Diagnostic value of transthoracic needle biopsy in lung tumors.

OBJECTIVE: Thoracic ultrasonography is widely used in imaging peripheral lesions and invasive interventional procedures. The aim of this study was to assess the diagnostic value of thoracic ultrasonography-guided transthoracic needle aspiration biopsy and the factors affecting the diagnosis of peripheral tumoral lung lesions. METHODS: The lesion size, biopsy needle type, number of blocks, complications, and pathology results were compared in 83 patients between January 2015 and July 2018. The cases with pathological non-diagnosis and definite pathological diagnosis were determined. For the assessment of the factors affecting diagnosis, the size of the lesions and the biopsy needle type were evaluated. Biopsy preparations containing non-diagnostic atypical cells were referred to a cytopathologist. The effect of the cytopathological examination on the diagnosis was also evaluated. RESULTS: Pathological diagnosis was made in 66.3% of the cases; cell type could not be determined in 22.9% of the cases, and they were referred to a cytopathologist. After the cytopathologist's examination, the diagnosis rate increased to 80.7%. Diagnosis rates were higher when using tru-cut than Chiba and higher in cases with tumor size >2 cm than smaller. CONCLUSION: Thoracic ultrasonography-guided transthoracic needle aspiration biopsy is a preferred approach to the diagnosis of peripheral tumoral lung lesions, given its high diagnostic rate, in addition to being cheap, highly suitable for bedside use, and safe, and the lack of radiation exposure.

Diagnostic value of transthoracic needle biopsy in lung tumors

SUMMARY OBJECTIVE: Thoracic ultrasonography is widely used in imaging peripheral lesions and invasive interventional procedures. The aim of this study was to assess the diagnostic value of thoracic ultrasonography-guided transthoracic needle aspiration biopsy and the factors affecting the diagnosis of peripheral tumoral lung lesions. METHODS: The lesion size, biopsy needle type, number of blocks, complications, and pathology results were compared in 83 patients between January 2015 and July 2018. The cases with pathological non-diagnosis and definite pathological diagnosis were determined. For the assessment of the factors affecting diagnosis, the size of the lesions and the biopsy needle type were evaluated. Biopsy preparations containing non-diagnostic atypical cells were referred to a cytopathologist. The effect of the cytopathological examination on the diagnosis was also evaluated. RESULTS: Pathological diagnosis was made in 66.3% of the cases; cell type could not be determined in 22.9% of the cases, and they were referred to a cytopathologist. After the cytopathologist's examination, the diagnosis rate increased to 80.7%. Diagnosis rates were higher when using tru-cut than Chiba and higher in cases with tumor size >2 cm than smaller. CONCLUSION: Thoracic ultrasonography-guided transthoracic needle aspiration biopsy is a preferred approach to the diagnosis of peripheral tumoral lung lesions, given its high diagnostic rate, in addition to being cheap, highly suitable for bedside use, and safe, and the lack of radiation exposure.

Evaluation of Exudative Pleural Effusions: A Multicenter, Prospective, Observational Study.

PURPOSE: The aim of this study is to determine the diagnostic performances of pleural procedures in undiagnosed exudative pleural effusions and to evaluate factors suggestive of benign or malignant pleural effusions in tertiary care centers. METHODS: This was a multicenter prospective observational study conducted between January 1 and December 31, 2018. A total of 777 patients with undiagnosed exudative pleural effusion after the initial work-up were evaluated. The results of diagnostic procedures and the patients' diagnoses were prospectively recorded. Sensitivity, specificity, and accuracy estimates with 95% confidence intervals were used to examine the performance of pleural procedures to detect malignancy. RESULTS: The mean age ± SD of the 777 patients was 62.0 ± 16.0 years, and 68.3% of them were male. The most common cause was malignancy (38.3%). Lung cancer was the leading cause of malignant pleural effusions (20.2%). The diagnostic sensitivity and accuracy of cytology were 59.5% and 84.3%, respectively. The diagnostic sensitivity of image-guided pleural biopsy was 86.4%. The addition of image-guided pleural biopsy to cytology increased diagnostic sensitivity to more than 90%. Thoracoscopic biopsy provided the highest diagnostic sensitivity (94.3%). The highest diagnostic sensitivity of cytology was determined in metastatic pleural effusion from breast cancer (86.7%). CONCLUSION: The diagnostic performance increases considerably when cytology is combined with image-guided pleural biopsy in malignant pleural effusions. However, to avoid unnecessary interventions and complications, the development of criteria to distinguish patients with benign pleural effusions is as important as the identification of patients with malignant pleural effusions.

