The Differentiation of Metastatic Mediastinal Lymph Nodes From Benign Hypermetabolic Lesions.

Background Anthracosis may cause a positron emission tomography/computed tomography (PET/CT) false positivity in mediastinal and hilar lymph nodes. We aimed to evaluate the radiological features and the maximum standardized uptake values (SUVmax) of the mediastinal lymph nodes with anthracosis or squamous cell lung cancer metastasized. Methodology Patients diagnosed with anthracosis or squamous cell lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) between January 1, 2015, and November 15, 2020, in a tertiary hospital were enrolled. The squamous cell subtype of lung cancer was selected due to its association with tobacco use, biomass, and air pollution. Anthracosis may occur due to the same etiologic reasons. Results A total of 190 patients met the study enrollment criteria, of which 86 were diagnosed with anthracosis and 33 with squamous cell lung cancer lymph metastasis. Median values for short axis, long axis, SUVmax, shape features, and presence of calcification were found significantly different between the groups. In receiver operating characteristic (ROC) analysis, the SUVmax cut-off value was calculated as 6.61. With this cutoff value, the negative predictive value (NPV) was 92.5% and the positive predictive value (PPV) was 54% for differentiating anthracosis and malignant lymph nodes metastasis. Conclusions We conclude that the evaluation of the shape and metabolic activities of the anthracotic lymph nodes detected by PET/CT together with EBUS-TBNA granted a more accurate staging of the patients and more cancer patients will benefit from surgical treatment.

Complications of silicone Y stents placed due to malignant airway stenosis.

INTRODUCTION: Malignant central airway obstruction around the main carina often requires placement of Y­shaped stents. In this study, we aimed to determine the safety of silicone Y stents placed around the main carina in the malignant airway obstruction by examining the long term complications, emergence times and treatment approaches of complications. MATERIALS AND METHODS: Between May 2012 and July 2015, 47 silicone Y stents were placed in 46 patients with malignant external compression or mixed type stenosis around the main carina. Patient stents were placed via rigid bronchoscopy under total intravenous anesthesia in operating room conditions. RESULT: In the half of the patients (23/46), stents were placed under urgent conditions due to acute respiratory failure. Stents were deployed successfully in all the patients. No procedure related deaths were observed. The median time of survival following stent insertion was 157 days. The total long-term complication rate of silicone Y stents was 28.3%. Mucostasis (8.7%) and migration (2.2%) were observed within the first month after placement of the silicone Y stents (median 18 days), stent-edge granulation tissue development (13.0%) was observed at the earliest one month (median 64, range 34-386 days) and stent-edge tumor tissue development (4.3%) were observed at the earliest 3 months (median 151, range 85-217 days). A total of 7 (15.2%) stents were removed, 2 of which were due to mucostasis and 5 of which were due to granulation tissue development. One patient's stent was replaced with a longer silicone Y stent due to stent-edge tumor tissue development. CONCLUSIONS: The best palliative treatment of malignant tumor stenosis around the main carina is still silicone Y stent placement, but the long-term complication rate can be high. For this group of patients, bronchoscopy to be performed at the first and third months after silicone Y stent placement may provide early detection of stent-edge tissue development.

Adequacy of EBUS-TBNA specimen for mutation analysis of lung cancer.

OBJECTIVE: Convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) is a minimally invasive technique with high sensitivity in the mediastinal staging of non-small cell carcinoma (NSCLC). In recent years, molecular testing has been developed to study genetic mutations in NSCLC. There are studies revealing improved survival in advanced NSCLC using targeted therapy as the first-line treatment in these patients. The aim of this study was to evaluate the adequacy of EBUS-TBNA in providing adequate size specimens for EGFR, ALK and ROS1 genetic mutation analysis in patients with adenocarcinoma or not otherwise specified (NOS) lung cancer. MATERIALS AND METHODS: Charts of patients diagnosed with lung adenocarcinoma or NOS via EBUS-TBNA were retrospectively reviewed. Information on patient demographics, number of lymph nodes sampled, their size and location, targeted gene mutations and the adequacy of the material sampled for the molecular testing was recorded. RESULTS: A total of 114 patients were included in the study, adenocarcinoma 86 (75%) and NOS 28 (25%). EGFR gene mutation was studied in all of the patients included in the study while ALK in 113 and ROS1 in 98. The material adequacy ratios for EGFR gene mutation, ALK and ROS1 rearrangements were found to be 88.6%, 93.8% and 91.8%, respectively. EGFR gene mutation, ALK and ROS1 rearrangements were found positive in 13 (11.4%), 9 (8%) and 1 (1%) patients, respectively. CONCLUSION: The study demonstrated that EBUS-TBNA provides adequate material for mutation analysis in patients with newly diagnosed adenocarcinoma or NOS lung cancer.

