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BACKGROUND: Thoracentesis using suction is perceived to have increased risk of complications, including pneumothorax and re-expansion pulmonary oedema (REPO). Current guidelines recommend limiting drainage to 1.5â L to avoid REPO. Our purpose was to examine the incidence of complications with symptom-limited drainage of pleural fluid using suction and identify risk factors for REPO. METHODS: A retrospective cohort study of all adult patients who underwent symptom-limited thoracentesis using suction at our institution between January 1, 2004 and August 31, 2018 was performed, and a total of 10â344 thoracenteses were included. RESULTS: Pleural fluid ≥1.5â L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%) and persistent cough (13%). Pneumothorax based on chest radiography was detected in 3.98%, but only 0.28% required intervention. The incidence of REPO was 0.08%. The incidence of REPO increased with Eastern Cooperative Oncology Group performance status (ECOG PS) ≥3 compounded with ≥1.5â L (0.04-0.54%; 95% CI 0.13-2.06â L). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (p<0.01). CONCLUSIONS: Symptom-limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPO are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPO increased with poor ECOG PS and drainage ≥1.5â L. Symptom-limited drainage using suction without pleural manometry is safe.
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Derrame Pleural , Neumotórax , Adulto , Drenaje , Humanos , Derrame Pleural/epidemiología , Derrame Pleural/etiología , Derrame Pleural/terapia , Neumotórax/epidemiología , Neumotórax/etiología , Neumotórax/terapia , Estudios Retrospectivos , Succión , ToracocentesisRESUMEN
BACKGROUND AND OBJECTIVE: Pleuroscopy is the test of choice for patients with suspected malignant pleural effusion and negative cytology. Biopsies negative for malignancy are frequently attributed to non-specific pleuritis, which poses a dilemma in patients with a known active malignancy, raising concern for a false-negative result. Our primary objective was to determine the outcomes of patients with active malignancy who had a non-malignant diagnosis on pleuroscopy. METHODS: Retrospective review of all pleuroscopy cases from January 2005 to January 2015 at our institution was conducted. Biopsies were categorized by histopathology as malignant, eosinophilic or non-specific pleuritis. Malignant histopathology was considered a true positive. Eosinophilic or non-specific pleuritis was categorized as malignant, if malignancy was later identified during follow-up, or chemotherapy induced, possible radiation induced, other paramalignant, other benign or idiopathic. RESULTS: Of the 199 pleuroscopy cases reviewed, 172 (86%) had a history of active malignancy. On histopathology, 73 (42%) had malignancy, 9 (5%) had eosinophilic pleuritis and 90 (52%) had non-specific pleuritis. Three patients with non-specific pleuritis were diagnosed with malignancy at follow-up. Pleuritis in 24 patients was chemotherapy induced, 27 were possibly radiation induced, 11 were other paramalignant and 3 were other benign. Idiopathic pleuritis was diagnosed in 31 patients. Patients were monitored for a mean of 23 ± 11 months. CONCLUSION: The prevalence of malignant pleural disease was lower than expected for our patient population. Patients with no malignancy on histopathology were most likely to have non-specific pleuritis, a cause for which was identified in a majority of patients after clinical review.
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Derrame Pleural Maligno/diagnóstico , Pleuresia/etiología , Pleuresia/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Biopsia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Toracoscopía , Adulto JovenRESUMEN
RATIONALE: Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy. OBJECTIVES: To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. METHODS: We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions. MEASUREMENTS AND MAIN RESULTS: Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16). CONCLUSIONS: Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.
