Malignant and Benign Tracheobronchial Neoplasms: Comprehensive Review with Radiologic, Bronchoscopic, and Pathologic Correlation.

Tracheobronchial neoplasms are much less common than lung parenchymal neoplasms but can be associated with significant morbidity and mortality. They include a broad differential of both malignant and benign entities, extending far beyond more commonly known pathologic conditions such as squamous cell carcinoma and carcinoid tumor. Airway lesions may be incidental findings at imaging or manifest with symptoms related to airway narrowing or mucosal irritation, invasion of adjacent structures, or distant metastatic disease. While there is considerable overlap in clinical manifestation, imaging features, and bronchoscopic appearances, an awareness of potential distinguishing factors may help narrow the differential diagnosis. The authors review the epidemiology, imaging characteristics, typical anatomic distributions, bronchoscopic appearances, and histopathologic findings of a wide range of neoplastic entities involving the tracheobronchial tree. Malignant neoplasms discussed include squamous cell carcinoma, malignant salivary gland tumors (adenoid cystic carcinoma and mucoepidermoid carcinoma), carcinoid tumor, sarcomas, primary tracheobronchial lymphoma, and inflammatory myofibroblastic tumor. Benign neoplasms discussed include hamartoma, chondroma, lipoma, papilloma, amyloidoma, leiomyoma, neurogenic lesions, and benign salivary gland tumors (pleomorphic adenoma and mucous gland adenoma). Familiarity with the range of potential entities and any distinguishing features should prove valuable to thoracic radiologists, pulmonologists, and cardiothoracic surgeons when encountering the myriad of tracheobronchial neoplasms in clinical practice. Attention is paid to any features that may help render a more specific diagnosis before pathologic confirmation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Overview of Interventional Pulmonology for Radiologists.

Interventional pulmonology is a growing field specializing in minimally invasive procedures of the mediastinum, lungs, airways, and pleura. These procedures have both diagnostic and therapeutic indications and are performed for benign and malignant diseases. Endobronchial US has been combined with transbronchial needle aspiration to extend tissue sampling beyond the airways and into the lungs and mediastinum. Recent innovations extending the peripheral access of bronchoscopy include electromagnetic navigational bronchoscopy and thinner bronchoscopes. An important indication for therapeutic bronchoscopy is the relief of central airway obstruction, which may be severe and life threatening. Techniques for restoring patency of the central airways include mechanical debulking and multiple modalities for ablation, stent placement, and balloon bronchoplasty. Bronchoscopic lung volume reduction improves quality of life in certain patients with severe emphysema and is an important less invasive alternative to lung volume reduction surgery. Bronchial thermoplasty is likewise a nonpharmacologic treatment in patients with severe uncontrolled asthma. Many of these procedures have unique selection criteria that require precise evaluations at preprocedure imaging. Postprocedure imaging is also essential in determining outcome success and the presence of complications. Radiologists should be familiar with these procedures as well as the relevant imaging features in both planning and later surveillance. Evolving techniques that may become more widely available in the near future include robotic-assisted bronchoscopy, bronchoscopic transparenchymal nodule access, transbronchial cryobiopsy, ablation of early-stage cancers, and endobronchial intratumoral chemotherapy. An invited commentary by Wayne et al is available online. ©RSNA, 2021.

Bronchoscope-Guided Percutaneous Endoscopic Gastrostomy Tube Placement by Interventional Pulmonologists: A Feasibility and Safety Study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tube placement is a procedure frequently done in the intensive care unit. The use of a traditional endoscope can be difficult in cases of esophageal stenosis and theoretically confers an increased risk of infection due to its complex architecture. We describe a technique using the bronchoscope, which allows navigation through stenotic esophageal lesions and also minimizes the risk of endoscopy-associated infections. METHODS: Prospective series of patients who had PEG tube placement guided by a bronchoscope. Procedural outcomes including successful placement, duration of the entire procedure, time needed for passage of the bronchoscope from the oropharynx to the major curvature, PEG tube removal rate, and mortality were collected. Procedural adverse events, including infections and long-term PEG-related complications, were recorded. RESULTS: A total of 84 patients underwent bronchoscope-guided PEG tube placement. Percutaneous endoscopic gastrostomy tube insertion was completed successfully in 82 (97.6%) patients. Percutaneous endoscopic gastrostomy tube placement was performed immediately following percutaneous tracheostomy in 82.1%. Thirty-day mortality and 1-year mortality were 11.9% and 31%, respectively. Overall, minor complications occurred in 2.4% of patients, while there were no major complications. No serious infectious complications were identified and no endoscope-associated hospital acquired infections were documented. CONCLUSIONS: The use of the bronchoscope can be safely and effectively used for PEG tube placement. The use of bronchoscope rather than a gastroscope has several advantages, which include the ease of navigating through complex aerodigestive disorders such as strictures and fistulas as well as decreased health-care utilization. In addition, it may have a theoretical advantage of minimizing infections related to complex endoscopes.

