lymph
node metastasis, 1 patient). Because the target lesions in the
8 patients were small, all specimens contained a cluster of a
few cancer cells. In 2 of the 8 re-biopsy specimens, squamous
cell carcinoma was confirmed by histology. Five re-biopsy
specimens had the acquired EGFR mutation T790M and the
3 remaining specimens did not have any other mutations. Initial re-biopsy was performed successfully in 7 of 8 patients.
The initial re-biopsy specimen of the eighth patient, who had
undergone chemoradiation therapy, was negative for cancer
cells. A second re-biopsy was performed successfully for this
patient.
[Conclusion] It was difficult to successfully obtain re-biopsy
specimens from small target lesions in patients who relapsed
after EGFR-TKI therapy. As many specimens as possible
should be obtained using various modalities such as EBUSTBNA, EBUS with a guide sheath, and virtual navigation.
Division of Pulmonary and Critical Care Medicine, Mayo
Clinic, USA1), Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA2), American College of Chest Physicians, North Brook, IL, USA3)
John Joseph Mullon1), Eric Edell1), Fabien Maldonado1),
Septimiu Murgu2), Chad Jackson3), Ed Dellert3)
Background: The concept of the flipped classroom , where
didactic instruction is delivered electronically outside of the
classroom environment allowing maximal time in the classroom for hands-on instruction, is rapidly becoming a preferred method of instruction in many institutions of adult
learning. Studies show up to 2.5 standard deviation improvement in test scores relative to traditional instruction when
the flipped classroom technique is employed. This method
is particularly well-suited for procedural education and has
been adopted as the optimal format for several pulmonary
procedural training programs offered in the United States.
Methods: Since 2008 the flipped classroom technique has
been utilized annually for the Midwest Introductory Pleural
and Bronchoscopic Procedures Course conducted at the
Mayo Clinic. In 2013 this technique was further employed by
the AABIP during their Interventional Pulmonology Introductory Course, and by the ACCP during their Essentials of
Bronchoscopy and Essentials of Endobronchial Ultrasound
(EBUS) courses. In each instance pre-course didactic materials were provided via a secure website allowing maximal
time for on-hands and problem-based instruction during the
on-campus portion of the course. Learner satisfaction, selfassessments, and!
or objective skill assessments were determined following the courses.
Results: Between 2008-2013 142 incoming fellows completed
the Midwest Introductory Pleural and Bronchoscopic Procedures Course. Their self-assessment competency, on a 4point scale (4=very competent) improved from 2.2 (1.6-2.8) to
3.8 (3.5-4.0, p<0.05) in pleural procedures, and from 1.8 (1.2-2.2)
to 3.3 (2.9-3.9, p<0.05) in bronchoscopic procedures. In July
2013 18 incoming interventional pulmonology fellows completed the AABIP IP Introductory Course. Their selfassessment competency, on a 4-point scale improved from 1.8
(1.7-1.9) to 2.9 (2.9-3.0, p<0.01). In August 2013the ACCP reformatted its Essentials of Bronchoscopy and Essentials of
EBUS courses to incorporate the flipped classroom structure. In post-course surveys 89% of Essentials of Bronchoscopy learners rated the new format excellent or good with
the remaining 11% remaining neutral. Similarly 100% of Essentials of EBUS learners rated the new format excellent or
good. There was also a 41% objective improvement in EBUS
performance using a validated assessment tool at completion
of the course.
Conclusion: The flipped classroom technique is uniquely
well suited for adult procedural training. Its use with both
novice and advanced proceduralists, and in teaching basic
and advanced bronchoscopic procedures results in both subjective and objective improvement in procedural skill.
295
Poster Presentation
IP-P16-7
Impact of simulation training on bronchoscopy competence in singapore
Department of Medicine, National University Hospital, Singapore
Adrian Kee, Hui Fang Lim, Wen Ting Siow, Melvin Tay,
Kay Leong Khoo, Pyng Lee
Background
Over time, bronchoscopic training programs have evolved
from the conventional apprenticeship model to a simulationbased model. This study aims to assess the impact of simulation training on proficiency of trainee bronchoscopists in Singapore. We hypothesize that short intensive structured
training with the simulator leads to better procedural performance.
Methods
Three trainees each were randomly selected from two hospitals with nationally-accredited respiratory medicine training
programs. The trainees in hospital A were assigned to the
control group where they practiced the apprenticeship
model of hands-on bronchoscopy training on patients. The
trainees in hospital B were assigned to the intervention
group where they underwent a structured web-based Essential Bronchoscopyc curriculum, simulation training one hour
per week over 8 weeks and hands-on bronchoscopy training
on patients. After 8 weeks, each trainee performed and
video-taped 2 bronchoscopies. Each video was graded by a
pair of blinded experts using the validated BSTAT assessment form. The maximum achievable BSTAT score was 46
instead of 100 as components such as posturing, entry-ondemand, nomenclature and specific tasks were not assessed.
Results
There was excellent inter-rater agreement within each expert pair. The kappa value for Pair X was 0.962 (p<0.01) and
the kappa value for Pair Y was 0.948 (p<0.01). Hospital A s
trainees had a median of 104.00 ( 16.29) weeks of prior bronchoscopy practice and Hospital B s trainees had 104.00 (
46.19). (p=0.70). Hospital A s trainees performed a median of
120 ( 25.79) bronchoscopies while hospital B s trainees performed a median of 61 ( 33.83) (p=0.05). Despite performing
significantly fewer bronchoscopies, trainees who underwent
simulation training were able to obtain higher BSTAT
scores 41 ( 8.98) vs 38 ( 4.36) (p=0.699). This was not statistically significant and was due to the small sample size. Trainees in hospital B spent longer duration per procedure but
this was not statistically significant. They spent more time
performing thorough airway anaesthesia as shown by the
significantly higher number of airway anaesthesia manoeurves performed (10 0.52 vs 2.50 1.55, p=0.002). Trainees in hospital B unanimously agree that simulation training
helped to improve their skills.
Conclusion
This is a novel study where trainee bronchoscopists in two
hospitals were assessed based on two different bronchoscopic training models. There is a strong signal suggesting
bronchoscopic simulation allows trainee bronchoscopists to
become proficient earlier. We believe that this will reduce
the burden of procedure-related training on patients.
296
IP-P16-7
Poster Presentation
IP-P16-8
IP-P17-1
The effect of music therapy on anxiety levels in patients undergoing bronchoscopy
A case of relapsing pulmonary pleomorphic carcinoma
resected endscopically using a electrosurgical snare
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University,
Thailand
Naparat Amornputtisathaporn, Tirachart Sewatanon,
Chariya Laohavich, Viboon Boonsarngsuk
Background: In patient whom was scheduled for flexible
bronchoscopy (FB) always experienced some degree of anxiety from various causes including worrisome diagnoses, unfamiliar operating room environment or the invasive procedure itself. Music therapy has been recognized through
many studies as an unharm, inexpensive, feasible to conduct
and having anxiolytic effect. Review of a few prior studies on
music therapy during bronchoscopy found inconclusive result. Ethnics, cultures and kinds of music might make different result on anxiety levels of patients. Objective is to study
is to assess the effect of music therapy on anxiety levels in
Thai patients undergoing FB.
Method: A prospective study was performed on 167 adults
scheduled for outpatient FB. Subjects were randomly assigned to receive standard FB protocol or to receive music
therapy throughout the procedure period. 81 patients were
in control group and 86 patients were in music therapy
group. State-Trait Anxiety Inventory (STAI) in Thai version
and visual analog scale (VAS) evaluating anxiety level were
given to all subjects before and after the FB procedure. Vital
signs were recorded pre-, during and post-bronchoscopy.
Result: Control and music therapy groups had similar baseline patient-related characteristics (age in years 56.1 14 vs
56.4 14; p=0.90, female gender 41 (50.6%) vs 54 (63.8%); p=
0.12). Baseline trait and state anxiety levels were not different between study groups (41.7 10 vs 43.3 8; p=0.24 and
45.8 10 vs 44.6 9; p=0.41). Subjects in both groups reported
less anxiety at the end of procedure compare to baseline (p<
0.001), post-FB state anxiety levels were decreased to 40.6
11 in control group and 41.5 9 in music group, but not from
music therapy (p=0.89). VAS for anxiety level were decreased after the procedure (p<0.001) but no difference between groups (p=0.56). There were significant reduction of
mean arterial blood pressure, heart rate and respiratory rate
post-FB in overall subjects compare to baseline vital signs
(p<0.001) without demonstrated effect from music therapy
(p=0.14, 0.81 and 0.23, respectively).
Conclusion: Music therapy played in the operative room has
neither decrease the anxiety level nor physiologic responses
to stressful precedure in Thai-patient undergoing flexible
bronchoscopy. End of FB procedure, itself, reduces an anxiety levels in overall subjects.
Respiratory Medicine, Ishikawa Prefectural Central Hospital,
Japan
Masaru Nishitsuji, Koichi Nishi, Noriyuki Okura,
Mayuko Tani
Background. Pulmonary pleomorphic carcinoma is a rare
lung tumor, and has poor prognosis.
Case. A 69-year-old man admitted with severe dyspnea, stridor and respiratory failure. He was taken right middle lobectomy because of pulmonary pleomorphic carcinoma 2 years
ago. Chest computed tomography revealed a tracheal tumor.
We removed the tumor with an electrosurgical snare. Postoperative pathologic examination revealed the relapse of the
pulmonary pleomorphic carcinoma. Auto- fluorescence imaging showed residual tumor one week after the resection, and
radiation therapy was added.
Conclusion. Endoscopic electrosurgery is useful treatment
for relapsing solitary bronchial tumors at medical emergency state.
297
Poster Presentation
IP-P17-2
IP-P17-3
Tracheobronchial recurrence of NSCLC treated with
endoscopic laser resection, external and endocavitary
radiotherapy
The role of endobronchial electrocautery of tumors localized in the large airways
Division of Thoracic Surgery, European Institute of Oncology,
Italy1), Division of Radiotherapy, European Institute of Oncology, Milan, Italy2)
Juliana Guarize1), Stefano Donghi1), Andrea Vavassori2),
Gaia Piperno2), Monica Casiraghi1), Lorenzo Spaggiari1)
Background
Endotracheal and endobronchial local recurrence of non small cell lung cancer confined to the endobronchial space is infrequent clinical practice and causing obstruction can be a life treating condition. The optimal treatment remains controversial.
We report a case of an endotracheal and endobronchial local recurrence of
squamous cell carcinoma of the lung previous treated with radical surgical resection successfully treated with a combined therapy: laser and mechanical resection
of booth lesions, chemotherapy, external and endocavitary brachytherapy.
Case report
A 72 years old male patient with a past medical history of aortic aneurismectomy,
aortic valve replacement and diabetes underwent a righ upper lobectomy (RUL)
and radical lymph node dissection in 2011 (pT2apN0) with regular follow-up until
2013. Two years after surgery computer tomography (CT) and positron emition tomography (PET-FDG) scans reveal a double recurrence at the median proximal
part of the trachea and at the origin of the left main bronchus with almost complete
obstruction of the bronchial lumen (Figure 1: images 1 and 2). Patient underwent a
rigid bronchoscopy and laser assisted mechanical resection of both lesions with
complete patency of the bronchial and tracheal lumen.
Subsequently, chemotherapy (4 cycles chemotherapy with Carboplatin 300 mg total
dose plus Paclitaxel 175 total dose 200mg) and concomitant external radiotherapy
(50 Gy in 25 fractions). Endocavitary brachytherapy was performed using a 6Fr
catheter previous positionated with flessible bronchoscopy. A total dose of 5 Gy!
fraction was performed in both sites (tracheal and bronchial) to consolidate the
treatment. No major complications or toxicity occurs.
At 9 months of the treatment patient is free of disease with complete patency of tracheal and bronchial lumen (Figure 1: images 3 and 4).
Conclusion
The combination of laser resection and external radiotherapy with high-dose-rate
endobronchial brachytherapy boost is an effective treatment with acceptable toxicity in patients with endocavitary recurrence of non-small-cell lung cancer.
298
Department of Bronchology, INP Marius Nasta Institute, Romania1), Department of Pneumology, Marius Nasta Institute,
Bucharest2), Department of Intensive Care Unit, Marius Nasta
Institute, Bucharest3), Department of Bronchology, Elias Hospital, Bucharest4)
Ruxandra Ulmeanu1), Elena Ramona Nedelcu2),
Radu Stoica3), Genoveva Cadar3), Iolanda Ion3),
Dan Ioan Ulmeanu4), Florin Dumitru Mihaltan2)
Introduction: Endoscopic electrocautery is used for treating
benign and malignant disease with both curative and palliative intent. Endobronchial interventions are important in the
multimodality management of tumors of the tracheo-bronchial
tree and should become standard considerations in the management of these patients. Endoscopic treatment is frequently the best choice for benign tumors (curative treatment) or for malignant stenosis of the central airways (symptoms palliation and improving quality of life).
Aim: To demonstrate the practical value of endobronchial
electrocautery- an excellent method with virtues of diagnosis, curative or palliative treatment in the management of obstructing endobronchial tumors.
Method: We present a practical review for endoscopically diagnosis and treatment of 16 cases of tumors located in the
large airways, between 2006-2013 in the Marius Nasta Institute, Bucharest.
We used rigid bronchoscopy with jet ventilation.
The fibrobronchoscope was inserted through the rigid bronchoscope for maneuvers of electrocautery. We performed
endoscopic cauterization maneuvers using cautery wire
snares for 6 benign conditions and 10 malignant tumors
whose etiology was as follows:
8 metastases of nonsmall cell lung cancer (adenocarcinoma,
squamous cell carcinoma)
1 hemangiopericytoma of left main bronchus
1 tracheal metastasis of thyroid cancer
1 tracheal hemangioma
4 lipomas (3 tracheal and 2 left main bronchus)
1 tracheal polyp
Technique used was resection loop (lasso technique) for tumor, then electrode resection for tumor base. For 10 patients
with malignant tumors technique was used for palliative purpose for severe obstruction of large airways (several sessions). All patients with benign tumors needed only a single
endoscopic procedure.
There were no anesthetics complications or major complications of endoscopic resection; only reduced bleeding for the
malignant disorder (below 15-20 ml).
Conclusions: Obstructive tumors of large airways is a permanent challenge for the practitioner.
Our experience argue for great safety and effectiveness for
diagnosis and treatment of endobronchial wire snare electrocautery for these central airways disorders.
Poster Presentation
IP-P17-4
IP-P17-5
Factors influence on photodynamic therapy for central
airway carcinoma
Study on risk judgment and management for the removal of bronchial foreign sharp bodies in adults
Department of respiratory, Affiliated Futian People s Hospital
of Guangdong Medical College, China
Department of respiratory, Affiliated Futian People s Hospital
of Guangdong Medical College, China
Yiping Zhou, Xiaoke Chen, Hui Liu, Liping Xia, Nian Liu,
Haiqiong Yu, Xia Chen
Yiping Zhou, Li-ping Xia, Xiao-ke Chen, Hui Liu,
Hai-qiong Yu, Nian Liu, Xia Chen, Ai-fen Li
Objective) To explore the factors influencing the effects of
photodynamic therapy for the central airway obstruction in
patients with advanced lung cancer. Methods) Two patients
were reported, and the factors influence on photodynamic
therapy were analysed. Results) The first case whose right
main bronchial was obstructed with squamous cell carcinoma, received argon plasma coagulation for thermal ablation of tumor, followed with endobronchial photodynamic
therapy twice, is still in good situation up to now. Another
case whose right intermediate bronchus and the lower lobe
bronchus were widely infiltrated with tumor. Biopsy
showed: poorly differentiated tumor, small cell lung cancer.
Chemotherapy was refused. While photodynamic therapy
was accepted twice.The latter case suffered from cancer-like
syndrome and died. Conclusion) For localizated carcinoma in
central airway, photodynamic therapy followed by APC
thermal ablation of tumor may achieved good clinical effects.
For airway pipe wall and multi lobe involved with carcinoma, photodynamic therapy may bring more risk, the exposure dosage and duration should be taken into account. Too
much tirradiation dose or exposure time may cause serious
reaction. Bronchial stents or thermal ablation of tumor prior
to photodynamic therapy should be considered in this situation.
Objective To study the risk judgment and technical points in
the management of adults with bronchial foreign sharp bodies. Methods Introduce and analysis 5 cases of adults with
bronchial foreign sharp bodies. Results 4 cases under local
anesthesia, while 1 case under general anesthesia with laryngeal mask assisted ventilation. The foreign bodies included
root cannel needle of stomatology, clamp shape crab claw,
flat bone of Fish head, triangle sclerite, Fish head sclerite.
Conclusion Bronchial foreign sharp bodies should be treated
as soon as possible. The risk of operation should be fully assessed before the management. Proper anesthesia and insertion mode are the key points for the removal of foreign bodies. Iced saline and epinephrine dilution should be prepared
during the operation.
299
Poster Presentation
IP-P17-6
IP-P17-7
An adult case of congenital esophagobronchial fistula
accompanied with sarcoidosis and lung adenocarcinoma
Rare case of congenital pulmonary atresia with rare
variant of MAPCA originating from coronary artery
Department of Surgery, University Hospital Mizonokuchi,
Teikyo University School of Medicine, Japan1), Department of
the 4th Internal Medicine, University Hospital Mizonokuchi,
Teikyo University School of Medicine, Japan2)
Shozo Fujino1), Takehiro Okumura1), Toshiyuki Kogane2),
Hikari Koyama2), Tadashi Kohyama2)
Background: Congenital esophagobronchial fistulae are uncommon anomalies generally discovered during the neonatal
period due to overt symptoms. When symptoms are slight, it
will be discovered in adulthood. We report an adult case of
Braimbridge type I congenital esophagobronchial fistula.
Case report: A 63-year-old woman had presented with repeated attacks of pulmonary infection from her childhood
and had a several years history of recurrent cough after eating
or drinking. Preoperative examinations including esophagography and esophagoscopy revealed existence of a fistula between middle thoracic esophagus and right B6 bronchus.
The fistula was surgically removed with right middle and
lower lobes. The neck of the diverticulum and the fistula
were divided with a stapling technique. Intraoperative
esophagoscopy was found to be useful for the definite localization and complete excision of the fistula and the diverticulum and the avoidance of stenosis of the esophagus. Postoperative course was uneventful. However sarcoid reaction in a
mediastinal lymph node and an adenocarcinoma in the lower
lobe were found by pathological examination, neither adhesion nor invasion of malignancy was found in the surrounding tissues of the fistula. Conclusion: The differential diagnosis between the congenital and acquired types is sometimes
very difficult, but we diagnosed this case as a congenital
esophagobronchial fistula according to surgical and pathological findings.
300
Department of Medicine, Hatyai Medical Education Center,
Thailand
Narongwit Nakwan
Major aortopulmonary collateral artery (MAPCA) is a rare
anomaly vessel defect arising from the systemic arteries and
supplying flow to the pulmonary capillary circulation which
frequently associate with cyanotic heart disease particularly
pulmonary atresia coexisting with ventricular septal defect
and tetralogy of Fallot. The branches of MAPCA usually
originate from aorta descending aorta, while feeding vessel
from coronary artery directing to pulmonary vasculature is
rare occurrence. Herein, we present the first case of right
side pulmonary atresia with variant MAPCA originating
from left circumflex coronary artery to pulmonary capillary
circulation presenting with acute coronary syndrome.
Poster Presentation
IP-P17-8
IP-P18-1
Chronic cough and dyspnea due to right sided aortic
arch in adult male
A case of upper tracheal blunt injury due to traffic accident
Pulmonology, Ain Shams University!
Cairo!
Egypt, UAE
Ahmed Riad Almansoury
A case of right aortic arch with aberrant left subclavian artery was found in a 30-years old Jordon male, complaining of
unexplained coughing and dyspnea. For the past 2 years the
patient was treated from sinusitis, recurrent attacks of lower
respiratory tract infections and bronchial asthma.
KEY WORDS: right aortic arch, aberrant left subclavian artery, chronic dyspnea
Division of Respiratory and Infectious Diseases, Department
of Internal Medicine, St. Marianna University School of Medicine, Japan1), Division of Otorhinolaryngology St. Marianna
University School of Medicine Japan2), Department of Chest
Surgery, St. Marianna University School of Medicine, Japan3)
Kazutaka Kakinuma1), Shinya Azagami1), Kei Morikawa1),
Hiromi Muraoka1), Mariko Okamoto1), Ayano Usuba1),
Teppei Inoue1), Naoki Huruya1), Hroshi Handa1),
Hirotaka Kida1), Hiroki Nishine1), Atsuko Ishida1),
Seiichi Nobuyama1), Takeo Inoue1),
Masamichi Mineshita1), Teruomi Miyazawa1),
Yasuhiro Miyamoto2), Izumi Koizuka2), Hisashi Saji3),
Haruhiko Nakamura3)
Background. Injury of the trachea by blunt trauma is comparatively rare. It mainly occurs in traffic accidents and is
usually diagnosed with chest CT or by symptoms.
Case Report. The patient is a 17 year-old male with no medical history. He was injured in a traffic accident while riding a
motor cycle. His injuries included;complicated cerebral contusion and hepatic injury with severe intra-abdominal bleeding. He was immediately intubated and hepatic artery embolization was performed. His general condition gradually
improved after 1-week; however, extubation was unsuccessful and he complained of severe dyspnea. He was reintubated and administered with steroid, which resulted in successful extubation. After being discharge from hospital, he
experienced dyspnea on exertion, which gradually became
worse. His breathing was retractive and stridor was noted
without auscultation. CT revealed a severe stenosis at the
upper trachea. Emergency tracheostomy was performed on
the same day of admission to our hospital, and revealed several trachea cartilage fractures. Bronchoscopy revealed his
trachea was severely narrowed to the diameter of a pinhole.
The patient subsequently underwent surgical tracheoplasty
to hollow out the broken cartilage and connect the upper and
lower trachea with surgery. Complications such as recurrent
nerve paralysis and infection did not occur however; constant long-term monitoring of the trachea by bronchoscopy
and CT is necessary.
Conclusion. We experienced a case of severe upper tracheal
stenosis due to blunt injury related to the traffic accident
that went unnoticed three months. The proximate cause
that damaged the trachea might have been the helmet strap.
Surgical tracheoplasty obtained a good postoperative course
but constant observation will be necessary.
301
Poster Presentation
IP-P18-2
IP-P18-3
Management of hospitalized 472 patients with thoracic trauma during 20-year period
Recovery surgery after thoracoscopic right upper
lobectomy with mistook stapling of intermedial pulmonary artery
Department of Thoracic Surgery, GMMA Haydarpasa Training Hospital, Turkey
Turgut Isitmangil, Akin Yildizhan, Nurettin Yiyit,
Fatih Candas, Rauf Gorur, Haluk Sasmaz, Omer Yavuz,
Habil Tunc, Saban Sebit, Oryal Erdik
Thoracic trauma is any form of physical injury to the chest.
Thoracic traumas account for 25% of all deaths from traumatic injury. The initial management in the golden hour after injury relates directly to chances of survival in thoracic
trauma.
In this study we reviewed the consequences of various types
of thoracic injuries and treatment modalities. We hospitalized a total of 472 patients with major thoracic trauma, consisting of 252 cases with blunt trauma and 220 cases with
penetrating trauma (caused by 133 gunshot wounds and 87
stab wounds) between January 1993 and December 2012.
Four hundred twenty-one males and 51 females (mean age:
33.81) were enrolled into our study. In the blunt trauma
group, 17 hemopneumothoraces, 38 hemothoraces, 38 pneumothoraces, 35 major lung injuries, 6 flail chest, 2 contusion
of the heart and 161 ribs, 15 sternal and 9 clavicular fractures
were observed. One patient was quadroparalysed and polytrauma was seen in 33 patients. Among patients with gunshot wounds, there were 57 hemopneumothoraces, 42 hemothoraces, 15 pneumothoraces, and 35 lung injuries. Among patients with stab wounds, there were 22 hemopneumothoraces, 24 hemothoraces and 29 pneumothoraces.
In the patients with thoracic trauma, tube thoracostomy was
performed in 211, thoracotomy in 25, video-assisted thoracic
surgery in 8, laparotomy in 28, median sternotomy in 1 and
other non-thoracic operations in 20. Mean hospitalization was
7.6 days. There were five mortality in patients with blunt
trauma and two mortality in patients with penetrating
trauma.
Tube thoracostomy is very valuable in the management of
patients with pneumothorax and!
or hemothorax except for
some thoracic trauma cases with uncontrolled intrathoracic
bleeding or visceral organ injury.
302
Department of Surgery, Fukuoka University Chikushi Hospital, Japan1), Department of Thoracic Surgery, Fukuoka University School of Medicine, Japan2)
Satoshi Yamamoto1), Sosei Abe1), Takahumi Maekawa1),
Akinori Iwasaki2)
<background>
The vessel injury is one of most tense complication during
thoracoscopic pulmonary surgery. We made intermedial pulmonary trunk anastomosed to right superior pulmonary
trunk, after the intermedial pulmonary trunk was stapling
by mistook with the right upper pulmonary vein via complete VATS operation. We will show you the thoracoscopic
surgery and recovery operation by open thoracotomy.
<case>
68 year-old male, he was pointed out of 1.5cm in diameter
Grand Glass Attenuation (GGA) in the right upper lobe, it
was diagnosed as adenocarcinoma by TBLB. He had a 5ports complete VATS operation. During the operation, the
intermedial pulmonary trunk was stapling by mistook with
the right upper pulmonary vein. After make sure that, it was
converted to open thoracotmy, the intermedial pulmonary
trunk was anastomosed to right superior pulmonary trunk.
The operating time was 288 minutes. He had no major complication, and discharged to home at 5 days after operation.
According to Chest CT scan after 2 months operation, the
right pulmonary arteries were intact and patent, and he is no
symptom.
<conclusions>
The extra anatomical reconstruction is one of recovering options after major pulmonary vessel injury.
