Biopsy site selection for endobronchial ultrasound guide-sheath transbronchial biopsy of peripheral lung lesions.

BACKGROUND: Choice of biopsy method for peripheral lung lesions is usually between CT-guided fine-needle aspiration biopsy (CT FNA) and bronchoscopy. Endobronchial ultrasound guide-sheath biopsy (EBUS GS) is a new method to improve the yield of bronchoscopy. Guidance on which lesions would be appropriate for either method is needed. The aim of the study was to compare the diagnostic yields and pneumothorax rate of EBUS GS and CT FNA in terms of the location of the lesion needing biopsy, in particular, whether the lesion is touching the pleura. METHODS: Prospective series of EBUS GS were compared to retrospective review of CT FNA carried out simultaneously in a large teaching hospital. RESULTS: For EBUS GS 140 cases were carried out with mean lesion size 29 mm. Overall diagnostic sensitivity was 66%. For lesions not touching visceral pleura it was 74% compared with 35% where it was on the pleura (P < 0.01). For CT FNA 121 cases were carried out with mean lesion size 37 mm. The overall diagnostic sensitivity was 64%. Rate of pneumothorax and ICC placement in EBUS GS was 1 and 0% and in CTFNA was 28 and 6%, with P < 0.001 for both. CONCLUSION: Lesion location, in particular, connection to the visceral pleura, can improve decision-making in referral for either CT FNA or EBUS GS to maximize diagnostic yield and minimize pneumothorax rate.

Endobronchial ultrasonography with guide-sheath for peripheral pulmonary lesions.

The usefulness of endobronchial ultrasonography (EBUS) with guide-sheath (GS) as a guide for transbronchial biopsy (TBB) for diagnosing peripheral pulmonary lesions (PPL)s and for improving diagnostic accuracy was evaluated in this study. EBUS-GS-guided TBB was performed in 24 patients with 24 PPLs of < or =30 mm in diameter (average diameter=18.4 mm). A 20-MHz radial-type ultrasound probe, covered with GS was inserted via a working bronchoscope channel and advanced to the PPL in order to produce an EBUS image. The probe with the GS was confirmed to reach the lesion by EBUS imaging and X-ray fluoroscopy. When the lesion was not identified on the EBUS image, the probe was removed and a curette was used to lead the GS to the lesion. After localising the lesion, the probe was removed, and TBB and bronchial brushing were performed via the GS. Nineteen peripheral lesions (79.2%) were visualised by EBUS. All patients whose PPLs were visible on EBUS images subsequently underwent an EBUS-GS-guided diagnostic procedure. A total of 14 lesions (58.3%) were diagnosed. Even when restricted to PPLs <20 mm in diameter, the diagnostic sensitivity was 53%. In conclusion, endobronchial ultrasonography with guide sheath-guided transbronchial biopsy was feasible and effective for diagnosing peripheral pulmonary lesions.

[Treatment outcomes of multidrug-resistant tuberculosis--comparison between success and failure cases].

