Performance of endobronchial ultrasound transbronchial needle aspiration as the first nodal staging procedure for the determination of programmed death ligand-1 expression in non-small cell lung cancer patients.

PURPOSE: The determination of the programmed death ligand-1 (PD-L1) expression is part of the diagnostic algorithm for advanced non-small cell lung cancer (NSCLC) patients. We aimed to analyze the diagnostic performance of EBUS-TBNA performed as first-choice nodal staging procedure for the determination of PD-L1 expression in NSCLC patients. METHODS: Longitudinal-prospective study including NSCLC patients diagnosed between January 2018 and October 2019, for whom a primary tumor biopsy sample and an EBUS-TBNA cytological malignant sample were available. Samples with fewer than 100 malignant cells were considered inadequate. PDL-1 IHC 22C3 pharmDx antibody was used. The percentage of tumor cells expressing PD-L1, setting 1% and 50% as cutoff points, was collected. The weighted kappa coefficient was used to assess the concordance of PD-L1 expression. The PD-L1 expression was compared in precision terms. RESULTS: From a total of 43 patients, 53 pairs of samples were obtained, of which 23 (43.4%) were adequate and included for analysis. The weighted kappa coefficient for PD-L1 expression was 0.41 (95% CI 0.15-0.68) and 0.56 (95% CI 0.23-0.9) for cutoff values ≥ 1% and ≥ 50%, respectively. In advanced stages, the weighted kappa coefficient was 0.6 (95% CI 0.3-0.9) and 1 (95% CI 1-1) for PD-L1 expression cutoff values ≥ 1% and ≥ 50%, respectively. EBUS-TBNA showed a sensitivity, specificity, positive predictive value, and negative predictive value of 1 to detect PDL-1 expression ≥ 50% in advanced stages. CONCLUSION: EBUS-TBNA performed as first nodal staging procedure in advanced NSCLC patients provides reliable specimens for the detection of PD-L1 expression ≥ 50% and could guide immunotherapy.

Prevalence, clinical characteristics, and outcome of pleural effusions in ovarian cancer.

OBJECTIVES: The prevalence, clinical characteristics and prognosis of pleural effusions (PEs) associated with ovarian cancer (OC) have seldom been addressed systematically, as in the current investigation. METHODS: All records of consecutive women with a newly diagnosed OC in our institution over a 13-year period were retrospectively reviewed. Features of PEs on CT scans, pleural fluid analyses, need for definitive therapy of PEs, and the influence of PEs on the overall survival (OS) and progression-free survival (PFS) were evaluated. RESULTS: PEs were observed in 81 (43%) of 189 women with OC, either at presentation of cancer (55 patients) or during the course of the disease (26 patients). The causes of PEs were malignancy (55.5%), unknown (37%), or surgery-related (7.4%). The sensitivity of the cytologic diagnosis of malignant PEs was 79.1%. Sixty percent of malignant PEs required pleurodesis or indwelling pleural catheters for symptomatic relief. The presence of ascites strongly predicted PE development (odds ratio 43.2). Women with PEs fared much worse compared with those without PEs, in terms of OS (26.7 vs. 90.4 months), PFS (9.8 vs. 55.3 months) and tumor recurrences (86.4 vs. 43%). In multivariate analyses, PE remained as a relevant independent variable associated with poor outcome (hazard ratio 9.73 for OS, and 3.87 for PFS). Notably, PEs small enough to preclude tapping, and thus of unknown origin, had a similar bad prognosis as malignant PEs. CONCLUSIONS: OC patients with PEs experience decreased survival, including those with trace effusions not amenable to tapping.

Two vs. three weeks of treatment with amoxicillin-clavulanate for stabilized community-acquired complicated parapneumonic effusions. A preliminary non-inferiority, double-blind, randomized, controlled trial.

