Endobronchial ultrasound for detecting central pulmonary emboli: a pilot study.

BACKGROUND: Contrast-enhanced, computed tomography of the chest (angio-CT) is the preferred modality for evaluating central pulmonary embolism (PE). However, acute PE must be diagnosed quickly, and contraindications to contrast agents, hemodynamic instability preventing transport and radiation exposure may limit its use. Because the mediastinal vessels lie within 5 mm of the trachea and central airways, endobronchial ultrasound (EBUS) imaging may be a feasible alternative to detecting PE. OBJECTIVES: To demonstrate the feasibility of detecting PE in the central airways by EBUS. METHODS: In a prospective, multicenter pilot study, consecutive patients underwent flexible bronchoscopy with a convex EBUS probe under local anesthesia and moderate sedation within 24 h after angio-CT had documented a central PE. The EBUS images were compared to the CT findings. RESULTS: Among 32 patients (mean age 69 years, 20 men), angio-CT documented 101 PE, of which 97 (96%) were also detected with EBUS. The 4 emboli not detected consisted of 1 in a middle lobe and 3 in a left upper lobe artery. At least 1 embolus was detected with EBUS in every patient, which is sufficient to confirm a diagnosis of central PE. No bronchoscopic complications were observed. Mean procedure time was reduced from 5 min in the first 16 patients to 3 min in the last 16. CONCLUSIONS: In this pilot study, EBUS was a feasible and safe approach to detecting central pulmonary emboli. Blinded, comparative trials will be necessary to evaluate its use as a primary tool for diagnosing these emboli.

Real-time endobronchial ultrasound guided transbronchial needle aspiration for sampling mediastinal lymph nodes.

BACKGROUND: Transbronchial needle aspiration (TBNA) is an established method for sampling mediastinal lymph nodes to aid in diagnosing lymphadenopathy and in staging lung cancers. Real-time endobronchial ultrasound (EBUS) guidance is a new method of TBNA that may increase the ability to sample these nodes and hence to determine a diagnosis. A descriptive study was conducted to test this new method. METHODS: Consecutive patients referred for TBNA of mediastinal lymph nodes were included in the trial. When a node was detected, a puncture was performed under real-time ultrasound control. The primary end point was the number of successful biopsy specimens. Diagnostic results from the biopsies were compared with operative findings. Lymph node stations were classified according to the recently adopted American Thoracic Society scheme. RESULTS: From 502 patients (316 men) of mean age 59 years (range 24-82), 572 lymph nodes were punctured and 535 (94%) resulted in a diagnosis. Biopsy specimens were taken from lymph nodes in region 2L (40 nodes), 2R (53 nodes), 3 (35 nodes), 4R (86 nodes), 4L (77 nodes), 7 (127 nodes), 10R (38 nodes), 10L (43 nodes), 11R (40 nodes) and 11L (33 nodes). The mean (SD) diameter of the nodes was 1.6 (0.36) cm and the range was 0.8-3.2 cm (SD range 0.8-4.3). Sensitivity was 94%, specificity 100%, and the positive predictive value was 100% calculated per patient. No complications occurred. CONCLUSION: EBUS-TBNA is a promising new method for sampling mediastinal lymph nodes. It appears to permit more and smaller nodes to be sampled than conventional TBNA, and it is safe.

Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically normal mediastinum.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can sample enlarged mediastinal lymph nodes in patients with nonsmall cell lung cancer (NSCLC). To date, EBUS-TBNA has only been used to sample nodes visible on computed tomography (CT). The aim of the present study was to determine the accuracy of EBUS-TBNA in sampling nodes 1 cm) in the mediastinum underwent EBUS-TBNA. Identifiable lymph nodes at locations 2r, 2l, 4r, 4l, 7, 10r, 10l, 11r and 11l were aspirated. All patients underwent subsequent surgical staging. Diagnoses based on aspiration results were compared with those based on surgical results. In 100 patients (mean age 58.9 yrs; 68 males), 119 lymph nodes ranging 5-10 mm in size were detected and sampled. Malignancy was detected in 19 patients but missed in two; all diagnoses were confirmed by surgical findings. The mean diameter of the punctured lymph nodes was 8.1 mm. The sensitivity of EBUS-TBNA for detecting malignancy was 92.3%, specificity was 100%, and the negative predictive value was 96.3%. No complications occurred. In conclusion, endobronchial ultrasound-guided transbronchial needle aspiration can accurately sample even small mediastinal nodes, therefore avoiding unnecessary surgical exploration in one out of six patients who have no computed tomography evidence of mediastinal disease. Potentially operable patients with no signs of mediastinal involvement on computed tomography may benefit from pre-surgical endobronchial ultrasound-guided transbronchial needle aspiration and staging.

Transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy: a combined approach in the evaluation of mediastinal lesions.

BACKGROUND AND STUDY AIMS: It would be desirable to develop minimally invasive methods of tissue diagnosis from lymph nodes as well as solid lesions in the mediastinum. The aim of the present study was to test the combined method of transesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the evaluation of mediastinal lesions. PATIENTS AND METHODS: EUS-FNA and EBUS-TBNA were compared in 33 patients, for the staging of lung cancer in patients with an established diagnosis of non-small-cell lung cancer (n = 20) or for diagnosis of a suspicious mediastinal lesion in patients with suspected lung cancer (n = 13). EBUS-TBNA and EUS-FNA were unsuccessful in one patient each. The diagnoses were verified in 28 of the remaining 31 patients either at thoracotomy (n = 9) or during the clinical follow-up (n = 19). RESULTS: A total of 119 lesions were sampled by EUS-FNA (n = 59) and EBUS-TBNA (n = 60). EUS-FNA and EBUS-TBNA demonstrated cancer in 26 and 28 lesions, respectively, and benign cytology in 30 and 28 lesions, respectively. Suspicious cells were found in three and four lesions by EUS-FNA and EBUS-TBNA, respectively. When the 60 EBUS-TBNA samples were compared with the 59 EUS-FNA samples, 11 additional cancer diagnoses and three samples with suspicious cells were obtained by EBUS-TBNA that had not been obtained by EUS-FNA. Conversely, EUS-FNA diagnosed 12 additional cancer diagnoses, one suspicious and one specific benign diagnosis (sarcoidosis) in addition to EBUS-TBNA. With a combined approach (EUS-FNA + EBUS-TBNA) in 28 of the 31 patients in whom a final diagnosis was obtained in the evaluation of mediastinal cancer, 20 patients were found to have mediastinal involvement, whereas no mediastinal metastases were found in eight patients. The accuracy of EUS-FNA and EBUS-TBNA, in combination, for the diagnosis of mediastinal cancer was 100 % (95 % CI, 83 - 100 %). CONCLUSIONS: EUS-FNA and EBUS-TBNA appear to be complementary methods. A combined approach with both EUS-FNA and EBUS-TBNA may be able to replace more invasive methods for evaluating lung cancer patients with suspected hilar or mediastinal metastases, as well as for evaluating unclear mediastinal or hilar lesions.

Transesophageal endoscopic ultrasound/fine-needle aspiration diagnosis of a malignant adrenal gland in a patient with non-small cell lung cancer and a negative CT scan.

Adrenal metastasis is only seen on CT scan is less than 5% of patients with otherwise resectable NSCLS, but this diagnosis has a major impact on treatment and prognosis. We present a case of a patient with NSCLC and an adrenal metastasis, which was diagnosed by EUS/FNA of an enlarged adrenal gland, who had false-negative CT scan for adrenal metastasis. PET was not performed. Prospective studies are needed to assess the incremental yield of EUS/FNA over upper abdominal CT scan and PET for detecting left adrenal metastasis in patients with suspected or proven otherwise respectable NSCLC.

Preliminary experience with a new method of endoscopic transbronchial real time ultrasound guided biopsy for diagnosis of mediastinal and hilar lesions.

