In the era of ultrasound technology, could conventional trans-bronchial needle aspiration still play a role in lung cancer mediastinal staging?

BACKGROUND: To evaluate the feasibility of a combined strategy including conventional-trans-bronchial needle aspiration biopsy (C-TBNA) and endobronchial ultrasounds transbronchial needle aspiration (EBUS-TBNA) for sampling mediastinal adenopathies in patients with lung cancer in order to determinate whether in the era of ultrasound technology C-TBNA could still play a role in mediastinal staging. METHODS: It was a retrospective multicenter study including all consecutive patients with lung cancer and radiological mediastinal adenopathies undergoing TBNA for mediastinal staging (January 2014 - July 2016). C-TBNA was performed as first diagnostic procedure. All negative C-TBNA results were corroborated by EBUS-TBNA, and, if EBUS-TBNA was negative, by mediastinoscopy or surgery. The diagnostic yield of C-TBNA were then calculated. RESULTS: A total of 175 patients were included in the study for a total of 197 mediastinal adenopathies sampled. C-TBNA was positive in 125 cases and negative in 72 cases who underwent EBUS-TBNA. It was positive in 58 cases and negative in 14 patients. After surgical exploration (n=12) and mediastinoscopy (n=2), 11 patients did not present metastases (true negative) while 3 presented mediastinal involvement (false negative). Thus, C-TBNA had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of 67.2%, 100%, 100%, 15.3% and 69.0%, respectively. The sensitivity increased for sampling paratracheal versus subcarinal stations (80% versus 49%; P<0.001); and large adenopathies (≥15 mm) versus small adenopathies (<15 mm) (83% versus 43%; P<0.001). In all re-staging patients (n=4), Conventional-TBNA results were false negative. CONCLUSIONS: The combined use of C-TBNA and EBUS-TBNA as the most cost-effective strategy in the setting of mediastinal staging. C-TBNA performed before EBUS-TBNA is indicated for sampling large mediastinal adenopathies near to carina while EBUS-TBNA remains the first choice for puncturing small adenopathies far from carina and for re-staging after induction therapy.

Bronchoscopic lung volume reduction with endobronchial valves for heterogeneous emphysema: long-term results.

BACKGROUND: Bronchoscopic lung volume reduction (BLVR) with implant of one-way endobronchial valves (EBV) is a feasible treatment for management of heterogeneous emphysema (HE) with clinical benefits in the early follow-up. We aimed to evaluate the long-terms results and safety of this procedure in a consecutive series of patients with HE. METHODS: It was a retrospective single center study including all consecutive patients with HE undergoing EBV treatment and completing at least 5 years of long-term follow-up. Patients were splitted into Collapse and No-Collapse Group if a lobar collapse or not were obtained after valves implant. The difference of functional data and quality of life (QoL) before and after the procedure (measured at 3, 6, 9, 12 months from the valve implantation, and then annually up to a maximum of 5 years) were statistically evaluated to show the long-term benefits of the procedure (primary endpoint). Yet, morbidity, mortality and survival rates were also recorded to show the safe of the treatment (secondary endpoint). RESULTS: Thirty-three patients were included in the study. Of these, three patients underwent a bilateral treatment. Collapse Group patients (n=27) presented a significant improvement in FEV1% (+17%; P=0.001); in FVC% (+18%; P=0.002); in RV% (-39%; P=0.003); in 6MWT (P=0.001) and in SGRQ (P=0.001) in the early 12 months of follow-up and no significant decline was seen later. Conversely, No-Collapse Group (n=9) did not have significant benefits. No major complications and death related to the procedure were observed. The 1-,2-,3-,4- and 5-year survival rates were 100%, 90%, 78%, 71% and 71%, respectively. Collapse Group had a better survival than No-Collapse Group (45 vs. 24 months; P=0.001). CONCLUSIONS: Our study confirmed that the lobar collapse is the key success of EBV treatment and the early improvements of respiratory function could be maintained up to five years from the valves implant.

Endoscopic treatment with fibrin glue of post-intubation tracheal laceration.

Post-intubation tracheal laceration (PITL) is a rare and potential life-threatening condition requiring prompt diagnosis and treatment. A conservative treatment is indicated in patients with laceration <2 cm in length while surgery is the treatment of choice for laceration >4 cm. For laceration between 2-4 cm, the best treatment is debate; some authors recommend surgery while others do not definitely exclude endoscopic treatment. Herein, we reported the endoscopic treatment with fibrin glue of PITL. The procedure is performed using a standard video-bronchoscopy in operating room; the patient is in spontaneous breathing and deep sedation. After identification of tracheal laceration, the fibrin glue is injected through a dedicated double lumen catheter into the lesion. After mixing both components of fibrin glue, polymerization of fibrin occurs resulting in an elastic and opaque clot that closes the lesion. The key success of the procedure is based on accurate patient selection. Patients are eligible if (I) they are clinically stable and in spontaneous respiration; (II) with a small and superficial tracheal laceration (≤4 cm in length and without oesophageal injury); (III) localized at level of the upper or middle trachea; and (IV) without clinical and/or radiological signs of mediastinal collection, of emphysema or pneumomediastinum progression, and of infection.

Rare multiple primary malignancies among surgical patients-a single surgical unit experience.

BACKGROUND: A remarkable number of patients presents with multiple primary malignancies (MPM) over their lifetimes. In most cases inherited syndromes, iatrogenic, or viral factors are implicated, while in some cases it is not possible to ascertain a clear aetiopathogenesis. METHODS: Starting from a series of 315 patients with MPM, we focused our attention on those with extremely infrequent combinations of tumours. We retrospectively analysed patients' characteristics, type of first and second tumour and the interval between the two tumours. We made a comparison between our own data and data from surveillance, epidemiology, and end results cancer registries, the largest global series on this topic. RESULTS: Six patients presented with unusual associations, namely, central nervous system (CNS)/colon, testis/stomach, colon/CNS, CNS/kidney, uterus/soft tissue, and bone/breast. The median age was 50.5 years at the diagnosis of second neoplasm and the male:female ratio was 1:1. All six patients underwent surgery for both tumours. The median interval between the first and the second tumour was 11.3 years (range 1-36 years). Five patients were given chemotherapy as adjuvant systemic treatment, and two of them with CNS tumours also received radiotherapy. DISCUSSION: We analysed the behaviour of these rare tumours as first and second neoplasms. More frequent combinations and possible aetiological factors were evaluated. CONCLUSIONS: Follow-up for patients recovering from a first tumour must be strict, as there is the risk of developing MPM, even after a long time period. Advancement in biomolecular knowledge and cooperation among different specialists are strongly needed to reduce mortality related to MPM and to foresee their occurrence.