BACKGROUND: The optimal duration of antibiotic treatment for complicated parapneumonic effusions (CPPEs) has not been properly defined. Our aim was to compare the efficacy of amoxicillin-clavulanate for 2 vs. 3 weeks in patients with CPPE (i.e. those which required chest tube drainage). METHODS: In this non-inferiority, randomized, double-blind, controlled trial, patients with community-acquired CPPE were recruited from two centers in Spain and, after having obtained clinical stability following 2 weeks of amoxicillin-clavulanate, they were randomly assigned to placebo or antibiotic for an additional week. The primary objective was clinical success, tested for a non-inferiority margin of<10%. Secondary outcomes were the proportion of residual pleural thickening of>10 mm at 3 months, and adverse events. The study was registered with EudraCT, number 2014-003137-25. We originally planned to randomly assign 284 patients. RESULTS: After recruiting 55 patients, the study was terminated early owing to slow enrolment. A total of 25 patients were assigned to 2 weeks and 30 patients to 3 weeks of amoxicillin-clavulanate. Clinical success occurred in the 25 (100%) patients treated for 2 weeks and 29 (97%) treated for 3 weeks (difference 3%, 95% CI -3 to 9.7%). Respective between-group differences in the rate of residual pleural thickening (-12%, 95%CI -39 to 14%) and adverse events (-7%, 95%CI -16 to 2%) did not reach statistical significance. CONCLUSIONS: In this small series of selected adult patients with community-acquired CPPE, amoxicillin-clavulanate treatment could be safely discontinued by day 14 if clinical stability was obtained.

Predictors of Indwelling Pleural Catheter Removal and Infection: A Single-center Experience With 336 Procedures.

BACKGROUND: Indwelling pleural catheters (IPCs) offer ambulatory management of symptomatic persistent pleural effusions, but their widespread use is somewhat hampered by the risk of pleural infection and the inconvenience of carrying a catheter for a prolonged period of time. Factors associated with these 2 limitations were analyzed in this study. METHODS: Retrospective review of consecutive patients who had undergone IPC placement over a 5 ½-year period. Time to IPC removal was analyzed with the Fine and Gray competing risks survival model, with competing risk being death. A binary logistic regression method was used to evaluate factors influencing IPC-related pleural infections. RESULTS: A total of 336 IPCs were placed in 308 patients, mostly because of malignant effusions (83%). IPC removal secondary to pleurodesis was achieved in 170 (51%) procedures at a median time of 52 days. Higher rates of IPC removal were associated with an Eastern Cooperative Oncology Group (ECOG) grade of 0 to 2 [subhazard ratio (SHR)=2.22], an expandable lung (SHR=1.93), and development of a multiseptated pleural space (SHR=1.37). IPC-related pleural infections occurred in 8% of the cases, and were more often seen in hepatic hydrothoraces [odds ratio (OR)=4.75] and pleural fluids with a C-reactive protein <15 mg/L before the IPC insertion (OR=4.42). CONCLUSION: IPC removal is more likely to occur in patients with good performance status whose lungs fully expand after drainage. Hepatic hydrothorax is the most significant predictor of IPC-related infections.

Pleural Effusions in Diffuse Large B-Cell Lymphoma: Clinical and Prognostic Significance.

PURPOSE: Pleural effusion (PEs) may complicate diffuse large B-cell lymphomas (DLBCL). However, their real prevalence and prognostic significance have seldom been approached systematically. METHODS: Retrospective single-center evaluation of consecutive patients with DLBCL was conducted. Baseline characteristics, PEs on CT imaging, pleural fluid analyses, and outcome until death or censoring date were collected. RESULTS: Of 185 DLBCL patients, 55 (30%) had PEs, of which 27 (49%) were analyzed. Most tapped PEs were malignant (n = 24) and cytological and/or flow cytometric analyses provided the diagnosis in about 70% of the cases. Malignant PEs were exudates with adenosine deaminase levels > 35 U/L in 35% of the cases. More than one-third of lymphomatous PEs required definitive pleural procedures for symptomatic relief. PEs greater than 200 mL on CT scans were an independent predictor of poor survival in Cox regression modeling (hazard ratio 1.9). CONCLUSIONS: PEs are common in DLBCL and foreshadow a poor prognosis.

