Rare Synchronous Lung Cancers in a Nonsmoker with Epidermal Growth Factor Receptor and Mesenchymal-Epithelial Transition Alterations: A Case Report.

Introduction: Lung cancer is the second most common cancer; however, synchronous lung cancer is rare and challenging to treat. Case Presentation: We report the case of an 80-year-old female patient who presented with two lung lesions with primary tumor characteristics, which revealed squamous cell carcinoma and synchronous adenocarcinoma after histological sampling. Next-generation sequencing (NGS) analysis revealed a MET Exon 14 skipping mutation in squamous cell carcinoma and an epidermal growth factor receptor mutation in adenocarcinoma. Capmatinib and stereotactic radiotherapy were initiated for the adenocarcinoma with a good clinical response. Capmatinib treatment had to be discontinued because of stage 3 edema of the lower limbs, after which a left lobectomy was performed. Currently, the patient is considered to be in remission. Conclusion: This case highlights the need for histological analysis of every lung lesion with primary tumor characteristics, as well as for NGS analysis in search of specific mutations enabling the introduction of targeted therapies. mesenchymal-epithelial transition.

Data accuracy, consistency and completeness of the national Swiss cystic fibrosis patient registry: Lessons from an ECFSPR data quality project.

BACKGROUND: Good data quality is essential when rare disease registries are used as a data source for pharmacovigilance studies. This study investigated data quality of the Swiss cystic fibrosis (CF) registry in the frame of a European Cystic Fibrosis Society Patient Registry (ECFSPR) project aiming to implement measures to increase data reliability for registry-based research. METHODS: All 20 pediatric and adult Swiss CF centers participated in a data quality audit between 2018 and 2020, and in a re-audit in 2022. Accuracy, consistency and completeness of variables and definitions were evaluated, and missing source data and informed consents (ICs) were assessed. RESULTS: The first audit included 601 out of 997 Swiss people with CF (60.3 %). Data quality, as defined by data correctness ≥95 %, was high for most of the variables. Inconsistencies of specific variables were observed because of an incorrect application of the variable definition. The proportion of missing data was low with <5 % for almost all variables. A considerable number of missing source data occurred for CFTR variants. Availability of ICs varied largely between centers (10 centers had >5 % of missing documents). After providing feedback to the centers, availability of genetic source data and ICs improved. CONCLUSIONS: Data audits demonstrated an overall good data quality in the Swiss CF registry. Specific measures such as support of the participating sites, training of data managers and centralized data collection should be implemented in rare disease registries to optimize data quality and provide robust data for registry-based scientific research.

[Pulmonology 2021: year in review]. / Pneumologie.

Among the new therapeutic developments in pulmonology during 2021, we have identified three topics of interest. A new biotherapy is now available for the management of severe uncontrolled non-Th2 asthma. In the field of pulmonary arterial hypertension, upfront triple therapy at the time of diagnosis is associated with a survival benefit in high-risk patients. Riociguat is a therapeutic option for patients that remain at intermediate risk despite treatment with iPDE5. Sotatercept, a promising new class of drug for treatment of group 1 PAH will soon be available. Finally, the use of transbronchial cryobiopsies as a valid alternative to surgical lung biopsy for the diagnosis of diffuse interstitial lung diseases will also be discussed in this review.

Parmi les nouveautés thérapeutiques en pneumologie au cours de l'année 2021, nous aborderons trois sujets. Une nouvelle biothérapie est désormais disponible pour la prise en charge de l'asthme sévère non contrôlé non T-Helper 2. Concernant l'hypertension artérielle pulmonaire (HTAP), une triple thérapie d'emblée au moment du diagnostic est associée à un bénéfice sur la survie chez les patients à haut risque. Le riociguat est une option thérapeutique lors d'HTAP restant à risque intermédiaire malgré un traitement par inhibiteur de la phosphodiestérase de type 5, et le sotatercept vise une nouvelle cible thérapeutique prometteuse pour l'HTAP du groupe 1. Enfin, la place des cryobiopsies transbronchiques comme alternative valable à la biopsie chirurgicale pour le diagnostic des pneumopathies interstitielles diffuses selon des recommandations récentes se précise.

