Thoracic endosonography (EBUS/EUS-b) in the diagnosis of different intrathoracic diseases: A 4-year experience at a single-centre in Greece.

BACKGROUND: In the last decade, the advent of thoracic endosonography has revolutionised the field of diagnostic bronchoscopy. METHODS: We conducted a single-centre prospective study in "Sotiria" Chest diseases hospital between January 2016 and December 2019. The study aimed to evaluate the efficacy and diagnostic value of combined EBUS/EUS-b in comparison with EBUS-TBNA and EUS-b FNA in different intrathoracic diseases. RESULTS: A total of 266 patients were enrolled (70.7% males, 85.7% smokers, mean age ± SD: 62.8 ± 11.8). Diagnosis and staging of suspected lung cancer (LC) were the main indications for EBUS/EUS-b in 56.7% of patients, followed by lymphadenopathy of unknown origin in 27%, lymphadenopathy in previous malignancy in 10.9%, and staging of proven LC in 5.3%. EUS-b FNA alone or combined with EBUS-TBNA was performed in 14.7% of patients. A total of 512 lymph nodes was sampled (481 through EBUS-TBNA and 31 through EUS-b FNA). EBUS/EUS-b led to a definitive diagnosis in 68.4% of the patients. Most cases (50.4%) were malignancies, while 18% represented benign diseases (83.3% sarcoidosis). Sensitivity of combined EBUS/EUS-b was higher in comparison with sensitivity of both procedures alone (100% vs 89.4% vs 88.9%). Accordingly, the overall sensitivity of EBUS/EUS-b for the detection of malignancy and sarcoidosis was 93% and 95.2%, respectively. No severe complications were observed. CONCLUSION: Thoracic endosonography is an efficient, safe, minimally invasive tool yielding high sensitivity and diagnostic accuracy in patients with suspected malignancy and mediastinal lymphadenopathy. Experienced pulmonologists in EBUS-TBNA should more routinely perform EUS-b FNA to avoid unnecessary surgical interventions.

Diagnostic Accuracy of Multiple D-Dimer Cutoff Thresholds and Other Clinically Applicable Biomarkers for the Detection and Radiographic Evaluation of Pulmonary Embolism.

Background: Diagnostic work-up of pulmonary embolism (PE) remains a challenge. Methods: We retrospectively studied all patients referred for computed tomography pulmonary angiography (CTPA) with suspicion of PE during a 12-month period (2018). The diagnostic accuracy of different D-dimer (Dd) cutoff thresholds for ruling out PE was evaluated. Furthermore, the association of Dd and red cell distribution width (RDW) with embolus location, CTPA findings, and patient outcome was recorded. Results: One thousand seventeen (n = 1017) patients were finally analyzed (mean age: 64.6 years (SD = 11.8), males: 549 (54%)). PE incidence was 18.7%. Central and bilateral embolism was present in 44.7% and 59.5%, respectively. Sensitivity and specificity for conventional and age-adjusted Dd cutoff was 98.2%, 7.9%, and 98.2%, 13.1%, respectively. A cutoff threshold (2.1 mg/L) with the best (64.4%) specificity was identified based on Receiver Operating Characteristics analysis. Moreover, a novel proposed Dd cutoff (0.74 mg/L) emerged with increased specificity (20.5%) and equal sensitivity (97%) compared to 0.5 mg/L, characterized by concurrent reduction (17.2%) in the number of performed CTPAs. Consolidation/atelectasis and unilateral pleural effusion were significantly associated with PE (p < 0.05, respectively). Patients with consolidation/atelectasis or intrapulmonary nodule(s)/mass on CTPA exhibited significantly greater median Dd values compared to patients without the aforementioned findings (2.34, (IQR 1.29−4.22) vs. 1.59, (IQR 0.81−2.96), and 2.39, (IQR 1.45−4.45) vs. 1.66, (IQR 0.84−3.12), p < 0.001, respectively). RDW was significantly greater in patients who died during hospitalization (p = 0.012). Conclusions: Age-adjusted Dd increased diagnostic accuracy of Dd testing without significantly decreasing the need for imaging. The proposed Dd value (0.74 mg/L) showed promise towards reducing considerably the need of CTPA. Multiple radiographic findings have been associated with increased Dd values in our study.

