Use of an Extended Working Channel in High-Risk Transbronchial Biopsy: An Innovative Use of an Existing Modality to Minimize Bleeding and Hypoxia.

OBJECTIVE: Bleeding is one of the main complications of transbronchial lung biopsy (TBBx) more so with conditions such as azotaemia and coagulopathy. Baseline hypoxia worsens the consequences of TBBx bleeding and can lead to escalation of care. In our experience, TBBx performed through a guide sheath (GS) using it as an extended working channel (EWC) helps minimize bleeding risk. We hypothesized that the EWC produces a tamponade effect in the close vicinity of the biopsy site, both reducing bleeding risk and restricting bleeding to a smaller segment. In this study, we assessed the impact of an additional EWC in high-risk (HR) patients undergoing TBBx, to reduce bleeding and enhance safety. METHODS: Retrospective study between January 2014 and December 2018 looking at the risk of bleeding following TBBx performed through a GS (EWC) in patients at high risk for bleeding-related complications. Bleeding incidence and consequent hypoxic events requiring escalation of care were noted. The specimen diagnostic yield was also analyzed. SPSS statistics were used-data are reported as mean and standard deviation for continuous variables, and number and percentage for discrete variables. RESULTS: Eight hundred four TBBxs were performed during the study period, and 105 (13.1%) procedures were done in the HR individuals using a GS as an EWC. No significant bleeding requiring escalation of care was seen with the use of EWC-GS. Histopathology revealed adequate sampling in all cases. CONCLUSIONS: A GS as an EWC was used to reduce the bleeding risk, consequent hypoxia, and prevent escalation of care in TBBx in HR patients. Adequate tissue was obtained without any complications. Though prospective, randomized, multicenter trials using an EWC in HR-TBBx are important, they are challenging to do due to the HR population under study.

Primary tonsillar tuberculosis masquerading as carcinoma of the tonsil.

Primary tuberculosis (TB) of tonsil is a rare form of extra-pulmonary tuberculosis. Most tonsillar TB cases present with coexistent pulmonary tuberculosis. It can simulate tonsillar malignancy and poses a diagnostic challenge. Histopathological examination is often needed for confirmation. Herein, we report a case of primary tonsillar tuberculosis in a 55-year-old gentleman mimicking carcinoma of the tonsil.

Flexible bronchoscopy-guided vocal cord biopsy under conscious sedation: An option to surgical biopsy in special situations.

INTRODUCTION: Vocal cord (VC) biopsies are usually performed with rigid laryngoscopy under general anesthesia (GA). In patients with comorbidities such as cardiovascular or pulmonary disease, the risk of GA is high, with morbidity and potential mortality. We describe VC biopsy (VCB) in such a high-risk cohort, done safely and successfully with flexible bronchoscopy-VCB (FB-VCB) and conscious sedation. METHODS: FB-VCB was done in two groups of patients - the first at high risk for GA due to comorbidities and the second group where VC lesions were found incidentally in the course of FB done for other reasons. FB was done with local anesthesia and conscious sedation, and the VC lesion was identified. Flexible forceps were introduced through the working channel of the bronchoscope, and the lesions were carefully sampled. RESULTS: FB-VCB was performed in 15 patients (14 males and 1 female) with a mean age of 60.7 ± 12.1 years. Of these 15 patients, 6 patients were poor candidates for GA due to comorbidities and 9 patients had incidental VC lesions found during bronchoscopy. A diagnosis was made in 14/15 (93.3%) patients. Complications included a mild ooze and hoarseness of voice for a few days, which did not require any intervention. CONCLUSION: We report one of the few series of patients with VC biopsies done with FB (FB-VCB) under conscious sedation, without significant complications. It is safe and useful in high-risk patients who are poor candidates for GA, with a good diagnostic yield.

Utility of EBUS-TBNA in PET-positive mediastinal lymph nodes in subjects with extra-thoracic malignancy.

BACKGROUND/AIM: Patients with primary extra-thoracic malignancy (ETM) often have hyper-metabolic mediastinal lymph nodes (HM-MLN) in the PET-scan done for initial staging or post treatment follow-up. There is scant data on the etiology of HM-MLN in such patients, which can also be due to non-malignant causes. We used endobronchial ultrasound (EBUS) guided sampling to determine the etiology of HM-MLN in patients with ETM and study the relationship between PET-SUV values and a diagnosis of malignancy in this population. MATERIALS AND METHODS: 65 consecutive patients, from March 2013 to March 2017 with either known ETM for primary staging or post-treatment follow-up, with PET CT showing HM-MLN (SUV > 2.5) were included in the study. RESULTS: 65 patients with ETM had EBUS-TBNA for HM-MLN. 20/65 (30.7%) were malignant, 45/65 (69.23%) were benign MLN. In patients with benign etiology of HM-MLN, 6/45 (13.3%) had necrotising granulomatous, 24/45 (53.3%) had non- necrotising granulomatous MLN and 15/45 (33.3%) had reactive MLN. We found discordance (i.e. primary ETM responded to treatment and a new HM-MLN was detected) in 21/65 (32.3%) patients with PET-CT done for initial ETM staging, and 44/65 (67.7%) with a post-treatment PET-CT. showed. Correlating SUV with diagnoses, the SUV values in EBUS-proven malignant MLN were 8.9 ± 4.1, while they were 10.2 ± 5.57 in benign MLN. There was no statistically significant difference between the SUV of benign and malignant MLNs. CONCLUSION: This study shows a significant incidence of EBUS-TBNA proven benign diagnoses 45/65 (69.2%) in 'SUV-deemed-malignant MLN' and a poor relationship between high SUV and malignant MLN, in patients with known ETM. The ETM related HM-MLN have a significant chance of being benign, and a tissue diagnosis is imperative as it impacts on the treatment plan and prognosis.

Defining expanded areas in EBUS sampling: EBUS guided trans- and intra-pulmonary artery needle aspiration, with review of transvascular EBUS.

BACKGROUND: Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) has revolutionized the diagnostic approach to mediastinal diseases. Lesions located lateral to the pulmonary artery (trans-PA, Station 5), or in the lumen of the PA (intra-PA) are in the 'blind-spot' of EBUS. OBJECTIVES: We describe a case series where EBUS guided trans-pulmonary or intra-pulmonary aspiration (EBUS-TIPNA) was used for diagnosis. METHODS: Retrospective analysis of 10 patients who had EBUS-TIPNA over 3 years in 2 centres. The inclusion criteria included patients with station 5 lesions, or intrapulmonary artery lesions, where no other option was possible. RESULTS: The study included 4 males and 6 females, mean age 52 years, with 7 trans-PA and 3 intra-PA lesions. Adequacy was seen in 10/10, and a definitive diagnosis was made in 9/10 patients. There were no procedure-related complications. CONCLUSION: EBUS-TIPNA can be done as a safe and successful procedure and adds to the armamentarium of Convex Probe-EBUS (CP-EBUS), in carefully selected patients.

Poncet's Arthritis in a Patient with Multidrug-Resistant Tuberculosis.

A 17-year-old female diagnosed to have multidrug-resistant pulmonary tuberculosis (MDR-TB), presented with Poncet's arthritis which responded to second-line anti-TB treatment. Poncet's disease is more commonly present in association with extra-pulmonary TB and involves large and small joints. However, our patient had pulmonary MDR-TB and small joint involvement.