Bronchoscopy Using Virtual Navigation and Endobronchial Ultrasonography with a Guide Sheath (EBUS-GS) with or without Fluoroscopy for Peripheral Pulmonary Lesions.

OBJECTIVE: Endobronchial ultrasonography and guide sheath (EBUS-GS) technique has high diagnostic yield in lung nodules. Virtual bronchoscopic navigation (VBN) can lead bronchoscope to the target bronchi. The aim of this prospective study was to compare the diagnostic yield of two bronchoscopic procedures: bronchoscopy under EBUS-GS and VBN with or without x-ray fluoroscopy in small peripheral pulmonary lesions (PPLs, ≤30mm) with apparent CT-bronchus sign. METHODS: 31 patients with PPLs which had apparent CT-bronchus sign were randomly assigned to the X-ray or the non-X-ray groups (18 with and 13 without fluoroscopy) between September 1, 2012, and September 30, 2015. A bronchoscope was introduced into the target bronchus using the VBN system. Sites of specimen sampling were verified using EBUS-GS with or without fluoroscopy. RESULTS: The overall diagnostic yield was 83.3% in the X-ray and 69.2% in the non-X-ray group. The diagnostic yield of malignancy was 88.2% and 81.8%, respectively. The duration of the examination and time elapsed until the first EBUS visualization were similar in the X-ray and the non-X-ray group (9.0 (5.8-20.) min vs 11.0 (5.3-17.3) min, and 2.5 (1.3-14.2) min vs 4.1 (1.4-8.1) min, respectively). The fluoroscopy exposure time was 3.7 (2.9-10.56) min. The only adverse event was mild pneumothorax in a patient from the non-X-ray group, who had consequent TBB under fluoroscopy. CONCLUSIONS: There was a possibility that VBN-guided EBUS-transbronchial diagnosis without fluoroscopy might be equivalent to that under fluoroscopy. Further multi-center randomized study may be desired. (UMIN000008592).

Utility of cell blocks obtained by catheter aspiration via a guide sheath during endobronchial ultrasonography.

BACKGROUND: The demand for adequate tissue samples for both morphological assessment and molecular studies on lung cancer treatment has increased. The aim of this study was to evaluate whether cell blocks (CBs) prepared from endobronchial ultrasonography with guide sheath (EBUS-GS) rinsing following catheter aspiration provide additional information. METHODS: We produced CBs from rinse fluid obtained from washing the inside of the sheath with saline after conventional EBUS-GS between May 2012 and April 2013. During the first 7 months, the sheath was aspirated with 20mL of negative pressure while moving the catheter back and forth [aspiration group (Asp)]. During the next 5 months, the sheath was not aspirated, but only rinsed out [conventional group (Con)]. Patients diagnosed with lung cancer by EBUS-GS and/or CBs were identified and evaluated. The diagnostic rate of each sampling method was compared between the two groups. The number of tumor cells was also compared between the CB and EBUS-guided transbronchial lung biopsy (EBUS-TBB) groups. RESULTS: EBUS-GS was performed on 113 patients. Fifty-five patients were included in this study (Asp=30, Con=25). The diagnostic yield of CBs in Asp was higher than that in Con (56.7% vs 32.0%; p=0.06). Asp showed no significant difference in the number of tumor cells between CB and EBUS-TBB. One patient who showed negative EBUS-TBB pathological results but positive CB results was diagnosed only by immunohistological staining of CB. CONCLUSION: CB prepared from EBUS-GS rinsing following catheter aspiration may provide additional information.

Diagnostic utility of additional conventional techniques after endobronchial ultrasonography guidance during transbronchial biopsy.

BACKGROUND AND OBJECTIVE: Endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) has been used to diagnose peripheral pulmonary lesions (PPLs). In this study, we evaluated the diagnostic utility of conventional TBB after EBUS-GS TBB. METHODS: A retrospective analysis of patients who underwent conventional TBB after EBUS-GS TBB for PPL between August 1, 2012 and December 31, 2014. We performed multivariate analysis to examine the association of various clinical factors, including EBUS probe distance and sample size area, with diagnostic yield. RESULTS: Of 88 eligible patients, 57 (65%) were successfully diagnosed by EBUS-GS TBB. In 31 patients not diagnosed by EBUS-GS TBB, 15 (48%) were successfully diagnosed by additional conventional TBB. Ground glass opacity (GGO) was a significant factor associated with the diagnostic yield of additional conventional TBB following EBUS-GS TBB. Multivariate analysis and receiver operator curves revealed that distance between the PPL and the EBUS probe of less than 2.55 mm favored the utility of conventional TBB. CONCLUSION: Additional conventional TBB after EBUS-GS TBB could be a useful procedure for the diagnosis of ground glass opacity PPLs and in cases of a distance of less than 2.55 mm between the EBUS probe and the lesion.