Can we prevent recurrences in the endoscopic treatment of endobronchial hamartomas?

INTRODUCTION: Recently, treatment of endobronchial hamartomas with interventional bronchoscopic methods has become possible. Although there are several reports of therapeutic benefits, the protocol of administration varies between centers and high recurrence rates continue to be a problem. In this study, we aimed to show that cryotherapy applied to the root of the bronchial wall after removal of the intraluminal portion of endobronchial hamartoma with interventional bronchoscopic methods can prevent recurrences. MATERIALS AND METHODS: Between 2012-2016, the treatment outcomes and long-term follow-up data of patients with symptomatic endobronchial hamartomas treated by interventional bronchoscopic methods were prospectively recorded. After debulking, cryotherapy was applied to the root of the bronchial wall of all lesions. The data were analyzed retrospectively. RESULT: A total of 21 consecutive patients were studied. Twenty (95.2%) of the patients underwent complete resection and only 1 (4.8%) had incomplete resection with various interventional bronchoscopy techniques. One (4.8%) patient who underwent incomplete resection and ineffective cryotherapy relapsed. The other 20 (95.2%) patients were followed up periodically for an average of 36.0 ± 15.0 months. No recurrence was detected. No complications or deaths related to the procedure were observed. CONCLUSIONS: Debulking of endobronchial hamartomas with interventional bronchoscopic methods is effective and safe. Cryotherapy to the root of the lesion may prevent high recurrence rates.

EBUS may arise as an initial time saving procedure in patients who are suspected to have small cell lung cancer.

BACKGROUND: Small cell lung cancer (SCLC) commonly presents as hilar/mediastinal masses. In some occasions, conventional flexible bronchoscopy fails and a substantial amount of time is lost until establishing the diagnosis. OBJECTIVE: The aim of the study was to demonstrate the superiority of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) compared to conventional methods in establishing the diagnosis as an initial modality as well as to point out the saved time until the diagnosis. METHODS: We retrospectively reviewed the patients who were diagnosed as SCLC by EBUS-TBNA between April 2010 and January 2016. The demographics of the patients, smoking history were all recorded. We also compared the time between the first computed tomography (1stCT) and first diagnostic procedure (1stDP), 1stDP and final diagnosis (FDx), 1stCT and FDx, and 1stDP and EBUS procedure were also compared. RESULTS: One hundred and thirty-three patients were included in the study. The diagnostic yield of EBUS-TBNA was 98.5%. The mean time between the 1stCT and 1stDP; 1stDP and FDx; 1stCT and FDx; 1stDP and EBUS procedure were 7.0 ± 9.0; 11.8 ± 16.1; 18.8 ± 17.9; and 10.8 ± 16.0 days, respectively. The time between 1stCT to 1stDP was not significantly different in patients with or without previous diagnostic procedures. However, the time between 1stDP to FDx and 1stCT to FDx were significantly higher in the patients with previous procedures (P < .001). The difference in time between 1stDP to FDx and 1stCT to FDx was also similar in patients with only hilar and/or mediastinal lesions (P = .001, P = .006, respectively). CONCLUSION: EBUS-TBNA may be an initial diagnostic procedure in SCLC. Patients with only hilar/mediastinal masses without any endobronchial lesion could be directed to centers with the capability for performing EBUS-TBNA to have a rapid diagnosis without any time loss.

Mediastinal ectopic thyroid diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration: Report of three cases.