Adaptive Subsets Limit the Anti-Tumoral NK-Cell Activity in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a global health burden with increasing incidence, poor prognosis and limited therapeutic options. Natural killer (NK) cells exhibit potent anti-tumoral activity and therefore represent potential targets for immunotherapeutic approaches in HCC treatment. However, the anti-tumoral activity of NK cells in HCC associated with different etiologies, and the impact of the heterogeneous NK cell subset, e.g., adaptive and conventional subsets, are not understood in detail. By comparatively analyzing the NK-cell repertoire in 60 HCC patients, 33 liver cirrhosis patients and 36 healthy donors (HD), we show in this study that the NK-cell repertoire is linked to HCC etiology, with increased frequencies of adaptive NK cells in Hepatitis B virus (HBV)-associated HCC. Adaptive NK cells exhibited limited anti-tumoral activity toward liver cancer cells; however, this was not a result of a specific NK-cell impairment in HCC but rather represented an intrinsic feature, since the characteristics of circulating and intra-tumoral adaptive NK cells were conserved between HD, HCC and liver cirrhosis patients. Hence, the expansion of adaptive NK cells with reduced anti-tumoral activity, detectable in HBV-associated HCC, may have implications for tumor surveillance and therapy.

Phenotypic and functional differences of HBV core-specific versus HBV polymerase-specific CD8+ T cells in chronically HBV-infected patients with low viral load.

OBJECTIVE: A hallmark of chronic HBV (cHBV) infection is the presence of impaired HBV-specific CD8+ T cell responses. Functional T cell exhaustion induced by persistent antigen stimulation is considered a major mechanism underlying this impairment. However, due to their low frequencies in chronic infection, it is currently unknown whether HBV-specific CD8+ T cells targeting different epitopes are similarly impaired and share molecular profiles indicative of T cell exhaustion. DESIGN: By applying peptide-loaded MHC I tetramer-based enrichment, we could detect HBV-specific CD8+ T cells targeting epitopes in the HBV core and the polymerase proteins in the majority of 85 tested cHBV patients with low viral loads. Lower detection rates were obtained for envelope-specific CD8+ T cells. Subsequently, we performed phenotypic and functional in-depth analyses. RESULTS: HBV-specific CD8+ T cells are not terminally exhausted but rather exhibit a memory-like phenotype in patients with low viral load possibly reflecting weak ongoing cognate antigen recognition. Moreover, HBV-specific CD8+ T cells targeting core versus polymerase epitopes significantly differed in frequency, phenotype and function. In particular, in comparison with core-specific CD8+ T cells, a higher frequency of polymerase-specific CD8+ T cells expressed CD38, KLRG1 and Eomes accompanied by low T-bet expression and downregulated CD127 indicative of a more severe T cell exhaustion. In addition, polymerase-specific CD8+ T cells exhibited a reduced expansion capacity that was linked to a dysbalanced TCF1/BCL2 expression. CONCLUSIONS: Overall, the molecular mechanisms underlying impaired T cell responses differ with respect to the targeted HBV antigens. These results have potential implications for immunotherapeutic approaches in HBV cure.

Asymptomatic Pulmonary Embolism after Ablation.

BACKGROUND: Pulmonary embolism (PE) is a life-threatening event with a broad presentation spectrum ranging from asymptomatic cases to sudden cardiac arrest. It is unclear if right atrial emboli cause PE in patients with atrial fibrillation (AF) or if mild PE itself increases right cardiac pressure provoking AF. OBJECTIVE: To determine the incidence and predictors of asymptomatic PE in patients undergoing AF ablation. METHOD AND RESULTS: Patients (n = 93) were screened and those with previous or current symptomatic PE or venous thromboembolism, pulmonary hypertension, increased right heart pressures detected on echocardiography, a history of stroke, transient ischemic attack, coagulopathy or cancer and inappropriate contrast for the evaluation of pulmonary arterial tree were excluded. The remaining AF patients (n = 71) underwent guided ablation controlled with 3-dimensional, left atrial and pulmonary venous computed tomography. The asymptomatic PE was defined by using the modified Miller score by 2 independent assessors in 6 patients. Univariate logistic regression showed that age (OR: 1.094, 95% CI 1.007-1.188, p = 0.033), diabetes (OR: 12.000, 95% CI 1.902-75.716, p = 0.008), CHA2DS2-VASc score (OR: 2.800, 95% CI 1.304-6.013, p = 0.008), and pulmonary artery diameter (OR: 1.221, 95% CI 1.033-1.444, p = 0.019) were significantly associated with PE. However, multivariate analysis revealed that the CHA2DS2-VASc score (p = 0.047) remained the exclusive significant predictor for asymptomatic PE. CONCLUSION: The incidence of random asymptomatic PE in AF patients is high (>8%). The CHA2DS2-VASc score can predict silent PE. Since patients with a high CHA2DS2-VASc score are already anticoagulated, our results do not change clinical practice but are noteworthy in terms of the cause-effect relationship between AF and PE.

Does eosinophilic COPD exacerbation have a better patient outcome than non-eosinophilic in the intensive care unit?

