Axillary web syndrome: Incidence, pathogenesis, and management.

Axillary web syndrome (AWS) refers to the development of fibrotic bands or "cords" in the axilla of patients who have undergone axillary lymph node dissection for breast cancer. We review the incidence, pathogenesis, risk factors, and management of AWS. AWS is a common complication in patients who undergo axillary lymph node dissection. Even though AWS is self-limited in most cases, it causes significant morbidity. The optimal management of AWS is unclear but physiotherapy appears to be beneficial. The widespread use of less invasive procedures to evaluate the presence of metastasis in the axillary lymph nodes (ie, sentinel lymph node biopsy) is expected to reduce the incidence of AWS. The close collaboration of surgeons, oncologists, and physiotherapists is necessary for the prevention and management of this frequent condition.

The lymph node roundness index in the evaluation of lymph nodes of the neck.

The study assessed the validity of the lymph node "roundness index" (RI) in the evaluation of enlarged lymph nodes of the neck. A total of 107 subjects were included in the prospective study, and 135 enlarged lymph nodes were examined. All the subjects were examined clinically and sonographically, the lymph node roundness index was determined, and soon after the nodes was surgically removed and pathohistologically diagnosed. On the basis of pathohistological diagnosis the study subjects were divided into two groups. The first group consisted of patients with benign lymph nodes, and the second one comprised patients with malignant nodes. The second group was further divided into two sub-groups: those with primary malignant nodes and those with secondary lymph nodes (metastases). The study showed that the lymph node RI statistically differs between the groups. In benign lymphadenopathy the RI was 1.66 ± 0.26, in primary malignant lymphadenopathy it was 1.31 ± 0.25 and in secondary malignant lymphadenopathy 1.13 ± 0.11. The analysis demonstrated that 82.9% of subjects randomly chosen from the group with primary malignant lymphadenopathy and 94.6% from the group with the secondary malignant lymphadenopathy have a smaller RI compared to randomly chosen subjects from the group with benign lymphadenopathy. Sensitivity of the method for primary malignant lymphadenopathy was 66.7% and specificity was 92.9%. For secondary malignant lymphadenopathy the sensitivity was 95.5% and specificity 92.9%. Based on this result we can conclude that the lymph node RI is a valid, simple, cost-effective and non-aggressive method which may "increase the suspicion" for a benign or malignant lymphadenopathy. RI ≤ 1.5 is indicative of malignant lymphadenopathy and RI ≥ 1.5 of benign lymphadenopathy.

Hepatosplenic sarcoidosis: contrast-enhanced ultrasound findings and implications for clinical practice.

Sarcoidosis is a complex granulomatous disease that affects virtually every organ and tissue, with a prevalence that varies significantly among the sites involved. The role of conventional imaging, such as computed tomography and magnetic resonance imaging, in the assessment of hepatosplenic sarcoidosis is well established by revealing organ enlargement, multiple discrete nodules, and lymphadenopathy. In this review, we aim to describe contrast-enhanced ultrasound (CEUS) findings in liver and spleen involvement by sarcoidosis, reporting evidence from the literature and cases from our experience, after a brief update on safety profile, cost-effectiveness, and clinical indications of this novel technique. Furthermore, we highlight potential advantages of CEUS in assessing hepatosplenic sarcoidosis that may be useful in the clinical practice.

Efficacy and cost effectiveness of rapid on site examination (ROSE) in management of patients with mediastinal lymphadenopathies.