Poster Presentation
IP-P18-4
IP-P18-5
Extended bronchoplasty and pulmonary arterioplasty
with right upper-lower bilobectomy for lung cancer after CRT
Technical aspects of double reconstructions of pulmonary artery and bronchus for lung cancer
Division of Thoracic Surgery, Respiratory Disease Center,
Seirei Mikatahara General Hospital, Japan
Hiroshi Haneda, Hiroshi Niwa, Masayuki Tanahashi,
Haruhiro Yukiue, Eriko Suzuki, Naoko Yoshii
Background: Sometimes patients with advanced lung cancer
require a complete resection by pneumonectomy, but cannot
undergo surgical treatment because of poor performance
status (PS) and!
or poor pulmonary function. Therefore, surgical treatment is performed after chemoradiotherapy (CRT)
improves PS and pulmonary function for such patients. Here,
we report a case of a patient with lung cancer who could not
endure a pneumonectomy because of poor PS and pulmonary function. After CRT, the patient underwent a right
upper-lower bilobectomy using bronchoplasty and pulmonary arterioplasty to avoid a pneumonectomy.
Case report: A 66-year-old man was admitted with prolonged
cough and dyspnea. A chest radiograph showed a large mass
in the right hilum of the lung. Computed tomography
showed a large mass in the superior segment of the right
lower lobe and a huge hilar lymph node occluding the right
main bronchus. Biopsy specimens revealed a pulmonary
squamous cell carcinoma. Pulmonary function tests revealed
that his VC was 2.0L (57%) and FEV1 was 1.5L (76%). The patient was diagnosed with primary lung cancer classified as
cT3N1M0 stage IIIA. A radical pneumonectomy was
needed, but could not be endured because of poor PS and
poor pulmonary function. CRT was performed using docetaxel and cisplatin with concurrent 40Gy radiotherapy.
CRT reduced the tumor size, and PS and pulmonary function
quickly improved. CT revealed that the main tumor was reduced to 4 cm and the right main bronchus was patent.
Therefore, a radical procedure was required. He underwent
a right upper-lower bilobectomy using bronchoplasty and
pulmonary arterioplasty to preserve the middle lobe and
avoid a pneumonectomy. The middle lobe bronchus was anastomosed to the right main bronchus and the pulmonary artery underwent wide wedge resection and bovine pericardial patch repair. The postoperative course was good, and he
was discharged on POD 15. He was diagnosed pathologically
with squamous cell carcinoma classified as ypT1a (0.5 cm) N0
M0 stage IA and Ef2.
Conclusion: Preoperative CRT enabled surgical treatment
and middle lobe preservation.
Department of Thoracic Surgery, Tokyo Women s Medical
University Yachiyo Medical center, Japan
Atsushi Hata, Yasuo Sekine, Eitetsu Koh
Background: Double reconstructions of pulmonary artery
and bronchus are sometimes necessary for complete resection and functional preservation in central lung cancer surgery. There are various types of reconstructions and which
and how reconstruction should be performed first depends
on a case. We present two cases of double reconstruction of
pulmonary artery and bronchus for central type lung cancer.
Case presentation: First case is a 77-year old man who had
squamous cell carcinoma in left upper lobe. The stage was cT2aN1M0 stageIIA. The tumor obstructed left upper bronchus and invaded to pulmonary artery from A3 to A1+2. After clamping of pulmonary artery, left upper sleeve lobectomy was performed. Pulmonary artery was reconstructed
with a parachute suture using pericardial patch. Bronchoplasty was done with interrupted suture with 4-0 PDS.
Second case was a 71-year old man who had squamous cell
carcinoma in right upper lobe. The stage was c-T2aN1M0
stageIIA. The operation was performed at the 4th anterior
intercostal incision with video-assisted thoracic surgery. The
tumor obstructed right upper bronchus and invaded to A2.
After clamping of pulmonary artery, right upper lobectomy
with wedge resection of bronchus was performed. Pulmonary arterial reconstruction was performed with direct suture and bronchoplasty was performed with continuous
over-and over suture on membranous portion and with interrupted suture on cartilaginous region. In cases of wedge
bronchial resection, deep wedge trimming of bronchus was
critical in order to obtain good anastomosis.
Conclusion: Double reconstruction of pulmonary artery and
bronchus is feasible for functional preservation and good
prognosis for central type lung cancer.
303
Poster Presentation
IP-P18-6
IP-P18-7
Tracheal transplantation cases with endoscopic
follow-up： A revascularized graft and a decellular
graft
A fenestrated stent graft for surgical resection of lung
cancer invading the aortic arch
Department of Endoscopy, I.M.Sechenov First Moscow State
Medical University, Russia1), Petrovsky National Research
Center of Surgery, Russian Federation2)
Mikhail A. Rusakov1), Vladimir Parshin1),
Margarita Vyjigina2)
Background. Treatment of long cicatrical tracheal stenosis is
a great challenge in modern tracheal surgery. Synthetic implants carry a high risk of septic complications and restenosis. Problems associated with tracheal transplantation are
not well described.
Case reports. Two patients with long iatrogenic tracheal
stenosis received tracheal transplants. They were followed
up with endoscopic examinations and treatments as needed.
The endoscopic examinations and operations performed under a general or local anesthesia, depending on the patient s
condition and the nature of the procedure.
The first patient, a 37-year-old man, underwent tracheal
transplantation with revascularization through a transplanted thyroid gland by Dydykin s method on October 18th,
2006. He received postoperative immunosuppression as in
lung transplantation. Six months after the operation, a followup endoscopic examination revealed a normal appearance of
graft cartilages and good epithelialization of both anastomoses. However, he suffered chronic rejection of the transplanted thyroid, which impaired the blood supply to the tracheal transplant, resulting in cartilaginous deterioration evident 2 years after the operation. His graft malacia was
treated with insertion of a Dumont stent. The patient remains alive with an indwelling Dumont stent (7 years after
transplantation).
The second patient, a 26-year-old woman, was transplanted
with a regenerative graft developed through Macchiarini s
method on December 7th, 2010. A bioresorbable stent was
inserted endoscopically into the graft immediately after anastomosis. Signs of graft revascularization were apparent a
week after the operation, and complete epithelialization was
confirmed at her 1-year follow-up examination. The bioresorbable stent lost elasticity and thus no longer was fulfilling
its intended function 2.5 months after the operation. It was
dangling partially into the graft lumen, attached by granulated tissue. The non-affixed portion of the stent was removed endoscopically. Three attempts to restore function by
introduction of a Dumont stent were made, but they all
failed. Therefore, a tracheostomy was performed and a Ttube was introduced 4.5 months after transplantation. The
patient is alive with the T-tube still in place (2 years 11
months after transplantation).
Conclusion: Tracheal transplantation is feasible, but patients
need careful endoscopic follow-up and treatment.
304
Department of General Thoracic Surgery, Graduate School of
Medical and Dental Sciences, Kagoshima University, Japan1),
Department of Cardiovascular and Gastroenterological Surgery, Advanced Therapeutics, Cardiovascular and Respiratory Disorders, Graduate School of Medical and Dental Sciences, Kagoshima University2)
Toshiyuki Nagata1), Yoshihiro Nakamura1),
Hiroyuki Yamamoto2), Masami Sato1)
A fenestrated stent graft, including the orifice of the left subclavian artery, was used to resect a left upper lobe cancer invading the distal aortic arch without the use of cardiopulmonary bypass. No complications were observed. From our
literature search, fenestrated stent graft for distal aortic
arch invasion has not been reported. This method could reduce the risks of combined resection of the aortic arch during lung cancer surgery.
Poster Presentation
IP-P19-1
IP-P19-2
Experience with bronchial thermoplasty in a peninsular Malaysia state
Electrical impedance tomography and lung deflation
after endoscopic lung volume reduction with one-way
valves in pigs
Department of Internal Medicine, Universiti Putra Malaysia,
Malaysia1), Department of Internal Medicine, Serdang Hospital2), Department of Internal Medicine, Sultanah Bahiyah Hospital3)
Liza Ahmad Fisal1), Azlina Samsudin2),
Mustafa Kamal Razak3), Jamalul Azizi Abdul Rahaman2)
Background: Bronchial thermoplasty (BT) is a novel treatment modality reserved for severe refractory asthma where
radiofrequency ablation of airway smooth muscle results in a
reduction of bronchoconstriction during an exacerbation. In
our clinical case series we present three patients with severe
refractory asthma who had undergone BT.
Case report: The first patient was a 22-year-old female college student who suffered with asthma since childhood associated with an extensive history of allergies, rhinitis and
gastro-oesophageal reflux disease. She had regular exacerbations with repeated endotracheal intubations. Her Asthma
Control Test (ACT) score ranged between 9-15 with an FEV
1 averanging at 40% predicted. She was on maximal asthma
therapy including omalizumab. The second patient was a 56year-old female retired storekeeper who suffered with adult
asthma. She too had regular exacerbations with a history of
endotracheal intubation. Her ACT score was similarly offtarget with an FEV1 averaging at 60% predicted. She was on
maximal asthma therapy, requiring frequent courses of rescue oral corticosteroids. The third patient is a 24-year-old
dental nurse who suffered with asthma since adolescence
with associated allergic rhinitis. She had regular exacerbations requiring intensive care admissions resulting in multiple sick days. Her ACT score was consistently below 10.
They had undergone 3 sessions of BT under general anaesthesia at 3 weeks apart. All three patients had postprocedure exacerbations which responded to standard medical therapy. The first and third patients responded well to
BT with normalisation of their ACT score and discontinuation of oral corticosteroids. The second patient had not
fared as well where she continued to suffer with exacerbations but not as frequently and she had not required endotracheal intubation since.
Conclusions: BT is designed as an adjunct therapy rather
than replacing standard treatment in severe refractory
asthma. It has been shown to improve asthma symptoms,
quality of life and reduce exacerbations. In our limited experience, treatment outcome has been rather mixed which
may indicate the need for a better patient selection criteria
to identify those who will benefit most from BT.
Dept. Cardiopneumology, Division of Thoracic Surgery, InCor
(Heart Institute)-HCFMUSP, University of Sao Paulo School of
Medicine, Brazil1), Department of Cardiopneumology, Division
of Pulmonology, Faculty of Medicine of the University of Sao
Paulo, Brazil2), Department of Cardiopneumology, Service of
Respiratory Endoscopy, Heart Institute (InCor) - Hospital das
Clinicas, Faculty of Medicine of the University of Sao Paulo,
Brazil3), Discipline of Operative Technique and Experimental
Surgery. Faculty of Medicine of the University of Sao Paulo,
Brazil4), Biomedical Engineering Labotatory, Escola,
Politecnica-University of Sao Paulo, Brazil5)
Paulo F.G. Cardoso1), Vinicius Torsani2),
Roberta R. S. Santiago2), Addy L. M. Palomino3),
Susimeire Gomes2), Henrique T. Moriya5), Jose P. Otoch4),
Carlos R. R. Carvalho2), Paulo M. P. Fernandes1),
Marcelo B. P. Amato2)
Background: Endoscopic lung volume reduction (ELVR) with one-way valves has
been used for advanced stage emphysema. Best results are achieved when complete fissures and poor collateral ventilation are present. The redistribution of
ventilation and perfusion within the lungs following ELVR relies mostly on static
imaging procedures and is known to have an impact on the outcome. Electrical
impedance tomography (EIT) is a noninvasive, radiation-free monitoring method
that allows real-time measurement of ventilation and perfusion at the bedside.
This study focused on the use of EIT as a non-invasive and real time procedure
for the assessment of the regional ventilation following left lower lobe (LLL) deflation with one-way valves in pigs. Methods: Five 30kg swine were anesthetized,
paralized and submitted to pressure controlled ventilation via tracheostomy. The
electrode belt was positioned around the chest girdle and connected to the EIT
(DX1800, Dixtal Biomedica, Brasil). PEEP titration was provided by EIT and adjusted accordingly. Two protocols were carried out sequentially in each animal at
two FiO2 regimens (0,5 and 1,0) in a randomized fashion. The first protocol assessed the collateral ventilation with a baloon catheter (Chartis, Pulmonx, USA)
placed bronchoscopically to occlude the LLL bronchus; The second protocol included the deployment of 2 to 4 one-way valves (EBV Zephyr, Pulmonx, USA)
within the LLL segmental bronchi. Perfusion was assessed by EIT using IV injecions of hypertonic saline (NaCl 20%; 6mL aliquots). Hemodynamics, gas exchance
and pulmonary mechanics were measured along with all EIT readings at regular
intervals. Results: All swine showed no collateral ventilation in the LLL. EIT detected a decrease in volume in left lower lung after valve deployment. There was
a redistribution of volume mostly to the upper right lung quadrant and rapid reduction in perfusion on the left side. Lung deflation was faster under FiO2 1,0 during both baloon occlusion and after valve placement (figure). The PaO2 reduced
and PaCO2 increased, particularly after valve placement under a FiO2 of O,5.
Conclusion: In this animal model of lung deflation in the setting of low collateral
ventilation, the EIT findings suggested that lung deflation was achieved in both
protocols. The use of higher FiO2 concentration was related to a faster and steadier decline in left lung volumes secondary to occlusion of the LLL. Future studies
are under way to investigate the role of EIT for the assessment of lung deflation
and redistribution of lung volumes following ELVR.
305
Poster Presentation
IP-P19-3
IP-P19-4
Electrical impedance tomography in the assessment
of endoscopic lung volume reduction with one-way
valves for emphysema
Quantitative CT assessment of bronchoscopic lung
volume reduction with valve
Dept. Cardiopneumology, Division of Thoracic Surgery, InCor
(Heart Institute)-HCFMUSP, University of Sao Paulo School of
Medicine, Brazil1), Department of Cardiopneumology, Division
of Pneumology. Heart Institute (InCor)-Hospital das Clinicas,
Faculty of Medicine, University of Sao Paulo, Brazil.2), Department of Cardiopneumology, Respiratory Endoscopy Service,
Heart Institute (InCor)-Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo, Brazil.3)
Paulo F.G. Cardoso1), Roberta R. S. Santiago2),
Vinicius Torsani2), Regina C. Pinto2),
Frederico L. A. Fernandes2), Manuela Brisot2),
Viviane R. Figueiredo3), Carlos R. R. Carvalho2),
Paulo M. P. Fernandes1), Marcelo B. P. Amato2)
Background: Endoscopic lung volume reduction with one-way valves (ELVR) has been
used selectively in patients with emphysema. Assessment of volume reduction and redistribution of ventilation within emphysematous lungs relies mostly on static imaging procedures. Electrical impedance tomography (EIT) is a noninvasive, radiation-free method that
allows bedside real-time regional ventilation measurements. This report focuses on the use
EIT for the assessment of the regional ventilation following ELVR. Case report: 59 year-old
emphysematous female with dyspnea (MRC3), SpO2 90% at rest, with neither frequent exacerbations nor severe comorbidities. Pulmonary function showed FEV1=0,72L (31%), RV=
3,97L (196%), TLC=6,60L (126%). High resolution chest CT scan (HRCT) showed heterogeneous emphysema and lung volumetry was greater in the right lung (right=3210mL;left=
2512mL) with high heterogeneity score on the left lung (25%) and the presence of a complete fissure. The left upper lobe was tested negative for collateral ventilation (Chartis,
Pulmonx,USA) and was then treated with three one-way valves (EBV Zephyr-Pulmonx,
USA). Twenty minutes after the procedure, EIT (DX1800, Dixtal Biomedica, Brasil) measurements showed volume reduction on the left upper quadrant coinciding with left upper
lobe atelectasisas confirmed by a chest X ray. At two hours, EIT demonstrated a volume
increase in the left upper quadrant, possibly due to overexpansion of the left lower lobe,
whereas at 24 hours a volume increase was detected in the right lower quadrant suggesting trans-pulmonary volume redistribution. At 30 days the EIT showed an increase in volume in the left lower quadrant (figure) confirmed by HRCT and lung volumetry (left=1846
mL; right=3403mL). PFTs showed an increase in FVC (0,49L), FEV1 (0,43L;11% change
from pre-treatment), with a reduction in RV (0,73L) and TLC (0,11L). The SGRQ decreased 9
points and MRC reduced one point. To the best of our knowledge this is the first report on
EIT assessment of lung ventilation during and after ELVR with one-way valves. The findings showed that EIT was able to detect ventilation shifts following ELVR safely and accurately. Conclusion: EIT was accurate for the detection and measurement of volume
changes following ELVR and correlated with HRCT scan volumetry. Since EIT can be used
during and after ELVR repeatedly, with no radiation, at a low cost and with minimal discomfort to the patient, a clinical study is currently under way at our institution focusing on
the role of EIT for the assessment in patients submitted to ELVR along with other methods.
306
Department of respiratory medicine, Peking University First
Hospital, China1), Department of Radiology, peking University
First Hospital, China2)
Junfang Huang1), Rui Wang2), Jianxing Qiu2),
Zhang Hong1), Guangfa Wang1)
PURPOSE: To evaluate changes in quantitative parameters
at CT scan, as well as lung fuvntion, activity endurance and
syptom score after valve lung volume reduction procedure
in COPD patients
METHODS: four COPD patients, accepted valve volume reduction procedure during Sep.1st, 2011 and Dec 31st, 2012,
were enrolled into the study. A retrospective analysis of lung
function, 6MWD(six-minute walk distance), Borg scale and
CT quantitative parameters before and after the procedure
within three months was performed. The volume and %
950HU), in each lobe as
LAV-950(low attenuation volumep＜!
well as Ai(lumen area), WA%(percentage of wall area) of bilateral B1, B4 and B10 were compared by using ADW 4.2
software.
RESULTS: Operative sides included two right upper lobes,
one right middle lobe and one left lower lobe. After the procedure, 2(0.5-7)points(P=0.147) of best Borg scale decrease
was observed. The best 6MWD improvement was 175.25 (55290) meters, improved by 153.9(23.91-241)% (P=0.05). The
best improvement of FEV1 was 0.22(0.12!
0.47)L, improved
by 48.41(20.34!
70.15)%(p=0.057), while FVC was 0.74(0.36!
0.75)L, improved by 42.63(18.65!
48.04)%(P=0.012). The largest
RV reduction was 0.92(0.65!
1.12)L(P=0.003) and RV%TLC
was 7.5(5.83!
11.53)%(P=0.009). For quantitative CT analysis,
there were seven ipsilateral and eight contralateral lobes for
measurement. Likewise, there were eight ipsilateral and
twelve contralateral bronchi. Of the seven ipsiateral nontargeted lobes, six were observed with volume expanding by
0.15 (-0.03!
0.35)L,(P=0.041). Four of nine contralateral lobe
volumes were decreased. %LAV-950 was reduced in all target
lobes, six of seven ipsilateral lobes reduced by 3.59 (-0.95!
9.62) %(p=0.031). Ai enlargement[2.85 (-6.5-9.5)mm2,p=0.164]
and WA% [2.7 (-9.9!
13.2) %,P=0.547] reduction were observed
in five of eight ipsilateral bronchi and nine of twelve contralateral bronchi [2.35 (-1.4!
9.8) mm2 for Ai,P=0.016; 2.9 (-5.3!
10.3) %, P=0.051 for WA%].
CONCLUSIONS: The four COPD patients accepted bronchscopic valve volume reduction got significant improvement
physiologically. Quantitative CT analysis revealed that valve
volume reduction not only reduce the volume of the target
lobes but also have beneficial effects on ipsi- and contralateral lobes. It can increase the volume of non-target lobes,
dilate non-target bronchi and alleviate air trapping.
Poster Presentation
IP-P19-5
IP-P19-6
Long-term outcomes in 35 consecutive patients with
emphysema after endoscopic lung volume reduction
with Zephir valves
Endoscopic lung volume reduction as a weaning procedure
Department of Pneumology, CHU Grenoble, Joseph Fourier
University, Grenoble, France1), Department of Radiology, CHU
Grenoble, Joseph Fourier University, Grenoble2), Department
of Pharmacology, CHU Grenoble, Joseph Fourier University,
Grenoble3)
Cecile Bosc1), Emilie Reymond2), Adrien Jankowski2),
Francois Arbib1), Amandine Briault1),
Isabelle Federspiel3), Caroline Vincent3),
Wahju Aniwidyaningsih1), Gilbert Ferretti2),
Christophe Pison1)
Endoscopic lung volume reduction with valves statistically
improved lung mechanics, quality of life and exercise intolerance in one RCT (Sciurba et al. NEJM 2010;363:1233-44). Results were strongly related on integrity of lung fissures and
heterogeneity of lung emphysema. Taking in account these
important co-variables, we analyzed outcomes after Zephir
valves insertion (Pulmonx, CA) in 35 consecutives patients,
25 men, 10 women, 60.6 12.3 (SD) yrs old, post-BD FEV1
30.9 11.5% pred. [19-54, m-M], FVC 72.1 16.8, TLC 143.4
21.1, DlCO 32.1 18.1, room air PaO2 9.0 1.4, PaCO2 5.3 0.9, 6minute walking distance (6MWD) 370 115 m resulting in
BODE index of 4.8 2. All patients underwent pre-post procedures Pulmonary Function Tests (PFT), non-injected thoracic computed tomography to analyze fissures integrity and
emphysema lobar volume with lung density＜"
950 HU using
soft Myriam, Intrasens, Paris (Reymond et al. AJR 2013;201:
W571-5). Lobar volumes affected by emphysema in % of volume were RUL 39.7 19.0, RML 27.1 20.6, RLL 30.8 18.9,
LUL 30.9 14.9, LLL 24.9 20.7. Procedures were performed
on flexible bronchoscopy under local anesthesia between
January 2008 and July 2013, last news October 2013, median
follow-up was 15.8 [0.1"
68 months, m-M]. After February
2010, we performed in all candidates measurements of collateral ventilation with occlusive balloon (Chartis, Pulmonx, CA)
and patients were treated only if there were no collateral
ventilation. Heterogeneity as % differences in lobar volumes
adjacent to treated lobe, as defined＜"
950 HU, were 30.1
19.5%. Neither fissure integrity nor level of heterogeneity influenced PFT results. Complications included 1 death day 3,
8 cases with pneumothorax, 9 pulmonary!
bronchial infections, 4 hemoptysis, 6 migrations, 7 expulsions resulting at
the end to 9 patients with definitive valve ablations. Survival
was 77.3 by 15 and 68 months. FEV1%pred., FVC %pred. at 1
year and at last news showed no decline for the 35 cases and
an improvement in patients with atelectasis, n=13, at 1 year
FEV1 33.1 8.6 to 36.7 10.7, p: 0.03, FVC 73.4.1 16.4 to 81.1
24.6, p: 0.01 and persisted at last news. We conclude that
morbidity and mortality related to these procedures were
acceptable. Significant improvements were achieved in FEV
1 and FVC at 1 year and were sustained at last news 15.8
[0.1-68 months, m-M] in case of atelectasis in 13.
Department of Interventional Pneumology, Ruhrlandklinik Essen, Germany1), Department of intensive care, Ruhrlandklinik
Essen-University Clinic Essen, Germany2), Department of
pneumology, Ruhrlandklinik Essen-University Clinic Essen,
Germany3)
Kaid Darwiche1), Frank Bonin2), Urte Sommerwerck3),
Ruediger Karpf-wissel1), Lutz Freitag1)
Background:
Endobronchial valve placement is a relatively new procedure for patients with severe emphysema. COPD exacerbation of severe emphysema patients is a reason for long time
ventilation and sometimes weaning failure. Our case report
shows for the first time that valve placement for lung volume reduction may assist weaning from prolonged ventilation.
Case report:
A 66-year old female with alpha1-antitrypsin deficiency
(PiZZ-type) and severe lower lobe emphysema was referred
to our respiratory intensive care unit (RICU) after intubation
and invasive mechanical ventilation for COPD exacerbation.
Our RICU is a high volume certified weaning center with an
interdisciplinary skilled team. After extubation and reintubation two times due to acute respiratory failure despite
non-invasive ventilation, surgical tracheostomy was performed. Weaning from prolonged ventilation was interfered
by episodes of exacerbations and functional limitation, although intensive physiotherapy was applied. After four
month, decision was made in the multidisciplinary emphysema board to perform endoscopic lung volume reduction by
valve placement. Chartis measurement could exclude collateral ventilation and six Zephyr-valves were placed in the left
lower lobe. Radiography revealed an atelectasis and a reshaped diaphragm the following day. Ipsilateral pneumothorax occurred and was treated by temporary chest drainage
placement. The patient reported, that she was able to inspire
deeper than before and ventilator dependency time could be
reduced. Due to intensive physiotherapy, patient gains significantly in mobility and was able to manage her daily care
by herself with little assistance. Night time ventilation is still
performed but discharge to home was possible after six
month hospital stay.
Conclusion:
Endoscopic lung volume reduction with valves is an option to
improve weaning from ventilation in highly selected cases.
307
Poster Presentation
IP-P19-7
IP-P19-8
Emphysema image analysis using Apollo software
An unexpected result of endobronchial valve complication in bullous emphysema: Postinfectious volume
reduction
Department of Pulmonary Medicine and Bronchoscopy, Gifu
Prefectural General Medical Center, Japan1), Department of
Respiratory and Infectious Disease, St. Mariana University
School of Medicine, Kawasaki, Japan2), Department of Chest
Surgery, St.Marianna University School Of Medicine,
Kawasaki, Japan3), Department of Radiology, St.Marianna University School Of Medicine, Kawasaki, Japan4)
Akifumi Tsuzuku1), Teruomi Miyazawa2),
Fumihiro Asano1), Hiroshi Handa2),
Masamichi Mineshita1), Takeo Inoue2),
Seiichi Nobuyama2), Atsuko Ishida2), Hiroki Nishine2),
Hirotaka Kida2), Naoki Furuya2), Miwa Fujiwara2),
Teppei Inoue2), Mariko Okamoto2), Ayano Usuba2),
Hiromi Muraoka2), Kei Morikawa2), Noriaki Kurimoto3),
Shin Matsuoka4), Tsuneo Yamashiro4),
Yoshihiko Matusno1), Takuya Sobajima1),
Atsunori Masuda1), Anri Murakami1)
Background
Apollo software (VIDA diagnostics, inc.) is a quantitative
lung imaging software. It has significant algorithmic workflow and automation features applicable to high volume, repeatable parenchymal, airway, and fissure integrity analysis.