BACKGROUND: COPD exacerbations requiring intensive care unit (ICU) admission have a major impact on morbidity and mortality. Only 10%-25% of COPD exacerbations are eosinophilic. AIM: To assess whether eosinophilic COPD exacerbations have better outcomes than non-eosinophilic COPD exacerbations in the ICU. METHODS: This retrospective observational cohort study was conducted in a thoracic, surgery-level III respiratory ICU of a tertiary teaching hospital for chest diseases from 2013 to 2014. Subjects previously diagnosed with COPD and who were admitted to the ICU with acute respiratory failure were included. Data were collected electronically from the hospital database. Subjects' characteristics, complete blood count parameters, neutrophil to lymphocyte ratio (NLR), delta NLR (admission minus discharge), C-reactive protein (CRP) on admission to and discharge from ICU, length of ICU stay, and mortality were recorded. COPD subjects were grouped according to eosinophil levels (>2% or ≤2%) (group 1, eosinophilic; group 2, non-eosinophilic). These groups were compared with the recorded data. RESULTS: Over the study period, 647 eligible COPD subjects were enrolled (62 [40.3% female] in group 1 and 585 [33.5% female] in group 2). Group 2 had significantly higher C-reactive protein, neutrophils, NLR, delta NLR, and hemoglobin, but a lower lymphocyte, monocyte, and platelet count than group 1, on admission to and discharge from the ICU. Median (interquartile range) length of ICU stay and mortality in the ICU in groups 1 and 2 were 4 days (2-7 days) vs 6 days (3-9 days) (P<0.002), and 12.9% vs 24.9% (P<0.034), respectively. CONCLUSION: COPD exacerbations with acute respiratory failure requiring ICU admission had a better outcome with a peripheral eosinophil level >2%. NLR and peripheral eosinophilia may be helpful indicators for steroid and antibiotic management.

Mortality rates and risk factors associated with nosocomial Candida infection in a respiratory intensive care unit.

To determine the incidence and mortality rate of nosocomial Candida infections (NCI) with respect to associated risk factors in the respiratory intensive care unit (RICU) patients. Data of 163 RICU patients were analyzed for NCI in 2006 retrospectively. Diagnosis of NCI; at least one Candida spp. was isolated in patients with severe sepsis, hospitalized > 1 day intensive care unit (ICU). NCI positive vs. NCI negative were compared with respect to invasive procedure, comorbidities, mortality. Risk factors were analyzed by logistic regression test. NCI positive in 26 (15.9%) patients were mean age: 65 +/- 15 years (female/male ratio: 8/18). Candida albicans/non-albicans ratio was 13/13. ICU stay was longer in NCI positive than NCI negative (48.2 +/- 7.5 days vs. 10.3 +/- 0.8 days; p< 0.001). Higher mortality rates were demonstrated in NCI positive (14.6% vs. 30.8%; p< 0.05). Risk factors for NCI were as follow: Invasive mechanical ventilations (IMV), central catheters and related infections, total parenteral nutrition, multiple antibiotics, ventilator associated tracheobronchitis (VAT) (p< 001 for all and, odd ratio: 95% CI: 6.27, 2.05-19.16; 28.3, 4.61-32.04; 10.93, 4.04-29.56; 2.12-88.98; 14.99, 5.6-40.08, respectively) and sepsis and ventilator associated pneumonia (VAP) (p< 0.01, 7.34, 1.66-32.35; 3.87, 1.42-10.52, respectively). Presence of catheters and related infections, IMV, multiple antibiotics use, parenteral nutrition, VAT, sepsis and VAP were founded as major risk factors for our patients with NCI. Because of longer ICU duration and higher mortality in NCI patients with treated antifungal drugs, risk factors must be evaluated carefully in the ICU.

Recurrent pulmonary hydatid disease: analysis of ten cases.

PURPOSE: To investigate the incidence and define the importance of recurrent pulmonary hydatid cysts in developing countries. METHODS: We analyzed the records of 312 patients with pulmonary hydatid cyst disease diagnosed in our center between 1999 and 2005. RESULTS: A recurrent pulmonary hydatid cyst was diagnosed in 10 (3.2%) of the 312 patients [8 men and 2 women, mean age 36.9 (range 20-60) years]. The diagnosis was based on radiographic, clinical, or serological findings, established intraoperatively. The most frequent symptom of recurrent pulmonary hydatid cyst was hemoptysis (60%). The mean interval between diagnosis of the initial hydatid cyst and detection of recurrence was 8.75 (range 3-15) years. Bronchoscopy was performed in all patients, but proved diagnostic in only one. The localization of the initial and recurrent cysts differed in seven patients. A median follow-up period of 5 years revealed second recurrences in only two patients; manifesting as an intrapleural rupture of the cyst in one and as empyema in one. The recurrence was treated by resection in all patients; as cystectomy in eight patients, lobectomy in one patient, and pneumonectomy in one patient. CONCLUSION: Pulmonary hydatid cyst may recur in the same or a different location in the lung. Patients with a pleural lesion must be followed up regularly for any signs of recurrence.