BACKGROUND: The aim of the present study was to gain experience with a new method of endoscopic transbronchial ultrasonography with direct, real time guided fine needle aspiration biopsy (EBUS-FNA). METHODS: EBUS-FNA was performed in 11 patients. Selection of the patients for EBUS-FNA was based on computed tomographic (CT) scanning in 10 patients and on positron emission tomography in one. The ultrasonic bronchoscope used was a prototype with an outer diameter of 6.9 mm. The instrument has a small curved array transducer located in front of a 30 degrees oblique forward viewing optic lens and a biopsy channel of 2 mm. The procedures were performed under general anaesthesia. EBUS-FNA was performed by direct transducer contact with the trachea or main bronchi with a prototype 22 gauge needle. RESULTS: A total of 15 lesions were punctured. No complications were experienced. Four lesions were targeted in region 10L, four in region 10R, one in region 4L, three in region 4R, one in region 1, one in region 7, and one in region 2R. The size of the lesions ranged from 7 mm to 80 mm. EBUS-FNA identified malignant cells in 13 lesions and benign cells in two. CONCLUSIONS: EBUS-FNA is a promising technique for lymph node staging of lung cancer as well as for the primary diagnosis of solid lesions located adjacent to the trachea and main bronchi and not accessible by other methods apart from surgical intervention.

Impaired postoperative outcome in chronic alcohol abusers after curative resection for lung cancer.

OBJECTIVE: It has been demonstrated that chronic alcohol misusers, who drink at least 60 g of ethanol per day, are suffering increased postoperative morbidity after various non-pulmonary surgical procedures. The aim of this study was to evaluate the association between alcohol consumption and postoperative morbidity and mortality after potential curative resection for lung cancer. METHODS: The records of all patients who underwent curative resection for lung cancer in a single University Centre in Cardiothoracic surgery during 1997 and 1998 were retrospectively reviewed. One hundred and seven patients, 42 women and 65 men, median age of 64 (33-79) years, were included and subdivided with regard to alcohol consumption. There were 26 pneumonectomies, 68 lobectomies and 13 lesser resections. Clinical complications occurring within 30 days after surgery and requiring therapy, were registered and subdivided into major, potentially lethal complications, and minor complications. Mortality within 30 days after surgery was also registered. RESULTS: Patients drinking at least 5 drinks per day had increased postoperative mortality, 3/13 versus 2/94 (odds ratio (95% confidence limits): 13.80 (2.06-92.68); P=0.007). The rate of major, live threatening complications including septicaemia and cardiopulmonary insufficiency was significantly increased among patients drinking at least 5 drinks per day 6/13 versus 19/94 (odds ratio (95% confidence limits): 3.38 (1.02-11.25); P=0.047) in univariate analysis. However, in multivariate analysis this association was not significant. CONCLUSION: Postoperative mortality after curative resection for lung cancer was significantly increased among patients drinking at least 5 drinks of alcohol per day.

Endoscopic ultrasound guided biopsy of mediastinal lesions has a major impact on patient management.

BACKGROUND: A study was undertaken to evaluate the clinical impact of endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNA) in patients with mediastinal masses suspected of malignancy. METHODS: From April 1993 to December 1999, 84 patients were referred for EUS-FNA. In all patients CT scanning had shown a lesion of the mediastinum suspected of malignancy located adjacent to the oesophagus. In order to evaluate the clinical impact of EUS-FNA, the history of each patient up to referral for EUS-FNA was reviewed. A board of thoracic specialists was asked to decide the further course of the patient if EUS-FNA had not been available, and this diagnostic strategy was compared with the actual clinical course after EUS-FNA. RESULTS: For the 79 patients in whom sufficient verification was obtained, EUS-FNA had a sensitivity of 92%, specificity of 100%, PPV of 100%, NPV of 80%, and an accuracy of 94% for cancer of the mediastinum. In 18 of 37 patients (49%) a thoracotomy/thoracoscopy was avoided as a result of EUS-FNA, and in 28 of 41 patients (68%) a mediastinoscopy was avoided. The direct result of the cytological diagnosis obtained by EUS-FNA was that a final diagnosis of small cell lung cancer was made in eight patients resulting in referral for chemotherapy, and in another three patients with benign disease specific treatment could be initiated (sarcoidosis, mediastinal abscess, and leiomyoma of the oesophagus). CONCLUSIONS: EUS-FNA is a safe and sensitive minimally invasive method for evaluating patients with a solid lesion of the mediastinum suspected by CT scanning. EUS-FNA has a significant impact on patient management and should be considered for diagnosing the spread of cancer to the mediastinum in patients with lung cancer considered for surgery, as well as for the primary diagnosis of solid lesions located in the mediastinum adjacent to the oesophagus.