Tuberculous Pleural Effusion: Clinical Characteristics of 320 Patients. / Derrame pleural tuberculoso: características clínicas de 320 pacientes.

OBJECTIVES: To analyze the clinical and radiological characteristics and features of pleural fluid (PF) in patients with tuberculous pleural effusion (TPE). METHODS: Retrospective analysis of TPEs treated in our clinic over the last 23years. RESULTS: We included 320 patients with TPE (70% men; median age 33years). Mycobacterium tuberculosis was identified in the sputum or PF of 36% of the patients by microscopic examination, solid and liquid media cultures, or nucleic acid amplification tests. The greatest percentage of positive microbiological findings were associated with human immunodeficiency virus (HIV) co-infection (OR: 3.27), and with the presence in PF of proteins <4g/dL (OR: 3.53), neutrophils >60% (OR: 3.23), and glucose <40mg/dL (OR: 3.17). Pleural adenosine deaminase <35U/L was associated with TPEs that occupied less than half of the hemithorax (OR: 6.36) and with PF lactate dehydrogenase levels <500U/L (OR: 8.09). Radiological pulmonary opacities (30%) were more common in TPE occupying less than half of the hemithorax (OR: 2.73), in bilateral TPE (OR: 4.48), and in older patients (OR: 1.02). Factors predicting mortality were: HIV co-infection (OR: 24), proteins in PF <5g/dL (OR: 10), and greater age (OR: 1.05). CONCLUSIONS: Patients with TPE and HIV co-infection and those with lower concentrations of proteins in PF had higher rates of positive microbiological results and death. Moreover, older patients had more pulmonary opacities and a higher incidence of death.

Multifocal granular cell tumour of the biliary tree.

Fewer than 90 cases of granular cell tumour (GCT) of the biliary tract have been reported, including only five cases of multiple GCTs. We present the unusual case of a 40-year-old woman with multifocal GCTs affecting the intrahepatic biliary tree, which were initially suspected to be hepatic multiple metastases from a malignancy of unknown origin. The surgical specimen consisted of a hepatic segment in which five whitish nodular lesions were observed. On microscopic examination, nodular lesions were found in the portal tracts; these were composed of large polygonal cells with abundant highly granular cytoplasm. The nuclei were small and centrally located. The tumour cells tested diffusely positive for CD68-PGM1, S100 protein and α-inhibin, so a diagnosis of multifocal GCT of the biliary tree was made. Three years later, the patient is still alive and a MRI has shown no changes.

CT scan exposure in Spanish children and young adults by socioeconomic status: Cross-sectional analysis of cohort data.

Recent publications reported that children in disadvantaged areas undergo more CT scanning than others. The present study is aimed to assess the potential differences in CT imaging by socioeconomic status (SES) in Spanish young scanned subjects and if such differences vary with different indicators or different time point SES measurements. The associations between CT scanning and SES, and between the CT scan rate per patient and SES were investigated in the Spanish EPI-CT subcohort. Various SES indicators were studied to determine whether particular SES dimensions were more closely related to the probability of undergoing one or multiple CTs. Comparisons were made with indices based on 2001 and 2011 censuses. We found evidence of socio-economic variation among young people, mainly related to autonomous communities of residence. A slightly higher rate of scans per patient of multiple body parts in the less affluent categories was observed, possibly reflecting a higher rate of accidents and violence in these groups. The number of CT scans per patient was higher both in the most affluent and the most deprived categories and somewhat lower in the intermediate groups. This relation varied with the SES indicator used, with lower CT scans per patients in categories of high unemployment and temporary work, but not depending on categories of unskilled work or illiteracy. The relationship between these indicators and number of CTs in 2011 was different than that seen with the 2001 census, with the number of CTs increasing with higher unemployment. Overall we observed some differences in the SES distribution of scanned patients by Autonomous Community in Spain. There was, however, no major differences in the frequency of CT scans per patient by SES overall, based on the 2001 census. The use of different indicators and of SES data collected at different time points led to different relations between SES and frequency of CT scans, outlining the difficulty of adequately capturing the social and economic dimensions which may affect health and health service utilisation.