Nontuberculous Mycobacteria under Scrutiny in the Geneva Area (2015-2020).

BACKGROUND: Nontuberculous mycobacteria (NTM) are increasingly identified in industrialized countries, and their role as pathogens is more frequently recognized. The relative prevalence of NTM strains shows an important geographical variability. Thus, establishing the local relative prevalence of NTM strains is relevant and useful for clinicians. METHODS: Retrospective analysis (2015-2020) of a comprehensive database was conducted including all results of cultures for mycobacteria in a University Hospital (Geneva, Switzerland), covering a population of approximately 500,000 inhabitants. All NTM culture-positive patients were included in the analyses. Patients' characteristics, NTM strains, and time to culture positivity were reported. RESULTS: Among 38,065 samples analyzed during the study period, 411 were culture-positive for NTM, representing 236 strains, and 231 episodes of care which occurred in 222 patients. Patients in whom NTM were identified were predominantly female (55%), with a median age of 62 years, and a low BMI (median: 22.6 kg/m2). The Mycobacterium avium complex (MAC) was the most frequently identified group (37% of strains) followed by Mycobacterium gordonae (25%) and Mycobacterium xenopi (12%) among the slowly growing mycobacteria (SGM), while the Mycobacterium chelonae/abscessus group (11%) were the most frequently identified rapidly growing mycobacteria (RGM). Only 19% of all patients were treated, mostly for pulmonary infections: the MAC was the most frequently treated NTM (n = 19, 43% of cases in patients treated) followed by RGM (n = 15, 34%) and M. xenopi (n = 6, 14%). Among those treated, 23% were immunosuppressed, 12% had pulmonary comorbidities, and 5% systemic comorbidities. Cultures became positive after a median of 41 days (IQR: 23; 68) for SGM and 28 days (14; 35) for RGM. CONCLUSIONS: In Western Switzerland, M. avium and M. gordonae were the most prevalent NTM identified. Positive cultures for NTM led to a specific treatment in 19% of subjects. Patients with a positive culture for NTM were mostly female, with a median age of 62 years, a low BMI, and a low prevalence of immunosuppression or associated severe comorbidities.

[Diaphragmatic assessment by ultrasonography]. / Évaluation diaphragmatique par échographie.

Ultrasound of the diaphragm is an emerging technique that is performed at the bedside and allows assessment of diaphragm function in a variety of settings. Ultrasound is widely available, can be repeated if necessary, and is non-irradiating. First developed in intensive care, mainly for weaning from mechanical ventilation, its use is now extending to pulmonology. Different measurements are described such as diaphragmatic excursion, diaphragmatic thickness and diaphragmatic thickening fraction. The latter helps to diagnose dysfunction and is correlated with pulmonary hyperinflation. The main use in pulmonology is for the respiratory evaluation of patients with neuromuscular diseases, for the search of isolated diaphragmatic impairment and for patients with COPD. Numerous studies are in progress to better determine the role of diaphragmatic ultrasound.

La diffusion de l'accès à l'échographie a permis le développement de cette technique en pneumologie avec, plus récemment, l'évaluation du diaphragme. Plusieurs mesures sont décrites comme l'excursion, l'épaisseur et la fraction d'épaississement du diaphragme. Cela permet d'identifier la présence d'une dysfonction diaphragmatique, d'estimer l'activité et la capacité de réserve diaphragmatique. Cet outil non invasif, non irradiant et dynamique s'intègre de plus en plus à la prise en charge du patient. Des études ont permis de montrer l'existence d'une bonne corrélation entre l'échographie et les épreuves fonctionnelles respiratoires. D'autres sont en cours pour déterminer plus précisément l'impact de l'échographie diaphragmatique dans différentes prises en charge.

