Statistical approach to mediastinal staging in NSCLC with M.E.S.S.i.a. software.

The exclusion of pathological involvement of mediastinal lymph nodes in patients affected by NSCLC plays a central role in assessing  their prognosis and operability. Ceron et al. developed a software - called M.E.S.S.i.a (Mediastinal Evaluation with Statistical Support; instan approach) - that allows the calculation of the residual probability of lymph node involvement after a certain number of tests has been done, by integrating every test result with the pre-test prevalence. M.E.S.S.i.a. bridges a gap of current American College of Chest Physicians (ACCP) guidelines, providing probability values of mediastinal metastasis for a correct clinical decision. We conducted a preliminary retrospective study in a series of 108 patients affected by non small cell lung cancer (NSCLC). Pathological staging was compared to the probability of nodal involvement calculated by M.E.S.S.i.a. software. Forty-two out of 108 subjects (39%) had a calculated post-test probability <8%; none of these had proven N2/N3 metastasis at surgical staging (negative predictive value, NPV: 100%). In 12/41 cases M.E.S.S.i.a. was able to avoid invasive procedures. The remaining 66 (61%) patients did not reach the surgical threshold; among these, 11 displayed N2 positivity at pathological staging. Receiving operator curve (ROC) analysis produced an area under curve (AUC) value of  0.773 (p<0.001). These preliminary data show high accuracy of M.E.S.S.i.a. software in excluding N2/N3 lymph node involvement in NSCLC. We have therefore promoted a prospective multicenter study in order to to get a validation of the calculator at different levels of probability of lymph node involvement. The recruitable subjects are potentially operable NSCLC patients; the gold standard for detection of mediastinal disease is the surgical lymph node dissection.

Competence in endosonographic techniques.

Endobronchial ultrasound (EBUS) has revolutionized the field of bronchoscopy because it allows to observe peribronchial structures and distal peripheral lung lesions. The use of EBUS was first described by Hurte and Hanrath in 1992. EBUS technology exists in two forms: radial and convex transducer probes. The radial EBUS probe has a 20-MHZ (12-30 MHz available) rotating transducer that can be inserted together with or without a guide sheath through the working channel (2.0-2.8 mm) of a standard flexible bronchoscope. The transducer rotates and produces a 360-degree circular image around the central position of the probe. There are two types of radial EBUS probes: "peripheral" probes, used to identify parenchymal lung lesions, and "central" probes, with balloon sheaths, used for the assessment of airway walls and peribronchial lymph nodes.

Lobar Collapse Therapy Using Endobronchial Valves as a New Complementary Approach to Treat Cavities in Multidrug-Resistant Tuberculosis and Difficult-to-Treat Tuberculosis: A Case Series.

BACKGROUND: The poor treatment outcomes of multidrug-resistant tuberculosis (TB) and the emergence of extensively drug-resistant TB and extremely and totally drug-resistant TB highlight the urgent need for new antituberculous drugs and other adjuvant treatment approaches. OBJECTIVES: We have treated cavitary tuberculosis by the application of endobronchial one-way valves (Zephyr®; Pulmonx Inc., Redwood City, Calif., USA) to induce lobar volume reduction as an adjunct to drug treatment. This report describes the feasibility, effectiveness and safety of the procedure. METHODS: Patients with severe lung destruction, one or more cavities or those who were ineligible for surgical resection and showed an unsatisfactory response to standard drug treatments were enrolled. During bronchoscopy, endobronchial valves were implanted in the lobar or segmental bronchi in order to induce atelectasis and reduce the cavity size. RESULTS: Four TB patients and 1 patient with atypical mycobacteriosis were treated. The mean patient age was 52.6 years. Complete cavity collapses were observed on CT scans in 4 of the 5 cases. All patients showed improvements in their clinical status, and sputum smears became negative within 3-5 months. There were no severe short- or long-term complications. The valves were removed in 3 of the 5 patients after 8 months on average; there was no relapse after 15 months of follow-up. CONCLUSION: These data suggest that endobronchial valves are likely to be useful adjuncts to the treatment of therapeutically difficult patients. More data are required to confirm our findings.

Pneumomediastinum after transbronchial lung biopsy.

Pneumomediastinum is a rare complication of a transbronchial lung biopsy. Common symptoms are chest pain, dyspnea, dysphagia, and specific electrocardiographic changes. We report a case of pneumomediastinum after a transbronchial lung biopsy. During the in-hospital stay, the symptoms and clinical picture rapidly improved without invasive treatment; therefore, the patient could be discharged after a few days. Approximately 1 month later, chest computed tomography was performed, which showed a complete resolution of the pneumomediastinum.

A new diagnostic and therapeutic approach to pericardial effusion: transbronchial needle aspiration.

Pericardiocentesis was introduced during the 19th century, and reached its current level of development with the introduction of two-dimensional echocardiography. Although there is general agreement that complications are rare with skilled operators, a diagnostic and therapeutic problem often occurs when there is a posterior pericardial effusion, as it is not easy to quantify by echocardiography, and difficult to drain through a percutaneous access; therefore, it is usually treated surgically. We describe a new approach to pericardial effusion by a transbronchial access through the left lower lobe bronchus (which allows both diagnosis and evacuation of abundant amounts of fluid), or through the distal trachea (for diagnostic purpose only, in the presence of pericardial effusions filling the aortic recess of the pericardium). The technique is rather easy for operators skilled in transbronchial needle aspiration, and is safe, economical, and well tolerated.