Early experience of endobronchial ultrasound-guided transbronchial nodal cryobiopsy: a case series from Sabah, Malaysia.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an established minimally invasive method for the diagnosis of benign and malignant conditions. Continuous efforts are underway to improve the material adequacy of EBUS-TBNA, including the introduction of a new technique called EBUS-guided transbronchial nodal cryobiopsy (EBUS-TBNC). This method allows for the retrieval of larger and well-preserved histologic samples from the mediastinum. We present a case series of four patients who underwent combined EBUS-TBNA and EBUS-TBNC procedures in our centre. All procedures were performed under general anaesthesia using a convex probe EBUS scope (Pentax EB-1970UK). Two patients were diagnosed with malignancy and two with benign disorders (silicosis and tuberculosis). In the malignant cases, both EBUS-TBNA/cell block and cryobiopsy provided a diagnosis but cryobiopsy yielded more material for ancillary tests in one patient. However, in the benign cases, there was discordance between EBUS-TBNA/cell block and cryobiopsy. Only cryobiopsy detected granuloma in the patient with TB (tuberculosis), and in the patient with silicosis, TBNC provided a better overall histological evaluation, leading to a definitive diagnosis. No complications were observed. This case series supports the potential diagnostic value of combining EBUS-TBNA and EBUS-TBNC, particularly in benign mediastinal lesions (granulomatous diseases), and in cases requiring additional molecular tests in cancer diagnosis.

Exploring a new lymph node biopsy technique: case series from Sabah, MalaysiaWe explored a new technique for lung diagnosis called EBUS-guided transbronchial nodal cryobiopsy (EBUS-TBNC). This method helps get larger and well-preserved tissue samples from the chest area. In our study, we used this technique on four patients alongside the established method called EBUS-guided transbronchial needle aspiration (EBUS-TBNA). All procedures were done with the patient under general anesthesia using a specific type of scope. Two patients were found to have cancer, and two had non-cancerous conditions (silicosis and tuberculosis). In the cancer cases, both methods provided a diagnosis, but the cryobiopsy gave more material for additional tests in one patient. However, in non-cancer cases, there were differences between the two methods. Only the cryobiopsy detected granulomas in the tuberculosis patient, and in the silicosis patient, cryobiopsy gave a better overall tissue evaluation, leading to a clear diagnosis. No complications were seen in any of the cases. This study suggests that combining EBUS-TBNA and EBUS-TBNC can be valuable, especially for non-cancerous chest lesions (like granulomatous diseases) and when extra tests are needed for cancer diagnosis.

Determinants of Willingness to Undergo Lung Cancer Screening among High-Risk Current and Ex-smokers in Sabah, Malaysia: A Cross-Sectional Pilot Study.

BACKGROUND: Attitudes towards smoking, lung cancer screening, and perceived risk of lung cancer have not been widely studied in Malaysia. The primary objective of this study was to describe the factors affecting the willingness of high-risk current smokers and ex-smokers to undergo low-dose computed tomography (LDCT) screening for lung cancer. METHODS: A prospective, cross-sectional questionnaire study was conducted in current smokers or ex-smokers aged between 55 and 80 years at three hospitals in Kota Kinabalu, Sabah, Malaysia. The questionnaire recorded the following parameters: perceived lung cancer risk; Prostate Lung Colon Ovarian Cancer 2012 risk prediction model excluding race and ethnicity predictor (PLCOm2012norace); demographic characteristics; psychosocial characteristics; and attitudes towards lung cancer and lung cancer screening. RESULTS: A vast majority of the 95 respondents (94.7%) indicated their willingness to undergo screening. Stigma of lung cancer, low levels of knowledge about lung cancer symptoms, concerns about financial constraints, and a preference for traditional medication were still prevalent among the respondents, and they may represent potential barriers to lung cancer screening uptake. A desire to have an early diagnosis (odds ratio [OR], 11.33; 95% confidence interval [CI], 1.53 to 84.05; p=0.02), perceived time constraints (OR, 3.94; 95% CI, 1.32 to 11.73; p=0.01), and proximity of LDCT screening facilities (OR, 14.33; 95% CI, 1.84 to 111.4; p=0.01) had significantly higher odds of willingness to undergo screening. CONCLUSION: Although high-risk current smokers and ex-smokers are likely to undergo screening for lung cancer, several psychosocial barriers persist. The results of this study may guide the policymakers and clinicians regarding the need to improve lung cancer awareness in our population.

Pleural fluid milkshakes: three cases with different aetiologies.

In clinical practice, chylothorax is usually suspected in any patient with milky pleural fluid. However, contrary to popular belief, milky appearance of pleural fluid is seen in less than half of patients with chylothorax. A high index of suspicion for chylothorax is therefore needed in any turbid, bloody, or serosanguinous effusions of unclear aetiology. In this case series, we present three patients with biochemically proven chylothorax: each with a different presentation, pleural fluid appearance, underlying cause, management strategy and clinical outcome. The first patient developed 'milky' chylothorax secondary to lymphoma while the second patient's 'yellow' chylothorax is related to pleural tuberculosis. The final patient suffered from 'pink' chylothorax in the setting of systemic amyloidosis. In each of the cases, prompt diagnosis of chylothorax followed by efforts to elucidate the underlying cause are crucial steps to guide subsequent management with the main aim to ensure a better clinical outcome.