Prevention of air leakage by spraying vivostat fibrin sealant after lung resection in pigs.

STUDY OBJECTIVES: To evaluate Vivostat fibrin sealant in the prevention of air leakage after experimental lung resection in pigs. DESIGN: Randomized study. SETTING: University laboratory. METHODS: Six Landrace pigs were operated on in both lungs through a median sternotomy. Five different resection sites were created in each lung. INTERVENTION: Randomization was performed to either application of Vivostat fibrin sealant (ConvaTec; Skillman NJ) or human albumin 20% (control) at the resection sites. The lung parenchyma was occluded with a soft clamp for either 1, 2, 5, or 10 min in the treatment group and 10 min in the control group. After removal of the clamp, the lung was ventilated with an increasing intrabronchial pressure of 20, 30, and 45 cm H(2)O for 2 min at each step. RESULTS: At inspiratory pressures of 20 and 30 cm H(2)O air leaks were found in the control group but not in the Vivostat group (p < 0.001). At an inspiratory pressure of 45 cm H(2)O, there were two small air leaks in the Vivostat group at each clamping time (four at 5 min), compared with five small and seven large leaks in the control group. Analysis of the data after 10 min of clamping showed that the Vivostat group was superior to the human albumin group (p = 0.002). CONCLUSIONS: This randomized study shows that Vivostat fibrin sealant is effective in preventing air leakage after small lung resections in pigs, even at high inspiratory pressures.

[Autofluorescence bronchoscopy: Laser imaging fluorescence endoscope]. / Autofluorescensbronkoskopi: "Laser imaging fluorescense endoscope".

The LIFE (laser imaging fluorescence endoscope) system has been shown to increase the diagnosis of dysplasia and carcinoma in situ when used in combination with conventional bronchoscopy. A doubling to tripling of the rate of early centrally located lung cancer diagnosis is a step forward in the detection of early lung cancer. A wide spectrum of interventional procedures for endoluminal treatment of lung cancer in functionally inoperable patients makes it possible to treat this group of patients. The LIFE system works without exogenous sensitisers, with no increase in complications as compared to conventional bronchoscopy, and takes only a little longer in examination time.

[Neoadjuvant chemotherapy in non-small-cell lung cancer]. / Neoadjuverende kemoterapi ved ikke-småcellet lungekraeft.

Over the past 10 years, several studies of neoadjuvant chemotherapy for stage III Non Small Cell Lung Cancer (NSCLC) have been conducted. In eight Phase II studies, response rates of approximately 65% and resectability rates of approximately 50% have been achieved, with acceptable side effects. Two randomized trials with a total of 120 patients with stage IIIA cancer have been carried out to compare the effect of neoadjuvant chemotherapy plus surgery versus surgery alone. The trials were terminated early when interim analysis showed significantly increased survival in groups that received neoadjuvant chemotherapy. The incidences of treatment-related death did not differ significantly between the groups. Neoadjuvant chemotherapy for patients in stage III NSCLC is feasible and might prolong survival. However, the results of larger randomized trials must be awaited before firm general recommendations can be made.

Endoscopic ultrasonography and real-time guided fine-needle aspiration biopsy of solid lesions of the mediastinum suspected of malignancy.

STUDY OBJECTIVE: The study details our preliminary experience with endoscopic ultrasonography (EUS) guided fine-needle aspiration biopsy (FNAB) of mediastinal masses suspected of malignancy. DESIGN: Prospective uncontrolled study. PATIENTS: Nine patients had lesions suspected of malignancy ranging from 1 to 9 cm in diameter in various locations of the mediastinum. INTERVENTIONS: The EUS examination was performed with a gastroscope (Hitachi/Pentax FG-32 UA) equipped with an adjustable 5- or 7.5-MHz curved array ultrasonic transducer. The scanning plane is in the long axis of the endoscope allowing endosonographically guided biopsy to be performed. A 21-gauge (0.8 mm), full-length steel needle housed in a biopsy handle (type: Hancke/Vilmann; GIP-Medizin Technik; Grassau, Germany) was used for the biopsies. RESULTS: Nine patients had biopsy specimens taken from 13 lesions. The total number of needle passes was 18 (range, 1 to 3; median, 1.4). The cytologic diagnosis was conclusive for cancer in ten lesions and consistent with a benign lesion in three lesions. All ten malignant diagnoses and two benign diagnoses were confirmed either by operation or follow-up. In the last patient with lung cancer, a final diagnosis of the EUS-guided biopsy of an enlarged lymph node could not be obtained. No false-positive or negative biopsy diagnoses were recorded. The biopsy procedure was well tolerated by all patients, and there were no complications. CONCLUSIONS: EUS-guided aspiration biopsy is a significant advance in the differentiation between malignant and benign lesions of the mediastinum carrying a high diagnostic potential.