Using Apollo software, we analyzed the images of emphysema and examined the relationship between the extents of
the disease.
Methods
Thirty patients (3 women and 27 men; mean [ SD]age, 73 9
years)who had COPD were included in the study. All patients underwent paired inspiratory!
expiratory multidetector CT scans. Image analysis was performed using Apollo
software.
The emphysema score was defined as the proportion of pixels of less than­910 Hounsfield units.
The percentage of heterogeneity was defined as the difference in the quantitative emphysema score between the lobe
with the highest percentage of emphysema and the ipsilateral adjacent lobe.
We classified the high-heterogeneity group and the lowheterogeneity group by the 15% heterogeneity cutoff.
We described the relationship between the groups and the
emphysema score, demographics, smoking history, mMRC
(modified Medical Research Council), CAT (COPD Assessment Test), SGRQ-C (St.George s Respiratory Questionnaire
for COPD Patients), pulmonary function testing, 6-min- walk
testing, and exacerbation history.
Results
21 people were classified as the high-heterogeneity group,
and 9 people as the low-heterogeneity group.
Former smokers were significantly more in the highheterogeneity group than in the low-heterogeneity group. As
for the most factors, there were no significant differences between the two groups.
Conclusion
Heterogeneity of emphysema between lobes was an important factor for lung-volume-reduction surgery and
endobronchial-valve therapy. But it cannot be explained by
the severity of COPD by itself.
308
Department of Thoracic Surgery, Marmara University Faculty of Medicine, Turkey1), Department of Chest Diseases,
Marmara University Faculty of Medicine, Turkey2), Chest Diseases Clinic, Yedikule Chest Diseases and Chest Surgery
Training and Research Hospital, Turkey.3)
Korkut Bostanci1), Onur Ermerak1), Hakan Omercikoglu1),
Sehnaz Olgun2), Erdogan Cetinkaya3), Mustafa Yuksel1)
Bronchoscopic lung volume reduction (BLVR) has become a
serious alternative for surgery in patients with advanced
empysema. Among many techniques endobronchial valve
placement is the most popular. Valves can provide improvement in physiological parameters and quality-of-life scores.
Complication rates are low, the most common ones being
COPD exacerbation and pneumothorax.
In this study we present a case we placed valves and removed them because of suppurative infection, followed by
postinfectious volume reduction and clinical improvement.
A 67-year-old male with bullous empysema was decided to
have BLVR with valves, following the clinical, radiological
and radionuclide evaluation. Under sedation, 3 valves were
placed in his right upper lobe. No early postoperative complications were seen and the patient was sent home on medical
therapy. On the postoperative 4th week no complicaitons
were detected yet on the 6th week the patient was admitted
with high fever. Numerous air-fluid levels in radiography and
infectious findings in blood tests were detected, followed by
immediate removal of the valves and multi-drug antibiotherapy.
After a 2-week hospitalisation the patient was sent home
with no infectious findings, and the air-fluid levels were
dissapeared at the end of the 4th week. Control tomography
at the end of the 2nd month revealed significant volume reduction in the right upper lobe, and the patient had better
clinical findings with improvement in 6-minute-walk test and
quality-of-life scores.
Infection is a rare complication of BLVR. The suppurative infection with air-fluid levels after valve placement, followed
by postinfectious fibrosis and volume reduction is an unexpected outcome.
Poster Presentation
IP-P20-1
IP-P20-2
Efficacy of endoscopic ultrasound-guided biopsy of
lymph nodes in mediastinal lymphadenopathy in real
clinical practice
Clinical use of EBUS-TBNA in preoperative evaluation
of non small cell lung cancer
Department of Endoscopy, Central Tuberculosis Research Institute of RAMS, Moscow, Russia
Irina Shumskaya, Olga Lovacheva, Ilya Sivokozov,
Galina Evguschenko, Yurij Berezovsky
Background. Efficacy of endosonography in diagnostics of
mediastinal adenopathies differs between first clinical trials
and real practice with decrease in both sensitivity and specificity for malignant and benign diseases. Results of currently
reported large series in real clinical practice are controversial.
Aim. To assess an efficacy of EBUS or EUS-b guided needle
biopsy of mediastinal lymphnodes in real clinical practice.
Methods. 105 patients with mediastinal adenopathy revealed
by chest CT and referred to diagnostic endoscopy, were consequently enrolled into the study. All patients undergone
EBUS-TBNA or EUS-b-FNA in supine position under local
anesthesia, using dedicated 22G needles. Quality of material,
and diagnostic yield were analyzed for all patients depending on type of disease (benign or malignant).
Results. There were no complications after biopsies in any
patient. Acceptable quality of material was retrieved in 80
from 83 patients in benign diseases (96,3%) and 15 from 22
patients in malignant diseases (68,2%). Diagnostic yield
reached 75 from 83 (90,3%) patients in benign diseases, and
11 patients from 22 (50%) with malignancy were confirmed
by endosonography-guided biopsy, total efficacy for combined groups reached 86!
105 (81,9%). Most of patients in benign group were presented by sarcoidosis (73 from 83 patients), and in malignant diseases almost half of patients were
presented with lymphoma (7 from 22).
Conclusion. Endoscopic ultrasound-guided fine needle biopsy
of mediastinal lymphnodes is a safe, sensitive and effective
procedure in a real clinical practice for diagnostics of mediastinal adenopathies.
Internal medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand1), Department of surgery, Faculty of
medicine Siriraj hospital, Mahidol University2)
Jamsak Tscheikuna1), Supparerk Disayabutr1),
Wanchai Wongkornrat2), Punnarerk Thongcharoen2),
Pranya Sakiyalak2), Teeravit Pranchaiprtch2)
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has gained acceptance as a diagnostic
procedure to sample mediastinal lymph nodes in patients
with non-small cell lung cancer (NSCLC). The efficacy of
EBUS-TBNA is comparable to the gold standard mediastinoscopy in clinical staging of NSCLC. This study aims to evaluate the clinical efficacy of replacing mediastinoscopy by
EBUS-TBNA in the diagnostic investigation algorithm of radiologically normal size mediastinal lymph node before
NSCLC surgery.
Material and Method
Retrospective analysis was done on database of NSCLC patients who were referred for evaluation of mediastinal lymph
nodes by EBUS-TBNA at Division of Respiratory Diseases
and Tuberculosis, Department of Medicine between year
2010-2012. Only data of patients who had radiological normal
size mediastinal lymph node before surgery, negative cytological results of EBUS-TBNA and went on for surgery were
selected. Positron emission tomography (PET-CT) was not
done.The demographic data of patients, character of lymph
node, operative finding, pathological results of surgical specimens were collected. Clinical efficacy was referred as negative predictive value of EBUS-TBNA in this clinical situation.
Results
There were 62 patients who met the inclusion criteria. 2
were excluded because surgeru were wedge resection without lymphnode removal. 60 patients were evaluated in the
study. The mean age was 65+10 years. The mean duration
between EBUS-TBNA procedure and surgery was 35+25
days. The means number of N2 and N1 node that were recovered from the surgical specimens were 11 and 6 nodes
per patient respectively. The mean tumor size was 4.5+2.3
cms. There were 11 patients whose surgical N2 nodes were
positive for malignant cells. The negative predictive valve of
EBUS-TBNA was 81.6%. In this group, angiolymphatic invasion and visceral pleural involvement were found in all. Positive malignant cells were found in different nodal stations
from the EBUS-TBNA puncture station in half.
Conclusion
Clinical efficacy of EBUS-TBNA in radiological normal mediastinum lymph node for preoperative evaluation of non small
cell lung cancer was not high enough to routinely replace
this procedure for mediastinoscopy. The thoroughly examination of mediastinal lymph node with attention to all station
and sampling of all small size nodes especially in primary tumors that have visceral pleural involvement and angiolymphatic invasion may improves the negative predictive value
of EBUS-TBNA in this clinical situation.
309
Poster Presentation
IP-P20-3
IP-P20-4
Endobronchial ultrasound to evaluate downstaging of
lung cancer after combined chemotherapy and radiation treatment
Diagnostic efficacy of endobronchial ultrasoundguided transbronchial needle aspiration in malignant
lymphoma
Department of Internal Medicine, Bangkok Hospital Group,
Thailand
Department of Pulmonary Medicine and Clinical Immunology,
Dokkyo Medical University School of Medicine, Japan
Sawang Saenghirunvattana, Cheewantorn Boonpeng,
Thomas Lodi, Chittisak Napairee, Supada Chusaktrakul,
Cecille Lorraine Castillon, Kritsana Sutthisri,
Chitchamai Siangproh, Maria Christina Gonzales
Takafumi Umetsu, Akihiro Takemasa, Ryou Arai,
Kazuyuki Chibana, Masaaki Miyoshi, Yoshiki Ishii
Background
Chemotherapy and radiotherapy, separately or sequentially,
are established protocols in the management of lung malignancy. However, as early as 1999 a study in Osaka, Japan
concluded that the concurrent approach yielded a significantly increased response rate and enhanced median survival duration when compared with the sequential approach
as applied to selected patients with unresectable stage III
NSCLC). Endobronchial ultrasonography is currently considered the gold standard in the evaluation of mediastinal
lymph nodes and lung lesions along with its other usage in
the clinical set-up. EBUS might be an appropriate and effective method evaluation of lung cancer after combined chemotherapy and radiotherapy.
Material and Method
Combination of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) and Endobronchial Ultrasound with Guidesheath (EBUS-GS) was used to
obtain sample specimens for biopsy to determine downstaging of the cancer.
Results
Between 1 July 2012 to 1 July 2013, we performed the downstaging of lung cancer in three cases.
A Thai patient, 72-year old, male, was diagnosed with Adenocarcinoma stage 2. He was inoperable due to his poor lung
function. Chemotherapy and radiotherapy were administered. Repeated EBUS-GS revealed fibrosis of the previous
lung adenocarcinoma. No malignancy.
An Arabic patient, 62-year old, male, obtained combined chemotherapy and radiotherapy following his diagnosis of Adenocarcinoma stage 3. He underwentEBUS-GS and TBNA after mediastinal masses were seen in his recent CT and PET
CT Scan. Biopsy revealed it to be fibrosis. No malignancy
found.
A caucasian patient, 50-year old, male, diagnosed of Adenocarcinoma stage 2 by EBUS-GS underwent twoprotocols:
Taxotere 10mg and Carboplatin 50mg alternating every
other week with Cisplatin 10mg, Eteposide 10mg and Vinorelbine 10mg. After that, lobectomy was done back home
in Germany and pathology results revealed no presence of
malignancy in lung tissue.
Conclusion
Endobronchial Ultrasonography is an effective tool in evaluating downstaging in patients with lung cancer after combined chemotherapy and radiotherapy.
310
BACKGROUND
The diagnostic accuracy of endobronchial ultrasound-guided
transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of malignant lymphoma in patients with mediastinal
lymphadenopathy is not well defined. We therefore reviewed
our clinical data and pathological findings to examine the
clinical use of EBUS-TBNA in patients with mediastinal lymphadenopathy diagnosed finally as malignant lymphoma.
METHODS
A retrospective review was performed of all patients with
mediastinal lymphadenopathy referred for EBUS-TBNA between April 2006 and November 2013 in whom EBUS-TBNA
examinations were performed and final diagnoses were malignant lymphoma. Mediastinal biopsy specimens were taken
using an ultrasonic bronchoscope (Olympus BF-UC 260F)
and a 21!
22-gauge cytology needle (NA-201 SX-4021!
SX4022 Olympus) with on-site cytopathological support. The
EBUS-TBNA result was compared with a reference of standard pathological tissue diagnosis and clinical data.
RESULTS
EBUS-TBNA identified atypical cells in 8 out of 10 patients
(80%) with hematoxylin and eosin staining. The accurate diagnosis for malignant lymphoma was 70% (7 out of 10 patients) with a combination of immunohistochemistry, in case
only EBUS-TBNA examinations were applied. False negative cases were 3 out of 10, in which EBUS-TBNA specimens
were small amount for diagnoses of malignant lymphoma.
The main causes for false negative diagnoses were due to inadequate amount of samples.
CONCLUSION
EBUS-TBNA is a safe and useful tool in the investigation of
suspected malignant lymphoma, if adequate amount samples
are taken and!
or ancillary studies like immunocytochemistry are applied. In those cases, it may diminish the need for
more invasive procedures such as mediastinoscopy.
Poster Presentation
IP-P20-5
IP-P20-6
The value of EBUS-guided TBNA in the diagnosis of
isolated mediastinal lymphadenopathy of suspected
lymphoma patients
Solitary mediastinal lymph node metastasis from
mesothelioma of testis diagnosed by convex-probe
EBUS
Department of Chest, Ankara Ataturk Training and Research
Hospital, Turkey1), Ataturk Training and Research Hospital,
Pulmonary Disease Clinic, Ankara, Turkey2), Yildirim Beyazid
University, Pulmonary Disease Clinic, Ankara, Turkey3)
Department of Pneumonology and Interventional Bronchoscopy, Army General Hospital of Athens, Greece1), Department of Interventional Bronchoscopy, Ygeia Hospital, Athens, Greece2)
Hatice Kilic1,2), Senturk Aysegul1), Elif Babaoglu2),
Habibe Hezer2), H. Canan Hasanoglu3)
Stamatis Katsenos1), Markela-Elvira Antonogiannaki1),
Michael Doris2)
Background: Endobronchial ultrasound-guided transbronchial needle (EBUS-TBNA) has a high accuracy in diagnosing mediastinal lymphadenopathies of lung cancer and benign disorders. However, the utility of EBUS-TBNA in diagnosis of mediastinal lymphomas is unclear. The aim of this
study was to determine the diagnostic value of EBUS-TBNA
in patients with suspected lymphoma.
Methods: Consecutive patients suspected of having lymphoma with isolated mediastinal lymphadenopathy were included in a retrospective study. EBUS-TBNA was carried
out in outpatients under moderate sedation. The sensitivity,
specificity and diagnostic accuracy of EBUS-TBNA were calculated.
Results: 61 patients who had isolated mediastinal lymphadenopathy were included to the study. 32(52.5%) had sarcoidosis, 6(9.8%) had reactive lymphadenopathy, 9 (14.8%) had tuberculosis (TB), 1 patients (1.6%) had squamous cell carcinoma, 2 (3.3%) patients had sarcoma and 11(18%) had lymphoma (2 were diagnosed as follicular center cell lymphoma,1
as large B-cell primary lymphoma and 8 as hodgkin lymphoma). 10 lymphoma patients were diagnosed by EBUS and
1 patient by thoracotomy. The sensitivity, specificity, negative predictive value and diagnostic accuracy of EBUSTBNA for the diagnosis of lymphoma were calculated as
90.9%, 100%, 75%, and 92.8%, respectively.
Conclusion: EBUS-TBNA is a high diagnostic tool. We
showed that EBUS-TBNA can be employed in the diagnosis
of mediastinal lymphoma instead of most invasive surgical
biopsies.
Background: Malignant mesothelioma is most commonly
found in the pleura, peritoneum and pericardium, while
mesothelioma of the tunica vaginalis testis is exceedingly
rare. The usual sites of metastasis are inguinal and retroperitoneal lymph nodes as well as lung. Solitary mediastinal involvement has never been reported as metastatic site of this
extremely rare tumor.
Case Report: A 75-year-old male presented to our department for evaluation of solitary mediastinal lymph node enlargement. He was diagnosed with mesothelioma of tunica
vaginalis testis and underwent radical orchiectomy. Three
years after surgical excision, chest computed tomography
imaging revealed a single right paratracheal lymph node enlargement. A convex-probe real-time endobronchial ultrasound (EBUS) with transbronchial needle aspiration-biopsy
(TBNA!
TBNB) was directly performed and the diagnosis of
mediastinal metastasis from malignant mesothelioma of the
testis was made. In particular, by immunohistochemical
staining, the cells were found to be consistently positive for
cytokeratin stain and calretenin stain but negative for CEA
stain.
Conclusion: Convex probe EBUS is the first test for patients
with undiagnosed mediastinal lymphadenopathy either with
or without lung mass allowing simultaneous lymph node
staging as well as diagnosis. Malignant mesothelioma of testis can be metastasized to the mediastinum presenting as an
asymptomatic solitary lymph node enlargement without initially involving anatomic structures lined by mesothelium,
such as pleura, pericardium and peritoneum.
311
Poster Presentation
IP-P20-7
IP-P20-8
The value of EBUS-TBNA biopsy for diagnosis of mediastinal lymphadenopathy in patients with extrathoracic malignancy
EBUS-TBNA in metastatic medullary thyroid carcinoma
Department of Chest, Ankara Ataturk Training and Research
Hospital, Turkey1), Department of Chest Diseases, Yildirim
Beyazit University, School of Medicine.2)
Aysegul Senturk1), Hatice Kilic1), Habibe Hezer1),
Funda Karaduman Yalcin1), H. Canan Hasanoglu2)
Background: Mediastinal lymph nodes are common in the
course of extrathoracic malignancy should not be always
considered as a metastatic lesion. The purpose of this study
was to determine the diagnostic value of Endobronchial
Ultrasound-guided Transbronchial Needle Biopsy (EBUSTBNA) in patients with extrathoracic malignancy.
Methods: 60 consecutive patients with extrathoracic malignancies who underwent EBUS-TBNA for diagnosis in patients with suspected mediastinal metastases.
Results: Using the method of EBUS-TBNA, among the diagnosis of mediastinal metastases in 33 of the 60 cases (55%),
primer lung cancer was observed in 8 cases (13.4%), sarcoidlike reaction in two cases (3.3%), tuberculosis in five cases
(8.3%) and reactive lymph nodes in 18 cases (30%). In three
patients (5%), a specific diagnosis could not be observed
which was following EBUS-TBNA. Among two patients who
underwent surgical staging of mediastinum, in one patient
mediastinal metastases were detected and reactive lymph
nodes inthe other. The sensitivity, specificity, negative predictability and diagnostic accuracy values of EBUS-TBNA
for diagnosis of extrathoracic malignancies were calculated
as 94.2%, 100%, 92.5% and 96.6% respectively.
Conclusion: EBUS-TBNA is a safe and effective procedure.
We should consider EBUS-TBNA first diagnostic tool for diagnosis of mediastinal lymphadenopathy in patients with extrathoracic malignancy.
312
Pulmonary, Critical Care & Sleep Medicine, Kettering Network Fort Hamilton Hospital, USA1), Dept of Pathology, Kettering Network Fort Hamilton Hospital, USA2)
Michael Gabrilovich1), Patricia Mcdowell2),
Richard Sternberg1)
Endobronchial ultrasound-guided transbronchial needle aspiration
(EBUS-TBNA) is a new but established modality for diagnosis and
mediastinal staging of primary lung and metastatic malignancies.
MTC is a rare (4% of thyroid malignancies) but aggressive cancer
with a potential for pulmonary spread. On occasion, it is found to
involve the mediastinum as a sole metastasis. In a large series
from MD Anderson cancer center only 2 out of 928 lymph nodes
(0.22%) from 1 patient were positive for TMC on EBUS-TBNA. Occasionally, somatostatin receptor whole body scan or PET scan
have to be performed to discover metastasis. Surgery is usually required to establish the diagnosis. Calcitonin immunostain is widely
accepted in the pathological diagnosis of MTC.
63 yo female with a history of medullary thyroid carcinoma (MTC)
treated with the resection 2 years ago and colon adenocarcinoma
in situ, resected soon after, was referred by her primary pulmonologist for tissue diagnosis. She denied any complaints or constitutional symptoms; however, there was an increase of right
paratracheal lymph node (station 4R) from 6 months prior, from 3
mm to 9 mm in size on a follow up CT scan. Small pulmonary nodules, slowly increasing in size, were seen over the last 4 years, remained sub centimeter, and were deemed to be of a low yield for
nonsurgical biopsy. In addition, new skin lesions appeared which
were biopsied and were consistent with sarcoidosis. PET scan was
negative. Her CEA and CT were minimally elevated but slowly
rising. Differential diagnosis of pulmonary sarcoidosis, metastatic
thyroid carcinoma and metastatic colon carcinoma among others
was entertained.
Bronchoscopy with hybrid bronchoscope (BF-UC180F, Olympus,
Japan) was performed (Figure). Cytological and core biopsy specimens were obtained using dedicated TBNA needle (NA-201SX4021, Olympus, Japan). Two small 9 mm LNs were identified at station 4R and biopsied separately. Cellblock was positive for calcitonin immunostain and histological specimen showed positivity for
calcitonin (Figure), CEA, chromogranin, TTF-1, and pancytokeratin (AE1!3) and negativity for thyroglobulin consistent with MTC.
In conclusion, EBUS-TBNA can reliably be used for diagnosis of
even small mediastinal metastasis of MTC.
Poster Presentation
IP-P21-1
IP-P21-2
The efficacy of CT or PET or EBUS-TBNA for confirmation of metastasis in mediastinum lymph nodes of
lung cancer
Determinants of success in EGFR mutation status
analysis in EBUS-TBNA specimens: The role of PETCT
Medical Oncology and Molecular Respirology, Tottori University, Japan
Department of Medicine and Therapeutics, Prince of Wales
Hospital, Hong Kong
Haruhiko Makino, Masahiro Kodani, Hirokazu Touge,
Yasuto Ueda, Tomohiro Sakamoto, Shizuka Itou,
Jun Kurai, Masaki Nakamoto, Akira Yamasaki,
Tadashi Igishi, Eiji Shimizu
Alvin Hon Man Tung, Jenny Chun Li Ngai,
Ka Pang Chan, Susanna So Shan Ng, Kin Wang To,
Fanny Wai San Ko
(Background) To decide the treatment course for lung cancer, the judgment of the presence of metastasis on lymph
nodes in the mediastinum is very important. Although CT
and PET are useful for the purpose, there are some falsepositive or false-negative cases. EBUS-TBNA is useful and
less-invasive method to make a pathological diagnosis of
lymph nodes in the mediastinum. We evaluated the safety
and efficacy of EBUS-TBNA comparing to PET and CT for
making a diagnosis of metastasis in lymph nodes for staging
of lung cancer patients in our hospital. (Methods) We retrospectively evaluated the 31 cases which we performed
EBUS-TBNA to decide staging of lung cancer during April 1
st 2010 to October 30th 2013. We assessed the safety by the
occurrence of serious complication. The lymph nodes with
high SUV(>2.0) by PET was defined as positive metastasis.
We assessed the metastasis positive lymph node measured
by CT with two different definitions, the longest diameter
more than 15mm or the shortest diameter more than 15mm.
We evaluated the accuracy of diagnosis as positive metastasis with CT or PET to compare with pathological diagnosis
by EBUS-TBNA. We also evaluate the accuracy of EBUSTBNA to compare the diagnosis from resected lymph nodes
after surgery. (Results) EBUS-TBNA for evaluation of staging of lung cancer was performed for 46 lymph nodes from
31 patients. All cases were diagnosed as lung cancer by biopsy from primary tumor in advance (adeno carcinoma 21,
squamous carcinoma 9, small cell carcinoma 1). We had no
major complication with EBUS-TBNA exaimnation. The average of patient s age was 72.4 years old(52y to 86y). The
false positive or false negative rate by PET were 61.0% (25!
43) and 0% (0!
3). The false positive or false negative rate by
CT with the definition of longest diameter more than 15mm
or with the definition of shortest diameter more than 15mm
were 59.4% (19!
32) and 18.2%(2!
11) or 73.9% (17!
23) and
36.7%(11!
30),respectively. Surgical operation was performed
for 19 patients after EBUS-TBNA. We had 2 cases which had
metastasis positive lymph nodes in mediastinum after EBUSTBNA examination. Those positive lymph nodes were occults metastasis and biopsy had not been performed on
them. (Conclusion) For the evaluation of metastasis of lung
cancer in lymph nodes in mediastinum, PET and CT showed
high false positive rate. EBUS-TBNA is eligible even for aging patients and useful to confirm the diagnosis of staging of
lung cancer.
Objectives: Endobronchial Ultrasound guided Transbronchial
Needle Aspiration (EBUS-TBNA) is useful in obtaining Epidermal Growth Factor Receptor (EGFR) mutation status in patients with advanced Non-Small Cell Lung Cancer (NSCLC), but
determinants of successful EGFR mutation status analysis remained unknown.
Methods: We retrospectively reviewed case files from patients
undergoing EBUS-TBNA in our Division to search for determinants of success in obtaining EGFR mutation status.
Results: 93 patients undergoing EBUS-TBNA were identified
between January 2012 and March 2013. Of these, 58 were diagnosed with NSCLC and 14 patients had PET-CT performed
with SUV data available. Twenty-seven (46.55%) underwent
testing for EGFR mutation status, with 12 patients tested positive and 6 rejected. Our yield was 78% with an EGFR mutation
rate of 57%. Bivariate correlation analysis showed that females
(r=0.523, p=0.015), never smokers or light smokers (r=0.523, p=
0.015) were the predictors of EGFR mutation status. Lesion
sizes, number of passes, FEV1, duration of procedure and SUV
on PET-CT were not correlated to EGFR mutation status. For
the predictors of success in EGFR testing, number of passes
(r=-0.463, p=0.015) and SUV on PET-CT (r=0.635, p=0.02) were
the only predictors of success in EGFR testing. Receiver Operations Characteristics (ROC) curve (Figure) showed that with a
SUV cut-off of 9.6 or more conferred a sensitivity of 66.7% with
a specificity of 80%, with an AUC of 0.933 (95% CI 0.782-1.084,
p=0.028) in predicting rejection in EGFR testing for mutation
status.
Conclusion: In our Chinese cohort of advanced NSCLC with mediastinal nodal involvement, we were unable to demonstrate an
effect of SUV on PET-CT scans and EGFR mutation status, although we showed that patients with high SUV (>9.6) could
predict inadequacy of cellular material in obtaining EGFR
status in EBUS-TBNA samples. Furthermore, the number of
EBUS-TBNA passes also predicts success in EGFR testing.