New trends in interventional pulmonology.

PURPOSE OF REVIEW: As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications. RECENT FINDINGS: The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia. SUMMARY: The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described.

Progressive Dyspnea in a Woman With Tracheal Stenosis and Rheumatoid Arthritis.

CASE PRESENTATION: An 82-year-old woman with a remote tracheostomy due to vocal cord paralysis and long-standing erosive, seropositive rheumatoid arthritis (RA) well controlled with methotrexate sought treatment at the ED with 1 month of dyspnea, chest tightness, and cough productive of blood-tinged sputum. She had been treated unsuccessfully as an outpatient with multiple courses of antibiotics. She did not smoke or drink alcohol and had no recent travel outside the country. Given concern for airway compromise, she was admitted to the hospital.

Bedside sonography for detection of postprocedure pneumothorax.

OBJECTIVES: Bedside sonography for diagnosis of pneumothorax has been well described in emergency and trauma medicine literature. Its role in detection of iatrogenic pneumothorax has not been well studied. We describe the performance of bedside sonography for detection of procedure-related pneumothorax and highlight some limitations. METHODS: A total of 185 patients underwent thoracentesis (n = 60), transbronchial biopsy (n = 48), and computed tomography-guided needle lung biopsy (n = 77). Bedside preprocedure and postprocedure transthoracic sonography and postprocedure chest radiograph were performed in all patients. Patients in whom the pleural surface was not well imaged with sonography were said to have a limited examination. Chest radiography was the standard for diagnosing pneumothorax. RESULTS: Chest radiography showed pneumothorax in 8 of 185 patients (4.0%). These patients had undergone computed tomography-guided needle lung biopsy (n = 7) and transbronchial needle lung biopsy (n = 1). Sonography showed pneumothorax in 7 of these patients. The sensitivity, specificity, and diagnostic accuracy were 88%, 97%, and 97%, respectively. Limited-quality sonographic examinations due to preexisting lung disease were seen in 43 of 185 patients. The positive and negative likelihood ratios for patients with adequate scans were 55 and 0.17, respectively. The likelihood ratio for patients with limited-quality scans was 1.08. CONCLUSIONS: When a good-quality scan is achieved, bedside chest sonography is a valuable tool for evaluation of postprocedure pneumothorax. Patients with preexisting lung disease, in whom the quality of the sonographic examination is limited, should be studied with chest radiography.

37-Year-Old Tracheostomized Woman With Overdistended Tracheostomy Cuff and Difficulty Ventilating.

CASE PRESENTATION: A 37-year-old woman with a medical history of myasthenia gravis resulting in progressive respiratory failure requiring continuous mechanical ventilation via tracheostomy, as well as multiple cardiac arrests leading to severe anoxic brain injury, was brought to the hospital from a nursing home because of difficulties with ventilation and oxygenation. On presentation to the ED, the patient was found to be agitated and tachypneic on a ventilator, generating low tidal volumes despite elevated peak airway pressures. Before the current presentation, the patient had been mechanically ventilated at a long-term acute care facility for the past 5 years. More recently, staff has noted intermittent loss of tidal volumes, temporarily responding to overinflation of tracheostomy cuff. Additionally, the tracheostomy tube was exchanged for an extra-long tracheostomy tube to improve tidal volumes; however, the problem persisted, prompting the current presentation.

Diagnostic Performance and Safety Profile of Robotic-assisted Bronchoscopy: A Systematic Review and Meta-Analysis.