Computed tomography scoring system for discriminating between parapneumonic effusions eventually drained and those cured only with antibiotics.

BACKGROUND AND OBJECTIVE: Due to limited data, we aimed to develop and validate a computed tomography (CT)-based scoring system for identifying those parapneumonic effusions (PPEs) requiring drainage. METHODS: A retrospective review of all patients with PPE who underwent thoracentesis and a chest CT scan before any attempt to place a tube thoracostomy, if applicable, over an 8-year period was conducted. Eleven chest CT characteristics were compared between 90 patients with complicated PPEs (CPPEs), defined as those which eventually required chest drainage, and 60 with non-complicated effusions (derivation sample). A scoring system was devised with those CT findings identified as independent predictors of CPPE in a logistic regression analysis, and further validated in an independent population of 59 PPE patients. RESULTS: CT scores predicting CPPE were pleural contrast enhancement (3 points), pleural microbubbles, increased extrapleural fat attenuation and fluid volume ≥400 mL (1 point each). A sum score of ≥4 yielded 84% sensitivity (95% CI: 62-85%), 75% specificity (95% CI: 62-85%), 81% diagnostic accuracy (95% CI: 73-86%), likelihood ratio (LR) positive of 3.4 (95% CI: 2.1-5.4), LR negative of 0.22 (95% CI: 0.13-0.36) and area under the receiver operating characteristic curve (AUC) of 0.829 (95% CI: 0.754-0.904) for labelling CPPE in the derivation set. These results were reproduced in the validation sample. The CT grading scale also exhibited a fair ability to identify patients who needed surgery or would die from the pleural infection (AUC: 0.76, 95% CI: 0.61-0.9). CONCLUSION: A novel CT scoring system for adults with PPE may allow clinicians to predict the need for chest tube drainage with good accuracy.

Three dimensional computed tomography for preoperative assessment of the pulmonary artery in patients undergoing endoscopic lobectomy or segmentectomy. / Rentabilidad de la reconstrucción volumétrica de la arteria pulmonar para la planificación de lobectomías y segmentectomías endoscópicas.

BACKGROUND: The interest for endoscopic pulmonary anatomic resections has grown exponentially during the last decade. During thoracoscopic procedures surgeons cannot rely on digital handling and operative field is viewed on a two-dimensional video monitor, thus frequently encountering anatomical difficulties. The hypothesis is that foreknowledge of the anatomy of each patient would greatly contribute to the safety and accuracy of the operation. The aim of the study was to evaluate the effectiveness of 3dimensional multidetector computed tomography (3D-MDCT) software to identify the pulmonary artery branching pattern during the preoperative study of endoscopic lobectomies and segmentectomies. METHODS: Descriptive prospective study of 25consecutive patients scheduled from November 2015 to July 2016 in a tertiary referral academic hospital for VATS lobectomy or segmentectomy and evaluated about branching pattern of the pulmonary artery with preoperative 16-row 3D-MDCT angiography. Intraoperative findings of the pulmonary branching pattern were compared with the preoperative 3D-MDCT angiography images. RESULTS: According to the intraoperative findings, 67 out of 68 (98%) of pulmonary artery branches were well defined in the 3D-MDCT angiography images. There was a unique 2mm undetected branch. No conversion to open thoracotomy was needed because of intraoperative bleending. CONCLUSION: 3D-MDCT angiography imaging is useful for preoperative identification of the pulmonary artery branching pattern.

Trends and patterns in the use of computed tomography in children and young adults in Catalonia - results from the EPI-CT study.