313
Poster Presentation
IP-P21-3
IP-P21-4
Performance of the 19 gauge excelon transbronchial
aspiration needle: Preliminary result at a cancer center
Clinical success of the 25-gauge EBUS-TBNA needle:
a case report and institutional review
Division of Pulmonary and Critical Care Medicine, Sun YatSen Cancer Center, Taipei, Taiwan1), Division of Thoracic Surgery, Sun Yat-Sen Cancer Center, Taipei, Taiwan2), Department of Pathology, Sun Yat-Sen Cancer Center, Taipei, Taiwan3)
Li-han Hsu , Chia-chuan Liu , Jen-sheng Ko
1)
2)
3)
Background
The 19 gauge conventional TBNA needles could obtain larger
specimens in hilar-mediastinal diagnosis and staging. In addition to histology diagnosis, it also provides sufficient specimen
for gene mutation testing which is essential in the era of personalized therapy.
Wang transbronchial histology needle, MW-319 (Bard-Wang,
Billerica, USA) remained the gold standard of various TBNA
needles. Because of a shortage of MW-319 needle supply in
Taiwan between August 2012 and December 2012, another 19
gauge eXcelon transbronchial needle (Boston Scientific, Boston, Massachusetts) was tried. We will review its performance.
Methods
Patients with mediastinal and!or hilar lesions indicated for
TBNA were enrolled. Histology needles were used when the
pathology was suspected to be of benign origin or lymphoproliferative processes. All examinations were performed under
conscious sedation by the same pulmonologist. R.O.S.E. was
routinely used. eXcelon TBNA was used in the abovementioned period. The result was compared with our historical control using MW-319 needle or 21 gauge NA-2C-1 needle
(Olympus, Tokyo, Japan) between September 1999 and July
2012.
Results
Eight patients including 3 female with a mean age of 55.3
years were recruited. Thirteen lymph nodes (LN) were aspirated. (right paratrachea in 3, anterior carina in 2, posterior
carina in 2, right upper hilar in 2, left hilar in 2, subcarina in 1
and sub-subcarina in 1) Sarcoidosis was diagnosed in 3 patients, lymphoma in one, adenocarcinoma in one and Castleman s disease in one. Two with cartilage and respiratory epithelial cells aspirated and were regarded as inadequate for diagnosis. VATS diagnosed spindle cell neoplasm in one. The
other was classified as benign lymphadenopathy as stable on
follow-up. The mean LN diameter was 23.3 11.2 mm. The
number of needle passes was 2.7 1.4. The diagnostic accuracy
was 75%. In control group of 275 patients with hilarmediastinal lesions, the mean LN diameter was 14.4 3.0 mm.
The number of needle passes was 2.4 0.6. The diagnostic accuracy was 76.7%.
Conclusion
Although the diagnostic yield of 19 gauge eXcelon needle was
comparable to that of MW-319 needle, the dedicated design of
MW-319 needle using a 21 gauge needle to prevent plugging
of the 19 gauge needle by a piece of normal bronchial mucosa
leads to more adequate specimen and less needle passes.
Higher price and brisk bleeding on needle withdrawal which
possibly attributed to the longer needle bevel are another two
factors need to be considered before adopting eXcelon needle.
314
Pulmonary Medicine, Walter Reed National Military Medical
Center, USA1), 2Cancer Treatment Centers of America, Interventional Pulmonary and Critical Care Medicine, Goodyear,
AZ, USA2)
Scott Charles Parrish1), Timothy Ori1), J. Francis Turner2),
Paul Zarogoulidis2), Robert Browning1)
PURPOSE: Endobronchial ultrasound-guided transbronchial
needle aspiration (EBUS-TBNA) is widely accepted as a safe
and effective approach to evaluation of mediastinal lymphadenopathy. While originally performed using a 22-gauge (22
G) needle with eventual addition of a 21-gauge (21G) alternative, literature from the endoscopic ultrasound-guided fine
needle aspiration (EUS-FNA) community suggests that use
of a 25-gauge (25G) needle may be equally, or more, effective.
We present a case of EBUS-TBNA in which samples were
obtained from 2 distinct sites using a combination of the
available needles. Additionally, we present results to date
from cases utilizing the 25G needle in our center.
PRESENTATION: Our patient is a 69-year-old male undergoing EBUS-TBNA for evaluation of mediastinal and hilar
lymphadenopathy in the setting of an enlarging pulmonary
nodule. At the 10R station, 4 passes were performed (21Gx1,
22Gx1, 25Gx2) with adequate tissue successfully obtained
only by the 25G needle passes. At the 11L station, 4 additional passes were performed (22Gx 2, 25Gx2), again with
adequate samples obtained only by the 25G needle attempts.
The 10R samples yielded a diagnosis of metastatic pulmonary adenocarcinoma while the 11L samples demonstrated
reactive lymph tissue.
In addition to the presented case, the 25G needle has been
used in 6 other EBUS-TBNA procedures at our institution.
In total, 17 passes were made during the 6 cases with adequate samples obtained for evaluation on 14 of these attempts. Adequate tissue for diagnosis was obtained in all 6
cases using the 25G needle, and in 2 of the 6 cases, successful
use of the 25G needle followed unsuccessful attempts with a
21G and!
or 22G needle immediately prior.
CONCLUSIONS: Employment of a 25G EBUS-TBNA needle
is a novel approach to the evaluation of mediastinal and hilar
lymphadenopathy. Our 7 cases demonstrate the viability for
the 25G needle as a permanent fixture in the EBUS-TBNA
repertoire. Additionally, as demonstrated in our primary
case, the 25G needle may prove superior to the standard 21G
and 22G options in some cases, warranting larger scale comparisons in the future.
Poster Presentation
IP-P21-5
IP-P21-6
Conventional transbronchial needle aspiration for diagnosis and staging. Still useful?
Diagnostic yield and safety of conventional TBNA in
SVCS patients: Experiences from a university affiliated hospital
Department of Pulmonology, Portuguese Institute of Cancer
Lisbon, Portugal
Jorge Santos Dionisio, Ambrus Szantho,
Jose Duro da costa
Background: The development of real-time ultrasound guidance
has detracted the importance of conventional transbronchial needle aspiration (cTBNA). However, cTBNA is available to all bronchoscopists and allow cytological, histological or microbiological
sampling of mediastinal lymph nodes and pulmonary lesions.
Objective: Analysis of the experience with cTBNA in a single institution.
Methods: We reviewed 3 years (2010-2012) of routine clinical practice with cTBNA in diagnostic bronchoscopy. Clinical and radiological files, bronchoscopy database and video reports were reviewed. Indications, type of lesions and results were registered.
The cytologic samples of the lesions were reported as positive
(positive for malignant cells or granulomas), negative (negative
for malignant cells and presence of lymphocytes) or inadequate
(without or rare lymphocytes observed). The statistical analysis
was based in frequency distribution with Pearsońs Chi-squared
test.
Results: 395 patients, 293 men, mean age: 62.6 years. 439 bronchoscopies and 563 cTBNA were performed. Deep sedation under
anesthesiologist supervision was used in 86% of bronchoscopies.
Mean duration of procedures was 33 12 minutes. Rapid on-site
evaluation (ROSE) was available in 322 bronchoscopies (73.3%).
Indications for bronchoscopy were: lung cancer diagnosis!staging in 279 cases; secondary lung cancer diagnosis in 70 cases; mediastinal lymphadenopathy diagnosis in 62 cases and other indications in 28 cases.
cTBNA was performed in 455 mediastinal lymphadenopathy and
in 108 tumoral lesions.
Adequate material was obtained in 79.1% TBNA with ROSE and
61.7% without (p<0.0001).
Out of the 349 bronchoscopies done for lung cancer diagnosis, 232
were diagnostic and in 91(39,2%), cTBNA was the only ancillary
method that was positive and enabled a diagnosis. Additionally
cTBNA allowed diagnosis of infectious disease in 4 patients (one
with Mycobacterium tuberculosis and 3 with bacterial infection),
and in 9 granulomatous lymphadenitis (2 tuberculosis and 7 sarcoidosis).
Conclusions: Our results emphasize the value of cTBNA as a diagnostic procedure in central lesions and as a mediastinal staging
procedure mainly for stations 4 and 7 lymphadenopathy.
ROSE enhances diagnostic yield of conventional cTBNA.
In some cases cTBNA can be the single and most useful diagnostic bronchoscopic procedure.
Department of Respiratory Medicine, The second Xiangya
Hospital, Central South University, China1), Department of
Respiratory Medicine, Changsha Central Hospital, Changsha,
China2)
Kui Xiao1), Jiehan Jiang2), Rui Zhou1), Ping Chen1),
Zhihui Shi1), Naixin Kang1), Shan Cai1), Yan Chen1),
Lanyan Zhu1), Dongyuan Zheng1)
Background: Superior vena cava syndrome (SVCS) requires
a timely histopathological diagnosis for appropriate management while many patients failed due to certain reasons.
Methods: We retrospectively evaluated the diagnostic yield
and complications of conventional transbronchial needle aspiration (C-TBNA) among patients with SVCS in our hospital.
From January 2009 to February 2013, 37 consecutive patients referred with clinical SVCS without a prior diagnosis
underwent flexible bronchoscopy and TBNA.
Results: The ultimate diagnoses were small cell cancer
(SCLC) in 22 patients, non-small cell lung cancer (NSCLC) in
14, and non-Hodgkin lymphoma in 1 patient. TBNA was diagnostic in all 36 patients with bronchogenic carcinoma, but not
in lymphoma, which was subsequently diagnosed via bone
marrow aspiration. The overall diagnostic yield of C-TBNA
was 97%, and the 95% confidence interval (CI) of diagnostic
yield was 82-100%. C-TBNA solely provided the diagnosis in
11 patients with NSCLC (79%), and in 12 with SCLC (55%),
and confirmed the diagnosis established via forceps biopsy in
13 patients. Age, gender, radiological involvement and
TBNA site were comparable in cases with and without forceps biopsy. There was no major complications related to
either flexible bronchoscopy or C-TBNA.
Conclusion: We concluded that C-TBNA is safe and has a
high diagnostic yield in SVCS caused by bronchogenic carcinoma.
315
Poster Presentation
IP-P21-7
IP-P22-1
Impact of EBUS-TBNA diagnosis of isolated mediastinal lymphadenopathy
Diagnostic value of transbronchial lung biopsy and
videoassisted thoracoscopy in diffuse parenchymal
lung diseases
Department of Medicine, Siriraj Hospital, Mahidol University,
Bangkok, Thailand
Chittima Thibbadee
Background: Endobronchial ultrasound- guided transbronchial needle aspiration (EBUS-TBNA) is an effective and safe
method for examining the mediastinal lymph node. The purpose of this study was to investigate the impact of EBUSTBNA in diagnosis of mediastinal lymphadenopathy.
Methods: Our EBUS-TBNA database between June 2009
and February 2012 were comprehensively reviewed. Isolated mediastinal lymphadenopathy of unknown nature (in
the absence of known pulmonary malignancy, and!
or chest
radiography that could not explain the etiology of lymphadenopathy) also taken into the study. Final diagnosis was determined by the results of EBUS-TBNA, surgery, mediastinoscopy and!
or the minimum of one year clinical follow up.
Results: There were number of sixty-eight patients matched
the inclusion criteria. Only 49 patients were engaged in this
study, however, 19 patients were excluded due to loss to follow up. In the group there were 26 males (53.1%) and 23 females (46.9%) with mean age of 59 years old. The right lower
paratracheal (4R) lymph node station was most frequently
sampling site. EBUS-TBNA could make diagnosis in 25 of 49
patients (51%). Result of EBUS-TBNA showed 6(12.2%) metastasis, 6(12.2%) sarcoidosis, 5(10.2%) NSCLCA, 5(10.2%) tuberculosis, 2(4.1%) SCLCA, 1(2%) lymphoma. 20(40.8%) patients showed polymorphous lymphoid cells (normal histology). These patients were stabilized after following up at
least one year, when taken to analyze it had shown that the
EBUS-TBNA could make diagnosis 45 of 49 patients (91.83%).
In 4(8.2%) patients showed false negative (peripheral T cell
lymphoma, NSCLCA, sarcoidosis and tuberculosis) which
had to be done by other procedures. The mean size of the
mediastinal lymph node detected by EBUS was 1.76cm
(range 0.94-3.06cm).The EBUS-TBNA procedures were uneventful and were without complications.
Conclusion: Endobronchial ultrasound- guided transbronchial
aspiration is considered effective and safe procedure. It can
make diagnosis in isolated mediastinal lymphdenopathy
91.83% and prevent further invasive procedures.
316
Department of Internal Diseases, City Clinic Sofia, Bulgaria1),
Pulmonology Department, Tokuda Hospital, Sofia2), Head of
Thoracic Surgery Department, Tokuda Hospital, Sofia3), Head
of Pulmonology Department, Tokuda Hospital, Sofia4), Head of
Radiology Department, Tokuda Hospital, Sofia5), Former Head
of Pathology Department,Tokuda Hospital, Sofia, passed
away.6), Pathology Department, Tokuda Hospital, Sofia7)
Anna Benova-Malinova1), Anton Penev2),
Cvetan Minchev3), Natalia Stoeva4), Galia Kirova5),
Marin Velev6), Hristo Mavrov7), P Dakova7)
Background: According to the current ATS!
ERS!
JRS!
ALAT Guidelines for Diagnosis and Management of Interstitial Lung Diseases!
ILD!
，the principle of integrating High
Resolution Computed Tomography!
HRCT!
and histopathological data is crucial to the diagnosis.
Methods: This retrospective study was set to assess the diagnostic yield of transbronchial lung biopsy!
TBLB!
and surgical biopsy by Videoassisted Thoracoscopy!
VATS!
in the
process of evaluating the disease in patients who showed radiological pattern on HRCT suggestive of a diffuse lung disease. We performed TBLB in 61 patients- 26 women and 35
men from Jan. 2007 to April 2013 in the Pulmonology department of Tokuda Hospital in Sofia. All the patients had precedent HRCT showing diffuse nodular, infiltrative, reticular or
groundglass opacities.
Results: TBLB enabled to obtain a histological diagnosis in 36
patients, the positive diagnostic rate achieved was 59%. The
diseases, confirmed by TBLB were 12 classified Interstitial
Lung Diseases!
ILD!
, 8 sarcoidosis, 8 neoplastic diseases, 7
tuberculosis, 1 pulmonary infarction. In the rest 25!
41％!
patients in whom TBLB failed to make a definite diagnosis, we
performed surgical biopsy by VATS. 14!
22,9％!
patients
more were diagnosed, including 4 neoplastic diseases,3 tuberculosis, 2 ILD, 2 cardiogenic pulmonary edema!
CPE!
, 2
sarcoidosis, 1 Wegener granulomatosis. The diagnostic yield
was raised up to total positive rate of 81,9%. In overall of 11!
18％!
patients the specimens obtained either by TBLB or
VATS did not show any findings consistent with a definite
lung disease. The diagnosis in these patients was made by
taking into consideration the clinical course, radiological features and concomitant pathology.
Conclusion: Histopathological diagnosis can be obtained by
TBLB in approximately half!
59％!
of the patients with diffuse lung disease pattern on HRCT. Surgical biopsy by
VATS is a complementary tool that should be applied after
TBLB has failed to determine the specific histology. TBLB is
especially efficient in the diagnosis of sarcoidosis, ILD, neoplastic diseases and tuberculosis.
Poster Presentation
IP-P22-2
IP-P22-3
Comparison analysis of EBUS TBLB result: Brushing
and forceps for peripheral pulmonary nodules in Jakarta
Peripheral lung lesion
Departement of Pulmonology and Respiratory Medicine, University of Indonesia, Indonesia
Sukara Safril Kusuma Jaya, Wahju Aniwidyaningsih,
Dicky Soehardiman, Prasenohadi Bin,
Boedi Swidarmoko, Faisal Yunus
Background
The Endobronchial ultrasound-guided transbronchial lung
biopsy (EBUS-TBLB) is a new diagnostic method for the diagnosis of pulmonary lesions in our center. but it is not considered to be the first choice in investigation of solitary pulmonary nodules (SPN).This study was designed to investigate about comparison analysis of EBUS TBLB result from
brushing and forceps for peripheral pulmonary nodules. The
main idea of this study was to determine the sensitivity and
specificity of bronchial brushings and forceps in TBLB at
Persahabatan Hospital, Jakarta.
Methods
Performed a retrospective study on 165 patients who had
underwent fiberoptic bronchoscopy in lung mass of X-rays
and thorax CT-Scan at Persahabatan Hospital from January
2009 to December 2012. Lung mass proved to be malignant
by cytology and histology of the data contained in the patient s medical record.
Result
Of 165 patients with lung cancer underwent brush and forceps biopsy through a fibreoptic bronchoscope. The biopsy
was taken from the area of suspected malignancy which had
been brushed. The EBUS TBLB data, consisted of 119 males
(72.1%) and 46 female (27.9%). Age range 20-89 years with an
average of 55.12 12 752 years. On bronchial brushings from
165 patients, 63 (38%) showed positive results consisted of
adenocarcinoma 29 (17.6%), squamous cell carcinoma 4 (2.4%),
non small cell carcinoma 6 (3.6%), small cell carcinoma 1
(0.6%), others (laryngeal nodules, necrotic tissue and fibrotic
tissue) found 23(13.9%) and no sign of malignant cells 102
(61.8%). Whereas from bronchial biopsy of 165 patients, 50
(30%) showed positive results consisting of adenocarcinoma
33(20.0%), squamous cell carcinoma 5 (3.0%), non small cell
carcinoma 7 (4.2%), small cell carcinoma 3(1.8%), others (tuberculoma, aspergillosis) 2 (1.2%), unrepresentative preparations 10 (6.1%) and no sign of malignant cells 105 (63.6%).
Discussion
Adenocarcinoma present predominantly in lung cancer account for approximately more than 30% of all cases. Brushing provide the higest yield of technique used to obtain sample from lesion. This benefit results from combining the advantages of the brush and a needle.
Conclusion
Bronchial brushing and forceps biopsy have a similar cell
typing results. The diagnostic result of bronchial brushing
for malignancies is higher than forceps biopsy. Both procedures must be taken into consideration in the management
of individual cases and combine both techniques will increase
the percentage of diagnostic.
Department of pulmnonology, University Clinic Golnik, Slovenia
Jernej Sitar
We present a case of a 55 year old male smoker who presented with a nodule in the RLL found on regullar follow up
appointment due to latent tuberculosis treatment. CT scan
revealed spiculated lesion in the RLL 20mm in diameter.
Bronchus sign was present on a CT scan. During flexible
bronchoscopy with the radial ultrasound probe and guiding
channel the lesion was located and position confirmed diascopically. The lesion was ultrasonographically visible in the
total length of 10mm while it was possible to pass the ultrasound probe further peripherally. Combination of transbronchial biopsy and transbronchial needle aspiration under diascopic control was used for tissue sampling. All taken samples
were positive for microcellular carcinoma. No distant metastases were found.The patient was treated with chemoradiotherapy due to poor lung function. We conclude that concomitant use of different imaging and sampling techniques
during bronchoscopic diagnosis of a small peripheral node
can increase a diagnostic yield.
317
Poster Presentation
IP-P22-4
IP-P22-5
Comparison of diagnostic performances among bronchoscopic sampling techniques in the diagnosis of
PPLs
Role of rapid on-site evaluation of bronchial biopsy
with radial probe EBUS for diagnosis peripheral pulmonary lesions
Department of Medicine, Ramathibodi Hospital, Mahidol University, Thailand1), Department of Pathology, Ramathibodi
Hospital, Mahidol University2)
Viboon Boonsarngsuk1), Wasana Kanoksil2),
Sarangrat Laungdamerongchai1)
Background: Radial endobronchial ultrasound (R-EBUS) has
been developed to enhance the diagnostic yield of peripheral
pulmonary lesions (PPLs) and is widely accepted by interventional pulmonologists nowadays. However, data regarding the diagnostic performances among bronchoscopic sampling techniques is limited.
Objective: To compare the diagnostic yields among bronchoscopic sampling techniques in the diagnosis of PPLs.
Methods: A prospective study was conducted on 71 patients
who were diagnosed with PPLs and underwent EBUSguided bronchoscopy between October 2012 and November
2013. Sampling techniques, included transbronchial lung biopsy (TBLB), brushing cell block, brushing smear, rinsed
fluid of brushing, and bronchoalveolar lavage (BAL), were
evaluated for the diagnosis.
Results: The mean diameter of the PPLs was 22.7 9.2 mm.
The final diagnoses included 46 malignancies and 25 benign
lesions. The overall diagnostic yield of EBUS-guided bronchoscopy was 80.3%. The performance of TBLB rendered
the highest yield among these specimens (76.1%, 35.2%,
57.7%, 45.1%, and 38.0% for TBLB, brushing cell block, brushing smear, rinsed brushing fluid, and BALF, respectively; p<
0.001). TBLB provided high diagnostic yield irrespective of
size and etiology of the PPLs. Combination of TBLB and
brushing smear achieved the maximum diagnostic yield. Of
21 infectious PPLs, BALF culture gave additionally microbiological information in 14 cases.
Conclusion: The performance of TBLB rendered the highest
diagnostic yield; however, to achieve the highest diagnostic
performance, TBLB, brushing smear and BAL should be
performed together.
318
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital,
Taiwan1), Division of Thoracic surgery, Department of Surgery, China Medical University Hospital2)
Chia Hung Chen1), Chih-yen Tu1), Te-chun Hsia1),
Hung-jen Chen1), Wei-chih Liao1), Chuen-ming Shih1),
Chih-yi Chen2), Wu-huei Hsu1)
Objectives
To evaluate the impact of ROSE(rapid on-site evaluation) and
the factors that predict the diagnostic yield of radial probe
endobronchial ultrasonography (EBUS) for peripheral pulmonary lesions (PPLs).
Design
Retrospective analysis.
Methods
We analyzed the diagnostic yields of TBB or brushing using
EBUS for patients with PPLs in a tertiary university hospital
from December 2007 to December 2010.
Results
A total of 640 patients with PPLs were included. A definite
diagnosis was made by EBUS-guided TBB or brushing for
541 patients (85%). A total of 249 patients (38.9%) were examined by a rapid on-site cytology evaluation (ROSE) technique.
PPLs in right apical and left apical-posterior segment locations, small PPLs<3 cm without bronchus signs on CT scan,
PPLs with pleural effusions, and the position of probe is not
within are significant factors for predicting lower PPLs diagnostic yields by using EBUS guided TBB or brushing. The
PPLs diagnostic yields with ROSE were significantly higher
than without ROSE, no matter the PPLs are in the left apicalposterior and right apical segments or at the other location,
the position of the probe is within or not within, and if the lesion is surrounded with pleural effusion or not.
Conclusions
ROSE can improve the PPLs diagnostic yield when using
EBUS guided TBB or brushing.
Poster Presentation
IP-P22-6
IP-P22-7
A case of adult T-cell leukemia!
lymphoma with an endobronchial nodule
In vivo fibred confocal fluorescence microscopy in pulmonary alveolar proteinosis
Department of Medical Oncology and Immunology, Nagoya
City University Graduate School of Medical Sciences, Japan
Hiroya Ichikawa, Osamu Takakuwa, Takamitsu Asano,
Hiroki Murase, Yuuko Kawaguchi, Takehiro Uemura,
Hirotsugu Ohkubo, Masaya Takemura, Ken Maeno,
Atsushi Nakamura, Tetsuya Oguri, Akio Niimi
Endobronchial lesion is rare in adult T-cell leukemia!
lymphoma (ATLL). We report a case of ATLL presenting an endobronchial nodule. A 60-year-old woman who was followed
as ATLL in our hospital was consulted because of continued
dry cough. Chest computed tomography showed a nodule in
the inlet of right upper bronchus. Bronchoscopic examination showed an endobronchial polipoid nodule in the position.
Pathological finding of endobronchial biopsy specimens
showed infiltration with CD3-positive T-lymphocytes and
ATLL was diagnosed. After the treatment for ATLL, the lesion was decreased in size. Physicians are needed to consider
that ATLL is may be one of causative disease presenting an
endobronchial nodule.
Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, China1), The first affiliated hospital of
Guangzhou medical university, China2)
Wz Luo1), Shiyue Li1), Yu Chen2), Ch Zhong2), Xiaobo Chen2)
Backgroup: Fibred confocal fluorescence microscopy
(FCFM) allows microscopic imaging of the alveoli. When
FCFM at 488 nm excitation wavelength, it can detect alveolar macrophages and lipoproteinaceous material. Pulmonary
alveolar proteinosis(PAP) is a rare disease, which characterized by impaired surfactant metabolism that leads to accumulation in the alveoli of lipoproteinaceous material rich in
surfactant protein and its component. However, the onset of
PAP is usually insidious and the presenting symptoms are
non-specific, often causing a significant delay in the diagnosis
or misdiagnosis.
Methods: FCFM was performed in 3 patients who were diagnosed as PAP from September to December 2013. The AlveoFlex miniprobe (diameter 1.4 mm) was passed through
the working channel of the bronchoscope and gently pushed
down until the alveolar structure could be recognized. After
FCFM was complete, bronchoalveolar lavage (BAL) was performed using 20ml saline in the right middle lobe andlung biopsies were taken later on. BAL was centrifuged and the
miniprobe contacted the sediment for FCFM imaging. Lung
tissue and BAL sediment was assayed by histological examination.
Results: The FCFM imaging showed alveolar filling with
highly fluorescent globular structures, which was typical
lipoproteinaceous material of PAP confirmed by histological
examination with lung tissue. The FCFM imaging for BAL
sediment showed highly fluorescent globular structures too,
which was lipoproteinaceous material confirmed by pathological examination.
Conclusion: The FCFM images have a highly fluorescent
globular structures which is lipoproteinaceous materialin
both alveolar and BAL sediment. It may provide specific in
vivo imaging of PAP.