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Broncoscopía/estadística & datos numéricos , Enfermedades Pulmonares/diagnóstico , Anciano , Biopsia con Aguja Fina/estadística & datos numéricos , Lavado Broncoalveolar/estadística & datos numéricos , Broncoscopía/efectos adversos , Broncoscopía/métodos , Femenino , Humanos , Pulmón/patología , Enfermedades Pulmonares/patología , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/patología , Masculino , Neumotórax/etiología , Pautas de la Práctica en Medicina/estadística & datos numéricos , Sistema de Registros/estadística & datos numéricos , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
RATIONALE: Data about the influence of the type of sedation on yield, complications, and tolerance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are based mostly on retrospective studies and are largely inconsistent. OBJECTIVES: To determine whether the type of sedation influences the diagnostic yield of EBUS-TBNA, its complication rates, and patient tolerance. METHODS: Patients referred for EBUS-TBNA were randomized (1:1) to undergo this procedure under general anesthesia (GA) or moderate sedation (MS). Pathologists were blinded to group allocation. MEASUREMENTS AND MAIN RESULTS: The main outcome was "diagnostic yield," defined as the percentage of patients for whom EBUS-TBNA rendered a specific diagnosis. One hundred and forty-nine patients underwent EBUS-TBNA, 75 under GA and 74 under MS. Demographic and baseline clinical characteristics were well balanced. Two hundred and thirty-six lymph nodes (LNs) and six masses were sampled in the GA group (average, 3.2 ± 1.9 sites/patient), and 200 LNs and six masses in the MS group (average, 2.8 ± 1.5 sites/patient) (P = 0.199). The diagnostic yield was 70.7% (53 of 75) and 68.9% (51 of 74) for the GA group and MS group, respectively (P = 0.816). The sensitivity was 98.2% in the GA group (confidence interval, 97-100%) and 98.1% in the MS group (confidence interval, 97-100%) (P = 0.979). EBUS was completed in all patients in the GA group, and in 69 patients (93.3%) in the MS group (P = 0.028). There were no major complications or escalation of care in either group. Minor complications were more common in the MS group (29.6 vs. 5.3%) (P < 0.001). Most patients stated they "definitely would" undergo this procedure again in both groups (P = 0.355). CONCLUSIONS: EBUS-TBNA performed under MS results in comparable diagnostic yield, rate of major complications, and patient tolerance as under GA. Future prospective multicenter studies are required to corroborate our findings. Clinical trial registered with www.clinicaltrials.gov (NCT 01430962).
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Anestesia General , Sedación Consciente , Biopsia Guiada por Imagen/métodos , Ganglios Linfáticos/patología , Neoplasias/patología , Biopsia del Ganglio Linfático Centinela/métodos , Adulto , Anciano , Anciano de 80 o más Años , Biopsia con Aguja Fina , Endosonografía , Femenino , Humanos , Ganglios Linfáticos/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Neoplasias/diagnóstico por imagen , Estudios Prospectivos , Sensibilidad y EspecificidadRESUMEN
PURPOSE OF REVIEW: The purpose of this review is to examine the literature on lung cancer screening with an emphasis on the prevalence of cancer in screen-detected nodules. On the basis of the evidence, we will then develop a practical approach to screen-detected lung nodules. RECENT FINDINGS: The first large randomized controlled trial using low-dose computed tomography (LDCT) found that persons undergoing three annual screening examinations with LDCT had a 20% relative reduction in lung cancer mortality as compared with those screened with annual chest X-rays. The probability of cancer in screen-detected nodules depends on their size and whether the nodules are detected on prevalence or incidence screens. The probability of cancer in screen-detected nodules ranges from 2.4 to 5.2%. Management strategies for screen-detected nodules that have been used successfully include careful observation using serial CT imaging, CT-guided fine needle biopsy, and surgery in carefully selected cases. The most frequently used strategies involve serial CT imaging and CT-guided biopsy for larger nodules and those that demonstrate growth on follow-up. SUMMARY: There is now evidence that LDCT in carefully selected high-risk populations can lead to better outcomes but the cost effectiveness of mass screening with LDCT is still unknown. Only patients at high risk for cancer should be screened.