An ectopic thyroid gland results from the abnormal migration of the thyroid in the course of its development. Primary ectopic mediastinal thyroid is very rare and occurs in less than 1% of all goiters that can be surgically excised. Ectopic thyroid tissue has a characteristic sonographic appearance as smooth-bordered, homogeneous, hypoechoic tissue with fine specular echoes. We report 3 cases of mediastinal ectopic thyroid diagnosed by endobronchial ultrasound-guided transbrochial needle aspiration biopsy.

Comparison of two new techniques for the management of malignant central airway obstruction: argon plasma coagulation with mechanical tumor resection versus cryorecanalization.

BACKGROUND: The development of central airway obstruction during malignant diseases is an important cause of morbidity and mortality. Endobronchial therapies can decrease the patient's symptoms and improve quality of life. Here, we compare airway recanalization methods: argon plasma coagulation with mechanical tumor resection (APC + MTR) and cryorecanalization (CR efficiency, complications, restenosis rate, and time to restenosis) in patients with malignant exophytic endobronchial airway obstruction. METHODS: A total of 89 patients were included who were admitted to our hospital between 2005 and 2012. The data were analyzed retrospectively. Initially, a CR procedure was performed in 52 patients using rigid bronchoscopy under general anesthesia; the APC + MTR procedure was performed in 37 patients with malignant airway obstruction. RESULTS: The airway patency rate with APC + MTR was 97.3% (n = 36) and CR was 80.8% (n = 42). The APC + MTR procedure was more effective than CR for recanalization of malignant endobronchial exophytic airway obstruction. Additionally, the achievement rate of airway patency with APC + MTR was significantly higher in tumors with distal bronchial involvement. There was no statistically significant difference between groups in terms of complications, restenosis rate, and time to restenosis. CONCLUSIONS: The APC + MTR procedure is preferred over CR to introduce and maintain airway patency in patients with malignancy-related endobronchial exophytic airway obstruction.

A case of relapsing polychondritis mimicking lung cancer.

Relapsing polychondritis (RP) is a rare autoimmune disease, characterized by episodic inflammatory attacks on cartilaginous tissue. Elastic cartilage of the ears and nose, hyaline cartilage of the peripheral joints, vertebral fibrocartilage, tracheobronchial cartilage, and tissues rich in proteoglycan such as those in the eyes, heart, blood vessels, and inner ear are more likely to be affected. A 35-year-old male presented with complaints of hoarseness, tinnitus and dyspnea for 19 years, with a history of several diagnostic and therapeutic interventions for laryngeal and respiratory tract. He was diagnosed to have inflammation of the tracheobronchial cartilage, cardiac valvulopathy and conductive hearing loss after intensive diagnostic studies. He responded well to low-dose steroids in combination with methotrexate. RP is a diagnostically challenging condition and may cause significant morbidities during diagnosis. RP should be considered in differential diagnosis of airway obstruction as a rare condition.

An amazing cause of false PET positivity: Diagnosed after a lung cancer surgery.

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) has an effective role in both diagnosis and management of patients with lung cancer. There are many reasons could cause false positivity on PET/CT.A 60-year-old man was admitted a mass on thorax CT and diagnosed as squamous cell carcinoma. Lobectomy with lymph node dissection was performed after evaluation of distant metastases. There were pathological lymph nodes detected on PET/CT at six month following period. Endobronchial ultrasonography guided transbronchial needle aspiration was performed for differantial diagnosis. The pathologic diagnosis was granuloma which developed in response to suture material. We interpreted this granulomatous reaction as gossypiboma which developed against long-left or forgotten suture material. In conclusion, based on this case, gossypiboma (or granulomatous inflammation in response to foreign bodies) should be also considered in differential diagnosis of intrathoracic lymph nodes with PET positivity in a previously operated patient.

How many samples would be optimal for endobronchial cryobiopsy?

