Performance insights of endobronchial ultrasonography (EBUS) and mediastinoscopy for mediastinal lymph node staging in lung cancer.

INTRODUCTION: Endobronchial Ultrasonography (EBUS) and mediastinoscopy are used for mediastinal lymph node staging in patients with suspected non-small cell lung carcinoma (NSCLC). In our hospital, confirmatory mediastinoscopy has been largely abandoned, which may reduce the number of surgical interventions and health care costs. This study provides insight into EBUS and mediastinoscopy performance in patients with proven NSCLC from January 2007 until January 2019. METHODS: This is a single-centre, retrospective study, evaluating unforeseen N2 rates, negative predictive value and survival, providing insight into the diagnostic yield of EBUS and mediastinoscopy. Surgical lung resection with lymph node dissection was used as reference. RESULTS: A total of 418 patients with proven NSCLC after lung resection (mean age: 66 years; 61 % male) and 118 patients who underwent mediastinoscopy, have been included in the study. The overall prevalence of N2 metastases after lung resection was 10.5 %. The percentage of unforeseen N2 cases after negative EBUS was 14.5 %, and 14.3 % after negative mediastinoscopy. Over the past nine years, none of the confirmatory mediastinoscopies were tumor positive after negative EBUS results. The median survival in patients with surgically confirmed N2 metastases was 33 months, compared to 23 months in patients with EBUS/mediastinoscopy-proven N2 metastases. CONCLUSION: Despite optimisation of mediastinal staging procedures, it remains difficult to identify all patients with N2 metastases in the workup of NSCLC. In our institute, confirmatory mediastinoscopy has no added value after tumor-negative EBUS procedures, and has been abandoned as standard procedure.

[A man with dyspnoea after a kidney transplant]. / Een man met kortademigheid na niertransplantatie.

We present a 62-year-old man with a kidney transplant in the past. Because of progressive dyspnoea a CT-scan was made, which showed ground glass in the upper fields with calcifications. He was diagnosed with metastatic pulmonary calcification, which is mostly seen in patient with renal failure and secondary hyperparathyroidism.

Clubbing in patients with fibrotic interstitial lung diseases.

BACKGROUND: Clubbing is associated with poor prognosis and is variably present in patients with idiopathic pulmonary fibrosis (IPF), but is also seen in other fibrotic interstitial lung diseases (ILDs). Little is known about the best methodology to assess clubbing in ILDs and, hence, the prevalence and clinical utility and clinical significance of clubbing. We therefore aimed to evaluate the agreement between different clubbing assessment methods in patients with fibrotic ILDs. Additionally, we assessed the prevalence of clubbing in different fibrotic ILDs and related clubbing to disease severity and quality of life. METHODS: Consecutive outpatients with fibrotic ILDs of two tertiary referral centers were included. Clubbing was assessed with the phalangeal depth ratio, the digital index, the Schamroth sign test, and by the treating physicians and investigator. RESULTS: We included 153 patients (100 men), mean age 65 (range 33-88), mean FVC 79% (25-145%), mean TLCOc 50% (16-104%). Different methods for assessment of clubbing had poor correlation, and as a result, clubbing prevalence varied according to the method used, ranging from 7 to 42% in the total group of patients and 7-52% in IPF. The degree of clubbing did not correlate with FVC or TLCOc (p > 0.2) or with quality of life scores, but lower mean TLCOc scores were seen in patients with clubbing than in those without. CONCLUSION: Clubbing was present in 7-42% of our fibrotic ILD cohort and showed no correlation with disease severity. Although considered an important clinical feature, assessment methods for clubbing showed no to poor agreement. Further studies are therefore needed to gain more insight into measuring clubbing reliably and the possible prognostic value and evolution of clubbing.

"Twist of the wrist" a rare case of carpal dislocation.

A rare case of a scaphoid-trapezium dislocation is presented. The treatment was open reduction, ligament repair, and internal fixation with a Kirschner wire. After 4 weeks of immobilization, the Kirschner wire was removed, and full recovery was obtained 12 weeks after the trauma.