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Detección Precoz del Cáncer/métodos , Neoplasias Pulmonares/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Análisis Costo-Beneficio , Detección Precoz del Cáncer/economía , Humanos , Neoplasias Pulmonares/mortalidad , Nódulos Pulmonares Múltiples/diagnóstico por imagen , Medición de Riesgo , Tomografía Computarizada por Rayos X/economía , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is used to stage mediastinal lymph nodes in cancer patients to optimize treatment strategies. In this retrospective study, the authors determined the utility of EBUS-TBNA biopsy in the evaluation of mediastinal lymphadenopathy at a high-volume cancer center. MATERIALS AND METHODS: The pathology database was searched for all patients who had undergone EBUS-TBNA biopsy of mediastinal lymph nodes over a one-year period. Cytologic diagnoses were correlated with clinical histories, subsequent resection, and clinical follow-up data. RESULTS: Of 928 lymph node samples, 226 (24%) were diagnosed as malignant, 4 (0.4%) were suspicious for malignancy, 9 (1%) were atypical, 640 (69%) were benign, and 47 (5%) were insufficient for evaluation. In 89 (9.6%) cases, the patients had surgical resection. There was one false positive, in which the primary tumor contained infiltrating lymphocytes, had been sampled. There were five false-negative cases, which resulted from sampling errors, including two with micrometastases. The sensitivity, specificity, and positive and negative predictive value rates for EBUS-TBNA biopsy in the evaluation of mediastinal lymph nodes were 68.7% and 98.6% and 91.6% and 93.5%, respectively on a per lymph node basis. The overall clinical sensitivity, specificity, and positive and negative predictive value rates after one year clinical/radiological and histologic follow-up were 97%, 99.3%, 96.7% and 99.4%, respectively. CONCLUSIONS: EBUS-TBNA biopsy is a sensitive and specific method for evaluating mediastinal lymphadenopathy in patients with lung and other primary tumors.
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PURPOSE OF REVIEW: The technique and clinical applications of medical thoracoscopy have substantially evolved in the last few decades. The recent development of a semirigid thoracoscope, which is handled similarly to a bronchoscope, has made this procedure more attractive to pulmonologists. We will review the latest data on clinical applications, recently developed techniques, and safety of medical thoracoscopy, focusing mainly on its role in thoracic malignancies. RECENT FINDINGS: Recent data confirm the high diagnostic yield of medical thoracoscopy - both with rigid and semirigid instruments - in detecting pleural metastases and determining the origin of pleural effusions. The degree of pleural adhesions found during thoracoscopy has been proposed by some authors as a prognostic factor for survival in patients with malignant pleural effusion. A large prospective multicenter study has established the safety of talc poudrage with large-particle talc, showing no cases of acute respiratory distress syndrome. SUMMARY: Medical thoracoscopy is an excellent tool to establish diagnosis in patients with exudative pleural effusion of unclear origin. It is highly valuable in clarifying the origin of pleural effusions in patients with lung cancer, as the presence of a malignant pleural effusion is associated with poor survival and precludes the possibility of treatment with curative intention. Pleurodesis with talc poudrage is efficacious and well tolerated, especially with the use of large-particle talc.
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Toracoscopios/tendencias , Toracoscopía/métodos , Toracoscopía/tendencias , Humanos , Derrame Pleural/diagnóstico , Derrame Pleural Maligno/diagnóstico , Pleurodesia/instrumentación , Pleurodesia/métodos , Pleurodesia/tendencias , Pronóstico , Neoplasias Torácicas/diagnósticoAsunto(s)
Quiste Broncogénico/diagnóstico , Enfermedades del Mediastino/diagnóstico , Quiste Broncogénico/terapia , Diagnóstico Diferencial , Drenaje/métodos , Humanos , Masculino , Enfermedades del Mediastino/terapia , Mediastino/diagnóstico por imagen , Persona de Mediana Edad , Tomografía Computarizada por Rayos X/métodos , UltrasonografíaAsunto(s)
Obstrucción de las Vías Aéreas/diagnóstico por imagen , Enfermedades Bronquiales/diagnóstico por imagen , Obstrucción de las Vías Aéreas/etiología , Enfermedades Bronquiales/complicaciones , Broncografía/métodos , Constricción Patológica/complicaciones , Constricción Patológica/diagnóstico por imagen , Femenino , Humanos , Persona de Mediana Edad , Tráquea/diagnóstico por imagenRESUMEN
BACKGROUND: Bronchoscopy is a safe procedure, but current guidelines recommend transfusion for platelets <20 K/µL. Studies of bronchoscopy in thrombocytopenia are limited. OBJECTIVES: Our objective was to evaluate the incidence of bleeding with flexible bronchoscopy in those with thrombocytopenia especially those <20 K/µL. METHOD: We performed a retrospective review of all flexible bronchoscopies between June 1, 2008 and December 31, 2010. Biopsies and therapeutic procedures were excluded. The χ, Fisher exact, and Rank-sum test were conducted to evaluate associations of clinically significant bleeding. RESULTS: There were 1711 patients who underwent 2053 flexible bronchoscopies. Cancer diagnosis included hematologic (61.3%) and solid organ malignancy (34.9%). Half of the bronchoscopies had moderate to severe thrombocytopenia (<100 K/µL) with the following ranges: 14.7% with 50 to <100 K/µL, 20.6% with 20 to <50 K/µL, 10.6% with 10 to <20 K/µL, 4.1% with <10 K/µL. Platelet transfusion was given in 90.6% of those with platelets <10 K/µL and 55.5% of those with platelets 10 to <20 K/µL. The nasal route for bronchoscopy was used in 92.4%. Bleeding complication rate however was 1.1% (0.2% major) and not affected by platelets. CONCLUSION: Bronchoscopy with lavage can be safely performed without platelet transfusion in those with platelets of ≥10 K/µL. In the absence of nasal bleeding, trauma, or deformity, the nasal route can be used for bronchoscopy.