Rationale: Conventional electromagnetic navigation bronchoscopy and other guided bronchoscopic modalities have a very desirable safety profile, but their diagnostic yield is only 60-70% for pulmonary lesions. Recently, robotic-assisted bronchoscopy (RAB) platforms have been introduced to improve the diagnostic performance of bronchoscopic modalities. Objectives: To determine the diagnostic performance and safety profile of RAB (using shape-sensing and electromagnetic navigation-based platforms) by performing a systematic review and meta-analysis. Methods: The PubMed, Embase, and Google Scholar databases were searched to find studies that reported on the diagnostic performance and/or the safety profile of one of the RAB systems. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was performed using MedCalc version 20.118. Pooled diagnostic yield was calculated using a Freeman-Tukey transformation. We planned to use a random-effects model if the I2 index was >40%. Results: Twenty-five studies were included: 20 including diagnostic and safety analyses and 5 including only safety analyses. The pooled diagnostic yield of RAB (20 studies, 1,779 lesions) was 84.3% (95% confidence interval, 81.1-87.2%). The I2 index was 65.6%. On the basis of our subgroup analyses, the heterogeneity was likely driven by differences in study designs (prospective vs. retrospective) and procedural protocols (such as different RAB systems). Lesion size > 2 cm, the presence of a computed tomography bronchus sign, and concentric radial endobronchial ultrasound view were associated with a statistically significant increase in the odds of diagnosis with RAB. The overall rates of pneumothorax, need for tube thoracostomy, and significant hemorrhage were 2.3%, 1.2%, and 0.5%, respectively. Conclusions: RAB systems have significantly increased the diagnostic yield of navigational bronchoscopy compared with conventional systems such as electromagnetic navigation bronchoscopy, but well-designed prospective studies are needed to better understand the impact of various factors, such as the use of three-dimensional imaging modalities, cryobiopsy, and specific ventilatory protocols, on the diagnostic yield of RAB.

High-riding Superior Pericardial Recess: A Key Pitfall in Misinterpretation During CT Evaluation of the Mediastinum.

An understanding of thoracic computed tomographic anatomy is vital for procedural planning in bronchoscopy. When reviewing computed tomographic images in preparation for endobronchial ultrasound-directed staging for lung cancer, the presence of fluid in pericardial recesses can often be mistaken for mediastinal lymphadenopathy, potentially causing pitfalls in radiologic interpretation. We describe 2 cases of a high-riding superior aortic recess extending into right paratracheal lymph node station mimicking paratracheal lymphadenopathy. We review the anatomy and imaging characteristics of pericardial recesses with emphasis on differentiating these findings from mediastinal lymphadenopathy.

A Diagnostic Conundrum: Progressive Tubular Lung Mass in Asymptomatic Young Woman.

CASE PRESENTATION: A 39-year-old female avid marathon runner presented with an abnormal chest radiograph obtained during preoperative evaluation prior to bilateral knee replacement because of osteoarthritis. As shown in Figure 1, chest radiograph revealed a focal nodular opacity in the middle lobe. She did not have any prior imaging for comparison.

Endobronchial valves for persistent air leak all-cause mortality and financial impact: US trend from 2012-2016.

Background: Endobronchial valves (EBV) are considered an innovation in the management of the persistent air leak (PAL). They offer a minimally invasive alternative to the traditional approach of pleurodesis and surgical intervention. We examined trends in mortality, length of stay (LOS), and resources utilization in patients who underwent EBV placement for PAL in the US. Methods: We utilized discharge data from the Nationwide Inpatient Sample (NIS) for five years (2012-2016). We included adults diagnosed with a pneumothorax who underwent EBV insertion at ≥ 3 days from the day of chest tube placement; or following invasive thoracic procedure. We analyzed all-cause mortality, LOS, and resources utilization in the study population. Results: A total of 1,885 cases met our inclusion criteria. Patients were mostly middle-aged, males, whites, and had significant comorbidities. The average LOS was 21.8 ± 20.5 days, the mean time for chest tube placement was 3.8 ± 5.9 days, and the mean time for EBV insertion was 10.5 ± 10.3 days. Pleurodesis was performed before and after EBV placement and in 9% and 6%, respectively. Conclusions: Our study showed that the all-cause mortality rate fluctuated throughout the years at around 10%. Despite EBV being a minimally invasive alternative, its use has not trended up significantly during the study period. EBVs are also being used off-label in the US for spontaneous pneumothorax. This study shall provide more data to the scarce literature about EBV for PAL.

Needle-based Optical Coherence Tomography to Guide Transbronchial Lymph Node Biopsy.

BACKGROUND: Transbronchial needle aspiration (TBNA), often used to sample lymph nodes for lung cancer staging, is subject to sampling error even when performed with endobronchial ultrasound. Optical coherence tomography (OCT) is a high-resolution imaging modality that rapidly generates helical cross-sectional images. We aim to determine if needle-based OCT can provide microstructural information in lymph nodes that may be used to guide TBNA, and improve sampling error. METHODS: We performed ex vivo needle-based OCT on thoracic lymph nodes from patients with and without known lung cancer. OCT imaging features were compared against matched histology. RESULTS: OCT imaging was performed in 26 thoracic lymph nodes, including 6 lymph nodes containing metastatic carcinoma. OCT visualized lymphoid follicles, adipose tissue, pigment-laden histiocytes, and blood vessels. OCT features of metastatic carcinoma were distinct from benign lymph nodes, with microarchitectural features that reflected the morphology of the carcinoma subtype. OCT was also able to distinguish lymph node from adjacent airway wall. CONCLUSIONS: Our results demonstrate that OCT provides critical microstructural information that may be useful to guide TBNA lymph node sampling, as a complement to endobronchial ultrasound. In vivo studies are needed to further evaluate the clinical utility of OCT in thoracic lymph node assessment.