319
Poster Presentation
IP-P23-1
IP-P23-2
Pleural effusion as an initial sign of multiple myeloma:
A case report and review of literature
A case of thoracic empyema caused by bronchial foreign body (fish bone)
Department of Respirology & Critical care medicine, Xiangya
Hospital of Central South University, China
Yuanyuan Li, Lili Zhang, Chengping Hu, Pengbo Deng,
Huaping Yang
Objective: Discuss and improve the understanding of the
clinical characters and diagnostic methods of myelomatous
pleurisy, particularly of the patients with pleural effusion as
an initial manifestation.
Background: A 53 year-old male, who had been misdiagnosed as tuberculous pleurisy in a local hospital, was diagnosed as multiple myeloma with pleural infiltration. We reviewed the literature on clinical manifestations, serum and
pleural effusion characters, treatment and diagnostic options
of this exceptionally rare presentation of multiple myeloma.
Methods:We conducted a search of the published medical literature since 2000 in MEDLINE and PubMed using search
criteria ( pleural effusion AND multiple myeloma ) OR
( myelomatous pleural effusions ). The search led to 64 case
reports, and 16 cases with pleural effusion as an initial manifestation were included in this review. We have also
searched for recent advances in diagnosis.
Results and Conclusions: Myelomatous pleurisy is a rare
complication of multiple myeloma and its clinical presentations and experimental results are non-specific. Therefore, to
make definite diagnosis has been mainly relied on histopathology of pleura biopsy tissues or pleural effusions. Pleural
biopsy under thoracoscope is not only a reliable but also a
safe and effective method. So far the treatments of this kind
of multiple myeloma are mainly chemotherapy. But the response rate was relatively low with the overall medium survival time of 4 months.
320
Department Of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Japan1), Department Of Surgery Youmeikai Obase Hospital Japan2), Second Department of Surgery, School of Medicine, University of
Occupational and Environmental Health, Japan3)
Tatsuo Takama1), Kazuki Someya1), Hiroki Otubo1),
Takashi Kido1), Fumihiko Kamezaki1), Yamaie Hitoshi2),
Fumihiro Tanaka3), Toshihiko Mayumi1)
◆Background
Obstructive pneumonia, atelectasis and bronchitis were often
caused by a bronchial foreign body, but thoracic empyema is a
rare complication and only a few reports were published, and
thus we report a case of thoracic empyema caused by aspiration
of a fish bone.
◆Case
A 88-year-old man with dementia and glaucoma, visited our
emergency room for dizziness and falling on the floor. No obvious
traumas were observed, however, C-Reactive Protein (CRP: 16.3
mg!dl) and White Blood Cell (WBC:14200!mm3) were elevated on
his laboratory data, so we investigated minutely.
Chest computed tomography(CT) showed a foreign body in the
left main bronchus and left pleural effusion. Thoracocentesis produced cloudy yellow and suppurative fluid. We diagnosed this
case as thoracic empyema caused by bronchial foreign body. The
foreign body was removed using forceps through a flexible bronchoscope. The removed object was a fish bone fragment, 2 1cm
in size. Thoracic drainage was performed, and we started irrigation with saline solution and general antibiotics. We could remove
the drainage tube on the 26th day with no respiratory complication but patient died of acute cholangitis 54days after the procedure.
◆Conclusion
Symptoms of bronchial foreign body are cough, dyspnea, and
chest pain, however, sometimes asymptomatic and clinical condition progress without knowing it.
In this case, foreign body aspiration was also occurred without
symptoms and delayed in recognition and progress to empyema.
When we experienced recurrent pneumonia, atelectasis, and thoracic empyema, we have to keep it in mind to think about bronchial foreign body.
Poster Presentation
IP-P23-3
IP-P23-4
Port-access thoracoscopic debridement under local
anesthesia for empyema (parapneumonic effusion)
A case of streptococcus constellatus empyema
treated with tunneled pleural catheter
Second Department of Surgery, Faculty of Medicine, Yamagata University, Japan
Hirohisa Kato, Hiroyuki Oizumi, Makoto Endoh,
Hikaru Watarai, Mitsuaki Sadahiro
Background: Recently, thoracoscopic debridement has
played a major role in managing the intermediate, fibrinopurulent phase of empyema. Usually, thoracoscopic debridement has been performed with three ports under general anesthesia. However, it may be difficult to decide to use general
anesthesia, which is associated with a risk of pulmonary dysfunction, in high-risk patients. We present our technique of
two-port-access thoracoscopic debridement under local anesthesia for treating a high-risk patient with empyema.
Case report: A 69-year-old man was admitted to our hospital
with pleural effusion and a thin peel on the left pleural cavity
that was suspicious for empyema with pneumonitis. Treatment with chest tube insertion, continuous suction, and intrapleural administration of fibrinolytic agents was not enough
to achieve a cure. Operative treatment under general anesthesia was risky because the patient was bedridden due to a
past spinal cord infarction and cerebral infarction; moreover,
he could not easily expel sputa. Therefore, we performed our
technique of two-port-access thoracoscopic debridement.
The patient was placed in the lateral decubitus position, and
local anesthesia using 1% lidocaine with epinephrine was injected at two port sites. One 12.5-mm port and one 5-mm
port were used. The first port, placed through the fourth intercostal space at the midaxillary line, was inserted in site of
preoperative chest tube, and used for inserting a suction instrument. A finger was placed into the chest at the port sites
to perform preliminary deloculation and to create a working
space in which the endoscope and instruments could be maneuvered. An endoscopic rod-lens telescope (5 mm, 30̊) was
positioned at the anteroaxillary line, through the fourth intercostal space. Fluid and debris were completely removed using our customized suction instrument under local anesthesia without any other pain control. The operation took 75
minutes. The total amount of 1% lidocaine used for local anesthesia was 18 mL. Bleeding was minimal. His fever has resolved after the operation. The chest tube was removed on
postoperative day 3, and the patient was discharged on postoperative day 20.
Conclusion: Our customized suction instruments enable the
rapid removal of pleural debris. Two-port-access thoracoscopic debridement under local anesthesia can be safely
performed and is minimally invasive.
Pulmonary, Critical Care and Sleep disorders Medicine, division of Interventional pulmonology, University of Louisville,
USA1), Pulmonary, Critical Care and Sleep disorders Medicine,
University of Louisville, KY, USA2)
Mostafa Tabassomi1), Umair Gauhar1),
Bhaskara Lakshmi Gowkanapalli2)
Background:
Tunneled pleural catheters (TPCs) are very well recognized palliative intervention for
patients with recurrent malignant pleural effusions. Compared to thoracoscopy and
pleurodesis, they are less invasive and can be performed on an outpatient basis. They
are particularly useful in cases of trapped lung where pleurodesis is not effective. TPCs
have also been used successfully to treat para-pneumonic effusions and have been
found to be as effective as large bore chest tube that are traditionally used to drain
such effusions.
We report a case of Streptococcus consellatus empyema successfully treated with
placement of an indwelling pleural catheter. To our knowledge, this is the first such reported case.
Case Report:
A 65 year old Caucasian male with 40 pack year smoking history and known diagnosis
of metastatic left lower lobe squamous cell carcinoma of lung, presented to emergency
room with chief complain of dyspnea, cough, and low grade fever.
Chest xray followed by computed tomography revealed a recurrent large left sided
pleural effusion (Picture 1). Cytology from two prior therapeutic thoracentesis for dyspnea was negative for malignancy but he had relief after being tapped.
The patient was started on broad spectrum antibiotics for suspected post obstructive
pneumonia. Diagnostic thoracentesis was performed which revealed foul smelling purulent fluid consistent with the diagnosis of empyema. A TPC was placed and 1200 ml
of pus drained. The pleural fluid later on grew Steptococcus constellatus and the antibiotics were narrowed based on sensitivities. The patient underwent daily drainage of
the pleural space with dramatic improvements in his dyspnea and discharged home 2
days later.
Repeat CT scan of the chest 2 weeks after placement of the TPC showed minimal fluid
in the pleural space with a trapped lung. The decision was made to leave the pleural
catheter in place with twice weekly evacuations and continued follow up in the clinic.
Conclusion:
Empyema causes by Streptococcus consellatus has been rarely reported in past. Despite the fluid being extremely thick and viscous, we were able to drain adequately
with a small caliber TPCs as opposed to a large bore chest tube. In our case, a TPC was
successfully used to treat the empyema and palliate the patient s symptoms. This is of
paramount importance, especially in patients with metastatic cancer and limited life expectancy. This type of treatment is cost effective, but also ensures the patient s comfort, and enabling them to spend quality time with their family.
321
Poster Presentation
IP-P23-5
IP-P23-6
Pleural irrigation following pleuroscopic debridement
in empyema: Redefining management strategy
Use of axotrack ultrasound guidance system to perform a thoracentesis in a patient with a loculated pleural effusion
Dept of Internal Medicine, University of South Carolina, USA
Franklin Riley McGuire, Mohammed Moizuddin,
Muhammed Imtiaz
Background
Empyema is a debilitating medical disease associated with
substantial morbidity and mortality. Despite antibiotic treatment and chest tube drainage, often patients have prolonged
hospitalizations, repeated operative procedures and significant health care costs 1. Pathologically, empyema has a spectrum of disease ranging from exudative stage, fibro-purulent
stage to an organized state. Medical therapy is usually directed towards debridement of the rind and obliteration of
pleural space, continuous chest tube drainage and appropriate intravenous antibiotic therapy. Despite these steps incomplete resolution of dense pleural adhesions are commonly
noted which can prevent complete re-expansion of the lung
requiring additional expensive therapy with fibroinolytics
and DNAse.
We report a patient who had successful resolution of his empyema and a cavitary pneumonia pleurocopic debridement
and drainage following by a pleural irrigation protocol.
Case Report
A 57 year old patient was admitted with complaints of subjective fever, productive cough and progressive dysnea of few
days duration. His past medical history was significant for
Schizophrenia, Coronary artery disease, Hypertension,
Chronic obstructive pulmonary disease. Physical examination
revealed a febrile hypotensive patient with respiratory distress and hypoxia. Chest X-ray and Computed tomography
(CT) chest scan revealed large, loculated, left pleural effusion
and a well circumscribed fluid density measuring 3.2 2.8 cm
consistent with pulmonary abscess. Pleuroscopy demonstrated fibropurulent multi-loculated pleural space requiring
extensive disruption of adhesions without complete rexpansion of lung. Two chest tubes were placed, one used for warm
irrigation of normal saline at 100"150 ml!hr and other attached to suction over the next 48 hours. Within 12 hours, the
patient s fever resolved, his blood pressure and the white
blood cell count improved. He did not require intubation for
the procedure nor afterwords. He was moved out of the medical intensive care unit on hospital day #2. The chest tube output by day 4 was 30 ml and follow-up CT scan of the chest
showed improving abscess and near resolution of his pleural
effusion. Pleural fluid analysis revealed exudative effusion
with growth of oropharyngeal flora, likely from aspiration.
Conclusion
Pleuroscocopy with pleural debridement in combination with
post-operative pleural irrigation can be used as first line of
therapy in patients with empyema2. It may enhance the efficacy of treatment and shorten the course of the disease.
Reference
1. Thourani VH etal. Evaluation of treatment modalities for
thoracic empyema: a cost-effective analysis
2. Hutter JA etal. The management of empyema thoracis by
thoracoscopy and irrigation. Ann Thorac Surg 1985;39:517-20
322
Dept of Internal Medicine, University of South Carolina, USA
Franklin Riley McGuire, Matthew D Kolok
Background
Pulmonary and critical care physicians are using ultrasound to
guide a variety of procedures. We use ultrasound extensivly in the
intervential pulmonology service and as a result we were asked to
evaluate a novel US probe and software application. The AxoTrack
system provides simulated tracking for needle insertion. This system works by combining an ultrasound transducer with a needle
guide. A hall effect sensor transmits the precise needle position,
that information is then overlaid on the screen in real time as both
the projected needle path and a virtual needle.1 We describe the application of this novel device and software to drain perform a thoracentesis in a case where an US guided thoracentesis had failed.
Case Report
Our case involved a male ICU patient in his mid 80 s. He had a small
pleural effusion on the right side, and thoracentesis for microbiology was requested. The site was identified with a SonoSite linear
ultrasound probe at the bed side and a ultrasound guided thoracentesis was attempted by a second year pulmonology fellow, however
no fluid could be aspirated. A second thoracentesis was performed,
this time using the Axotrack ultrasound guidance system. Once
again the effusion was located with an ultrasound probe and under
continuous use the guidance system mapped the exact path of
travel for the aspiration needle. A virtual needle was seen overlaid
the actual needle and was observed entering the effusion and 40 cc
of reddish fluid was obtained. The patient tolerated this second procedure well and had no complications from the procedure.
Conclusion
Thoracentesis is indicated on patients with a plural effusion, with
analysis of the aspirate often yielding clinically useful information.
The standard of care has moved to using ultrasound guidance during the procedure2, however, small effusions can still be difficult to
aspirate. In this case the use of a supplemental guidance system to
both plan the needle path and to visualize the needle progression allowed for a successful aspiration and eventual treatment in a patient with an otherwise difficult to reach effusion. This is the first
description of the AxoTrack system to guide a thoracentesis.
1. Ferre, R.M. et al. The Use of novel Device Improves Real-Time
Ultrasound Guided IV Access. Supplement to Annals of Emergency
Medicine, Sept. 2010;56:3:S74
2. Feller-Kopman D.Ultrasound-guided thoracentesis. Chest. 2006
Jun;129(6):1709-14.Review
Poster Presentation
IP-P23-7
IP-P23-8
Is bilateral chylothorax possible after simple cough?:
Yes
Acute respiratory failure in a patient with malignant
pleural effusion after pleuredesis with talc insufflation
Thoracic surgery, GATA Haidarpasha Teaching Hospital,
Turkey1), Thoracic surgery, GATA HEH, Turkey2)
Ahmet Rauf Gorur1), Fatih Candas2), Akin Yildizhan2)
Chylothorax refers to the accumulation of the chylous fluid
in the pleural space as a result of impaired integrity of thoracic duct or its brances. In all patients, the causes of chylothorax are trauma, congenital and spontaneous Treatment
for chylothorax is essentially medical. In the event of failure
or apperance of a massive effusion, surgical treatment is
needed. We examined a patient in whom bilateral chylothorax developed after a simple cough.
Case Report
A 65-year-old woman presented at the emergency department of our hospital with swallow of the neck and supraclavicular area, dyspnea, and thoracic pain. Chest X-ray showed
a blunt sinus bilaterally. Computed tomography of the chest
and neck showed bilateral minimal pleural fluid. Ultrasound
guided transthoracic aspiration from right hemithorax (20ml)
resulted in chylous fluid macroscopically and the level of triglycerides was 2000 mg!
dl↑ on biochemical analysis. The
patient was hospitalized and was given a medium-chain triglyceride diet to diminish the flow of chyle. Thoracentesis
yielded 40 ml of milky fluid from the left thoracic cavity and
30 ml from the right. Level of triglycerides was 2000 mg!
dl↑
on biochemical analysis also from the left side. Oral mediumchain triglyseride intake was continued, and antibiotherapy
were initiated. Follow-up chest X-ray obtained daytoday,
showed normal findings at third day. She was maintained on
normal diet at fifth day. She was discharged eight day after
admission to hospital. We have not seen any problem one
month period.
In conclusion, in elderly patients, as bilateral chylothorax
rapidly impairs the clinical manifestation. A simple coughing
may lead bilateral chylothorax and it can successful recovery with thoracic aspiration, and oral low-fat intake.
Department of Pulmonary Medicine, GATA Haydarpasa
Training Hospital, Turkey1), Department of Thoracic Surgery,
GATA Haydarpasa Training Hospital, Turkey2)
Ersin Demirer1), Sedat Demirsoy1), Omer Yavuz2),
Kadir Canoglu1), Omer Ayten1), Dilaver Tas1),
Faruk Ciftci1)
Background: Pleurodesis is a procedure performed to obliterate the pleural space to prevent recurrent pleural effusion.
Talc is the most effective sclerosant available for pleurodesis
in malignant pleural effusion. Adverse events may ocur after
talc pleurodesis.
Case report: A 69-year- old woman was admitted to hospital
for further investigations of bilateral pleural effusion. She
had a history of breast cancer and left radical mastectomy
with axillary node dissection 15 years ago. She was diagnosed with mixed ductal-lobular breast cancer. She received
both radiation therapy and chemotherapy after surgery.
Thoracentesis and pleural biopsy was performed during the
evaluation of bilateral pleural effusion on the last hospitalization. Breast cancer metastatic to pleura was diagnosed. Thoracostomy was performed due to massive right sided pleural
effusion. Pathologic uptake was obseved at PET-CT on the
left axillar region and left lung lower lobe. Pleuredesis and
chemotherapy was planned. A 4 g of talc diluted with 40 cc
of 0.9% NaCl and 10 cc prilocaine. The solution was insufflated to pleural space. The patient had pain, dsypnea and
tachycardia after a short time. Noninvasive mechanical ventilation therapy was initiated. She was consulted with allergy
and cardiology departments. Acute allergic or cardiac reason was excluded. Arterial blood gase anlysis was as follows;
pH: 7.07, pCO2: 110 mmHg, pO2: 61.2 mmHg. Respiratory failure was observed and she was intubated after three hours.
Conclusion: Pain, fever, arrhthmia, dyspnea may be observed
after talc pleurodesis in malignant pelural effusions. This
case is a rare presentation of acute respiratory failure after
the procedure of talc pleurodesis.
Disclosure of funding source: None
323
Poster Presentation
IP-P24-1
Pleuroscopy in suspected malignant pleural effusions:
Result and complications
Pulmonology and Respiratory Medicine, Faculty of Medicine
University of Indonesia, Persahabatan Hospital, Jakarta, Indonesia
Nurfanida Librianty, Faisal Yunus,
Wahju Aniwidyaningsih
Background
Pleural diseases occurs mainly with pleural effusion, sometimes diagnostic measures become quite challenging. Biochemical, bacteriologic and cytologic studies of pleural fluid
combined with closed pleural biopsy will yield a diagnosis in
only 20-30% of neoplastic pleural due to patchy abnormality of
the pleura. Pleuroscopy is one of pleural diagnostic procedure
performed by pulmonologists, are terms used interchangeably
to describe a minimally invasive procedure that provides a
window into the pleural space, to perform biopsy of the parietal pleura under direct visual guidance, chest tube placement,
and pleurodesis of malignant pleural effusion or pneumothorax in selected patients. A visual inspection of the pleural
space, drainage of pleural effusion, and performance of pleural
biopsies are the commonly performed procedures during
pleuroscopy. The aimed of study was to evaluate the result
and complications of pleuroscopy in diagnosis of patients with
suspected malignant pleural effusion in our centre.
Materials and Methods
A retrospective study of 61 suspected malignant pleural effusions patients who underwent pleuroscopy in Persahabatan
Hospital during period 2010 until 2012.
Result
Sixty-one patients were performed the procedure (34 male
and 27 female). Median age was 50 years (range 18-72). For the
61 patients having diagnostic pleuroscopy, the yield was 88.5%
(54 patients). Malignancy was diagnosed in 37 (60.6%) patients,
13 (21.3%) patients had non-specific inflammation, tuberculosis
was found in 4 (6.6%) patients, and non-diagnostic in 7 (11.5%)
patients. Of the 61 patients, 7 (11.5%) gave positive cytology
findings from pleural fluid and 35 (57.4%) gave positive histopathological findings with pleural biopsy showed malignancy.
Only 4 (6.6%) patients from whom were found malignancy
from pleural fluid were also found as malignant by biopsy of
pleura also. Lung cancer was the most common malignancy
caused of primary malignancy. The most common primary
lung cancer with involvement of the pleura was the adenocarcinoma (81%), and bronchioloalveolar carcinoma (5.4%). Some
minor complications were detected in 13 (21.3%) patients.
There were: pain (14.8%), fever (1.6%), and localized subcutaneous emphysema (3.3%). There was one (1.6%) case of death
from the procedure due to the severe case of this patient, after
all other none diagnostic procedures have already performed
on this patient.
Conclusion
Pleuroscopy is a rapid, simple, efficient procedure, a low morbidity and mortality. For the evaluation of pleural disease,
pleuroscopy has good diagnostic yield in patients with suspected malignant pleural effusions. Serious complications following pleuroscopy are rare.
324
IP-P24-1
Poster Presentation
IP-P24-2
IP-P24-3
Medical thoracoscopy for undiagnosed exudative
pleural effusion, retrospective study in a single institution
Proposal use of disposable bronchoscope as medical
thoracoscope
Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Japan
Masahiro Kodani, Tomohiro Sakamoto, Hirokazu Touge,
Hroki Izumi, Haruhiko Makino, Jun Kurai, Shizuka Ito,
Yasuto Ueda, Tadashi Igishi, Eiji Shimizu
Purpose: When a pleural effusion of unknown etiology is
identified, pleural fluid is generally analyzed for cellular contents, chemistries, smears and culture of microorganisms,
and cytology. The diagnostic accuracy of thoracoscopy is estimated to be between 70 and 96 percent, which is higher
than thoracentesis plus blind percutaneous needle biopsy.
The aim of this retrospective study was to investigate
whether combination of thoracentesis and medical thracoscopy was beneficial.
Methods: We retrospectively reviewed the medical records
of 14 consecutive patients with undiagnosed exudative pleural effusion who underwent parietal pleural biopsy using
medical thoracoscope following thoracentesis between January 2012 and October 2013. We assessed diagnostic yield,
thoracoscopic findings and safety.
Results: 14 patients (median age 64 years (56-78 years), 12
male, 2 female) were performed ultrasound-guided thoracentesis (1-3 times) followed by medical thoracoscopy. Diagnostic yield of parietal pleural biopsy was 85.7%(=6!
7) in malignant disease, and 66.7%(=2!
3) in tuberculous pleurisy. The
findings of thoracoscopy were pleural thickening in all cases,
nodular or elevated lesion in 6 cases. Thoracoscopic examination failed to obtain pathological diagnosis in 2 cases. One
was pleural dissemination of breast cancer after treatment of
aromatase inhibitor, and another was tuberculous pleurisy in
late timing examination. Both of two cases had no nodular or
elevated lesion. Cytology performed in all cases proved no
evidence of malignant disease or tuberculous pleurisy. No reexpansion pulmonary edema was found following medical
thoracoscopy.
Conclusions: Our findings suggest that medical thoracoscopy
is useful for diagnosis of undiagnosed exudative pleural effusion due to thoracentesis. However, diagnostic accuracy may
be restricted to elevated or nodular lesion with direct visualization.
Department of respiratory medicine, Tokyo Medical Univercity Hachiouji Medical Center, Japan1), Department of respiratory surgery, Tokyo Medical University Hachiouji Medical
Center, Japan2)
Kenta Utsumi1), Toshio Ichiwata1), Shuji Ooishi1),
Naohiro Shimizudani1), Hideaki Takahashi2),
Hiroyuki Miura2), Eiji Nakajima2), Jyun-ichiro Oosawa2)
Disposable bronchoscope (aScope, Ambu) is usually used as
bronchoscope in emergency room or operation room. This
scope is useful for a rapid confirmation of tracheal intubation.
This bronchoscope is length 830mm and outer diameter 5.4
mm. It s weight is 130g. We used this bronchoscope as medical thoracoscope for pleural space observation, pleural biopsy, and guidance tool at thoracic tube insertion. Medical
thoracoscope is sometime difficult to perform in emergent
setting. This disposable medical thoracoscopy is easy handling for emergency. We introduce some cases.
325
Poster Presentation
IP-P24-4
IP-P24-5
Pleuroscopic manifestation of malignant pleural effusion
Flex-rigid pleuroscopy under local anesthesia in patients with radiological dry pleural dissemination
Department of Internal Medicine, Phramongkutklao Hospital,
Thailand
Department of Endoscopy, Respiratory Endoscopy Division,
National Cancer Center Hospital, Japan
Anan Wattanathum, Pornanan Domthong,
Nittha Oer-areemitr
Yukio Watanabe, Shinji Sasada, Takehiro Izumo,
Takaaki Tsuchida
Background: Flex-rigid pleuroscopy is a minimally invasive
procedure allowing pulmonologists to access pleural space
for diagnosis and management of malignant pleural effusions
(MPEs). However, few pleuroscopic manifestations of pleural
abnormality in patients with MPEs have been reported.
Methods: We retrospectively analyzed all patients with
MPEs receiving pleuroscopy between January 2008 to September 2013. The procedures using flex-rigid pleuroscopy
model LTF 160!
240, Olympus, Japan were performed in a
bronchoscopy suite under conscious sedation with intravenous morphine and midazolam.
Results: Sixty-seven patients with MPEs were enrolled in the
study (36 male and 31 female; mean age, 63 years). Diagnoses
included 57 (85.1%) bronchogenic carcinomas, 9 (13.4%) metastatic pleural effusions (3 breast cancers, 3 cancers of gastrointestinal tracts and 3 cancers of various other organs),
and 1 (1.5%) malignant mesothelioma. There were no normal
parietal pleura in all patients with MPEs. The five major
pleuroscopic manifestations of parietal pleura were small
nodules (26 of 67, 38.8%), small to large-sized nodules (12 of 67,
17.9%), large-sized nodules (21 of 67, 31.3%), pleura thickening
(7 of 67, 10.4%), and pleural plaques (19 of 67, 28.4%). Fifty-five
(82.1%), 55 (82.1%), and 25 (37.3%) of the cases had visceral,
diaphragmatic, and apical pleural abnormality, respectively.
Additionally, the visceral pleura manifestations of MPEs
were normal (12 of 67, 17.9%), small nodules (32 of 67, 47.8%),
large-sized nodules (3 of 67, 4.5%), thicken pleura (13 of 67,
19.4%), and pleural adhesion (7 of 67, 10.4%).
Conclusion: There were pleural abnormalities in patients
with MPEs. The major manifestations were pleural nodules
varying in sizes, thickening, and plaques. Flex-rigid pleuroscopy was considered useful and effective in the diagnosis
of MPEs.