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Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Broncoscopía , Neoplasias/epidemiología , Trombocitopenia/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Transfusión de Plaquetas , Estudios Retrospectivos , Factores de Riesgo , Trombocitopenia/sangre , Adulto JovenAsunto(s)
Ganglios Linfáticos , Enfermedades del Mediastino/diagnóstico , Pericardio/diagnóstico por imagen , Anciano , Diagnóstico Diferencial , Femenino , Humanos , Neoplasias del Mediastino/diagnóstico , Neoplasias del Mediastino/secundario , Tomografía Computarizada por Rayos X/métodos , UltrasonografíaAsunto(s)
Broncoscopios/efectos adversos , Endosonografía/efectos adversos , Falla de Equipo , Neoplasias Pulmonares/diagnóstico por imagen , Enfermedades Linfáticas/diagnóstico por imagen , Anciano , Anestesia General/métodos , Biopsia con Aguja/efectos adversos , Biopsia con Aguja/métodos , Líquido del Lavado Bronquioalveolar/citología , Remoción de Dispositivos , Endosonografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Máscaras Laríngeas , Neoplasias Pulmonares/patología , Enfermedades Linfáticas/patología , Mediastino/diagnóstico por imagen , Mediastino/patologíaRESUMEN
This study aimed to validate and implement a methodology in which fiducials implanted in the periphery of lung tumors can be used to reduce uncertainties in tumor location. Alignment software that matches marker positions on two-dimensional (2D) kilovoltage portal images to positions on three-dimensional (3D) computed tomography data sets was validated using static and moving phantoms. This software also was used to reduce uncertainties in tumor location in a patient with fiducials implanted in the periphery of a lung tumor. Alignment of fiducial locations in orthogonal projection images with corresponding fiducial locations in 3D data sets can position both static and moving phantoms with an accuracy of 1 mm. In a patient, alignment based on fiducial locations reduced systematic errors in the left-right direction by 3 mm and random errors by 2 mm, and random errors in the superior-inferior direction by 3 mm as measured by anterior-posterior cine images. Software that matches fiducial markers on 2D and 3D images is effective for aligning both static and moving fiducials before treatment and can be implemented to reduce patient setup uncertainties.
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Imagenología Tridimensional/métodos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/patología , Planificación de la Radioterapia Asistida por Computador/métodos , Tomografía Computarizada por Rayos X/métodos , Anciano de 80 o más Años , Algoritmos , Simulación por Computador , Humanos , Masculino , Oncología Médica/métodos , Fantasmas de Imagen , Intensificación de Imagen Radiográfica/métodos , Reproducibilidad de los Resultados , Programas Informáticos , Factores de TiempoRESUMEN
PURPOSE: The purpose of this work was to assess the magnitude of setup uncertainties and respiratory-induced motion of lung tumors by monitoring the location of fiducials implanted in the vicinity of the tumors. METHODS AND MATERIALS: Gold fiducials were implanted in the periphery of lung tumors in 5 patients who had Stage III non-small-cell lung cancer. Fiducial motion was measured using weekly repeated four-dimensional computed tomography (4DCT) imaging and during gated treatment each day using an electronic portal imaging device (EPID). Setup uncertainties were quantified using both the EPID images and the 4DCT data sets. RESULTS: We observed a reduction in fiducial motion (left/right and superior/inferior directions) during gated treatment; however, large gated motion was present (>1 cm). Systematic and random uncertainties based on patient setup ranged from 4 to 6 mm in all three directions as measured using fiducials on gated EPID images and repeat 4DCTs, and using bony anatomy on repeat 4DCTs. CONCLUSIONS: Respiratory gating may be an effective method of reducing average motion during the course of treatment, but large motion is still possible when delivering gated treatment. Setup uncertainties were on the order of, if not larger than, residual gated motion. We recommend careful consideration of all sources of error before reducing margins on the basis of respiratory motion management alone without a strategy for accurate patient setup on a daily basis.