Impact of Confinement in Patients under Long-Term Noninvasive Ventilation during the First Wave of the SARS-CoV-2 Pandemic: A Remarkable Resilience.

BACKGROUND: During the first wave of the SARS-CoV-2 pandemic in Switzerland, confinement was imposed to limit transmission and protect vulnerable persons. These measures may have had a negative impact on perceived quality of care and symptoms in patients with chronic disorders. OBJECTIVES: To determine whether patients under long-term home noninvasive ventilation (LTHNIV) for chronic respiratory failure (CRF) were negatively affected by the 56-day confinement (March-April 2020). METHODS: A questionnaire-based survey exploring mood disturbances (HAD), symptom scores related to NIV (S3-NIV), and perception of health-care providers during confinement was sent to all patients under LTHNIV followed up by our center. Symptom scores and data obtained by ventilator software were compared between confinement and the 56 days prior to confinement. RESULTS: Of a total of 100 eligible patients, 66 were included (median age: 66 years [IQR: 53-74]): 35 (53%) with restrictive lung disorders, 20 (30%) with OHS or SRBD, and 11 (17%) with COPD or overlap syndrome. Prevalence of anxiety (n = 7; 11%) and depressive (n = 2; 3%) disorders was remarkably low. Symptom scores were slightly higher during confinement although this difference was not clinically relevant. Technical data regarding ventilation, including compliance, did not change. Patients complained of isolation and lack of social contact. They felt supported by their relatives and caregivers but complained of the lack of regular contact and information by health-care professionals. CONCLUSIONS: Patients under LTHNIV for CRF showed a remarkable resilience during the SARS-CoV-2 confinement period. Comments provided may be helpful for managing similar future health-care crises.

Self-proning in COVID-19 patients on low-flow oxygen therapy: a cluster randomised controlled trial.

RATIONALE AND OBJECTIVES: Prone positioning as a complement to oxygen therapy to treat hypoxaemia in coronavirus disease 2019 (COVID-19) pneumonia in spontaneously breathing patients has been widely adopted, despite a lack of evidence for its benefit. We tested the hypothesis that a simple incentive to self-prone for a maximum of 12 h per day would decrease oxygen needs in patients admitted to the ward for COVID-19 pneumonia on low-flow oxygen therapy. METHODS: 27 patients with confirmed COVID-19 pneumonia admitted to Geneva University Hospitals were included in the study. 10 patients were randomised to self-prone positioning and 17 to usual care. MEASUREMENTS AND MAIN RESULTS: Oxygen needs assessed by oxygen flow on nasal cannula at inclusion were similar between groups. 24 h after starting the intervention, the median (interquartile range (IQR)) oxygen flow was 1.0 (0.1-2.9) L·min-1 in the prone position group and 2.0 (0.5-3.0) L·min-1 in the control group (p=0.507). Median (IQR) oxygen saturation/fraction of inspired oxygen ratio was 390 (300-432) in the prone position group and 336 (294-422) in the control group (p=0.633). One patient from the intervention group who did not self-prone was transferred to the high-dependency unit. Self-prone positioning was easy to implement. The intervention was well tolerated and only mild side-effects were reported. CONCLUSIONS: Self-prone positioning in patients with COVID-19 pneumonia requiring low-flow oxygen therapy resulted in a clinically meaningful reduction of oxygen flow, but without reaching statistical significance.

[Novel therapies in respiratory management]. / Pneumologie.

In this review of the recent medical literature, we have identified 4 topics of interest for the readers of Revue Médicale Suisse. Use of antifibrotic drugs in interstitial lung diseases will soon be extended to a phenotype labeled « progressive fibrosing interstitial lung disease ¼ (PF-ILD). While awaiting for evidence-based treatment, consensual recommendations for a treatment algorithm in pulmonary sarcoidosis has been published. New guidance for non-invasive ventilation in COPD and obesity-hypoventilation syndrome are available in Switzerland and are in line with international recommendations. New treatments targeting CFTR protein activity have become available and could become a therapeutic option for up to 85% of cystic fibrosis patients in Switzerland.