A 52-Year-Old Man Presented With Cough, Chest Pain, and a Mass in the Right Lung.

CASE PRESENTATION: A 52-year-old man, current smoker with a 50 pack-year history, presented to our department with cough, yellow sputum, and localized right chest pain. Chest radiograph revealed a large mass in the right upper lobe. He denied the presence of fever, night sweats, or weight loss. He has a medical history of COPD and anxiety disorder. He was receiving long-acting beta agonists/long-acting muscarinic antagonists as a treatment for COPD and quetiapine 100 mg for anxiety disorder.

Clinical utility of thoracic endosonography (EBUS/EUS-b) in mediastinal staging of patients with non-small cell lung cancer: comparison with integrated PET/CT-a real-life prospective study in Greece.

BACKGROUND: Accurate mediastinal staging in patients with non-small cell lung cancer (NSCLC) is crucial for the determination of optimal treatment management. METHODS: This was a real-life prospective study enrolling 140 patients between December 2016 and August 2018. We aimed to determine the clinical utility of EBUS/EUS-b in mediastinal staging of patients with NSCLC in comparison with integrated PET/CT. Furthermore, SUVmax cut-off value with the highest specificity/accuracy was evaluated. Subgroup analysis according to histological type was performed. RESULTS: One hundred and thirty patients were eligible for analysis (mean age ± SD: 67.6±7.6, males 97). Three hundred different lymph node stations were sampled (272 through EBUS-TBNA and 28 through EUS-b FNA). Mean SUVmax of all malignant lymph nodes was 7.46 (SD =5.54). Sensitivity, specificity, PPV and NPV of EBUS/EUS-b for the identification of mediastinal malignant lymph nodes was 93.8%, 100%, 100%, and 93.4%, respectively. Accordingly, PET/CT yielded 92.2% sensitivity, 43.9% specificity, 64.8% PPV and 83.3% NPV. For adenocarcinoma (n=76) NPV were 86.2% with EBUS/EUS-b and 75% with PET/CT. NPV for squamous cell (n=46) was 100% with EBUS/EUS-b and 90.9% with PET/CT. EBUS/EUS-b staging yielded excellent agreement with final staging (97.5%, Tau 0.94, P<0.001). ROC curve analysis identified the value 4.95 as the optimal SUVmax cut-off value with the best specificity (87.4%) and accuracy (79%) (AUC 0.69; 95% CI: 0.73-0.84, P<0.001). CONCLUSIONS: Thoracic endosonography is an excellent, minimally invasive tool yielding high sensitivity and diagnostic accuracy in mediastinal staging of patients with NSCLC. Implementation of both EBUS/EUS-b and PET/CT is necessary before any surgical intervention.

A Rare Case of Primary Intrapulmonary Neurilemmoma Diagnosed in a 43-Year-Old Asymptomatic Man with a Well-defined Intrapulmonary Mass.

Neurilemmoma (NL), also termed schwannoma, presents as a well-circumscribed and encapsulated mass in the human body and is almost always solitary. CT scan of a patient with NL shows a round, ovoid, or lobulated well-demarcated solid mass of soft tissue density. Primary intrathoracic neurogenic tumors location varies. However, the development of such tumors is by far more common in the costovertebral angle of the posterior mediastinum. Here, we report a rare case of a 43-year-old patient, never smoker and previously healthy, who presented with a mass adjacent to the right pulmonary hilum. This was an incidental finding on a chest X-ray after annual checkup at his workplace. The diagnosis was primary intrapulmonary NL. Primary intrapulmonary NL is an extremely rare tumor. However, based on the above, chest CT findings of a well-defined solid mass in an asymptomatic patient should raise the suspicion of NL, irrespective of the tumor localization.