326
Background
A medical thoracoscopy using flex-rigid pleuroscope under
local anesthesia is a recent diagnostic procedure for malignant pleural metastasis. Although almost of the previous
studies have shown a utility especially in wet pleural dissemination, the feasibility of flex-rigid pleuroscopy in patients with suspicious for dry pleural dissemination (DPD)
has not known well.
Purpose
We assessed the utility and safety of the flex-rigid pleuroscopy under local anesthesia for patients with suspicious
for DPD.
Methods
56 patients underwent flex-rigid pleuroscopy at National
Cancer Center Hospital from October 2011 to September
2013. Out of 56 patients, 16 patients who have suspicious
DPD finding which asymmetric pleural thickening or pleural
nodules without pleural effusion on chest tomography scan
(Dry group) were retrospectively reviewed pleuroscopic parameters, and then compared to remained patients with
pleural effusion (Wet group).
Results
The patients were 8 men and 8 women, with median age of
61 years (range, 48-74 years). The definitive diagnoses were
as follow; 10 adenocarcinoma, 2 mesothelioma, and 3 chronic
inflammation. Diagnostic accuracy was 93.8% (15!
16). Only 2
minor complications were observed; 1 chest pain and 1 transient hypoxia. No major complications including pneumothorax were observed. Regarding complications, operating time,
and accuracy, there were no statistically differences between in two groups. The duration of placing chest tube after procedure in the Dry group was shorter than that with
Wet group (2.31 day versus 5.89 day, P<0.001).
Conclusions
The flex-rigid pleuroscopy under local anesthesia is a rapid,
safe, and well-tolerated procedure for diagnosing DPD histopathologically. A further preoperative chest wall assessment
of adhesion using an ultrasound should be considered to prevent lung parenchyma injury.
Poster Presentation
IP-P24-6
IP-P24-7
Medical thoracoscopy under local anesthesia for diagnosing pleural metastasis of renal cell carcinoma
Eosinophilic pleuritis caused by aspergillus fumigatus : A case report
Department of Surgery, Yaizu City Hospital, Japan1), Department of Surgery, Suzukake Central Hospital, Japan2)
Division of Medical Oncology and Molecular Respirology, Tottori University, Japan
Yusuke Kita1), Ryo Kobayashi1), Hiroshi Nogimura1),
Chieko Kitamura1), Ryohei Koreyasu1), Ayaka Tsuboi1),
Kazuki Yakuwa1), Yoshihumi Nishino1),
Natsumi Fukuhara1), Hideyo Miyato1), Kumiko Hongo1),
Yukio Ishihara1), Naoki Takabayashi1),
Takeyuki Hiramatsu1), Kazuya Suzuki2)
Tomohiro Sakamoto, Hiroki Izumi, Shizuka Itou,
Kousuke Yamaguchi, Yasuto Ueda, Hirokazu Touge,
Jun Kurai, Haruhiko Makino, Masahiro Kodani,
Masaki Nakamoto, Tadashi Igishi, Eiji Shimizu
Introduction Medical thoracoscopy is useful procedure for
diagnosing pleural diseases. Malignant pleural dissemination
without pulmonary involvement caused by renal cell carcinoma (RCC) metastasis is relatively rare. We report a case of
pleural dissemination of RCC, diagnosed by thoracoscopic
pleural biopsy under local anesthesia.
Case A 65-year-old man visited our hospital for sort of breath
and right-sided pleural effusion. He had no history of malignancy but abdominal aortic aneurysm. A chest X-ray
showed a right pleural effusion. CT revealed bilateral pulmonary dissemination with pleural effusion. Serous serosanguinal effusion was observed by thoracic drainage. No malignant cells were checked by cytology. We performed medical
thoracoscopy and found a number of white large tumors on
parietal pleura. A histopathological findings of biopsy revealed clear cells and diagnosed as pleural metastasis of
RCC.
Conclusions The diagnosis of pleural metastasis from RCC is
difficult by cytology of effusion. Medical thoracoscopy revealed large-sized pleural tumors. This finding was useful for
the diagnosis of pleural metastasis of RCC.
【Background】
Aspergillus species cause various lung diseases including
pulmonary aspergilloma, chronic necrotizing pulmonary aspergillosis, invasive pulmonary aspergillosis and allergic
bronchopulmonary aspergillosis. However, primary eosinophilic pleuritis caused by Aspergillus has not been reported
in the literature.
【Case】
A 73 year-old asymptomatic male visited our hospital because of abnormal chest roentgenogram. Chest computed tomography scan revealed small pleural effusion, nevertheless,
the cause remained undiagnosed at the initial visit. After five
months, pleural effusion increased. Thoracentesis fluid
showed hemorrhagic pleural effusion with a high degree of
eosinophils. He did not have a past history of thoracic injury,
and serologic test of parasitemia was negative. We performed local anaesthetic thoracoscopy to distinguish malignant diseases including malignant mesothelioma and lung
cancer. Parietal pleura tissues obtained at biopsy revealed a
lot of filamentous fungus and eosinophil infiltration. Those
fungus were identified Aspergillus fumigatus by culture.
This eosinophilic pleuritis was suspected to be due to allergic
reaction caused by Aspergillus fumigates . Therefore, we administered prednisolone and voriconazole. Pleural effusion
does not reaccommodate after initiation of therapy.
【Conclusion】
This case suggests that Aspergillus fumigatus may cause
eosinophilic pleuritis through an allergic mechanism same as
allergic bronchopulmonary aspergillosis.
327
Poster Presentation
IP-P24-8
IP-P25-1
Diagnosis and treatment in a case of a primary lymphangiomatosis with chylopericardium and chylothorax
An algorithm to evaluate success of silicone stenting
in peri-anastomotic bronchomalacia in lung transplant
Clinic of Pneumology, University of medicine and Pharmacy
Targu Mures, Romania1), Thoracic Surgery Clinic, Emergency
Military Hospital, Bucharest, Romania2), Marius Nasta Institute
of Pulmonology, Bucharest, Romania3)
Gabriela Jimborean1), Claudiu Eduard Nistor2),
Simona Edith Ianosi1), Alexandra Comes1),
Roxana Nemes3)
Background: Diagnosis and treatment analysis in a primary
lymphangiomatosis with chylopericardium and chylothorax.
Case report: A 25 year old female patient was treated in an
extraterritorial hospital with antituberculous antibiotics and
steroids for a pericardial tuberculosis suspicion (chronic pericardial effusion, weight loss, asthenia, low fever and loss of
appetite). As the patient s clinical evolution was unfavorable
she was transferred in our Pulmonology Clinic. The patient
performed multiple investigation and we noted: same clinical
pattern without any extrathoracic pathology, negative tuberculin skin test, minimal pulmonary fibrosis on chest x-ray,
any evidence of Koch bacilli and other bacterial flora in sputum and bronchial aspirate, normal aspect in bronchoscopy,
normal biochemical blood examination. Heart ultrasound and
thoracic computed tomography noted an important pericardial effusion. We obtained chylous fluid through pericardial
punction with high fat level and without cytological or bacteriologic abnormalities. Pericardial, pleural, and pulmonary biopsies made in the cardiovascular surgery department
showed pericardial lymphangiomatosis and pulmonary fibrosis. Initialy there was performed a pericardial window to
avoid cardiac tamponade and subsecvently the patient developed recurrent chylothorax. We sent the patient to the Cardiovascular Unit in the Military Hospital in Bucharest for further investigation and treatment. There was performed
wide pericardectomy and pleurectomy. Immediate postoperatory evolution and evolution during the next 9 years were
favorable (without symptoms, without chylopericardium or
chylothorax). Conclusion: Biopsy (by thoracoscopy) and histopathology are indicated in all chronic pericardial!
pleural collections without known etiology by noninvasive methods.
Histopathology may provide positive and differential diagnosis and therapeutic orientation in some rares diseases of lymphatics (lymphangiomatosis, lymphangioleiomiomatosis, lymphatic congenital dysplasia, lymphangiectasia). Thoracic surgery was indicated for treatment (large pericardectomy and
pleurectomy).
328
Division of Pulmonary, Allergy, and CC, section of Interventional Pulmonology, Perelman School of Medicine of the University of Pennsylvania, USA
Anthony Reed Lanfranco, Jamie Bessich, Andrew Haas,
Daniel Sterman, Randall Solly
BACKGROUND: Peri-anastomotic malacia after lung transplant
is described as 50% of greater narrowing of the airway with expiration within one centimeter of the suture line. This focal form
of bronchomalacia is thought to be associated with ischemic injury to the donor bronchus and is best diagnosed with direct
visualization at bronchoscopy. Incidence is difficult to estimate,
and no widely-accepted treatment algorithm exists. We describe
a case series of four patients with peri-anastomotic malacia
treated with endobronchial silicone stent insertion and the process of post-stent evaluation for treatment success.
METHODS: Four cases of peri-anastomostic malacia identified at
bronchoscopy in post-lung transplant patients were reviewed.
Our practice to determine the success of endobronchial stenting
in peri-anastomotic malacia consists of pre- and post-operative
pulmonary function testing and patient interviews.
RESULTS: Two transplants were performed for COPD, one
right single lung transplant and one bilateral transplant. Two additional bilateral transplants were performed, one for cystic fibrosis and one for non-specific interstitial pneumonia (NSIP).
Three cases involved right mainstem peri-anastomotic malacia
with a right mainstem silicone stent placed, and one involved
both right mainstem and left mainstem peri-anastomostic malacia with bilateral silicone stents placed six weeks apart. Pulmonary function tests obtained between 8 and 14 days postoperatively improved after three of five stents placed, with an increase in FEV1 ranging from to 150 mL (12%) to 590 mL (69%). Of
the remaining two stents placed, forced vital capacity improved
in one by 130 mL (9%). In one case, both FEV1 and FVC decreased post-stent placement, resulting in subsequent stent removal and referral for re-transplant. All patients, with the exception of the patient requiring stent removal, reported improvement in subjective dyspnea.
CONCLUSION: Treatment of peri-anastomotic malacia with insertion of either metal or silicone stents has been described. In
our series, silicone stents were used exclusively to treat airway
collapse, and an algorithm for measurement of success is reported. Additional studies are necessary, including a larger patient series, use of a validated questionnaire to rate dyspnea, the
addition of pulmonary exercise testing to the evaluation process,
and determination of an acceptable increase in FEV1 that could
be considered a significant improvement.
Poster Presentation
IP-P25-2
IP-P25-3
Fibrotic airway stenosis following radiotherapy in patients with adenoid cystic carcinoma
Interventional bronchoscopy without fluoroscopy for
treatment of acute respiratory failure secondary to airway disease
Division of Pulmonology, Allergy and Critical Care Medicine,
Department of Internal Medicine, Pusan National University
Hospital, Korea1), Division of Pulmonary and Critical Care
Medicine, Department of Medicine, Samsung Medical Center,
Sungkyunkwan University School of Medicine, Seoul, Korea2)
Jung Seop Eom1), Kim Hojoong2)
Background and Objective: Radiotherapy is usually administered to the central airway in patients with unresectable adenoid cystic carcinoma (ACC). The purpose of this study was to
investigate the incidence and characteristics of symptomatic fibrotic airway stenosis following radiotherapy in patients with
unresectable ACC. In addition, the clinical outcomes of therapeutic bronchoscopy were analyzed in detail.
Methods: Forty-seven patients with ACC, who underwent radiotherapy of the tracheobronchial tree from January 1995 to
December 2011, were reviewed retrospectively. Fibrotic airway stenoses were diagnosed using three-dimensional computed tomography, flexible bronchoscopy, or both.
Results: Eleven (23%) of the 47 patients with ACC suffered fibrotic airway stenosis following radiotherapy and received
bronchoscopic intervention. The detailed characteristics of the
11 patients with RBS who underwent therapeutic bronchoscopy are shown in Table 1. The median interval from radiotherapy to diagnosis of fibrotic airway stenosis was 7 months.
One patient had a stable clinical course after mechanical dilation without silicone stent implantation and survived 74
months after radiotherapy. Silicone stents were placed in 10
patients (91%), and the median duration of stenting was 21
months (interquartile range, 9-47 months). Bronchoscopic intervention provided both immediate symptomatic relief and improvement of lung function in all patients, and no procedurerelated death or immediate major complication such as pneumomediastinum, pneumothorax, pneumonia, or massive bleeding was observed. Insertion of a straight silicone stent was required in 10 patients (91%), and 4 (36%) eventually received Yshaped silicone stents. The patients could not remove the silicone stent once they were implanted; however, the stents
were well-tolerated for a prolonged period in all patients.
Conclusions: The incidence of fibrotic airway stenosis following
radiotherapy in patients with ACC was relatively high. In addition, bronchoscopic intervention, including silicone airway
stenting, was a safe and useful method for treating radiotherapyinduced fibrotic airway stenosis in patients with ACC.
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital,
Taiwan
Chih Yen Tu, Chen Chia-hung, Liao Wei-chih,
Wu Biing-ru, Hsia Te-chun, Chen Hung-jen,
Shih Chuen-ming, Hsu Wu-huei
Objective
To determine whether flexible bronchoscopic intervention,
including endobronchial electrocautery or stenting without
fluoroscopic guidance, affected the need for continued mechanical ventilation in intensive care unit (ICU) patients with
acute respiratory failure from malignant or benign central
airway disorders.
Design and setting
A retrospective study, from May 2005 to July 2013, in a university hospital.
Patients
A total 82 ICU patients with respiratory failure due to malignant or benign airway disease during this period.
Interventions
These patients underwent flexible bronchoscopy with electrosurgery or Ultraflex (Boston Scientific) stents implantation under bronchoscopic visualization and local anesthesia
in ICU without fluoroscopic guidance throughout the procedure.
Measurements and Main Results
Eight-two patients (mean [ SD] age, 60.7 10.3 years; 88%
men) underwent 58 stents implantation without fluoroscopy
for the following main causes of airway obstruction related
mechanical ventilation dependence: lung cancer (n=31,
37.8%), esophageal cancer (n=20, 24.4%) and benign lesion (n=
19, 23.2%). The overall in-hospital mortality rate was 36.6%
(30!
82). Of the 82 patients, bronchoscopic intervention allowed discontinuation of mechanical ventilation in 39 (47.6%).
The patients who successfully liberated from ventilator
were significantly to have fewer days of mechanical ventilation (p<0.001), lower in-hospital mortality (p<0.001), be able to
receive additional treatment after procedures (p<0.001),
higher rate of hospital discharge (p=0.001), and longer survival (p=0.026) than patients who unsuccessfully liberated
from ventilator. Pneumothorax was the only complication,
and it occurred in five patients (6.1%). Both patients had a favorable outcome after drainage.
Conclusion
Endoscopic electrosurgery or metallic stents insertion under
bronchoscopic rather than fluoroscopic guidance in ICU patients with acute respiratory failure from central airway disorders is feasible and can allow successful withdrawal from
mechanical ventilator. The procedures appeared to improve
the clinical outcomes in patients who successfully liberated
from ventilator when surgery is not feasible for these patients.
329
Poster Presentation
IP-P25-4
IP-P25-5
A case of relapsing polychondritis treated successfully with an ultraflex (TM) stent: A long-term survivor
A case of double covered-self-expandable metallic
stents in patient with acquired subglottic tracheal
stenosis
Department of General Thoracic Surgery, Maebashi Red
Cross Hospital, Japan
Mitsuhiro Kamiyoshihara, Hitoshi Igai, Takashi Ibe,
Natsuko Kawatani
Background: Relapsing polychondritis (RP) is a rare inflammatory disease of unknown etiology that affects cartilage
and connective tissue throughout the body. In the respiratory system, cricothyroid or tracheal cartilage involvement
can cause critical airway stenosis. Here, we report a case of
RP treated successfully with an Ultraflex(TM) stent.
Case: A 57-year-old man had increased inflammatory reactions, thickening of the tracheal wall, and a saddle nose deformity. A rib cartilage biopsy led to a diagnosis of RP. Subsequently, he was treated with oral prednisolone. Five
months later, the patient suddenly developed dyspnea and
fell into a coma. He was taken to hospital by ambulance, received emergency medical care, was intubated, and transferred to our hospital.
Results: After a tracheotomy, Ultrafle(TM) stents were
placed in the trachea and bilateral main bronchi. On the day
of the stent placement, he was taken off the mechanical ventilator, and we replaced the tracheotomy tube with a T-tube.
After stent placement, the patient recovered without any
complications, and has been performing his normal daily activities without developing airway narrowing. Six years
later, however, the respiratory failure began to progress
gradually, and the patient died 6 years and 7 months after
stent placement.
Conclusion: The Ultrafle(TM) stent is useful in RP, although
its utility in its long-term management remains debated. We
present a long-term survivor of relapsing polychondritis
treated with an Ultrafle(TM) stent.
330
Internal Medicine, Chonbuk National University Hospital, Korea1), Department of Critical Care Medicine, Samsung Medical
center, Korea, Republic of (South Korea)2), Department of Internal Medicine, Korea University College of Medicine, Korea,
Republic of (South Korea)3), Internal Medicine, Chonbuk National University Hospital, Korea, Republic of (South Korea)4)
SeungYong Park1), Chi ryang Chung2),
Kyoung Hoon Min3), Yeoung Hun Choe4), So Ri Kim4),
Seoung Ju Park4), Yong Chul Lee4), Heung Bum Lee4)
The incidence of tracheal post intubation stenosis has increased because of the increasing number of patients who
require mechanical ventilator support. Resection of the
stenotic segment and reconstruction or Montgomery T tube
insertion are considered the ideal management. But these
procedures require introduction with a rigid bronchoscope,
surgical procedures, and an operating room under the general anesthesia.
Recently, as alternative options, airway stents have been extensively introduced with various results of success, and low
intra-operative and early postoperative complications rates.
However stenting for subglottic stenosis (SGS) remains a difficult therapeutic problem for the interventional pulmonologist in respect of its location relating stent migration and
granulation formation as well as shear stress inducing 2
ndary tracheo-laryngeal injury.
Herein, we reported a case of 74 years old man who treated
with double covered self expandable metallic stents, guided
by flexible bronchoscope and fluoroscope, for post intubation
subglottic stenosis that disrupted end to end anastomosis.
Poster Presentation
IP-P25-6
IP-P25-7
Temporally stenting to a severe central airway stenosis; A case report
Airway management of a 12-year-old implanted metallic stent for adenoid cystic carcinoma
Division of General Thoracic Surgery, Saga-Ken Medical Centre, Koseikan, Japan
Cardiovascular, Thoracic and General Surgery, University of
Miyazaki Hospital, Japan
Yusuke Okamoto, Yasuhiro Terazaki,
Masahiro Mitsuoka
Takanori Ayabe, Masaki Tomita, Chousa Eiichi,
Makoto Ikenoue, Nakamura Kunihide
INTRODUCTION:
The role of the airway stent insertion to the patient with central airway stenosis is not only avoidance from suffocation
but also a bridge to the next aggressive therapy. We report a
case of sever dyspnea due to a huge mediastinal tumor who
be saved her life by temporally stenting and performed chemotherapy after stent insertion.
PATIENT and OUTCOME:
The case was 27 years female. She met an internist because
of her dyspnea and palpitation. Those symptoms were supposed by pregnancy then. One month later, she visited our
urgent care center caused by increasing dyspnea. A huge
mediastinal tumor with 18 cm in size was detected on her
computed tomography and the carina had severe stenosis.
After a Dumon Y stent was inserted to her carina emergently, dyspnea was improved dramatically. The patient was
made a diagnosis as B cell lymphoma by biopsy from the
specimen through a small incision on the chest wall. Chemotherapy using with cyclophosphamide, doxorubicin, vincristine, and predonisolon was started immediately. Ten days after the initialization of chemotherapy, the silicon Y stent was
removed caused by patient discomfort due to reduction of
the tumor size. Now, four month has past from the stent insertion, the patient spends her life in good condition and continue the treatment.
CONCLUSIONS:
Airway stent insertion is very effective to the patients with
malignant airway stenosis. On the other hand, placement of
an airway stent could be induced to patient discomfort because a stent is a foreign body. Temporally stenting may be
an ideal strategy for malignant airway stenosis, especially in
the patients with responsible diseases such as lymphoma.
Background
Early on, metallic stents were frequently used for tracheobronchial stenosis, but found to cause several long-term
complications. Hence, silicone stents are now usually chosen
as the first stent, while metallic stents are mainly used for
the palliative care of patients with a short life expectancy.
For an inoperative critical airway obstruction (bilateral tracheobronchial stenosis (BTS)) and!
or endstage cases with a
malignancy, we succeeded in improving the patient s severe
dyspnea by the combination of bilateral bronchial stent dilatation, and this interventional therapy may be approved as
an option for the temporary remission therapy of carina
stenosis and good quality of life along with improving the severe dyspnea for 3 months until the patient s death. On the
other hand, in the case of BTS due to a low grade malignancy of an adenoid cystic carcinoma (ACC), we had implanted not only silicone, but also a metallic stent. We report
the unusual events of long-term complications and the difficulty of airway management due to a 12-year-old implanted
metallic stent. Eventually, salvage surgery, a pneumonectomy, was performed on the destroyed lung due to the fractured nonremovable metallic stent with cardiopulmonary
bypass (CPB).
Case report
In 1999, a 60-year-old female diagnosed with tracheobronchial ACC, was rejected due to the high risk reconstruction
surgery of the carina. Our interventional radiological doctor
implanted metallic stents for BTS (right: Ultraflex, left: Spiral
Z stent) to prevent endobronchial edematous asphyxia during radiation therapy. Radiotherapy showed that the tumor
had decreased in size. The migrated right metallic stent was
removed but the left one remained because it could not be
removed. She had been unevenful for 3 years after the metallic stent implantation. In the 4th year, bronchoscopic balloon
dilatation therapy (BBDT) had been performed for the produced dyspnea due to the exuberant granulation once every
year for 4 years. The left lung had been destroyed by resuscitate pneumonia, thus we performed a pneumonectomy as
salvage surgery using a CPB. The postpneumonectomy syndrome, dysphagia and dyspnea had confused her. BBDT had
been continued for the right single airway stenosis every
three months for 2 years. Eventually, she died of respiratory
failure due to the recurrence of the disease after 12 years of
treatment.
Conclusion
We should require use of a silicone stent for the low grade
malignancy of tracheobronchial airway stenosis. Eventual
open thoracotomic removal should be done for management
of the long-term complications of nonremovable metallic
stents.
331
Poster Presentation
IP-P26-1
IP-P26-2
Risk factors of severe postintubation tracheal stenosis
The initial results of interventional bronchoscopy for
treatment of central airway obstruction in hospital 103
vietnam
Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, China
Ch Zhong, Yu Chen, Shiyue Li
Method and Material: A retrospective study of risk factors
was made among 17 patients suffering from severe postintubation tracheal stenosis, who were treated in the first affiliated hospital of Guangzhou medical university from October
2012 to October 2013.
Result: 17 patients (9 males, 8 females, 16 yrs∼71 yrs) were
incubated because of trauma, toxicosis, heart failure, operation, etc. The intubation time was between 3 hours and 20
days(median:8.5 days). 1 patient(1!
17, 5.9%) was incubated
with tubes size<=7.0, while 16 patients (16!
17,94.1%) were incubated with tube size>=7.5. There is a very significantly
difference between these two groups(5.9% vs 94.1%, z=15.54,
P<0.001). 15 patients stenosis were located in upper tracheal,
while 2 patients stenosis were located in middle tracheal.
The lumen diameter of stenosis was between 2mm to 6mm
(average:4.4mm).
Conclusion: We should pay more attention to tracheal stenosis after intubation. The size of endotracheal tube may be
one of the main factors leading to severe postintubation tracheal stenosis.
332
Respiratory Disease, Vietnam Military Medical University,
Viet Nam
Thang Ba Ta, Quyet Do, Luc Nguyen huy
Interventional bronchoscopy is an effective method for treatment of central airway obstruction. Objective: To evaluate
the results of interventional bronchoscopy for treatment of
central airway obstruction in hospital 103. Method: interventional therapeutic bronchoscopy was performed on 26 patients with benign and malignant central airway obstruction
at hospital 103 from April 2012 to October 2013. Results:
100% of patients with mechanical dilatation and cutting lesions by forceps, 84,61% of patients with laser ablation and
15,38% with silicon airway stent placement. The clinical
symptoms, chest X-ray images, the level of airway obstruction markedly changed one week after treatment. The rate
of overall complication was 46.15% with mild hemoptysis being 42.3%, respiratory infection 15.38% and respiratory failure 7.69%. Conclusion: Interventional therapeutic bronchoscopy achieves good results with high safety in treatment of
central airway obstruction.
Keywords: Central airway obstruction; Interventional bronchoscopy
Poster Presentation
IP-P26-3
IP-P26-4
Endoscopic therapeutic options in tracheal stenosis
Topical mitomycin C for control of recurrent tracheal
stenosis by flexible bronchoscopy
Bronchology, Pneumology Clinic Cluj-Napoca, Romania1), Generally Surgery, Cluj-Napoca2)
Marioara Simon1), Petrut Vremaroiu1),
Mihaela Patraulea1), Dana Alexandrescu1), Ioan Simon2)
Background:
Management of tracheal stenosis (TS) varies with the type
and extent of the disease and is influenced by the patient s
age and general health status. Tracheal stenosis is sometimes a potentially life-threatening condition and needs
emergency treatment.
Aims:
To evaluate the indications and outcome of different techniques in tracheal stenosis treatment.
Methods:
From the total number of 3940 fibrobronhoscopies made in
the Bronchology Department of the Pneumology Clinic, ClujNapoca, between 2012-2013 we retrospectively reviewed 20
patients who were treated for tracheal stenosis. Patients
with symptomatic TS were treated both using flexible and
rigid bronchoscopy therapeutic modalities including: balloon
dilatation, rigid bronchoscope dilatations, electrocautery, surgical knife incisions, silicone stent (Dumon) placement.