Lung cancer patients have the highest malignancy-associated suicide rate in USA: a population-based analysis.

PURPOSE: Previous studies have reported that psychological and social distresses associated with a cancer diagnosis have led to an increase in suicides compared to the general population. We sought to explore lung cancer-associated suicide rates in a large national database compared to the general population, and to the three most prevalent non-skin cancers [breast, prostate and colorectal cancer (CRC)]. METHODS: The Surveillance, Epidemiology and End Results (SEER) database (1973-2013) was retrospectively reviewed to identify cancer-associated suicide deaths in all cancers combined, as well as for each of lung, prostate, breast or CRCs. Suicide incidence and standardised mortality ratio (SMR) were estimated using SEER*Stat-8.3.2 program. Suicidal trends over time and timing from cancer diagnosis to suicide were estimated for each cancer type. RESULTS: Among 3,640,229 cancer patients, 6,661 committed suicide. The cancer-associated suicide rate was 27.5/100,000 person years (SMR = 1.57). The highest suicide risk was observed in patients with lung cancer (SMR = 4.17) followed by CRC (SMR = 1.41), breast cancer (SMR = 1.40) and prostate cancer (SMR = 1.18).Median time to suicide was 7 months in lung cancer, 56 months in prostate cancer, 52 months in breast cancer and 37 months in CRC (p < 0.001).We noticed a decreasing trend in suicide SMR over time, which is most notable for lung cancer compared to the other three cancers. In lung cancer, suicide SMR was higher in elderly patients (70-75 years; SMR = 12), males (SMR = 8.8), Asians (SMR = 13.7), widowed patients (SMR = 11.6), undifferentiated tumours (SMR = 8.6), small-cell lung cancer (SMR = 11.2) or metastatic disease (SMR = 13.9) and in patients who refused surgery (SMR = 13). CONCLUSION: The cancer-associated suicide rate is nearly twice that of the general population of the United States of America. The suicide risk is highest among the patients with lung cancer, particularly elderly, widowed, male patients and patients with unfavourable tumour characteristics. The identification of high-risk patients is of extreme importance to provide proper psychological assessment, support and counselling to reduce these rates.

Characteristics and financial costs of patients with respiratory failure at bronchoscopy.

BACKGROUND: A case-control study was conducted to identify the possible risk factors for acute respiratory failure in patients undergoing bronchoscopy. We also aimed to estimate the financial costs incurred in the care of high-risk patients. METHODS: All hypoxic respiratory complications that occurred during bronchoscopy between January 2005 and March 2009 were reviewed. Mild hypoxia was defined as the need for up to 6 L of nasal cannula, moderate hypoxia as requiring up to 100% nonrebreather face mask, and severe hypoxia requiring intubation and mechanical ventilation to maintain pulse oximetry above 90%. The Wilcoxon 2-sample test was used to compare continuous groups. Categorical variables were assessed using χ(2), Fischer exact, and Kruskal-Wallis tests. We calculated the cost of medical care for patients admitted to the intensive care unit after bronchoscopy. RESULTS: During our study period, 26 patients were reported to have hypoxia with bronchoscopy. The mean age for our study group was 66.1 years, and body mass index 26.1 kg/m(2) (SD, 7.6). The study group's mean albumin was 2.9 g/dL (SD, 0.6) compared with 3.3 g/dL (SD, 0.7, P=0.0019), the study group's hematocrit was 32.4% (SD, 5.7) compared with 37.9% (SD, 5.5, P=0.0241), the study group's forced expiratory volume to forced vital capacity ratio ratio was 65.0 (SD, 15.8) compared with 78.0 (SD, 18.8, P=0.0133), and the study group's forced expiratory volume was 59.5% compared with 71.2% (P=0.0606). The study group's mean pCO(2) was 53.7 mm Hg (SD, 18.6). Six patients required intensive care unit admission after bronchoscopy and the total cost of care for this group was $80,353. CONCLUSIONS: Prescreening of selected patients may reduce respiratory failure and possibly the total cost of medical care.