BACKGROUND: The diagnostic and staging approach for the mediastinal lymphadenopathies, with or whithout pulmonary lesions endoscopically visible, is based on transbronchial needle aspiration (TBNA) during fiberoptic bronchoscopy and on mediastinoscopy. One important factor impacting on TBNA sensitivity is the rapid on site cytological examination (ROSE). AIM: The aim of this study was to evaluate the economic impact of TBNA and TBNA + ROSE, in the diagnosis of these lesions. PATIENTS AND METHODS: 120 patients, affected by mediastinal lymphadenopathies suspected for lung cancer, underwent TBNA during fiberoptic bronchoscopy: 60 patients without ROSE (group A) and other 60 with ROSE (group B). Whenever needle aspirations failed to provide diagnosis, the patient underwent mediastinoscopy. The economic impact of the diagnostic process was performed. RESULTS: In group A, 39 patients (65%) obtained a diagnosis with TBNA while 21 patients (35%) required mediastinoscopy. In group B, 48 patients (80%) obtained a diagnosis with TBNA + ROSE, while 12 patients (20%) required mediastinoscopy. With regards to the costs of the procedures performed in the diagnostic process, the use of TBNA with ROSE as first diagnostic approach has saved a considerable amount of euros (19,413) compared to the use of TBNA without ROSE and the combined procedure increased (p < 0.02; chi square test) the sensitivity of TBNA by 15%. CONCLUSIONS: ROSE significantly impacts on the diagnostic yield, as well as on the overall management costs of patients with mediastinal lymphadenopathy, suspected for lung cancer.

Cytologic assessment of endobronchial ultrasound-guided transbronchial needle aspirates in sarcoidosis.

BACKGROUND: The purpose of this study was to determine interobserver variability, the relative importance of cytologic preparations, and factors influencing the diagnostic yield of mediastinal lymph node aspirates in suspected sarcoidosis. METHODS: Analysis of mediastinal lymph node aspirates obtained during a randomized study of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) and conventional TBNA in patients with suspected sarcoidosis. All aspirates were processed by the monolayer ThinPrep method and cell blocks were prepared when feasible. The slides were reviewed by 2 cytopathologists, blinded to the study group. Lymph node location, size, number of aspirates, and diagnosis were recorded. A research cytopathologist recorded the presence of noncaseating granulomas in the monolayer and cell block preparations separately. RESULTS: Fifty patients were enrolled in the study, with 152 lymph nodes available for analysis (95 EBUS-TBNA, 57 conventional TBNA). The overall diagnostic yield was 64.5% on a per-lymph node basis. There was good agreement between cytopathologists (κ=0.677, P<0.001). Both liquid-based cytology and cell blocks were important in identifying granulomatous inflammation, with each being solely positive in 22% of cases. The diagnostic yield was not altered by lymph node location, size, or number of aspirates per node. CONCLUSIONS: Liquid-based cytology and cell block specimens are equally important in maximizing the diagnostic yield in EBUS-guided and conventional TBNA in suspected sarcoidosis. Good interobserver agreement between cytopathologists was noted, with improved diagnostic yield after review by a pulmonary cytopathologist. None of the clinical factors assessed impacted on the diagnostic yield of the procedure on a per-node basis.

Comparative cost analysis of endobronchial ultrasound-guided and blind TBNA in the evaluation of hilar and mediastinal lymphadenopathy.

BACKGROUND: The superior accuracy of endobronchial ultrasound (EBUS) averts many diagnostic surgical procedures. This likely leads to significant cost savings despite an increased per procedure cost. We sought to compare the true costs of endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) compared with "blind" fiberoptic bronchoscopy-transbronchial needle aspiration (FB-TBNA) factoring in the impact of diagnostic surgical procedures in the diagnosis of mediastinal lymphadenopathy. METHODS: In this retrospective case study, we selected 294 patients with thoracic lymphadenopathy as diagnosed by computed tomography at a university hospital. Information was extracted from the electronic record. Costs were determined from the Centers for Medicare and Medicaid Services resource-based relative value scale. We defined a positive diagnosis as one where benign or malignant disease was found. A negative biopsy was one where lymph node sampling was confirmed, but no pathology (benign or malignant) was seen. A nondiagnostic biopsy was one where no pathology was seen and lymph node sampling could not be confirmed. The total cost of endoscopic and surgical diagnostic procedures was tallied for each patient to obtain mean costs per patient. RESULTS: Thirty-seven patients underwent FB-TBNA and 257 underwent EBUS-TBNA. A diagnosis was found in 90% of patients in the EBUS group and 62.2% of patients in the FB-TBNA group (P<0.001). More patients in the FB-TBNA group underwent a diagnostic surgical procedure (HR= -0.1573, 95% confidence interval, -0.30 to -0.15; P<0.001). After accounting for all diagnostic procedures, the mean savings with EBUS was $1071.09 (P=0.09) per patient. CONCLUSIONS: EBUS-TBNA is less expensive than blind FB-TBNA in the evaluation of thoracic lymphadenopathy when accounting for diagnostic surgical procedures.