Dans cette revue de la littérature médicale récente, nous avons identifié quatre sujets d'intérêts pour les lecteurs de la Revue Médicale Suisse. L'utilisation de médicaments antifibrotiques dans les maladies pulmonaires interstitielles sera bientôt étendue à un phénotype étiqueté « maladie pulmonaire interstitielle fibrosante progressive ¼. Des recommandations consensuelles pour un algorithme de traitement dans la sarcoïdose pulmonaire ont été publiées. De nouvelles directives pour la ventilation non invasive dans la BPCO et le syndrome d'obésité-hypoventilation sont disponibles en Suisse et sont conformes aux recommandations internationales. De nouveaux traitements ciblant l'activité protéique CFTR (Cystic Fibrosic Transmembrane Conductance Regulator) sont disponibles et pourraient devenir une option thérapeutique pour 85 % des patients atteints de mucoviscidose en Suisse.

Acute lupus pneumonitis as the initial presentation of systemic lupus erythematosus.

Systemic lupus erythematosus is a multisystem autoimmune disease with wide-ranging pleuropulmonary manifestations. Acute lupus pneumonitis is one of its uncommon complications. We report a 36-year-old woman with acute lupus pneumonitis as the initial presentation of systemic lupus erythematosus. Clinical, biological, radiological and functional improvements were noticed with the administration of steroids, hydroxychloroquine and immunoglobulin.

[Revolution in the treatment of cystic fibrosis]. / Révolution dans le traitement de la mucoviscidose.

Cystic Fibrosis is a genetic disorder resulting in the absence or dysfunction of the CFTR protein, a chloride channel present on the surface of epithelia, particularly respiratory. Until recently, treatments only concerned the consequences of the disease. But a new type of molecules called «â€…modulators ¼, is already available to some patients and targets the origin of the disease. «â€…Modulators ¼ are divided into «â€…potentiators ¼, which improve the transport of chloride by the CFTR protein, and «â€…correctors ¼, increasing the amount of CFTR proteins. An oral triple therapy combining a potentiator and two correctors has just been approved in the USA and will treat 85 % of patients. The clinical benefit of «â€…modulators ¼ is remarkable, and these drugs are revolutionizing the treatment of Cystic Fibrosis.

La mucoviscidose est une maladie génétique entraînant une absence ou des dysfonctions de la protéine Cystic Fibrosis Transmembrane Conductance Regulator (CFTR), un canal chlore présent à la surface des épithélia, notamment respiratoire. Jusqu'à récemment, les traitements ne concernaient que les conséquences de la maladie. Mais un nouveau type de molécules appelées «â€…modulateurs ¼ est déjà à la disposition de certains patients et cible l'origine de la maladie. Les «â€…modulateurs ¼ sont divisés en «â€…potentiateurs ¼, permettant d'améliorer le transport du chlore par la protéine CFTR, et en «â€…correcteurs ¼, augmentant la quantité de protéines CFTR. Une trithérapie orale combinant un potentiateur et deux correcteurs vient d'être approuvée aux États-Unis et permettra de traiter 85 % des patients. Le bénéfice clinique des «â€…modulateurs ¼ est remarquable et ces médicaments bouleversent le traitement de la mucoviscidose.

Comparison of intrapleural use of urokinase and tissue plasminogen activator/DNAse in pleural infection.