BACKGROUND: Although there are undeniable diagnostic benefits of CT scanning, its increasing use in paediatric radiology has become a topic of concern regarding patient radioprotection. OBJECTIVE: To assess the rate of CT scanning in Catalonia, Spain, among patients younger than 21 years old at the scan time. MATERIALS AND METHODS: This is a sub-study of a larger international cohort study (EPI-CT, the International pediatric CT scan study). Data were retrieved from the radiological information systems (RIS) of eight hospitals in Catalonia since the implementation of digital registration (between 1991 and 2010) until 2013. RESULTS: The absolute number of CT scans annually increased 4.5% between 1991 and 2013, which was less accentuated when RIS was implemented in most hospitals. Because the population attending the hospitals also increased, however, the rate of scanned patients changed little (8.3 to 9.4 per 1,000 population). The proportions of patients with more than one CT and more than three CTs showed a 1.51- and 2.7-fold increase, respectively, over the 23 years. CONCLUSION: Gradual increases in numbers of examinations and scanned patients were observed in Catalonia, potentially explained by new CT scanning indications and increases in the availability of scanners, the number of scans per patient and the size of the attended population.

Derivation and validation of a CT scan scoring system for discriminating malignant from benign pleural effusions.

BACKGROUND: Chest CT scanning has become an integral part of the workup for undiagnosed pleural effusions. We aimed to develop a CT scan-based scoring system for differentiating between benign and malignant pleural effusions. METHODS: A number of chest CT scan abnormalities were compared between 228 patients with benign and 115 with malignant effusions (derivation cohort). A logistic regression analysis was used to identify the independent predictors of malignancy and generate CT scan scores, with more points assigned to those findings associated with higher ß-coefficient values. The diagnostic accuracy of the CT scan scoring system was calculated for the derivation cohort and further evaluated in two independent populations (n = 80 and 42, respectively) by two radiologists. RESULTS: CT scan scores predicting malignancy included any pleural lesion (ie, nodule, mass, or thickening) ≥ 1 cm (5 points); the presence of liver metastases, an abdominal mass, or a lung mass or nodule ≥ 1 cm (3 points each); and the absence of either pleural loculations, pericardial effusions, or cardiomegaly (2 points each). In the first validation cohort, a sum score of ≥ 7 yielded a sensitivity of 88% (95% CI, 73%-95%), specificity of 94% (95% CI, 83%-98%), likelihood ratio positive of 13.8 (95% CI, 4.6-41.5), likelihood ratio negative of 0.13 (95% CI, 0.05-0.33), and area under the receiver operating characteristics curve of 0.919 (95% CI, 0.849-0.990). Moreover, 69% of 42 patients with pathologically unconfirmed malignant effusions from a second independent cohort would have been correctly labeled by the predictive score. CONCLUSIONS: A simple CT scan-based scoring system can help physicians to separate malignant from benign pleural effusions.

Higher carotid intima media thickness predicts extracranial vascular events and not stroke recurrence among transient ischemic attack patients.

BACKGROUND: Increased common carotid artery intima-media thickness has been associated with an increased risk of vascular ischemic events. We investigated the relationship between common carotid artery intima-media thickness and extracranial vascular events (coronary heart disease and peripheral arterial disease) or stroke recurrence in a cohort of transient ischemic attack patients from the REGITELL registry. METHODS: High-resolution B-mode ultrasonographic measurements of the common carotid artery intima-media thickness were performed in a series of 283 consecutive transient ischemic attack patients. Clinical, neuroimaging, ultrasonographic, and etiological data were collected. Patients were followed prospectively for six-months or more. Extracranial vascular events and stroke recurrence were recorded. RESULTS: Fifteen extracranial vascular events (12 coronary heart disease and three peripheral arterial disease) and 29 recurrent strokes occurred during a median follow-up period of 12.3 months. Patients who experienced extracranial vascular events had significantly (P < 0.001) higher common carotid artery intima-media thickness values (1.087 (standard deviation 0.189) mm) than subjects who were free of extracranial vascular events (0.887 (standard deviation 0.195) mm). Nevertheless, common carotid artery intima-media thickness was not found to correlate with stroke recurrence. Cox proportional hazards multivariate analyses identified hypercholesterolemia (hazard ratio 6.87, 95% confidence interval: 1.93-24.39, P = 0.003) and common carotid artery intima-media thickness > 0.939 mm (hazard ratio 8.90, 95% confidence interval: 2.00-39.49, P = 0.004) as independent predictors of extracranial vascular events after transient ischemic attack. Almost one of every three patients with hypercholesterolemia and high common carotid artery intima-media thickness had extracranial vascular events. CONCLUSIONS: An elevated common carotid artery intima-media thickness value was associated with a higher long-term risk of extracranial vascular events but no with stroke recurrence. Hypercholesterolemia was the main risk factor for extracranial vascular events. The combination of hypercholesterolemia and common carotid artery intima-media thickness > 0.939 mm justify the establishment of aggressive therapies and the study of subclinical coronary heart disease and peripheral arterial disease.