Semipermeable membrane dressings can be used with the nicotine transdermal system and do not interfere with nicotine absorption.

OBJECTIVE: Adverse skin reactions as a local side effect of nicotine patches sometimes interfere with smoking cessation therapy. We studied the effects of semipermeable membrane dressings (SMD) used under nicotine patches (NP) on nicotine absorption, as assessed according to the urinary cotinine levels, and skin symptoms. METHODS: First, the urinary cotinine levels were compared in eight nonsmokers that applied NP over SMD and NP without SMD (Study 1). The urinary cotinine levels were measured using a highly sensitive competitive enzyme immunoassay. Second, 28 subjects undergoing NP therapy for diagnosed nicotine dependence were randomly assigned into two groups in a crossover design to receive NP over SMD and NP without SMD. The urinary cotinine levels and skin symptoms were compared between the two treatment groups. During the follow-up period of 48 weeks, the smoking cessation rate was evaluated (Study 2). RESULTS: No statistical differences were observed in the urinary cotinine levels between the NP over SMD and NP without SMD groups. In Study 2, the skin symptoms improved with the use of SMD in 42.8% (6/14) of the patients and worsened in 28.5% (4/14) of the patients. No serious skin disorders were reported. The subjects followed in Study 2 exhibited smoking cessation rates of 92.8%, 78.5% and 64.2% at 12, 24 and 48 weeks, respectively. CONCLUSION: The use of NP over SMD is a safe and effective alternative application to NP treatment for preventing the skin symptoms caused by NP without interfering with nicotine absorption.

Visualized changes in respiratory resistance and reactance along a time axis in smokers: a cross-sectional study.

BACKGROUND: Early detection of changes in respiratory function in smokers is important for the prevention of chronic obstructive pulmonary disease (COPD). The objective of this study was to investigate any changes in the respiratory impedance of smokers with normal FEV1/FVC. METHODS: We assessed and compared the impedance components, respiratory resistance, and reactance in both the inspiratory and expiratory phases of nonsmokers, smokers, and COPD patients. RESULTS: Approximately 60% of smokers showed elevated resistance and a negative shift in reactance, mainly in the expiratory phase, as observed in COPD patients. Smokers showed an increased gap between the maximum and minimum R5 and X5 values (R5sub, X5sub) in comparison with nonsmokers. Furthermore, R5-R20 was significantly higher in smokers than in nonsmokers. The expiratory-inspiratory gaps in resistance and reactance were also significantly higher in smokers than in nonsmokers. In smokers and COPD patients, the magnitude of expiratory X5 was more negative than that in nonsmokers. In smokers with V·50/V·25≥3, R5-R20 was significantly higher than those in smokers with V·50/V·25<3. CONCLUSIONS: Approximately 60% of smokers were shown to exhibit apparent impedance changes despite having normal FEV1/FVC values. Smoking-induced early remodeling of the small airways may be responsible for the observed changes in airway function of smokers. Further studies are necessary to determine if the change in respiratory impedance observed in smokers is an early indicator of COPD.

[Pulmonary tumor thrombotic microangiopathy associated with cancer of unknown origin].

A nonsmoking, 52-year-old woman presented with a 4-month history of persistent dry cough. Chest X-ray film on admission showed small granular shadow in bilateral lung fields. Bronchoscopic biopsy did not yield a diagnosis. Two months later, she complained of dyspnea. Physical examination showed signs of pulmonary hypertension. Five days after the onset of dyspnea, she died of respiratory failure. An autopsy showed pulmonary embolism and swollen abdominal lymph nodes consisting of metastatic signet-ring cell carcinoma and poorly differentiated adenocarcinoma. There was also marked fibrocellular intimal proliferation and thrombus formation causing luminal stenosis in small pulmonary arterioles. Thrombi were organized by recanalization and included atypical cells. We diagnosed pulmonary tumor thrombotic microangiopathy (PTTM). In spite of various immunohistological staining procedure, we could not find out the primary lesion of this cancer. This case suggests that we should aggressively biopsy a large specimen of the lung to make a differential diagnosis of PTTM, because bronchoscopic biopsy is not enough to diagnose PTTM.