Fibrinolysis can be used to improve fluid drainage in pleural infection. Treatment with either urokinase or tissue plasminogen activator (t-PA) in association with DNAse via a chest tube has been effective at reducing the need for surgery. This study is the first to compare the efficacy of these two treatments. We performed a single-centre, controlled, prospective cohort study. All individuals with pleural infection admitted to our hospital between January 2014 and December 2017 who were treated with antibiotics, a chest tube and fibrinolysis were included in this study. The rate of additional procedure requirements (additional chest tube or surgery) after initial fibrinolysis, complications, costs, and radiological and biological outcomes were analysed. Among the 93 patients included in this study, 34% required additional procedures after an initial fibrinolysis, including 21% who received an additional chest tube and 13% who underwent thoracoscopy. The need for additional procedures arose due to presence of multiple pleural collections (p=0.01) and was associated with the use of large-bore drain (p=0.01). The success rate of fibrinolysis was not significantly different between urokinase and t-PA/DNAse (p=0.35). The differences in drainage duration and in length of hospital stay were not significant either (p=0.05 and p=0.12, respectively). Treatment with t-PA/DNAse was cheaper (p=0.04) but was associated with a higher rate of haemothorax (p=0.002). In conclusion, treatment with urokinase is safer and equally effective when compared with treatment with t-PA/DNAse.

Endoscopic control of gastric emptying after administration of intravenous erythromycin in an awake patient scheduled for urgent rigid bronchoscopy.

Certain interventional pulmonology procedures such as the placement of a tracheal stent or resection of stenosing tracheal tumours require rigid bronchoscopy under general anaesthesia. Unlike an endotracheal tube with a cuff, the rigid bronchoscope only partially protects the airway from bronchoaspiration. For this reason, this procedure is performed on an elective basis in fasted patients. We describe the case of a 60-year-old man with acute respiratory distress requiring emergent rigid bronchoscopy following distal migration of a tracheal stent. One hour before the procedure, the patient had eaten a full meal. Gastric emptying was accelerated by perfusion of intravenous erythromycin and verified by endoscopy with a small diameter gastric endoscope under local anaesthesia. This 1 min procedure was very well tolerated by the patient and allowed to verify with certainty that the stomach was empty. The urgent rigid bronchoscopy for stent retrieval could then be performed safely without any risk of bronchoaspiration.

New insights and improved strategies for the management of primary spontaneous pneumothorax.

The pathophysiology and management of primary spontaneous pneumothorax (PSP) are a subject of debate. Despite advances in the understanding of its etiopathogenesis and improvements in its management, implementation in clinical practice is suboptimal. In this manuscript, we review the recent literature with a focus on PSP pathophysiology and management. Blebs and emphysema-like changes (ELC) are thought to contribute to the pathophysiology of PSP but cannot explain all cases. Recent studies emphasize the role of a diffuse porosity of the visceral pleura. Others found a relationship between smoking, occurrence of a PSP and bronchiolitis, which could be the initial pathological process leading to ELC development. Recent or ongoing studies challenge the need to systematically remove air from the pleural cavity of stable patients, introducing conservative management as a valuable therapeutic option. Evidence is growing in favour of needle aspiration instead of chest tube insertion, when air evacuation is needed. In addition, ambulatory management is considered as a successful approach in meta-analyses and is under exploration in a large randomized study. Because of a high recurrence rate of PSP, the benefit of performing a pleurodesis at first occurrence is under evaluation with interesting but not generalizable results. Better identification of 'at risk patients' is needed to improve the investigation strategy. Finally, recent publications confirm the efficacy, security and cost-effectiveness of graded talc poudrage pleurodesis to prevent PSP recurrence. In conclusion, PSP pathophysiology and management are still under investigation. The results of recently published and ongoing studies should be more widely implemented in clinical practice.

[New treatments in respiratory medicine in 2018 : asthma, cystic fibrosis and nocturnal positive pressure (CPAP or NIV)]. / Pneumologie: Asthme, mucoviscidose et pression positive nocturne.