The thirty-two times of treatment in 27 patients with multidrug-resistant tuberculosis (MDR-TB) were analyzed retrospectively. In twenty-eight times of treatments cases had previous histories of antituberculosis chemotherapy. Drug sensitivity tests were performed by Microtiter method for isoniazid (INH), rifampicin (RFP), ethambutol, streptomycin, kanamycin, enviomycin, ethionamide, para-aminosalicylic acid and cycloserine. A drug is defined as 'active drug' when the drug was proved to be sensitive by the drug sensitivity tests or never used in the past or used for not more than 2 months in case of pyrazinamide (PZA) and less than one month for fluoroquinolones. Outcomes of treatments were grouped as follows; A: bacteriologically negative for more than 24 months, B: bacteriologically negative for more than 6 months but less than 24 months, C: bacteriologically relapsed after negative conversion, D: continuously bacilli positive for M. tuberculosis. Mean age of patients in each group were; 61.0 yrs for group A (n = 10), 61.0 yrs for group B (n = 7), 52.5 yrs for group C (n = 4), 57.9 yrs for group D (n = 11). All patients had cavitary disease and positive sputum smears for acid-fast bacilli. Mean numbers of 'active drugs' used per treatment in each group, were 3.6, 3.3, 2.5 and 1.8 respectively, while the mean number of resistant drug including INH and RFP were 2.8, 3.3, 2.5 and 3.7. The number of drugs, which was unable to use due to toxicity, were 0.20, 0.14, 0.50, and 0.73 per treatment respectively. All of 9 patients treated with four 'active drugs' were in group A or B and succeeded to achieve negative conversion. The duration of chemotherapy in group A was 13 to 44 months. Treatment had failed in 4 out of 11 patients treated with 3 'active drugs' and 11 out of 12 patients treated with less than 2 'active drugs'. Fluoroquinolones (ofloxacin, levofloxacin or sparfloxacin) were used in 7 out of 10 patients in group A and in 6 out of 9 patients treated with four-drug regimens while they were used only in 3 out of 11 patients in group D. Regimens with at least 4 sensitive drugs are mandatory for the successful treatment of MDR-TB and fluoroquinolones are needed in the majority of cases to ensure the four-drug regimen, because of frequent drug resistance or toxicity to other antituberculosis drugs.

[Small adenocarcinoma of the lung under long-term observation].

A 68-year-old man presented with symptoms of common cold at our hospital on March 8, 1995. Ground glass opacity (GGO) was detected in the right S 4 a by high resolution computed tomography (HRCT) during a routine examination. Except for mild traction of the nearest pleura, the lesion itself demonstrated little change on HRCT images for 2 years. HRCT images disclosed slight enlargement of the lesion over a long-term period of follow-up observation. Exactly 25 months after the first examination, HRCT scans demonstrated an area of centralized dense concentration. Right middle lobectomy was performed 30 months after the lesion was first detected. Pathologic findings from the resected specimen revealed Noguchi's small adenocarcinoma of the lung (type B classification: localized bronchioloalveolar carcinoma with collapse of alveolar structure). The lesion was scanned 8 times with HRCT during the follow-up period. The change to GGO with centralized density and spicula was observed in detail, and thought to be evidence of a progression from type A to type B. We concluded that a set of fixed settings should be utilized for repeated HRCT examinations of small peripheral lesions exhibiting GGO.

Assessment of usefulness of endobronchial ultrasonography in determination of depth of tracheobronchial tumor invasion.

STUDY OBJECTIVE: We assessed the usefulness of endobronchial ultrasonography in the determination of the depth of tumor invasion of the tracheobronchial wall. METHODS: We performed a needle-puncture experiment on normal tissue of 45 specimens to determine the laminar structure of the tracheobronchial wall. In addition, we compared the ultrasonographic determinations of tumor invasion from 24 lung cancer cases with the histopathologic findings. RESULTS: The cartilaginous portions of the extrapulmonary bronchi and the intrapulmonary bronchi exhibited a five-layer structure. Starting on the luminal side, the first layer (hyperechoic) was a marginal echo, the second layer (hypoechoic) was the submucosal tissue, the third layer (hyperechoic) was the marginal echo on the inner side of the bronchial cartilage, the fourth layer (hypoechoic) was bronchial cartilage, and the fifth layer (hyperechoic) was the marginal echo on the outer side of the cartilage. In the membranous portions, the first layer (hyperechoic) was a marginal echo, the second layer (hypoechoic) was smooth muscle, and the third layer (hyperechoic) corresponded to the adventitia. Comparisons between the ultrasonograms and the histopathologic findings in 24 lung cancer cases revealed that depth diagnosis was the same in 23 lesions (95.8%) and was different in 1 lesion (4.2%). In the single case in which the findings were different, lymphocytic infiltration that protruded between the cartilage rings was mistakenly interpreted as tumor infiltration. CONCLUSIONS: This method allows visualization of the laminar structure of the tracheobronchial wall, which is impossible with other diagnostic imaging methods.