Value of ultrasound elastography in assessment of enlarged cervical lymph nodes.

BACKGROUND: To investigate the value of ultrasound elastography (UE) in the differentiation between benign and malignant enlarged cervical lymph nodes (LNs). METHODS: B-mode ultrasound, power Doppler imaging and UE were examined to determine LN characteristics. Two kinds of methods, 4 scores of elastographic classification and a strain ratio (SR) were used to evaluate the ultrasound elastograms. RESULTS: The cutoff point of SR had high utility in differential diagnosis of benign and malignant of cervical lymph nodes, with good sensitivity, specificity and accuracy. CONCLUSION: UE is an important aid in differential diagnosis of benign and malignant cervical LNs.

Endobronchial ultrasound-guided transbronchial needle aspiration prevents mediastinoscopies in the diagnosis of isolated mediastinal lymphadenopathy: a prospective trial.

RATIONALE: Patients with isolated mediastinal lymphadenopathy (IML) are a common presentation to physicians, and mediastinoscopy is traditionally considered the "gold standard" investigation when a pathological diagnosis is required. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is established as an alternative to mediastinoscopy in patients with lung cancer. OBJECTIVE: To determine the efficacy and health care costs of EBUS-TBNA as an alternative initial investigation to mediastinoscopy in patients with isolated IML. METHODS: Prospective multicenter single-arm clinical trial of 77 consecutive patients with IML from 5 centers between April 2009 and March 2011. All patients underwent EBUS-TBNA. If EBUS-TBNA did not provide a diagnosis, then participants underwent mediastinoscopy. MEASUREMENTS AND MAIN RESULTS: EBUS-TBNA prevented 87% of mediastinoscopies (95% confidence interval [CI], 77-94%; P < 0.001) but failed to provide a diagnosis in 10 patients (13%), all of whom underwent mediastinoscopy. The sensitivity and negative predictive value of EBUS-TBNA in patients with IML were 92% (95% CI, 83-95%) and 40% (95% CI, 12-74%), respectively. One patient developed a lower respiratory tract infection after EBUS-TBNA, requiring inpatient admission. The cost of the EBUS-TBNA procedure per patient was £1,382 ($2,190). The mean cost of the EBUS-TBNA strategy was £1,892 ($2,998) per patient, whereas a strategy of mediastinoscopy alone was significantly more costly at £3,228 ($5,115) per patient (P < 0.001). The EBUS-TBNA strategy is less costly than mediastinoscopy if the cost per EBUS-TBNA procedure is less than £2,718 ($4,307) per patient. CONCLUSIONS: EBUS-TBNA is a safe, highly sensitive, and cost-saving initial investigation in patients with IML. Clinical trial registered with ClinicalTrials.gov (NCT00932854).

Diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle biopsy in mediastinal lymphadenopathy: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis of prospectively conducted studies to define diagnostic performance of endobronchial ultrasound-guided transbronchial needle biopsy (EBUS-TBNB) in mediastinal and hilar lymphadenopathy. METHODS: A comprehensive search was performed using the Embase, Ovid Medline, Ovid Medline In-Process and Other Non-Indexed Citations, All Evidence Based Medicine Reviews-Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CCTR), Health Technology Assessment (HTA), and SCOPUS databases, in the second week of November 2010. Studies were selected in 2 phases by 2 reviewers, independently. Data extraction from each study was performed using a standardized data extraction form. Quality assessment of study methodology was done using a checklist that was developed based on a Quality Assessment of Diagnostic Accuracy Studies tool and the nature of the test. Using the 2 × 2 tables, we computed the sensitivity, specificity, and likelihood ratios. RESULTS: The 14 studies included for quantitative data synthesis had a pooled cohort of 1,658 patients, from 8 different countries. The EBUS-TBNB had excellent pooled specificity of 100% (95% CI 0.90-1.00) and a positive likelihood ratio of 5.1 (95% CI 2.7-9.7). The pooled sensitivity was 0.92 (95% CI 0.91-0.93), and the pooled negative likelihood ratio was 0.13 (95% CI 0.09-0.19). The sensitivity of this intervention was not dependent on rapid on-site evaluation use or size of needle used. The pooled diagnostic odds ratio was 62.7 (95% CI 25.7-153.0). Only one major complication was reported, which resulted in early termination of the procedure. CONCLUSIONS: Evidence of moderate quality confirms the high diagnostic performance of EBUS-TBNB for mediastinal and hilar lymphadenopathy, both in malignant and non-malignant conditions. Available evidence also demonstrates the safety of this procedure.

Convex probe endobronchial ultrasound: pitfalls, training and service issues.

Convex probe endobronchial ultrasound is an evolving technology allowing real-time transbronchial needle aspiration used for lung cancer staging and diagnosis of cancer or unexplained mediastinal or hilar lymphadenopathy. This article focuses on setting up a service, pitfalls and training issues.

Sonographic assessment of cervical lymphadenopathy: role of high-resolution and color Doppler imaging.

BACKGROUND: The objective of this article was to study the role of high frequency ultrasound and color Doppler imaging in the diagnostic evaluation of patients with cervical lymphadenopathy. METHODS: The present study was carried out over a period of 18 months and included 64 patients of different age groups presenting with cervical lymphadenopathy. Comprehensive sonographic examination of the neck for cervical lymph nodes was performed using the LOGIQ 500 ultrasound machine (GE Wipro Proseries). The scanning was performed with the patient in the supine position, and with the neck hyperextended using a pad or pillow under the shoulders in order to provide optimum exposure of the neck. The parameters considered in this study included: site, mean long axis (L), mean short axis (S), shape index (S/L), echotexture and homogenicity, margins, ancillary features like calcification, necrosis, posterior enhancement, matting and surrounding tissue changes, vascular pattern, and mean arterial resistive index (RI). These findings were correlated with fine-needle aspiration cytology and excisional biopsy. The nodes were classified as reactive, lymphomatous, and metastatic. The results were subjected to statistical analysis using SPSS software. A p value of < .05 was considered to be significant. RESULTS: The results showed that malignant lymph nodes, especially metastatic nodes, are mostly accompanied with rounded shape, homogenous echotexture, peripheral vascularity, and significantly high RI. Among these sonographic findings, nodal shape (S/L ratio) and RI were more accurate for differentiating benign from malignant lymph nodes. Most of the malignant nodes had well-defined borders. Calcification, necrosis, posterior enhancement, matting, and hilar flow patterns were characteristically found in tubercular lymphadenitis. A combined ultrasound-guided and fine-needle aspiration (FNA) diagnosis had a high sensitivity (95.4%) and specificity (92.3) as compared with situations in which they were used alone. CONCLUSION: Sonographic findings have a high accuracy in differentiating benign from malignant cervical lymph nodes. An ultrasound scan can be used as the first-line imaging tool in the diagnostic evaluation of cervical lymphadenopathy, especially in developing countries like India due to its ease, noninvasiveness, reproducibility, and cost effectiveness. It can also be used as an imaging tool for the guided aspirations. However, because of some overlapping in sonographic appearances of benign and malignant nodes, this modality may not have definite diagnostic values. But when combined with FNA, it has a very high sensitivity and specificity.