Results:
Regarding the etiology of TS the majority were benign
stenosis 14 patients: post-endotracheal intubation (N=8), posttuberculosis (N=2), Wegener s granulomatosis (N=1), papilomatosis (N=2), idiopathic TS (N=2).
and 6 patients had malignant TS. The distribution of the patients according to the localization of the TS was: subglotic 10 patiens, middle of the trachea -6 patients, inferior trachea 4 patients. Endoscopic treatment modalities included: balloon
dilatation on 2 patients, mechanical desobstruction with rigid
bronchoscope on 4 patients, stent placement on 4 patients,
electrocautery and surgical knife incisions on 16 patients.For
the majority of the patients, different endoscopic techniques
were combined. The average session procedures per patient
was 6. Two thirds of the procedures were performed in local
anesthesia and one third in general anesthesia. Only 2 cases
required surgical treatment in complex stenosis. We obtained 70% successful endoscopic treatment. We will present
some suggestive cases we encountered.
Conclusions:
Our results confirm that TS should be managed primarily
using endoscopic procedures.
Endoscopy should be considered the first choice for simple
stenoses, whereas complex stenoses need a multidisciplinary
approach and often requering surgery.
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inha University Hospital, Korea1),
Department of Pulmonary and Critical Care Medicine, Hallym
University Kangdong Sacred Heart Hospital, South Korea2)
Hae-Seong Nam1), Changhwan Kim2), Jae hwa Cho1),
Jeong-seon Ryu1)
The optimal treatment of tracheal stenosis remains undefined. Traditionally, the treatment of choice for tracheal
stenosis is surgical reconstruction. However, the occurrence
of restenosis after surgical reconstruction is required broncoscopic procedure, such as mechanical dilation, heat modalities, or stent placement.
A 58-old-man with deep neck infection and post-intubation
tracheal stenosis which were developed during the intensive
care for acute myocardial infarction underwent tracheal reconstruction. Postoperatively, he presented with tracheal
restenosis due to granulation tissue formation. Electrocauterization was performed and granulation tissue was successfully removed. However, he developed a sudden onset of
shortness of breath and stridor after a month, and repeated
bronchoscopic procedure using electrocautery were performed eight times during 8 months. Alternative treatment
for recurrent tracheal stenosis was attempted topical application of mitomycin C, which was known inhibit fibroblast
proliferation. After removal of the granulation tissue, a cotton swab soaked in a solution of 0.4mg!
ml mitomycin C was
applied topically on the site of granulation tissue formation
for about 8 minutes under flexible bronchoscopy. All bronchoscopic procedures were performed under local anesthesia with mild conscious sedation using midazolam. Following
this procedure, the FEV1 increased to 3.10 L (94% of
precdicted) from 2.37 L (72% of predicted) on the 4 weeks.
Follow-up for 4 months showed no recurrence of symtoms.
Topical Mitomycin C is a useful adjunct in the management
of tracheal stenosis. It reduces granulation tissue and prevents recurrence.
333
Poster Presentation
IP-P26-5
IP-P26-6
A novel technique for application of mitomycin C in
tracheal stenosis
Bronchus shaping under bronchoscopy in endobronchial tuberculosis case
Department of Internal Medicine, The Ohio State University
Wexner Medical Center, USA1), Department of Otolaryngology, The Ohio State University, USA2), Department of Internal
Medicine, The Ohio State University Wexner Medical Center,
United States3), Department of Otolaryngology, University of
Texas Health Science Center San Antonio, USA4), Department
of Otolaryngology, University of Pittsburgh Medical Center,
USA5)
Muralidhar Kondapaneni1), Laura Matrka2), Brian Boyce2),
Rebecca Cloyes3), Timothy Udoji3), Blake Simpson4),
Clark Rosen5), Shaheen Islam3)
Bronchoscopic management of benign tracheal stenosis with laser
resection, cryotherapy, balloon bronchoplasty or stent placement are
acceptable options in patients who are not open surgical candidates.
Topical application of mitomycin-c (MMC) as an adjuvant treatment
for endoscopic management can reduce the recurrence of stenosis
by decreasing production of fibroblasts and scar tissue. However, the
application of topical MMC can be difficult. We describe a novel technique of MMC application which was not reported in bronchology literature without use of suspension laryngoscopy.
CASE
An obese 19-year-old female presented with post-intubation tracheal
stenosis extending from 1cm below the cricoid cartilage to about 4
cm distally. It was a complex stenosis with 5 fibrotic rings and
granulation tissue. The lumen was less than 5mm in diameter at the
most constricted area. Because of her obesity, diabetes and other comorbidities she was not a surgical candidate. She underwent several
flexible bronchoscopies with only temporary relief. A 16 40mm silicone stent was placed in her trachea but had to be removed after
two months as it migrated distally. A multidisciplinary team of interventional pulmonologists, otolaryngologists and thoracic surgeons
decided to treat the stenosis with topical MMC. After dilation
through a flexible bronchoscope, her trachea was intubated with a
13.2mm OD Dumon rigid tracheoscope. The tip of a size 5.0 endotracheal tube was then cut to a length of about 2cm. A pledget was
wrapped around and secured with sutures. The pledget with the
tube was grabbed with a rigid optical grasping forceps and soaked in
MMC (0.4mg!ml). It was passed through the tracheoscope and applied to the stenotic trachea. The pledget allowed application of
MMC in a circumferential manner on tracheal mucosa. Jet ventilation was used and precautions were taken against possible aerosolization of MMC and inadvertent application to the vocal folds.
DISCUSSION
MMC is usually applied to the stenotic area using rigid bronchoscopy or suspension laryngoscopy. Commonly, a rigid forceps holding MMC-soaked pledget is introduced through rigid scope and then
held against the mucosa of the stenotic area. These techniques have
limitations such as possible contact with vocal folds, non-circumferential
application with limited MMC efficacy, and abbreviated contact time
due to inadequate ventilation. Because of the circumferential nature
of the rolled pledget, it allowed continued jet ventilation while in contact.
CONCLUSION
Circumferential application of MMC can be safely achieved on a
larger surface area through a rigid bronchoscope with a pledget
wrapped around a cylindrical tube.
334
Department of Respiratory Medicine, The Second Xiangya
Hospital, China
Rui Zhou, Zeng Huihui, Xia Shulan, Zheng Dongyuan
Tuberculosis revivals in the developing countries, especially in Asia. Endotracheal and endobronchial tuberculosis is a kind of extra-pulmonary
tuberculosis, with nonspecial symptoms and worse prognosis.Here, we
presented a tracheobronchial obstruction case showing exciting improvement after bronchoscopy treatment.
A 48-year-old female, farmer, complained for 2 months of dyspnea. One
year ago, the patient was diagnosed as left principal bronchus tuberculosis with cough and fever for 3 months. In the past year, this case received with standard and full cause anti-tuberculosis treatment, and all
the symptoms were improved. However, this patient suffered growing
dyspnea in the last 2 months without cough, fever and night sweat. The
radiological examination showed left pulmonary atelectasis, and endoscopy showed the blockage of left principal bronchus (figure 1A, C).
The physical examination showed almost normal indexes, except low
saturation of oxygen, 92%, left shift trachea and obviously decreased
breath sounds in the left without any rales. Since the normal blood routine and coagulation, it was planned that minimally invasive treatment
remodeled the left principal bronchus under endoscopy. The patient
was nebulized with 2% lidocaine 5ml, and then injected intravenously
with midazolam 3mg. After nasal dropping 2% lidocaine 2ml, bronchoscopy (Olympus, T260, Japan) was inserted to trachea from right nostril.
This patient was supported with nasal oxygen, under cardiogram and
oxygen saturation monitoring. Once the bronchoscopy arrived at the
knuckle, electrofulguration tuber (fr1257, Nanjing, China) entered into
the bronchoscopy, and started to excision by electrofulguration at the
left of knuckle (figure1D, E), after direct spray of 0.01% noradrenaline 3
ml. Until the left principal bronchus shaping, endoscopy showed the
subordinate bronchus. After excising, the balloon was inserted into the
endoscopy, and dilated the excised bronchus with 8ml H2O pressure
(figure1F, G). At last, cryotherapy tuber entered into bronchoscopy, and
freeze the new shaped bronchus open. After this underbronchoscopy
treatmet, the patient showed improved symptom immediately. And
during the whole course of treatment, the case presented content tolerance and small bleeding volume. At the 2nd day after shaping, the chest
x-ray showed pulmonary recruitment maneuers (figure1H).
In this case, it is indicating satisfied tolerance and outcomes of bronchoscopy shaping. Without general anesthesia and mechanic ventilation, it
brings less economic burden and side effect. Also, this case warms that
endotracheal and endobronchial tuberculosis destroyed the construct of
airway, leading to obstruction and blockage of airway. It might be necessary to endoscopy treatment at early stage of endotracheal and endobronchial tuberculosis.
Poster Presentation
IP-P26-7
IP-P27-1
Recurrent membranous stenosis of trachea with tracheal diverticulum
A new bronchoscopic balloon dilatation method for
fibrostenostic endobronchical tuberculosis our initial
experience
Pediatrics, University Hospital Olomouc & Faculty of Medicine and Dentistry, Palacky University, Czech Republic1), Department of Pulmonology, University Hospital Olomouc &
Faculty of Medicine and Dentistry, Palacky University, Olomouc2)
Frantisek Kopriva1), Vitezslav Kolek2)
The association membranous stenosis of trachea and tracheal diverticulum is rare.
A 9-year old boy was admitted to hospital with wheezing
and progressive dyspnea for six months resulting restricted
activites and some difficulty with reading. Thre was no past
medical history of trauma to the respiratory tract or prior intubation. Multislice computed tomography (CT) of the chest
showed an incidental finding of a tracheal diverticulum(TD)
(6mm 2 mm.) Three-dimensional reconstruction CT demonstrated stenosis of the trachea approximetly 1.5 cm below
the vocal cords and orificium of tracheal diverticulum (the 2
nd cartilage of trachea)(Fig.1,). Pulmonary function tests revealed a reduction in flow spirometry values, with no postbronchodilator improvement. Flexible bronchoscopy showed
circular stenosis of the trachea and orificium of TD. Vaporization by NdYAG laser of the tracheal stenosis (Sharplan
3000, with energy of 30 W) was performed via rigide bronchoscope under general anesthesia. Dilatation by baloon
(Boston Scientific) was performed to widen the diameter of
trachea up to 8 mm. After one week pulmonary function test
revealed normal parameters without pathological symptoms.
Symptoms of dyspnea with membranous tracheal stenosis
recur despite laser intervention for five months- and 3-times
yearly intervals. Development of stenosis and its repetition
we can not currently explain.
Department of Respiratory Medicine, Tangdu Hospital,
Fourth Military Medical University, China
Faguang Jin, Deguang Mu, Yonghong Xie, Enqing Fu
Background: Balloon dilatation has been used as a useful
method for bronchial stenosis. The literatures concerning
about balloon dilatation are of case report or small sample
studies. As to their treatment procedure, the inflated balloon
kept at a desired pressure not exceeded 3 min. We used a
new balloon dilatation method with extended balloon compression time for about 3 years.
Objective: to evaluate the efficacy and safety of our new
method of bronchoscopic balloon dilatation (BBD) for fibrostenotic endobronchial tuberculosis.
Methods: We performed a retrospective study of 83 patients
who had bronchial stenosis caused by fibrostenositic endobronchial tuberculosis and underwent our new method of
bronchoscopci balloon dilatation at our department between
July 1, 2009 and June 30, 2011.
Results: All patients had initial success, including increased
airway dimensions and symptom relief. Long-term follow up
showed re-stenosis occurred in 5 patients. The main complications were laceration of mucosa, chest pain, retrosternal
oppressive feeling. No Mucosal necrosis, secondary pulmonary infection, esphago-trachea fistula, pneumothorax, trachea perforation or death occurred.
Conclusions: our new method of bronchoscopic balloon dilatation for bronchial stenosis caused by fibrostenotic endobronchial tuberculosis is very safe and effective.
335
Poster Presentation
IP-P27-2
IP-P27-3
Interventional bronchoscopy in the management of active bronchial tuberculosis: A case report
Lung cancer associated with pulmonary tuberculosishistological aspects and clinical considerations
Department of respiratory medicine, The First Affiliated Hospital of WenZhou Medical University, China
Department of Pulmonology, Craiova University School of
Medicine, Romania1), Pneumology Clinic Cluj-Napoca, ROMANIA2)
Xuru Jin, Chengshui Chen, Yuping Li
INTRODUCTION
Airway stenosis result from bronchial tuberculosis is one of
the most common cause of non-malignat airway stenosis. Balloon dilatation has become an accepted treatment to fibrotic
stenosis from bronchial tuberculosis. For stenosis from active bronchial tuberculosis, interventional bronchoscopy
treatment is controversial, still not standardized or unified
around the world. Now we report a case of bronchial stenosis
from active bronchial tuberculosis, in addition to active antituberculosis treatment, we also give several interventional
endoscopic treatments and success in the treatment.
CASE PRESENTATION
A 19-year-old girl presented with cough, low-grade fever for
6 months, and dyspnea for half month. She was a student
with non-smoke and no past medical history. She already received systemic antituberculosis treatment for 6 months.
Physical examination revealed diffuse wheezing in the lung,
and she was tachypneic. Initial chest CT scan showed right
mainstem bronchial stenosis, atelectasis of right middle lobe,
enlargement of mediastinal lymph node.
Bronchoscopy examination revealed large necrotic materials
and granulation tissue in the right middle bronchus and completely obstruct the the right middle lobe. Parts of the necrotic materials were removed with biopsy forceps. Tissue
also sent for pathologic examination and found necrotic granoloma in the tissue, bronchial brushings for acid-fast bacilli
were positive, then active bronchial tuberculosis was confirmed. In addition to continuing antituberculosis drug therapy, she was received interventional brochoscopy treatment
once a week, remove of necrotic materials,,injection of antituberculosis drugs in bronchus with INH(every time 0.1g) and
amikacin(every time 0.2g)and combine with crotherapy. After 2 months later, she received about 10times interventional
bronchoscopic treatment, she was improved and 6 months
later, she became asymptomatic.
6 maonths later, repeat CT scan revealed shrink of mediastinal lymph nodes, right middle lung infiltration was improved.
In the same time, bronchoscopy apperance showed significant improvement. 9 months later, CT scan showed little fibrotic abnormal in the right middle lobe and bronchoscopy
apperance showed right middle bronchus with scarring formation.
CONCLUSION
When active bronchial tuberculosis result in obstructive
pneumonia and ateclectasis,even bronchiectasis. In addition
toantituberculosis chemotherapy, interventional bronchoscope therapy may play a important role in the management.
336
Mihai Olteanu1), Mimi Nitu1), Marioara Simon2),
Emilia Crisan1), Cristian Didilescu1), Laurentiu Mogoanta1)
Tuberculosis (TB) is a bacteria that affects roughly a third of
the population on earth and is a major cause of morbidity
and mortality especially in developing countries. Lung cancer (LC) is the leading cause of cancer-related deaths for both
men and women worldwide and represents a major public
health problem worldwide. The association of pulmonary TB
and LC in the same patient has been reported in various case
series and case-control studies. We evaluated 33 patients diagnosed with both pulmonary TB and LC with histopathologic confirmation of endobronchial biopsy samples that
occurred simultaneously or sequentially between 2010 and
2013 in a TB endemic region (Romania, Dolj county) of European Union. Our goal was to determine the most frequent
histological type in relation with patient demographics, the
bronchoscopic characters of the lesions and the period of
time past since TB diagnosis in sequentially patients. Our
findings led to the conclusion that LC was encountered
mostly sequentially with pulmonary TB (20 vs. 13), in current
or ex-smoker males from rural areas around the age of 65,
and the predominant histological type was NSCLC epidermoid cancer. Bronchoscopic aspects were no different than
in TB free LC patients. Further analysis is needed especially
for LC screening purposes in TB endemic regions worldwide.
Poster Presentation
IP-P27-4
IP-P27-5
Endobronchial tuberculosis-A challenge for the bronchologist
Hydatid cystectomy endoscopic
Departament of Internal Medicine, HFR Riaz Fribourg, Switzerland1), Bronchology, Pneumology Clinic Cluj-Napoca2)
Petrut Vremaroiu1), Marioara Simon2), Aletta Vallasek2)
Background: Endobronchial tuberculosis (EBTB) is defined
as tuberculous infection of the tracheobronchial tree with microbial and histopathological evidence. It is seen in 10-40% of
patients with active pulmonary tuberculosis. Ten to 20 percent have normal chest radiograph. Bronchoscopic sampling
has been the key to the diagnosis producing more than 90%
yield on smear as well as on culture.
Aims: Frequency evaluation of EBTB and lessional profile of
bronchial tuberculosis in correlation with radiological and
clinical findings, illustrating the peculiarities and endobronchial aspects of some cases we encountered.
Methods: From a total of 9800 examined patients in the
Bronchology Departament of Pneumology Hospital ClujNapoca between 2009-2013, a number of 277 patients (2,83%)
had clinical and radiological aspects of pulmonary tuberculosis but with negative sputum or unable to expectorate. Bronchial lavage (BL) was performed for Mycobacterium tuberculosis (MTB) detection in all patients. Infiltrative ulcerative
and vegetant endobronchial lesions were biopsied.
Results: Bacteriological exam of BL confirmed tuberculosis
in 179 patients with a 64,6% confirmation rate: 61 patients
(34,07%) with positive MTB culture and positive acid fast bacilli (AFB) microscopy, 118 patients (65,92%) only with positive MTB culture. Endoscopic macroscopic aspects: hyperemic edematous forms -60 cases (33,5%), infiltrative ulcerative
"
45 cases(25,1%), vegetant forms "
30 cases(16,7%), normal aspects "
44 cases(24,5%). Out of 35 biopsies performed, histologic diagnosis of tuberculosis was possible in 22 cases with
62.85% confirmation rate. We found correlation between endoscopic and radiologic aspects: hyperemic edematous forms
and infiltrative tuberculosis, respectively between infiltrative ulcerative forms and cavitary!
ulcerative tuberculosis.
Conclusions: Bronchoscopy with BL and bronchial biopsy
can improve the yield diagnosis of pulmonary tuberculosis
and should be used in suggestive clinical and radiological
cases of tuberculosis and negative sputum.
Neumologia, Instituto Nacional de Torax, Bolivia
Marco Antonio Garcia
Overview
Pulmonary hydatidosis is frequent in the National Institute of chest. The
primary manifestation of and reason for consultation is bleeding of airway
which endangers the life of the patient. Definitive therapeutic behavior is
the surgical cystectomy. The present case reports endoscopic hidatid
membranes to find to be in sight, they were removed endoscopically,
avoiding in this way the surgical conduct.
Key words : hydatidosis, echinococcosis and hemoptysis
Introduction
Hydatidosis or echinococcosis is classified within the ciclozoonosis disease.
It comes in two forms, the larval stage (metacestode) and adults (had) the
parasite. Its spread is influenced by many factors (livestock, agricultural,
economic, cultural, etc.) especially living with animals. South America is
one of the regions most affected by hydatid disease. It is estimated that
more than 2,000 cases are reported each year. The most affected organs
are the lungs and liver. Are often asymptomatic, while not producing mechanical effects or break, resulting in this case variable respiratory bleeding and superinfection. The therapeutic approach is usually surgical.
Case report
Male patient, 28 years, farmer, rural Potosi-Bolivia. Had no medical history
except epidemiological probability of tuberculosis. One year clinical history with cough, progressive dyspnea, hemoptysis. Hospitalized in hometown for massive hemoptysis and anemia. He received antibiotics and antituberculosis no favorable response. Transferred to the National Institute
of Chest of La Paz Bolivia diagnosed with pulmonary tuberculosis and
bronchial adenoma suspected. Lab: anemia, hypoproteinemia, baciloscopynegative, HIV serology nonreactive. Radiology double heart profile. During his hospitalization, presents massive hemoptysis and hemodynamics
instability. La bronchoscopy displayed blood in RB9 and RB10. Is displayed
in RB8 hydatid membrane is eliminated entirely with forceps and suction.
Conclusion
Pulmonary hydatid disease is frequently complicated with hemoptysis.
When characteristics observed by radiology in countries with high tuberculosis epidemiology is often confused with this disease. If experience
therapeutic poses a new less invasive behavior: endoscopic hydatid cyst,
only in cases where the lesion is open to a bronchus.
337
Poster Presentation
IP-P27-6
IP-P28-1
Leishmaniasis with involvement of upper airway. An
unexpected finding bronchoscopic
Flexible bronchoscopies performed in an intensive
care unit Persahabatan Hospital, Jakarta, Indonesia
2011!
2013
Neumologia, Instituto Nacional de Torax, Bolivia
Marco Antonio Garcia
Overview
Leishmaniasis muco-cutaneous is a relatively common in tropical areas of
Bolivia. Co-exists with another endemic illness in the area: the tuberculosis
which also affects the upper airway. Both can be confused, so treatment
could be wrong. We present a case of leishmaniasis with characteristics of
own tuberculosis affectation.
Key words: Leishmaniasis Mucocutaneous or ulcer tropical, tuberculosis
Clinical case
Male patient, 50 years of age, area Altiplano of Bolivia. He worked in a gold
mine in tropics by 20 years until 8 years ago. 2 Years ago he attends the National Institute of chest by productive cough and hoarse dysphonia. Reportorta Specific chronic laryngitis laryngeal biopsy was performed.Negative
sputum smear. Otolaryngology repeat laryngoscopy concluding in TUBERCULOUS LARYNGITIS. Start TB treatment which leaves a month by gastric intolerance. By choice, it remains without medical care for two years. Go
back to this hospital with coughing mutism and afona dysphonia. Since the
beginning of his illness not present skin lesions. Laboratory: Serology HIV,
VDRL, smear, bacteriological culture and Mycosis deep, immune, negative
PPD. X-ray of thorax with bilateral alveolar infiltrate. New airway endoscopy showed swelling of mucosa and nasal ulcers; pharynx with loss of
morphology by granulomatous lesions, purulent discharge fibrin attached to
walls. Phonation identifies vocal cords; partial amputation of Epiglottis and
trachea to granulomatous lesions. Structure bronchial preserved but abundant purulent secretion. Review new biopsy histopathology: Libelous
chronic granulomatous process ; negative Giemsa staining. Serology: Antibodies antileishmania positive brazilensis by ELISA technique.
Conclusions
In Latin America 90% of cases of leishmaniasis Mucocutaneous occur in Bolivia, Brazil and Peru. Usually it is caused by Hematogenous spread of the
parasite after a skin lesion. Commitment to mucous membranes may be simultaneously a skin lesion, or decades later. The patient reference comes
from area Highlands but worked in the tropics, TB endemic area. Initially
was diagnosed as tuberculosis, supported in epidemiology, clinic, pathology
and endoscopic. The lack of information led to abandon the TB treatment
and go to new query when the lesions are extensive, they led to bacterial superinfection and progressive airway obstruction. Treatment with amphotericin B waiting to stop the progression of the lesions was started.
338
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Indonesia, Indonesia
Prasenohadi Sabarto Pradono, Dwi Handoko,
Dicky Soehardiman, Boedi Swidarmoko,
Wahyu Aniwidyaningsih
Background: Flexible bronchoscope (FB) is procedure of
choice in most airway explorations and is an important tool
in the diagnosis and treatment of a number of pulmonary disorders in critically ill patients. FB is an essential in Intensive
Care Unit (ICU) because the technique is relatively easy to
perform at the patient bedside, avoids the need for potentially dangerous patient transfer outside the ICU, and low
complications. In ICU, the most of FB was performed in patients with mechanical ventilation (MV). Under intubated
condition, the risks of FB performed was lesser than in spontaneously breathing patients.
Objective: To describe the main indications, clinical results
and complications associated with FB in the ICU.
Design: A retrospective survey, single-center observational
study.
Setting: Patients with or without undergoing MV who were
underwent FB in ICU Persahabatan Hospital, Jakarta, Indonesia.
Interventions: FB performed by a pulmonologist. The purpose of procedure was for diagnostic (upper and lower airway inspection) and for therapeutic (bronchial toilet, hemoptysis, airway management). Both topical anesthesia and sedation were used for FB. Appropriate diagnostic and therapeutic procedures were performed.
Result: A total of 19 FB were carried out in 13 patients admitted to the ICU. 13 FB procedures (68%) were performed
in patients with MV. The average patient age was 36.7 years
old (2 month-72 years). FB procedure was performed in 8
surgical patients. The most frequent indication for FB was
diagnostic confirmation of lower airway inspection (18 procedures) and we founded edema of arytenoid in 1 patient. The
most frequent therapeutic indication was the aspiration of
mucus and blood (8 procedures). Other indications were the
diagnosis and treatment of hemoptysis (5 procedures), control of tracheotomy (4 procedures), stent position evaluation
(4 procedures), weaning process (3 procedure). The most FB
procedures were done under sedation were 14 procedures
(73.7%), the remains procedures was done by topical anesthesia. 4 patients were died not associated with FB procedure,
but related with severe conditions. Arrhythmia occurred in
one patient during the FB procedures.
Conclusions: FB procedure in the ICU can be done in all patients and safe from infant to older. FB procedure contributes valuable diagnostic information and is useful for therapeutic purposes.
Poster Presentation
IP-P28-2
IP-P28-3
Primary systemic amyloidosis founded by the wall
thickening of the trachea and bronchus
A rare case of broncholithiasis merged with lung cancer of other lobe
Department og Respiratory Medicine, National Hospital Organization, Kanazawa Medical Center, Japan1), Department of
Respiratory Medeicine, Kanazawa University, Japan2)
Toshiyuki Kita1), Tomoyuki Araya1), Kouji Kurokawa1),
Yukari Ichikawa1), Yoshitaka Oribe1), Kazuo Kasahara2)
Background. We report on a case of primary systemic amyloidosis founded by the wall thickening of the trachea and
bronchus.
Case report. The patient was a 53-year-old man who complained of a discomfort in the throat and persistent nonproductive cough for 1 month. His dorsum of nose and both
auricle were swollen. The keloid formation of the skin was
generally present on the face, anterior chest and his back.