[Endobronchial ultrasonography for lung cancer].

We assessed the usefulness of endobronchial ultrasonography in the diagnosis of lung cancer. We performed a needle-puncture experiment on 45 normal tissue specimens to determine the luminar structure of the tracheobronchial wall. In addition, we compared the ultrasonographic determination of tumor invasion in 24 lung cancer patients with the histopathological findings. The cartilaginous portions of the extrapulmonary bronchi and the intrapulmonary bronchi exhibited a five-layered structure. Starting on the lumen side, the first layer (hyperechoic) was a marginal echo, the second (hypoechoic) was the submucosal tissue, the third (hyperechoic) was the marginal echo on the inner side of the bronchial cartilage, the fourth (hypoechoic) was bronchial cartilage, and the fifth (hyperechoic) was the marginal echo on the outer side of the cartilage. In the membranous portions, the first layer (hyperechoic) was a marginal echo, the second (hypoechoic) was smooth muscle, and the third (hyperechoic) corresponded to the adventitia. Comparisons between the ultrasonograms and the histopathological findings in 24 lung cancer patients revealed that depth diagnosis was the same in 23 lesions (95.8%) and different in 1 lesion (4.2%). We describe the usefulness of endobronchial ultrasonography in the diagnosis of peribronchial lymph nodes and peripheral pulmonary lesions.

[Thoracoscopic surgery by use of endo-GIA].

In the field of respiratory surgery there is a need for further research and clinical experience with thoracoscopic surgery. It has already proved excellent for pain reduction and mizing of the wound. We describe the method and results of thoracoscopic surgery, which was started in June, 1992. Twelve cases are reported. The procedure consist of : (1) trocar insertion, (2) observation by thoracoscopy, (3) lifting up and cutting off lung tissue, (4) drainage and removal of the trocar. The most important technique needed by the operator is the cooperative motion of both hands which handle forceps, GIA and other instruments. The two indications for thoracoscopic surgery are spontaneous pneumothorax (bullectomy) and diffuse interstitial pulmonary disease (biopsy). Our operation time was 50 to 145 minutes. No complication occurred on the eleven patients. Wound pain was controlled by diclofenac sodium (Voltaren) suppositories on the first day. The wounds (3 spots 2 cm in size) healed well.

[A case report; 5'-DFUR reduced gastric cancer with multiple liver metastasis].

We describe a case of gastric cancer with multiple liver metastasis that clearly decreased in size after administration of 5'-DFUR. The patient (a 63-year-old male) was inoperable because of multiple liver metastasis. 5'-DFUR 600 mg/day reduced the size of the multiple liver tumors (reduction rate 90%, partial response for four months), but the gastric tumor was unaltered. A rapid decrease in alkali-phosphatase indicated reduction of the liver tumors only one week after the initiation of 5'-DFUR.

[An operated case of Mycobacterium fortuitum infection with hemoptysis].

An operated case of M. fortuitum infection on the bronchiectatic lung was presented. A 68-year-old female had had hemoptysis due to bronchiectasis since she was 44 years of age. She had a history of pulmonary tuberculosis at the age of 58 and treated by anti-tuberculosis drugs for a year. She was referred to the National Sanatorium Hiroshima Hospital in March 1986 for surgical treatment, when M. fortuitum infection was found. Lobectomy of the right middle lobe, right S6 Segmentectomy and partial resection of right S2 were performed on December 1st 1986. After the operation, hemoptysis disappeared but M. fortuitum was still found in sputum. Chest X-ray examination revealed some new abnormal shadows. When radical surgical treatment for secondary M. fortuitum pulmonary infection is considered careful attention should be given to its indications including the extent of resection and the predicted post-operative pulmonary function.