In this review of novel therapies in pulmonary disorders in 2018, we cover 3 different entities. In GINA stage 1 and 2 asthma, new strategies allow a more individualized treatment. In more severe asthma, there is an increasing interest in biotherapies, with dupilumab, an anti-IL-4 receptor, completing the already available panel which includes anti-IgE, anti-IL-5 and anti-IL-5 receptor antibodies. In cystic fibrosis, a better understanding of the pathogenesis and the genetics of the disease is leading to new treatments acting directly on the function of the CFTR (Cystic fibrosis transmembrane conductance regulator), which, when used in combination, show very promising results. Finally, nocturnal positive pressure treatment (either CPAP or non invasive ventilation : NIV) is used more and more frequently. Recent studies have clarified therapeutic algorithms for the most frequent indications for NIV : COPD and obesity-hypoventilation.

Trois thématiques seront abordées dans cette revue annuelle 2018. Dans l'asthme léger, une approche plus personnalisée des patients en paliers 1 et 2 GINA est préconisée, alors que dans l'asthme plus sévère, la place des biothérapies progresse avec un antirécepteur de l'IL-4 (dupilumab) qui vient compléter la gamme des biothérapies disponibles en Suisse (anti-IgE, anti-IL-5 et antirécepteur de l'IL-5). Une compréhension plus approfondie de la pathogénie et de la génétique de la mucoviscidose ouvre la voie à de nouveaux traitements agissant directement sur le fonctionnement du CFTR qui, en combinaison, montrent des résultats très prometteurs pour certains génotypes. Enfin, l'assistance respiratoire nocturne (pression positive continue ou ventilation non invasive) est de plus en plus largement utilisée. Les algorithmes de prise en charge dans la BPCO et dans le syndrome obésité hypoventilation alvéolaire, indications les plus fréquentes, se clarifient.

Clinical experience with lung-specific electromagnetic transponders for real-time tumor tracking in lung stereotactic body radiotherapy.

BACKGROUND AND PURPOSES: Motion management is crucial for optimal stereotactic body radiotherapy (SBRT) of moving targets. We aimed to describe our clinical experience with real-time tracking of lung-specific electromagnetic transponders (EMTs) for SBRT of early stage non-small cell lung cancer in free-breathing (FB) or deep inspiration breath-hold (DIBH). MATERIAL AND METHODS: Seven patients were implanted with EMTs. Simulation for SBRT was performed in FB and in DIBH. We prescribed 60 Gy in 3, 5 or 8 fractions to the tumor and delivered SBRT with volumetric modulated arcs and a 6 MV flattening filter free photon beam. Patients' setup at the linac was performed using EMT positions and cone-beam CT (CBCT) verification. Four patients were treated in DIBH because of a dosimetric benefit. We analysed patient alignment and treatment delivery parameters using DIBH or FB and EMT real-time tracking. RESULTS: There were no complications from the EMT implantation. Visual inspection of CBCT before and/or after SBRT revealed good alignment of structures and EMTs. The median setup time was 9.8 min (range: 4.6-34.1 min) and the median session time was 14.7 min (range: 7.3-36.5 min). EMT positions in lungs remained stable during overall treatment and allowed real-time tracking both in FB and in DIBH SBRT. The treatment beam was gated when EMT centroid position exceeded tolerance thresholds ensuring correct delivery of radiation to the tumor. CONCLUSION: Using EMTs for real-time tracking of tumor motion during lung SBRT proved to be safe, accurate and easy to integrate clinically for treatments in FB or DIBH.

[Transbronchial cryobiopsies : a minimally invasive tool for the diagnosis of interstitial lung disease]. / Cryobiopsies transbronchiques : diagnostic minimalement invasif de la fibrose pulmonaire.

The diagnosis of interstitial lung disease (ILD) is challenging and relies on a multidisciplinary discussion involving clinical, radiological and sometimes histological features. Bronchoscopic lung cryobiopsies have emerged as a new minimally invasive method of lung sampling and an alternative to surgical lung biopsies. A good diagnostic performance and excellent safety profile make it an interesting and worthful procedure which could decrease the number of patients without proper diagnosis and treatment. There is a need for further studies to standardize the technique in expert centers and to establish its role in the diagnostic work-up of ILD.