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Carcinoma de Pulmón de Células no Pequeñas/diagnóstico por imagen , Neoplasias Pulmonares/diagnóstico por imagen , Movimiento , Prótesis e Implantes , Respiración , Tomografía Computarizada por Rayos X/métodos , Anciano , Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Femenino , Oro , Humanos , Neoplasias Pulmonares/radioterapia , Masculino , Persona de Mediana Edad , Planificación de la Radioterapia Asistida por Computador/métodos , Reproducibilidad de los Resultados , IncertidumbreRESUMEN
BACKGROUND: Recurrent chylothorax is a debilitating condition. We describe the usefulness of an indwelling pleural catheter (IPC) in the palliative management of recurrent symptomatic chylothorax in patients with cancer relapse or progressive disease despite adequate treatment. METHODS: In 10 years, 5,594 patients underwent 8,498 pleural procedures at our institution. Pleural fluid triglycerides were measured in 1,343 patients; of these patients, 130 had a chylothorax. Their medical records were reviewed. In 19 patients, recurrent symptomatic chylothorax appeared in association with cancer relapse. Treating physicians decided to place an IPC in 10 patients, and 9 patients had other palliative interventions. Baseline and postintervention changes in weight, absolute lymphocyte counts, and albumin levels in both groups were statistically compared. Hazard ratio and Kaplan-Meier curves of time to second pleural intervention after index procedure were also evaluated. RESULTS: The risk of requiring a second pleural intervention after the index procedure during the following 500 days was lower in the IPC group compared to the other pleural interventions (p=0.030), and Kaplan-Meier curves of time to second intervention were statistically different (p=0.025). Albumin levels decrease in the IPC group (p=0.007), but the decline was not worse than the decline observed in the control group (p=0.329), and recovered rapidly after IPC removal. CONCLUSIONS: Placement of an IPC may be considered as first-line palliative management for patients with symptomatic recurrent chylothorax poorly responsive to the treatment of the underlying malignancy.
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Catéteres de Permanencia , Quilotórax/terapia , Neoplasias/complicaciones , Adulto , Anciano , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , Quilotórax/etiología , Drenaje/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Cuidados Paliativos , Recurrencia , Resultado del TratamientoRESUMEN
RATIONALE: Accurate mediastinal staging is a cornerstone in the management of patients with lung cancer. For patients with radiographically normal mediastinum, current lung cancer guidelines recommend invasive mediastinal staging when tumors are centrally located. However, definitions of central tumors are nonspecific, and there are discrepancies among guidelines (e.g., some use the inner one-third of the hemithorax, whereas others use the inner two-thirds). OBJECTIVES: To describe the definitions of central tumors used by pulmonologists and thoracic surgeons in their practices. METHODS: An online questionnaire was e-mailed to members of the American Association for Bronchology and Interventional Pulmonology and members of the Cardiothoracic Surgery Network. MEASUREMENTS AND MAIN RESULTS: A total of 218 participants completed our survey (12% response rate). Most common definitions for central tumors were: inner one-third of the hemithorax (55%), in contact with hilar structures (29%), and inner two-thirds of the hemithorax (15%). Of note, 29% of participants chose a definition fabricated specifically for this survey and not supported by guidelines. Regarding the method to delineate the thirds of the hemithorax, 182 (84%) participants chose a system of concentric lines arising in the hilum, whereas 31 (14%) chose straight lines in the sagittal plane of the chest. We found strikingly similar responses in members of both societies. CONCLUSIONS: A uniform definition of tumor centrality is currently lacking, and should be formulated. Studies using objective measurements that evaluate the ability of these different definitions of central lung tumors to predict N2 disease are needed to construct a clear and evidence-based definition.