Major Complications Associated with Conventional Transbronchial Needle Aspiration.

OBJECTIVES: Transbronchial needle aspiration (TBNA) is a widely used sampling technique for diagnosis and staging of lesions centered around bronchoscopically accessible airways. We report our single-institution experience of complications associated with conventional TBNA (C-TBNA) performed in 606 consecutive cases. METHODS: Electronic medical records with bronchoscopy log data of C-TBNAs performed from January 2003 to December 2016 were assessed. All of the cases were included for a review of complications related to the performance of C-TBNA. C-TBNAs were performed in conjunction with other bronchoscopic sampling techniques such as brush, biopsy, and wash in most cases. Complications ascribed to C-TBNA only were included for this analysis and review. RESULTS: Infectious complications following the performance of TBNA are related to the inoculation of oropharyngeal bacteria from the airway lumen into the sterile mediastinal, pericardial, or pleural space. CONCLUSIONS: Complications related to TBNA are underappreciated mainly because of the lack of reporting and awareness. These findings should lead to heightened awareness and precaution in all patients undergoing TBNA, and extra vigilance and monitoring during and after the procedure in those receiving anticoagulant and antiplatelet therapies.

A 74-Year-Old Man Presenting With Cough, Malaise, and Mediastinal Lymphadenopathy.

CASE PRESENTATION: A 74-year-old white male farmer was admitted from his primary care physician's office after he presented with symptoms of cough productive of clear sputum, malaise, weakness, fatigue, and shortness of breath on exertion for 3 weeks. He was an ex-smoker with a history of hypertension, hyperlipidemia, and coronary artery bypass graft surgery. He did not report any chills, night sweats, or fevers during this presentation.

Dual time point positron emission tomography/computed tomography scan in evaluation of intrathoracic lesions in an area endemic for histoplasmosis and with high prevalence of sarcoidosis.

BACKGROUND: We explored the role of dual time point fluorodeoxyglucose positron emission tomography/computed tomography (DTP PET/CT) scan in the differentiation of benign and malignant lung and mediastinal lesions. METHODS: We studied a sample of 72 consecutive patients who underwent DTP PET/CT scan for intrathoracic lesions. Information on demographics, initial and delayed maximum standardized uptake values (SUVmax) of lesions and final diagnosis were collected. Clinical criteria to diagnose benign lesions were defined as stability or regression of the lesion on follow-up after 2 years of initial detection. Sensitivity, specificity, predictive values and likelihood ratio and retention index were calculated using standard methods. RESULTS: Sixty-three (87%) patients had increased SUVmax in delayed scan (1 hour after initial scan). Among the patients with increased delayed uptake, 51 (80%) had malignant lesion and 12 (20%) had nonmalignant lesions. All 9 patients whose SUVmax decreased on delayed scan had nonmalignant lesions. The increased SUV on delayed scan was 100% sensitive in diagnosis of cancer but was only 42% specific. The positive predictive value was 80%, whereas the negative predictive value was 100%. Likelihood ratio for positive test was 1.75. CONCLUSIONS: All the lesions with decreased SUVmax in delayed PET scan were nonmalignant. This was true for both lung and mediastinal lesions. This could be a very helpful diagnostic finding in areas with high prevalence of benign conditions such as histoplasmosis and sarcoidosis. Multiple invasive diagnostic modalities could be prevented in a significant percentage of patients, with attendant decrease in morbidity and health care costs.

Diagnosis of lung cancer: a bronchoscopist's perspective.

BACKGROUND: Guidelines recommend multiple types of cytologic and tissue samplings in the diagnosis of lung cancer by bronchoscopy, but differences of opinion exist as to the relative value of bronchial brushings and endobronchial or transbronchial biopsies. Our objective was to determine concordance of these procedures by a test of symmetry in a historical cohort referred to the pulmonary diagnostic laboratory. METHODS: From 1988 to 2001, patients with pathologic confirmation of primary lung cancer were examined by standard bronchoscopic techniques of that period. An electronic medical record system was used, with statistical analysis of symmetry between brushings and biopsies establishing the diagnosis. RESULTS: Of 968 patients, 98% had bronchoscopy for 624 central and 322 peripheral suspect lesions. Bronchial brushings from 915 patients confirmed pulmonary malignancy in 811 (89%) patients. Endobronchial or transbronchial biopsies from 739 patients showed lung cancer in 603 (82%) cases. Bronchial washings in 16 patients and transthoracic needle biopsies in 30 patients established diagnosis. Transbronchial needle aspiration of mediastinal nodes identified metastases in 94 patients. Only 14 patients required a surgical procedure for diagnosis, but 188 received surgical excision as primary treatment. Statistical evaluation used only patients with both bronchial brushings and endobronchial or transbronchial biopsies. Analysis by a test of symmetry showed a significant difference (P<0.0001). CONCLUSIONS: Positive, suspicious, and negative specimens were consistent, with bronchial brushings being more sensitive with a lower false-negative rate than endobronchial or transbronchial biopsies. Multiple techniques are recommended for bronchoscopic confirmation of lung cancer, but bronchial brushings should be collected initially, as technical or patient limitations might preclude diagnostic tissue biopsies.

Surgical biopsy prevented with PET/CT scan in a young female with intrathoracic lymphadenopathy.

Intrathoracic lymphadenopathy is a common clinical problem encountered in Histoplasma endemic zones. It is challenging for clinicians to distinguish the infectious lesions from the neoplastic ones. Bronchoscopy with or without lung sampling and transbronchial needle aspiration (TBNA) is commonly the first diagnostic procedure employed. If non-diagnostic, the next step is usually surgical biopsy. In our experience, a significant number of patients who go for surgical biopsy are diagnosed with histoplasmosis. A positron emission tomography (PET) scan with dual-time imaging may help us distinguish benign from malignant lesions, thus obviating the need for surgical sampling. We report a case of a young female who presented with progressively increasing intrathoracic lymphadenopathy and was treated successfully based on dual-time PET scan results, without proceeding to surgical lung biopsy.