Le diagnostic des pneumopathies interstitielles (PI) est complexe et repose sur l'analyse d'éléments cliniques, radiologiques et parfois histologiques dans le cadre d'une discussion multidisciplinaire. Pour l'obtention de biopsies pulmonaires, les cryobiopsies transbronchiques constituent une nouvelle méthode minimalement invasive, alternative aux biopsies chirurgicales. Leur très bonne performance diagnostique et leur profil de sécurité favorable expliquent l'intérêt grandissant pour cette technique qui pourrait permettre de diminuer le nombre de patients n'ayant pas de diagnostic définitif établi et de traitement adapté. Des études restent encore nécessaires, au sein de centres experts, afin de standardiser les modalités pratiques de cette technique et de déterminer sa place dans l'algorithme de prise en charge des PI.

Endobronchial coil therapy in severe emphysema: 6-month outcomes from a Swiss National Registry.

BACKGROUND: Endobronchial coils have been demonstrated in three randomized, controlled trials to improve quality of life, exercise tolerance, and lung function in patients with severe emphysema. This therapy is CE-marked and commercially available in Switzerland. Coil treated patients are followed in a post-market Swiss registry to collect safety and effectiveness data in routine clinical practice. METHODS: The Swiss coil registry was initiated in October 2013. At the end of November 2016, an interim analysis of all 64 patients treated in five centers was performed to evaluate safety and effectiveness at six months post treatment. RESULTS: patients had completed bilateral treatment with 6-month follow up at the time of data analysis. Patients had very severe, symptomatic emphysema and hyperinflation [38% male, mean age 66 years, BMI 24, FEV1 30% pred., residual volume (RV) 247% pred., 6-minute walking distance (6-MWD) 272 m, St. George Respiratory Questionnaire (SGRQ) 57 points]. Up to 6 months following treatment, seven serious adverse events (SAE) were reported in 6/29 patients. No device removals were necessary. At 6 months, responder rates [% achieving the minimal clinically important difference (MCID)] were as follows: RV (-0.35 L) 76%; FEV1 (+10%) 57%; SGRQ (-4 points) 87%; 6MWD (+26 m) 60%. CONCLUSIONS: Endobronchial coil therapy performed in expert centers in Switzerland yields high 6-month responder rates across all relevant outcome.

Utility of Rapid On-Site Cytologic Evaluation during Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Malignant and Nonmalignant Disease.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate procedure to sample mediastinal tissue. Rapid on-site cytologic evaluation (ROSE) has been advocated to improve the performance of this procedure, but its benefit remains controversial. Our objective is to assess the utility of ROSE for EBUS-TBNA diagnostic accuracy among unselected patients. METHODS: We prospectively collected data from all consecutive EBUS-TBNA procedures performed between 2008 and 2014. ROSE was introduced since 2011 in our daily practice. The accuracy of EBUS-TBNA with and without ROSE was compared in a univariate and multivariate model accounting for confounding factors. The impact of ROSE was then analyzed according to the etiology and size of the lesions. RESULTS: Among 348 EBUS-TBNA procedures analyzed, 213 were performed with ROSE. The overall accuracy tended to be better with ROSE than without (90.6 vs. 84.4%; p = 0.082). After adjustment in a multivariate model, the benefit of ROSE still did not reach statistical significance (adjusted odds ratio 1.86; 95% confidence interval 0.79-4.41). Similar results were obtained in subgroups of patients with malignant disease or sarcoidosis. The size of the lesion did not influence the impact of ROSE on accuracy. CONCLUSIONS: ROSE was associated with a moderate increase in the accuracy of EBUS-TBNA, but the difference was not statistically significant. The same effect of ROSE was observed in malignant and nonmalignant lesions and this effect was not influenced by the lesion's size.