Pneumothorax with Ortner syndrome: an unusual presentation of aortic dissection.

Ortner syndrome or cardiovocal syndrome is hoarseness of voice due to left recurrent laryngeal nerve palsy as a result of cardiovascular abnormality. It is not known that pneumothorax has any association with Ortner syndrome. A 56-year-old gentleman, with previous history of 20 pack-year smoking and 1-year history of hypertension, presented to us with cough for two weeks with intermittent haemoptysis, as well as hoarseness of voice for the past one year. Direct laryngoscopy confirmed that he had left vocal cord palsy. Clinical and radiological investigations suggested that he had left pneumothorax. Left chest tube thoracostomy was performed and computed tomography of chest revealed aortic isthmus aneurysm with dissection extending to distal left common iliac artery and residual left hydropneumothorax. The patient was then referred to the vascular team and cardiothoracic team for further management.

Diagnostic flex-rigid pleuroscopic biopsy of parietal pleura for exudative pleural effusions in suspected malignant and tuberculosis cases: a retrospective study of 219 cases.

OBJECTIVES: This study was carried out to ascertain the aetiology of exudative pleural effusions when other diagnostic investigations such as pleural fluid and sputum examination for cytology and acid fast bacilli fail to yield a definitive diagnosis and to differentiate between tuberculosis and malignancy in cases suspicious of malignancy. METHODS: Pleuroscopic biopsies were obtained in 219 cases by Chest Physicians in the endoscopy suite using flexi-rigid fiber-optic pleuroscopes. Histological sections were stained with H&E and microscopic examination performed. Ziehl-Nielsen stain for acid fast bacilli was performed in all suspected tuberculosis cases and immunohistochemistry for Thyroid transcription factor 1 and other markers were carried out for all cases suspicious of malignancy. RESULTS: Adequate biopsy material for interpretation was obtained in 210 (95.9%) of 219 cases. Histopathology revealed 79 (37.6%) cases were tuberculosis, 64 (30.5%) were malignant (primary from lung and other sites), 62 (29.5%) were non-specific inflammation and 5 (2.4%) were empyema. A definitive diagnosis of tuberculosis, malignancy and empyema was obtained in 70.5% of cases. Tuberculosis was encountered in a younger age-group than malignancy. Mean age for tuberculosis patient was 49 years while for malignant patients was 63 years. The majority (79.6%) of malignances encountered were metastatic lung adenocarcinoma.

Endobronchial glomus tumor.

We report a case of a 52-year-old patient who had undergone a bladder resection and an ileal conduit for a transitional cell carcinoma. He then presented with a short history of hemoptysis 3 months later. Rigid bronchoscopy was performed revealing an endobronchial lesion, which was removed via laser and debulking method without complications. Histopathologic examination confirmed it to be a benign endobronchial glomus tumor. On the basis of our literature search, this is the 34th reported case of glomus tumor arising from the respiratory tract, seventh reported case of an endobronchial glomus tumor treated bronchoscopically, and the first possibly coincidental finding in relation to a patient with primary transitional bladder cell carcinoma.

Pleuroscopy: early experience in an East malaysian state with high tuberculosis prevalence.

INTRODUCTION: Pleuroscopy using a flexi-rigid tube was introduced in Malaysia in late 2004 as part of the investigation for unexplained pleural effusion. Sabah, an East Malaysian state situated in Borneo, has the highest prevalence of tuberculosis (TB) in Malaysia. Therefore, exudative pleural effusion in Sabah was presumed to be predominantly because of TB. OBJECTIVE: To look at the diagnostic yield and safety of pleuroscopy in a TB endemic state in Malaysia. METHODS: A prospective study was conducted covering the period from September 2006 to May 2007. Consecutive patients with unexplained pleural effusion underwent pleuroscopy. Biopsy was performed if nodules, nodules with adhesions, or adhesions were visualized in the pleural space. Data were analyzed using the χ test and multivariate analysis. A P value of less than 0.05 was taken as statistically significant. RESULTS: Sixty-two patients underwent pleuroscopy. Biopsy specimens were obtained in 55 of 57 patients (96.4%). The diagnostic yield of nodules, nodules with adhesions, and adhesions was 92.0%, 66.7%, and 60.0%, respectively. TB and neoplasm were diagnosed in 22 (52.4%) and 20 (47.6%) patients, respectively. Neoplasm was more common in female patients and TB was more common in male patients (P=0.048). Neither neoplasm nor TB was significantly associated with ethnic groups (P=0.156). Sensitivity of the initial impression for TB and neoplasm was 59.1% and 90.0%, respectively. One patient experienced desaturation during pleuroscopy. CONCLUSIONS: Pleuroscopy is a safe diagnostic procedure and especially useful in sampling nodules indicating that the sample size obtained during pleuroscopy is satisfactory. Empirical TB treatment should be discouraged even in a state with high TB prevalence as certain neoplasms can present as pleural effusion. Pleuroscopy should be performed early in unexplained pleural effusion.