Lung function tests revealed an obstructive pattern, with a
forced expiratory volume in 1 s (FEV1) of 2,530 mL (78.3%)
and a vital capacity of 3,940 mL (104.5%) without reversibility. Thorax computed tomography (CT) scan showed a wall
thickening of the trachea and primary bronchi in this patient.
Bronchoscopy confirmed a diffuse infiltration of the mucosa
from the beginning of the trachea to the beginning of the tertiary bronchi. Direct fast scarlet (DFS) staining of biopsies of
bronchus, nasal septum, skin, the gastric mucosa and duodenum without the mucosa of the sigmoid colon and rectum
confirmed amyloidosis. He was diagnosed as having primary
systemic AL amyloidosis and was treated with high dose LPAM supported by auto peripheral blood stem cell transplantation (auto PBSCT). CT and bronchoscopy evaluation
after chemotherapy showed improvement of wall thickening
and diffuse infiltration of tracheal mucosa.
Conclusion. We reported that on a case of primary systemic
AL amyloidosis founded by the wall thickening of the trachea and bronchus.
Division of surgical Oncology, Nagasaki University Graduate
School of Biomedical Sciences, Japan1), Second Department of
Internal Medicine, Nagasaki University Hospital, Japan.2), Department of Pathology, Nagasaki University Hospital, Japan.3)
Hironosuke Watanabe1), Naoya Yamasaki1),
Ryusuke Machino1), Takuro Miyazaki1),
Keitaro Matsumoto1), Tomoshi Tsuchiya1),
Youichi Nakamura2), Tomayoshi Hayashi3),
Tkakeshi Nagayasu1)
Background: Broncholithiasis is sometimes incidentally detected during lung cancer screening and close examination
for the cause of hemoptysis, and its treatment indications are
evaluated in consideration of the risk of infection and hemorrhage.
Case report: We report a rare case of broncholithiasis which
is considered to have gradually grown over a period of 10
years, and simultaneously detected with lung cancer located
in another lobe. The patient was a 79-year-old woman. She
had a history of hemoptysis at the age of 69 years, but recovered by conservative treatment, and had not shown hemoptysis until the present episode. She consulted a local physician due to the present recurrence of hemoptysis and, on
close examination, exhibited a nodular shadow of 23 mm in
diameter in the right upper lobe, suggesting lung cancer. She
also showed a shadow of infiltration in the right lower lobe
and a focus of calcification 12 mm in diameter in the bronchus proximally to the infiltration.
Bronchoscopic examination showed an impacted calculus in
B6c, but its bronchoscopic removal was difficult. Surgery for
the broncholithiasis was indicated as well as the nodule of
the upper lobe due to the risk of obstructive pneumonia and
recurrence of hemoptysis, and the patient was referred to
our institution.Because of a poor pulmonary function, right S
1 and S6 segmentectomy with mediastinum lymph node dissection were performed. Her postoperative course was uneventful.
By pathological examination, a diagnosis of pT1bN1M0 and
pStageIIA lung cancer of the right upper lobe was made, and
marked inflammation of the lower lobe was noted. While no
clear history of infection or pathogenic organism could be
demonstrated, calcification of the mediastinal lymph nodes
suggested tubercle bacillus infection, and the calculus is considered to have grown over a course of about 10 years.
Conclusion: Both tumorous and non-tumorous diseases must
be considered for determination of the cause of hemoptysis.
Although their concurrence is rare, it also must be considered.
339
Poster Presentation
IP-P28-4
IP-P28-5
Clinical characteristics of bronchial anthracoflbrosis in
southwest china
A case of the acute respiratory failure by the bronchial
cast after chest drainage in patients with mesothelioma
First Department of Respiratory Medicine, First Hospital Affiliated to Kunming Medical University, China
Jiao Yang, Xi-qian Xing, Xu-wei Wu, Li-yan Zhang,
Ya-ji Yang, Yan-hong Liu, Ze-ming Yu
Background Bronchial anthracofibrosis is mainly occurred
in Asian countries, but there has not been reported in China.
So We will study the clinical characteristics of bronchial anthracofibrosis in southwest China.
Methods The clinical, radiological, bronchoscopic characteristics and comorbidities of 92 cases of bronchial anthracofibrosis were retrospective analyzed.
Results The bronchial anthracofibrosis mainly occurred in
female farmers who were older than 60 years old, but also occurred in workers who had exposure to mixed mineral dusts.
The main clinical symptoms are cough, dyspnea, hemoptysis.
The bronchoscopy can found some specific changes, such as
bronchial mucosa pigmentation, visible longitudinal mucosal
folds, hypertrophic scars, and other tumor-like changes in
the corresponding lobe and segmental bronchi with narrow,
twisting and occlusion. Bronchoscopic findings in patients
with bronchial anthracofibrosis revealed bilateral bronchial
involvement in 51.1% of the total patients. Our study documented right upper lobe involvement in 52 patients (56.5%),
left upper lobe in 49 (53.3%) and right middle lobe in 46
(50.0%). In the 92 cases, 32 cases (34.8%) patients with chronic
obstructive pulmonary disease, 23 cases (25.0%) patients with
obstructive pneumonia, 20 cases (21.7%) of pulmonary tuberculosis and (or) endobronchial tuberculosis, 7 cases (7.6%)
combined with lung cancer.
Conclusions The bronchial anthracofibrosis have no specific
clinical features and often is misdiagnosed, so we need to
strengthen awareness of the disease. The disease not only
occurred in farmers but also occurred in workers who had
exposure to mixed mineral dusts. Bronchoscopy is an important method to diagnose this disease. The disease mainly occurred in right upper lobe and right middle lobe, and was
often associated with chronic obstructive pulmonary disease,
obstructive pneumonia, tuberculosis and lung cancer.
340
Division of Medical Oncology and Molecular Respirology, Tottori University Faculty of Medicine, Japan
Yasuto Ueda, Hirokazu Touge, Ryouta Okazaki,
Yoshihiro Funaki, Kensaku Okada, Tomohiro Sakamoto,
Jun Kurai, Haruhiko Makino, Masahiro Kodani,
Tadashi Igishi, Eiji Shimizu
A 75-year-old woman, diagnosed left malignant pleural mesothelioma in November, 20XX had been received chemotherapy with 2 cycles of cisplatin and pemetrexed, followed by
maintenance therapy of pemetrexed. Furthermore, antituberculous drugs (rifampicin, ethambutol and clarithromycin)
were administrated because pulmonary atypical mycobacteriosis was complicated in this case. November, 20XX+1, she
visited to our hospital because of dyspnea from increase of
the left pleural effusion and left upper lobe atelectasis with
the progression of the mesothelioma. We tried the left chest
drainage of pleural effusion about 1000ml to improve the
dyspnea. But after chest drainage, severe cough and dyspnea and desaturation (SpO2 was 75% under 8L!
min O2) was
developed. We doubted reexpansion pulmonary edema with
the chest drainage, and administrated steroid (125mg of
methylprednisolone). But the dyspnea and desaturation was
not improved (SpO2 was 70% under 10L!
min O2). And pulmonary edema was not proved by the chest X-rays. After
hospitalization, we performed a bronchoscope under intubation. And white lump was filled from the left main bronchus
entrance part. After removing the white lump using a forceps, it was recognized the bronchial cast formed dendritic.
It was diagnosed of fibrin-like nonspecific viscous sputum by
the pathological examination.
As for the cause of the respiratory failure, the lung expanded
by chest drainage, and it was thought that a viscous bronchial cast was translocated to the center of left main bronchus from the opened peripheral bronchus lumen. She could
leave a respirator and discharged the hospital after 1 month.
We report this case because bronchial cast is rare as a cause
of the respiratory failure after the chest drainage.
Poster Presentation
IP-P28-6
IP-P29-1
A case of endobronchial metastasis from invasive thymoma presenting as a polypoid lesion of right truncus
intermedius
The dilated balloon in removal of refractory foreign
body(whistle)-A case report
Division of Respiratory Medicine and Clinical Allergy, Department of Internal Medicine, Fujita Health University, Japan
Mariko Morishita, Sumito Isogai, Takuya Okamura,
Yoshikazu Niwa, Sayako Morikawa,
Tomoyuki Minezawa, Tomoko Takeyama,
Teppei Yamaguchi, Masamichi Hayashi,
Mitsushi Okazawa, Kazuyoshi Imaizumi
Thymoma is one of the most common neoplasms of the anterior mediastinum. Invasive thymoma, which invades to adjacent tissue, is rarely accompanied with hematogeneous or
lymphatic metastasis.
(Case report)
A 69-year old woman was referred to our department with a
chief complaint of chronic cough. Chest computed tomography (CT) showed a well-defined mass in the anterior mediastinum and multiple abnormal shadows in the lung fields.
The mass in the right lower lobe showed an irregular shaped
tumor spreading along the right middle and lower bronchus.
Bronchoscopic examination demonstrated an endobronchial
polypoid tumor obstructing the right truncus intermedius. A
mediastinal tumor resection and right middle and lower lobe
lobectomy revealed that an endobronchial metastasis to the
bronchial wall of the middle lobe bronchus expanding along
the middle and lower segmental bronchus.
(Conclusion)
We experienced a rare case of invasive thymoma with an endobronchial metastasis presenting as a polypoid tumor in the
right truncus intermedius.
Department of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, China
Shiyue Li, Changhao Zhong, Yu Chen, Yingzhi Wang
Background: Airway foreign bodies are classic indication of endoscopic
treatment. To extract the refractory airway foreign bodies is a challenge for
bronchoscopists. There are different methods for different foreign bodies.
We adopted dilated balloon to remove refractory airway foreign body(whistle) in 1 case.
Case report: A 26 years old male inhaled a whistle carelessly while playing
20 years ago. He had a little cough and nothing else discomfortable without
any special treatment. During the last one year, his cough gradually exacerbated with a little blood in sputum occasionally.He came to local hospital for
treatment. His right lower lung atelectasis was found in CT scan. Then he
was sent to our hospital for further treatment. The CT scan report shown:
right lower lung atelectasis, the right lower lobe bronchus could see a high
density shadow, suggested there could be a foreign body. Bronchoscopy
shown: at the opening of right lower lobe bronchus, there were some granulations blocking the lumen. The lumen was recovery after APC was applied
to ablated the granulations. So we could see a hollow foreign body incarcerated in the lumen. We had use different kinds of foreign body forceps and
curets, but failed. Finally we employed a dilated balloon (diameter 6-7-8 mm)
to dilated the upper bronchus above the foreign body with 5 ATM pressure
(see picture). And then the balloon through the hollow foreign body(whistle),
the foreign body was pulled together with the balloon loaded with saline solution in 3 ATM pressure. The foreign body was extracted successfully. The
right lower lobe bronchus was open and clear on his bronchoscopy 1 week
later.
Conclusion: The dilated balloon in removal of refractory airway foreign fistular bodies is a very helpful.
341
Poster Presentation
IP-P29-2
IP-P29-3
Removal of endo-bronchial foreign body by fiber-optic
bronchoscopy: A case report
Cases report of removal foreign body aspiration in children
Department of Pulmonary Medicine, King George Medical
University Uttar Pradesh Lucknow, India1), Director, V P
Chest Institute New Delhi, INDIA2), ASSISTANT PROFESSOR, DEPARTMENT OF MEDICINE, GOVERNMENT
MEDICAL COLLEGE, SRINAGAR, INDIA3)
Ram Awadh Singh Kushwaha1), Rajiv Garg1),
S K Verma1), Santosh Kumar1), Rajendra Prasad2),
Manzoor Ahmad3), Gulam Mohammad3), Surya Kant1)
BACKGROUND: Foreign body (FB) aspiration is a common cause of respiratory emergency associated with a high rate of airway distress. Presentaion
may vary from a symptomless patient to impending airway failure. FBs are
more often found in the right endobronchial tree than in the left. Fiberoptic
Bronchoscopy (FOB) is commonly used technique for removal of FBs. Delay in
diagnosis and removal of an inhaled FB is associated with serious acute complications e.g. volume loss, necrotizing pneumonia, lung abscess, and bronchiectasis etc. Further, Identification and removal of FBs becomes more difficult due to local inflammation, edema, cellular infiltration, ulceration, and
granulation tissue formation leading to airway obstruction. Here we present a
case of 13 year aged male child who accidentally aspirated a large metallic FB.
CASE REPORT: This 13 year old male child from nearby village brought to us
(a tertiary care teaching medical institution) with a history of 10 days when he
accidentally aspirated a CYCLE NUT while he was playing in a mango orchard keeping it in his mouth. Just after it he developed choking sensation, intractable cough and chest pain. Immediately he reported to his parents who
thought that he would have swallowed it. They advised to ingest one Banana
so that it could pass into stools. This remedy did not work and they consulted a
local physician who prescribed antibiotics, cough syrup and pain killer. But
symptoms aggravated and child developed high grade fever, purulent expectoration and hemoptysis in addition to chest pain and cough. After 10 days of
event another physician advised a chest x-ray (PA) and detected presence of
radio opaque FB in right lung field and referred him to our center.
On examination child was dyspnic and pyrexic, respiratory rate 24!min, heart
rate 92 min, decreased breath sounds and coarse crepts were noted in right
side. Other systems were within normal limits. His total leukocyte count was
16,700 cell!cu ml and differential counts were 82% polymorphs and 18% lymphocytes.
Metallic FB was removed successfully by using fiber-optic bronchoscope under topical anesthesia. His symptoms were relieved after 7 days course of antibiotics and supportive care.
CONCLUSION: FOB is a patient friendly, safe and excellent procedure commonly done to remove FBs. This should be considered first to locate and remove FBs whenever possible especially in a resource limited settings to avoid
unnecessary general anesthesia and hospital cost and future complications.
342
Departement of Pulmonology and Respiratory Medicine, University of Indonesia, Indonesia
Nur Nina Rosrita Askaroellah,
Prasenohadi Sabarto Pradono, Aniwidyaningsih Wahju,
Dicky Soehardiman
Background
Foreign body (FB) aspiration is a serious and potentially fatal
situation. The severity of the symptom depends on the degree of airway obstruction. It affects mostly in children but
in some cases affected adults. Diagnosis of FB aspiration is
essential, delayed recognition and treatment can result in fatal damage. Bronchoscopy remains the gold standard for diagnosis and treatment of FB aspiration. It can be performed
with rigid or flexible bronchoscopy. In children rigid bronchoscopy is recommended in asphyxia, radiopaque FB or
unilaterally decreased breath sound patient.
Case 1: We report case of a 11 years old boy who was admitted with short of breath for just hours before. Respiratory
rate 26!
minute. Parents acknowledged that they paid less attention to his son when played outside with his friend and
stated that he swallowed something. His breath sound decreased in the left lung and dull in percussion. Chest X-Rays
showed almost full opacity in the left hemithorax. Laboratory showed leucocytosis with neutrophil dominance. Patient
underwent rigid bronchoscopy for the next hour after admitted to the hospital. A nail occluded the left main bronchus
that caused atelectasis in the chest x ray was removed. In
ward patients breath normally and laboratory decreased
near normal.
Case 2: We report case of a 16 years old girl who was admitted to the hospital with no symptoms. She acknowledged
swallowed a needle that she squeezed between her lips after
being surprised by her friends to wear hijab. No respiratory
symptomps was complained. The physical examination was
normal as well as the laboratory finding. Right and left hemitoraks was normal, but there were like shadow of line at the
trachea. This patient underwent flexible bronchoscopy under general anesthesia a day after she admitted. A needle in
the trachea proximal was removed. The patient back to
ward and feel relief.
CONCLUSION
Foreign body aspiration is a life threatening problem that
can affected all ages but mostly children compare to adult.
Assistance and understanding in children is adviseable for
parents to avoid FB aspiration. Bronchoscopy is important in
diagnose and treatment patient with FB aspiration.
Poster Presentation
IP-P29-4
IP-P29-5
Bronchoscopic removal of staple-line reinforcement
material
Needle extraction on lateral segmen right medial lobe
using fob biopsy forceps
Department of Surgery II, University of Miyazaki Hospital, Japan
Eiichi Chosa, Takanori Ayabe, Masaki Tomita,
Makoto Ikenoue, Kunihide Nakamura
Background. The most frequent complication after a thoracic surgical procedure for a patient with emphysema is a
prolonged air leak that increases the length of their hospital
stay. Standard therapy for treating air leaks after lung resection involves surgical stapling or suturing techniques and
electrocautery. To minimize air leaks, several preventive
techniques that reinforce the staple line using different materials have been developed, ie, strips of bovine pericardium,
expanded polytetrafluoroethylene (ePTFE) sleeves, absorbable reinforcement felt (polyglycolic acid, Neoveil, Gunze,
Kyoto, Japan), and biological glue. We report a rare case of
the migration of staple line reinforcement materials found as
an endobronchial foreign body and its successful removal using a flexible bronchoscope. Case report. A case was a 60year-old man who presented with severe productive cough
caused by an endobronchial foreign body, which was due to
the migration of a staple-line reinforcement material (Seamguard, W.L.Gore & Associates, Inc., Flagstaff, AZ). This material was placed over 5 years ago during a right upper lobe
lobectomy for a poorly differentiated adenocarcinoma, (T1N0
M0). We were able to remove the entire staple line by performing 2 separate flexible bronchoscopic interventions during a 1-year period without any consequences, thereby preventing an open thoracotomy. Our technique involved trimming the projecting reinforcement material with endoscopic
scissors and removing it by pulling or pushing the staple line
with a grasping forceps. Conclusion. We experienced migration of a staple-line reinforcement material into the endobronchial tree several months after a lobectomy. Our case
highlights the importance of using a bioabsorbable material
over the nonabsorbable one. Nevertheless, if endobronchially
migrated, the material can be excised and removed with the
help of a flexible scope, thus avoiding a thoracotomy. A
three-dimensional computed tomographic scan of the chest
is very helpful to detect the exact anatomic location of the
foreign body and its relation to the surrounding vital structures. Key Words: staple-line reinforcement material, removal, endobronchial foreign body.
Department of Pulmonology and Respiratory Medicine,
Brawijaya University, Indonesia1), Department of Radiology,
Brawijaya University, Indonesia2)
Erna Kusumawardhani Anasmoro1), Teguh Sartono1),
Ngakan Putu Parsama Putra1), Arief Iskandar2)
Background: Most foreign body aspiration occurs at a child
less than 3 years < it relates with tendency to putting something into their mouth but needle foreign body aspiration
usually occurs at the young female who wearing an islamic
veil. The finding of needle foreign body in respiratory tract is
an uncommon case in adult that really needs a brieve <
quick treatments < it can be an emergent life-threatening
condition if cause serious complication. The diagnosis of foreign body aspiration in respiratory tract established by
anamnesis, physical examination, radiologic examination <
bronchoscopy. The clinical symptoms of this foreign body aspiration depend on the size of foreign body, its location, type
< its shape, a type of its effect to irritate the mucosal of respiratory tract, its duration located in respiratory tract, degree
of obstruction < the present or absent of its complication.
Foreign body aspiration must be removed in optimal condition to minimalize risk of trauma to prevent complication
during extraction process.
Case Illustration: A case of a 15-year old woman who is complaining of needle aspiration by accident, when she is biting
it during putting of her islamic veil, followed with cough <
right chest pain after 2 days later. Physical examination reveals patient looks moderate coughing < pain on right chest
percussion. Chest X-ray PA < right lateral position show corpus alienum linear shape, metal density, about 3 cm, located
in projection of right hillar. After preparing optimal condition, the operator perform fiber optic bronchoscopy immediately under oral anesthesia < finds sharp needle located in
lateral segmen of right middle lobe. Several trial of extraction has done using biopsy forceps < finally the operator succeed in holding the needle in its sharp edge < then pull it out
carefully. Actually, this foreign body is a sharp needle in its
proximal with big round plastic material in its distal (Indonesia: Jarum Pentul ) so it hard for operator to pull it out.
Evaluation post extraction, the patient is in good condition,
so operator let her home that day.
Conclusion: There was reported one case of aspiration of
needle foreign body in the right middle lobe in a 15 year-old
woman who succesfully extracted using a biopsy forceps of
fiber optic bronchoscopy without complication.
343
Poster Presentation
IP-P29-6
IP-P29-7
A case of pulmonary actinomycosis caused by aspiration of cedar leaves
Aspiration of foreign bodies in dental practice thoracic
surgeon s point of view
Department of Pulmonary Medicine and Bronchoscopy, Gifu
Prefectural General Medical Center, Japan
Thoracic Surgery, Niguarda Hospital Milano, Italy1), Division of
Thoracic Surgery, Niguarda Hospital, Italy2)
Takuya Sobajima, Anri Murakami, Atsunori Masuda,
Akifumi Tsuzuku, Akihiko Matsuno, Fumihiro Asano
Massimo Torre1), Sava Durkovic2), Serena Conforti2),
Alessandro Rinaldo2)
Background: Aspiration is not rare in children and some
populations of adults (elderly and patients with neurological
disease). Various types of foreign body are aspirated depending on the lifestyle and food culture. The aspiration of foreign
bodies may cause various infectious diseases, including actinomycosis, and its association with foreign bodies has been reported. We encountered a patient with actinomycosis caused
by aspiration of cedar leaves.
Case report: The patient was a 56-year-old female who aspirated decorative cedar leaves contained in a lunch box while
eating a meal, and coughing and bloody phlegm occurred
thereafter. A mass was noted in the right lower lobe of the
lung on plain chest CT on the first consultation, and granules
of Actinomyces were noted on transbronchial lung biopsy.
Long-term antibiotic administration was performed, but no
improvement was obtained. Thus, right middle lobectomy
was performed. On postoperative pathological examination,
cedar leaves were present in the bronchus, bacterial colonies
adhered to these, and there was surrounding inflammatory
cell infiltration, mainly involving histiocytes and lymphocytes. Conclusion: Actinomyces infection caused by the aspiration of cedar leaves is very rare. Most cases of actinomycosis caused by an aspirated foreign body are improved by its
bronchoscopic removal, but cedar leaves are likely to enter
the peripheral bronchus because of their unique shape, and
the leaves cannot not be reached with a bronchoscope.
344
Introduction: Aspiration of a foreign body in dental practice
is a rare event. Treatment requires expertise in both pediatric and adult rigid bronchoscopy, and thoracic surgery.
Matherials and Methods: We retrospectively reviewed
eight cases of dental foreign bodies aspiration treated at our
Institution in the last 10 years.
Results: The youngest patient was 9 and the oldest was 71
years old. None of them had risk factors for aspiration. Seven
out of eight patients underwent rigid bronchoscopy for the
extraction and one patient underwent right thoracotomy.
One patient underwent dental procedure 20 days prior to admission, the others were admitted on the day of dental procedure. Data about preventive measures undertaken in the
dental office were not available for none of the patients in
our medical charts.
Conclusion: Should preventive dental measures fail aspirated foreign bodies should be treated at experienced centres.
Poster Presentation
IP-P30-1
IP-P30-2
Case report of glomus tumor in lower part trachea
Endobronchial pulmonary hamartoma: A case report
(revision)
Department of Internal Medicine, Phramongkutklao Hospital
and Phramongkutklao Collage of Medicine, Thailand
Virissorn Wongsrichanalai
Background: Tracheal glomus tumors are extremely rare.
Case report: We present the case of a 44-year-old man with
chronic cough and non-massive hemoptysis who was discovered to have a glomus tumour located in the lower trachea.
Initially, he had been diagnosed COPD and had suffered 2
episodes of respiratory failure, during which endotracheal
tubes were not able to be passed ubsequent bronchoscopy
showed a lower trachea polypoid mass above the carina. The
tumor was resected and pathologic diagnosis showed a
vascular-rich neoplasm, suggestive of glomus tumor. The patient underwent successful resection by rigid bronchoscope
with laser resection. After that, he was performed tracheal
reconstruction by CVT. A pathologic diagnosis of a glomus
tumor with clear surgical margins was confirmed afterwards, and the patient is well 2 years postoperatively with
an intact anastomosis.
Conclusion: A glomus tumor patient who presented with airway obstruction was performed rigid bronchoscope and tumor resection for rescue therapy. Finally, tumor resection
and tracheal reconstruction was done.
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine University of Indonesia, Indonesia
Nila Kartika Ratna, Christofan Lantu,
Wahju Aniwidyaningsih, Agung Wibawanto,
Susan Hendriarini Mety, Faisal Yunus
Background
Hamartomas are the most common form of benign lung tumors, they are twice as common in men as in women. About
5% to 10% of solitary pulmonary nodules are hamartomas.
Although pulmonary hamartomas are not uncommon, only
rarely do they occur within the bronchi and constitute only
1-19.5% of cases. CT findings such as internal fat or popcornlike calcifications help to distinguish hamartomas from malignancies but seen only in 30% of hamartomas. The diagnosis
of peripheral hamartoma can be established by transthoracic
needle aspiration biopsy and bronchoscopic transbronchial
biopsy. Unlike most of the pulmonary hamartomas which require only conservative management, endobronchial hamartomas may cause irreversible lung damage due to bronchial
obstruction if it is not diagnosed and treated properly. Appropriate indications for surgery might include the presence
of symptoms, growth of the tumor under radiographic observation, large size of the tumor, and impingement of the mass
on a vital structure.
Case Report
A 43 years old female was referred to our hospital with
worsening symptoms of cough, shortness of breath and loss
of bodyweight since 1 month before admission. Patient was
given antituberculosis drugs for the third times since 2008,
when she was having first symptoms. Follow-up chest Xrays showed worsening of right lung atelectasis. MRI findings revealed papillary mass on the right main bronchi. Diagnostic bronchoscopy was performed and a papilomatous
mass was found in the right main bronchi, needle aspiration
showed granulomatous findings. Second bronchoscopy was
done to remove the mass with bronchoscopic approach but
unable to remove the remaining stump in the right upper
lobe. The procedure was continued with open thoracotomy
and because the mass has extended to the right upper lobe.
Right upper lobe lobectomy and bronchoplas