Assessment of Tissue Adequacy by EBUS in Conjunction with PET Scan and Operator's Experience.

Mediastinal lymph node assessment is a crucial step in non-small cell lung cancer staging. Positron emission tomography (PET) has been the gold standard for the assessment of mediastinal lymphadenopathy, though it has limited specificity. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is quick, accurate, and a less invasive method for obtaining a diagnostic sample in contrast to mediastinoscopy. We performed a retrospective chart analysis of 171 patients to assess the adequacy of tissue obtained by EBUS for diagnosis and molecular profiling as well as the assessment of staging and lymph node (LN) stations diagnostic yield, in correlation to PET scan and the operator's level of experience. A significantly increased tissue adequacy was observed based on the operators' experience, with the highest adequacy noted in trained Interventional Pulmonologist (IP) (100%), followed by >5 years of experience (93.33%), and 88.89% adequacy with <5 years of experience (p = 0.0019). PET-CT scan 18F-fluorodeoxyglucose (FDG) uptake in levels 1, 2, and 3 LN had a tissue adequacy of 76.67%, 54.64%, and 35.56%, respectively (p = 0.0009). EBUS bronchoscopy method could be used to achieve an accurate diagnosis, with IP-trained operators yielding the best results. There is no correlation with PET scan positivity, indicating that both PET and EBUS are complementary methods needed for staging.

A Single US Center Experience of Transbronchial Lung Cryobiopsy for Diagnosing Interstitial Lung Disease With a 2-Scope Technique.

BACKGROUND: Transbronchial lung cryobiopsy (TBLC) has been used to establish the diagnosis of interstitial lung disease (ILD) in recent years. The technique and diagnostic yield vary among institutions. We report a new 2-scope technique and the results of TBLC in our institution. METHODS: This is a retrospective chart review of patients who underwent TBLC for evaluation of ILD. Bronchoscopy with TBLC was performed by a board-certified interventional pulmonologist with a 2-scope technique under general anesthesia. RESULTS: A total of 74 patients underwent TBLC with a 2-scope technique. Their mean age was 54±14 years. The mean tissue surface area was 63.54±6.76 mm. The average anesthesia time was 80.66 minutes. The diagnostic yield was 87.84%. The most common diagnosis was sarcoidosis pneumothorax, which occurred in 5 cases (7%). There was 1 case with bronchoscopic-related respiratory failure associated with significant bleeding. Death occurred in 3 cases (4%), which is comparable to recent mortality data for "elective" surgical lung biopsy for ILD (1.7% to 4.2%). CONCLUSION: TBLC with a 2-scope technique could be an alternative method for diagnosing various types of ILD in patients unfit for surgical lung biopsy. Further prospective studies should clarify its role in the diagnostic armamentarium for undiagnosed ILDs.

Methotrexate-induced pleuropericarditis and eosinophilic pleural effusion.

A 41-year-old man developed widespread skin rash involving his knees, elbows, and gluteal region. He received methotrexate for approximately 1 month and later developed dyspnea and a left-sided eosinophilic pleural effusion. He was transiently placed on oral steroids. Subsequent skin biopsy showed psoriatric arthritis. Methotrexate was restarted and 8 weeks into the treatment, he developed dyspnea, a hemorrhagic pericardial effusion, and a right-sided eosinophilic pleural effusion. Methotrexate was discontinued, but patient developed dyspnea with a recurrent right eosinophilic pleural effusion, 2 weeks later. Pleural biopsies were obtained through medical pleuroscopy that revealed mild chronic inflammation with prominent eosinophils and no evidence for malignancy. Oral steroids were restarted with significant improvement in his symptoms.

Occam's razor or Hickam's dictum?

Sarcoidosis is a multisystemic, inflammatory disorder characterized by non-necrotizing granulomas that can infiltrate almost any organ but involves the lungs most commonly. The exact pathogenesis of sarcoidosis remains unclear. Histoplasmosis is an infection caused by Histoplasma capsulatum that also predominantly affects the lungs and is characterized usually by necrotizing granulomas. The similar clinical features of sarcoidosis and histoplasmosis often make it difficult to distinguish these 2 processes. We report a young man who had histopathologic evidence of histoplasmosis and subsequently developed sarcoidosis. The similar clinical and radiographic manifestations of sarcoidosis and histoplasmosis and a possible role of histoplasmosis as an etiologic agent for sarcoidosis are discussed.