Performance of EUS-FNA for mediastinal lymphadenopathy: impact on patient management and costs in low-volume EUS centers.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of mediastinal lymphadenopathy has been shown to be a valuable diagnostic tool in high-volume EUS centers (≥ 50 mediastinal EUS-FNA/endoscopist/year). Our goal was to assess the diagnostic accuracy of EUS-FNA and its impact on clinical management and costs in low-volume EUS centers (<50 mediastinal EUS-FNA/endoscopist/year). METHODS: Consecutive patients referred to two Dutch endoscopy centers in the period 2002-2008 for EUS-FNA of mediastinal lymphadenopathy were reviewed. The gold standard for a cytological diagnosis was histological confirmation or clinical follow-up of more than 6 months with repeat imaging. The impact of EUS-FNA on clinical management was subdivided into a positive impact by providing (1) adequate cytology that influenced the decision to perform surgery or (2) a diagnosis of a benign inflammatory disorder, and a negative impact which was subdivided into (1) false-negative or inconclusive cytology or (2) an adequate cytological diagnosis that did not influence patient management. Costs of an alternative diagnostic work-up without EUS-FNA, as established by an expert panel, were compared to costs of the actual work-up. RESULTS: In total, 213 patients (71% male, median age= 61 years, range = 23-88 years) underwent EUS-FNA. Sensitivity, specificity, and negative and positive predictive values were 89%, 100%, 80%, and 100%, respectively. EUS-FNA had a positive impact on clinical management in 84% of cases by either influencing the decision to perform surgery (49%) or excluding malignant lymphadenopathy (35%), and a negative impact in 7% of cases because of inadequate (3%) or false-negative (4%) cytology. In 9% of cases, EUS-FNA was performed without an established indication. Two nonfatal perforations occurred (0.9%). Total cost reduction was €100,593, with a mean cost reduction of €472 (SD = €607) per patient. CONCLUSIONS: Mediastinal EUS-FNA can be performed in low-volume EUS centers without compromising diagnostic accuracy. Moreover, EUS-FNA plays an important role in the management of patients with mediastinal lymphadenopathy and reduces total diagnostic costs.

Endobronchial ultrasound-guided transbronchial needle aspiration cytology: a state of the art review.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a recently developed, accurate, safe and cost-effective technique that allows sampling of mediastinal lymph nodes and peribronchial lesions including pulmonary and mediastinal lesions. Its major indications are the nodal staging of non-small cell carcinomas of the lung, their restaging after chemotherapy and/or radiation, the diagnosis of sarcoidosis and of metastases from extrathoracic malignancies, and the diagnosis of mediastinal lymphadenopathy and masses of unknown aetiology. From our experience at the University of Minnesota and a comprehensive review of the literature, we discuss technical aspects of the procedure, its advantages and limitations in comparison with other methods of sampling mediastinal lymph nodes, focusing on the role of the cytopathologist in ensuring the effectiveness of the procedure. An algorithmic approach to the cytological diagnosis, starting with the determination of the adequacy of the sample, is also presented.

Cytological assessment of conventional transbronchial fine needle aspiration of lymph nodes.

OBJECTIVES: Transbronchial fine needle aspiration (TBNA) is a minimally invasive bronchoscopic technique that allows pathological examination of mediastinal and hilar lymph nodes. The aim of this study was to assess the cytopathological outcome of TBNA. METHODS: One hundred and eighty-seven patients who underwent TBNA of mediastinal and hilar lesions from May 2000 to June 2007 were reviewed. RESULTS: TBNA results were considered to be adequate if the cytological material revealed a malignant lesion or sufficient number of benign lymphoid cells. In the current study, 40 cases (21.9%) were reported as inadequate. When inadequate tests were excluded, the overall sensitivity and accuracy of TBNA in the diagnosis of malignant lesions were 83.5% and 88.0% respectively. The lowest sensitivity was noted in lymph node involvement by lymphoma. Regarding the workload associated with TBNA cytology, we found that the average number of conventionally prepared cytological slides per case was high (17 slides per case). CONCLUSION: Our results confirm that conventional TBNA is a sensitive and useful technique but it is relatively expensive and the protocols should be adapted to allow appropriate material to be collected for ancillary diagnostic tests.