BACKGROUND: Cryobiopsy, which provides larger specimens without crush artifact, is a good option for the diagnosis of visible endobronchial tumors. While there are several papers on diagnostic performance, application protocols vary between centers. In this study, we aimed to find the optimal number of cryobiopsies in endobronchial tumors. METHODS: We prospectively involved cases with a visible endobronchial tumor in which conventional diagnostic measures failed and/or a therapeutic interventional bronchoscopy was planned. Endobronchial tumor was visualized, and four cryobiopsies were taken with a dedicated flexible probe. The samples were evaluated by a pathologist who was blinded to the order of the biopsies. The cumulative performances of one to four cryobiopsies were compared, and a complication analysis was conducted. RESULTS: A total of 50 patients were involved. Four cryobiopsies were taken from 49 patients, and a single biopsy was taken from one case. The sensitivities of one, two, three and four biopsies were 82, 93.9, 93.9 and 95.9 %, respectively. The difference in performance of one and two biopsies was significant (p = 0.031), but the third and fourth biopsies were found to be unnecessary (p = 1.0 for second versus third and p = 1.0 for second versus fourth). Bleeding risk increased when ≥3 cryobiopsies were taken (Odds Ratio 2.758). CONCLUSIONS: When the diagnostic benefits and complication rates were considered, two cryobiopsies were found to be optimal for endobronchial tumors. In patients with non-diagnostic conventional bronchoscopy, endobronchial tumors may be diagnosed by cryobiopsy.

Endobronchial metastasis of mixed germ cell tumors: two cases.

Lung metastases from extrapulmonary malignancies are common however endobronchial metastases (EBM) from nonpulmonary neoplasms are rare. A variety of extrathoracic tumors have a tendency to EBM especially breast, colon, and renal carcinomas are most frequent reported tumors however EBM of germ cell tumors are extremely rare. A 39-year-old and a 27-year-old male patient were admitted to our hospital with hemoptysis and dyspnea at different times. Both of them had a history of left orchiectomy due to mixed germ cell tumor two years and one year ago, respectively. On chest X-Ray and thorax computed tomography, first had a right upper lobe atelectasis and second had right total atelectasis. Fiberoptic bronchoscopy (FOB) performed and a vascularized endobronchial lesion (EBL) which tended to bleed was seen in the orifis of right upper lobe in the first case and right main bronchus was totally obstructed by EBL also in the second. Interventional bronchoscopy was performed via rigid bronchoscopy for biopsy and palliative treatment (argon plasma coagulation and debulking) in both two patients because of tendency to bleeding. A partial aperture was achieved at right upper lobe bronchus in the first case and total atelectasis resolved in the second case. Immunohistochemically, histopathological examinations of both patients biopsies confirmed EBM of mixed germ cell tumors. In conclusion, EBM of the germ cell tumors especially with total or partial atelectasis are extremely rare. We want to present these cases to emphasize the importance of distinguishing EBM from primary lung carcinoma which treatment and survival could be different.

A case of tracheal leiomyoma misdiagnosed as asthma.

Primary benign tumors of trachea are rare. Of them, tracheal leiomyoma, constitutes only 1% of all benign lower respiratory tract tumors. Here, we present a case of tracheal leiomyoma who has been receiving high doses of inhaled corticosteroids and bronchodilators for a year with a misdiagnosis of asthma. As the symptoms did not resolve with an overtreatment, she has been undergone radiologic study to find a possible alternative diagnosis. The chest roentgenogram revealed an opacity in the upper mediastinum. In computed tomography, a lesion has been detected in proximal trachea, arising from the posterior wall and protruding through the lumen and almost obliterating the air column. Rigid bronchoscopy has been performed under general anesthesia due to a high risk of bleeding and the endobronchial lesion, freely moving with respiration, has been removed and cryotherapy was applied to the base of the lesion. Receiving the histopathological diagnosis of leiomyoma, the patient is now on 12th month of the follow-up without any recurrence.

Pulmonary involvement in sea-blue histiocytosis.

Sea-blue histiocytosis is one of the six types of Niemann-Pick disease. It is characterized by childhood onset of hepatosplenomegaly, lack of neurological involvement and diminished sphingomyelinase activity. Pulmonary system is rarely involved sea-blue histiocytosis. In this paper, we present a 39-years-old male who had previously diagnosed as sea-blue histiocytosis at the age of 15. He was admitted to our clinic due to productive cough, hemoptysis, fever and weight loss. His symptoms did not resolve with the antibiotic treatment and further investigations revealed pulmonary involvement of sea-blue histiocytosis. After diagnostic bronchoalveolar lavage, his symptoms were improved, interestingly. This rare entity was discussed with literature survey.