[How can determination of the carotid intima-media thickness contribute to the process of diagnosing transient ischaemic attacks?]. / Qué puede aportar la determinación del grosor íntima-media carotídeo al proceso diagnóstico del ataque isquémico transitorio?

PATIENTS AND METHODS: The carotid intima media thickness (IMT) is a new prognostic marker of vascular events. We studied its usefulness in the diagnosis workup of 211 consecutive transient ischemic attack (TIA) patients from the REGITELL registration. GIM was measured according to Mannheim criteria. It was established its relationship to the main prognostic variables described in TIA: ABCD2 scale, symptomatology and etiologic subtypes according to TOAST classification. RESULTS: Men value of carotid IMT was 0.91 ± 0.20 mm. After Bonferroni adjustment, IMT was associated with age of 60 years or older (0.95 ± 0.19 mm; p < 0.001), male sex (0.95 ± 0.20 mm; p = 0.003), ABCD2 scale (p < 0.001), association of risk factors are greater than or equal to 2 (0.94 ± 0.20 mm; p < 0.001), carotid plaque presence (0.98 ± 0.19 mm; p < 0.001), intracranial stenosis (1.09 ± 0.18 mm; p = 0.001), presence of ischemic chronic lesions on head CT (p <0.001) and etiology (p < 0.001). The patients presented with isolated sensory symptoms had significantly lower IMT (0.77 ± 0.18 mm; p = 0.002). Belonging to the third tertile of IMT was only an independent predictor of large-artery atherosclerosis (OR = 3,06; CI 95% = 1.31-7.13; p = 0.01). CONCLUSION: Based on our results, IMT determination seems to not improve the diagnostic accuracy of other ultrasonographic characteristics like the presence of plaques or the degree of stenosis.

Analysis of pleural effusions in acute pulmonary embolism: radiological and pleural fluid data from 230 patients.

BACKGROUND AND OBJECTIVE: The aims of this study were to describe the frequency and radiographical characteristics of pleural effusions in a large population of patients with acute pulmonary embolism (PE) and characterize the pleural fluid biochemistry in those patients who underwent diagnostic thoracentesis. METHODS: This was a retrospective observational single-centre study. A total of 230 consecutive patients with a diagnosis of PE over a 9-year period were enrolled. Spiral CT pulmonary angiography (52%) and high-probability ventilation and perfusion scans (42%) were used as the main reference methods. RESULTS: Pleural effusions were observed in 32% and 47% of patients by CXR and CT, respectively. Typically, pleural effusions were small (90% occupied less than one third of the hemithorax) and unilateral (85%), but occasionally they reached more than a half of the hemithorax. On CT, 21% of pleural effusions showed loculation. In patients with loculated pleural fluid the diagnosis of PE had been delayed for a mean of 12.2 days after symptoms developed. The presence of pleural fluid was not related to infarction. Twenty-six of 93 (28%) patients with effusions on imaging underwent thoracentesis. All the fluids met Light's criteria for exudate, 58% contained erythrocyte counts >10,000/microL and 46% showed neutrophilic predominance. CONCLUSIONS: Small pleural effusions, mostly unsuitable for diagnostic thoracentesis, were present in about one third of patients with PE. All the pleural effusions due to PE were exudates. If PE diagnosis was delayed the pleural effusion tended to become loculated.