[Treatment of non-small-cell lung cancer and solitary adrenal gland metastasis]. / Behandling af ikkesmåcellet lungecancer og solitaer binyremetastase.

A patient with non-small-cell lung cancer and a solitary adrenal metastasis was treated with right subsegmental pulmonary resection and right adrenalectomy. Four months later an upper right lobectomy was performed because of local recurrence. Forty-one months following the initial operation the patient is doing fine without signs or symptoms of recurrence. Adrenalectomy because of a solitary adrenal metastasis in patients with non-small-cell lung cancer may offer the opportunity of prolonged survival, when a radical thoracotomy can be performed.

[Pleural empyema]. / Pleuraempyem.

Despite of extensive use of antibiotics for respiratory tract infections pleural empyema is still seen as a complication to pneumonia (7-10 cases/100.000 inhabitants pr. year). Pleural empyema as a complication to pulmonary surgery is reported in 2-3% of the patients even with use of antibiotic prophylaxis. Pleural empyema is most often a serious disease of long duration. The diagnosis is obtained with microbiological and histological examination of the pleural fluid. Mixed infection occurs in over half of the cases, most often including anaerobic bacteria, but most human pathogens have been reported as etiological agents. Treatment includes drainage of pus and administration of relevant antibiotics, systemically and pleurally. Drainage can be performed via thoracocentesis, by tubes, or by resection of a part of the rib. The optimal treatment strategy is so far unknown, since good prospective comparative clinical studies are lacking.

[Male breast cancer. A review]. / Mandlig brystkraeft. En oversigt.

Male breast cancer is a rare disease, making up less than 1% of all breast cancers. A review of the literature does not disclose major differences between male and female breast cancer regarding etiological, prognostic or diagnostic features. In male breast cancer endocrine therapy is more widely used, but there are otherwise no differences in the therapeutic strategies used.

[10-year survival after lung resection for lung cancer]. / Tiårsoverlevelse efter lungeresektion ved lungecancer.

The purpose of the study was to investigate the prognosis for patients treated for lung cancer by operative resection in the Copenhagen area. Ninety-four consecutively operated patients were followed prospectively for ten years. Seventy-one percent of the patients had been operated radically. The five- and ten-year survival for this group was respectively 46 and 27%. All non-radically operated patients were dead after four years. The postoperative mortality and long-term survival correspond to international results. Type of cancer and mode of operation did not affect survival in the radically operated patients.

[Occurrence of lung cancer in Denmark 1943-1986. Reliability of the cancer registry]. / Forekomsten af lungekraeft i Danmark 1943-1986. Cancerregisterets pålidelighed.

A rise in the number of adenocarcinomas of the lung and a fall in squamous cell carcinomas are seen in Denmark since 1978; a change based on a growing number of lung cancers among women with an excess of adenocarcinomas. A fall in the frequency of autopsies in Denmark will entail the loss of an essential control of the quality of diagnosis of lung cancer, primary or secondary, and make future descriptive studies difficult to interpret. The validity of morphologic diagnosis of lung cancer as recorded by the Danish Cancer Registry during 1943-1986 was assessed. We extracted a stratified random sample of 5% of all recorded cases prior to 1978, these were then recorded according to the ICD-O classification. Cases after 1978 were originally coded in the Registry according to ICD-O, here we checked the coding against the original reports. The information on morphology prior to 1978 was too inprecise to merit evaluation of trends and proportionate distributions by morphology. After 1978 data was adequate, and after 1983 very precise.