Cryorecanalization: keys to success.

BACKGROUND: Symptomatic airway obstructions are common with endobronchial exophytic tumors and may result in lethal complications. Recently, a cryorecanalization procedure has emerged that plays a role in the immediate management of airway obstruction. This study was conducted to investigate the value of cryorecanalization for the immediate management of endobronchial obstructive pathology and to determine the factors that affect the success of the procedure. METHODS: We analyzed 40 patients with symptoms of airway obstruction who were admitted to our hospital from 2006 to 2010. Patients with exophytic stenosis due to primary bronchial or metastatic neoplasms who underwent cryorecanalization procedures were included. Patients were excluded if they had involvement of a major artery near the site of the intervention. The procedure was not performed on patients with coagulation abnormalities or thrombocyte count and aggregation problems. The data were collected retrospectively. RESULTS: Successful cryorecanalization was achieved in 72.5 % of patients. We found that the success rate was mainly related to the presence of the distal involvement and the older age of obstruction. Restenosis rate was 17.2 %. [corrected] The mean survival time after the cryorecanalization procedure was 11 ± 12.7 months. No complications occurred in 14 patients. No severe bleeding was observed for any patients, and moderate hemorrhaging occurred in ten patients, which was stopped with an argon plasma coagulator. We experienced no intraoperative mortality. CONCLUSIONS: Cryorecanalization is a successful and safe intervention for the immediate management of endobronchial stenosis. Appropriate patient selection and high success rates should be achieved after careful radiological assessments and with early management.

Endobronchial cryobiopsy or forceps biopsy for lung cancer diagnosis.

BACKGROUND: Invasive procedures such as bronchoscopic biopsy, bronchial washing, and bronchial brushing are widely used in diagnosis of lung cancers. The mean diagnostic rate with bronchoscopic forceps biopsy is 74% in central tumors. This study was designed to evaluate the efficacy of cryobiopsies in histopathological diagnosis. METHODS: Forty-one patients who had interventional bronchoscopy were included in this study. Three forceps biopsies and one cryobiopsy with cryorecanalization probe were obtained from each subject. Biopsies interpretations were done by one expert pathologist. RESULTS: Hemorrhage was the only complication in both procedures. There was no significant difference between these two procedures in the incidence of hemorrhage (P > 0.05). Mean diameters of samples taken with forceps biopsy and cryoprobe biopsy were 0.2 and 0.8 cm, respectively (P < 0.001). Thirty-two patients (78%) were diagnosed with forceps biopsies, and 38 patients (92.7%) were diagnosed with cryoprobe biopsies (P = 0.031). CONCLUSIONS: We concluded that cryoprobe biopsies were more successful than forceps biopsies in diagnosis. Nevertheless, further investigations are warranted to determine an efficacy of cryoprobe biopsy procedures and a rationale to use as a part of routine flexible bronchoscopy.

Spindle cell sarcomatoid carcinoma: first case reported in the trachea.

A 78-years-old man presented with weight loss, dyspnea, cough and hemoptysis. He was an ex-smoker with a smoking history of 30 pack-years. Imaging studies revealed an endoluminal carinal mass and a tumoral mass arising from the posterior wall of the trachea was observed bronchoscopically. Endoscopic argon plasma coagulation was performed to take biopsies and to regain the airway passage. Recanalisation of the right and left main bronchi and the trachea was achieved together with resection of more than 90% of the tumoural mass. Microscopically, the tumor was composed of fascicular pattern of spindle cells with atypical mitotic figures and nuclear pleomorphism, positively reactive to epithelial membrane antigen supporting a diagnosis of tumour with epithelial differentiation. These findings supported the diagnosis of a spindle cell sarcomatoid carcinoma of trachea. Spindle cell carcinoma cases are reported in many sites, such as head and neck region, larynx, digestive tract, breast, kidney, genital tract, skin and lung, but to our knowledge, not in trachea. Primary malignant tracheal tumours consist mainly of squamous cell carcinoma and adenoid cystic carcinoma and generally have an aggressive course with poor prognosis. We report the first presentation of a spindle cell sarcomatoid carcinoma of trachea together with the clinical course of the patient.