Robotic-Assisted Bronchoscopy: A Comprehensive Review of System Functions and Analysis of Outcome Data.

The past two decades have witnessed a revolutionary era for peripheral bronchoscopy. Though the initial description of radial endobronchial ultrasound can be traced back to 1992, it was not until the mid-2000s that its utilization became commonplace, primarily due to the introduction of electromagnetic navigation (EMN) bronchoscopy. While the diagnostic yield of EMN-assisted sampling has shown substantial improvement over historical fluoroscopy-assisted bronchoscopic biopsy, its diagnostic yield plateaued at around 70%. Factors contributing to this relatively low diagnostic yield include discrepancies in computed tomography to body divergence, which led to unsuccessful lesion localization and resultant unsuccessful sampling of the lesion. Furthermore, much of peripheral bronchoscopy utilized a plastic extended working channel whose tips were difficult to finely aim at potential targets. However, the recent introduction of robotic-assisted bronchoscopy, and its associated stability within the peripheral lung, has ignited optimism for its potential to significantly enhance the diagnostic performance for peripheral lesions. Moreover, some envision this technology eventually playing a pivotal role in the therapeutic delivery to lung tumors. This review aims to describe the currently available robotic-assisted bronchoscopy technologies and to discuss the existing scientific evidence supporting these.

Lung cancer staging, the established role of bronchoscopy.

PURPOSE OF REVIEW: Lung cancer is the leading cause of cancer-related deaths worldwide. In the absence of distant metastases, accurate mediastinal nodal staging determines treatment approaches to achieve most favourable outcomes for patients. Mediastinal staging differentiates N0/N1 disease from N2/N3 in surgical candidates. Likewise, presence of nodal involvement in nonsurgical candidates who are being considered for stereotactic body radiation therapy is also critical. This review article seeks to discuss the current options available for mediastinal staging in nonsmall cell lung cancer (NSCLC), particularly the role of bronchoscopy. RECENT FINDINGS: Although several techniques are available to stage the mediastinum, bronchoscopy with EBUS-TBNA with or without EUS-FNA appears to be superior in most clinical situations based on its ability to concomitantly diagnose and stage at once, safety, accessibility to the widest array of lymph node stations, cost and low risk of complications. However, training and experience are required to achieve consistent diagnostic accuracy with EBUS-TBNA. SUMMARY: EBUS-TBNA with or without EUS-FNA is considered the modality of choice in the diagnosis and staging of NSCLC in both surgical and nonsurgical candidates.

Bronchoscopy and endobronchial ultrasound for diagnosis and staging of lung cancer.

Various techniques, including standard bronchoscopy, transthoracic needle aspiration and mediastinoscopy, are used for diagnosis and staging of lung cancer. Minimizing the number of invasive procedures for lung cancer diagnosis and staging is preferred, however, and a growing number of bronchoscopic techniques are being used. Currently available techniques for the initial diagnosis of lung cancer include electromagnetic navigation bronchoscopy with computed tomography mapping and sample collection, endobronchial ultrasound (EBUS) using radial or convex probe tips, and the combination of the two approaches. EBUS with transbronchial needle aspiration (EBUS-TBNA) is highly specific and sensitive for the examination of mediastinal lymph nodes. Several studies have demonstrated the utility of this approach for less invasive lung cancer mediastinal staging. EBUS-TBNA has also been used in the collection of tissue samples for the analysis of tumor biomarkers that significantly influence the selection of cancer treatment strategies. Evidence suggests that EBUS-TBNA may be less useful for restaging patients with lung cancer after cytotoxic therapy.

Hemothorax treated with indwelling tunneled pleural catheter: are all hemothoraces the same?

Historically, patients presenting with a hemothorax of any cause have been treated with tube thoracostomy. We describe 2 patients with a hemothorax successfully treated with an indwelling tunneled pleural catheter. Our cases may suggest a new treatment modality for selected patients with hemothorax.

Mediastinal Infection After Ultrasound-guided Needle Aspiration.

We describe 2 cases of mediastinal abscess developing after endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with thoracic malignancies. The first case was that of a 68-year-old male patient with a history of colon cancer presenting with new mediastinal adenopathy. EBUS-TBNA confirmed metastatic colon adenocarcinoma; however, he developed fever and atrial fibrillation 32 days after the procedure and was diagnosed with mediastinal abscess. The patient was successfully treated with antibiotics. The second case was that of a 66-year-old previously healthy male who presented for evaluation of cough. Imaging showed a right paratracheal mass and he underwent EBUS-TBNA sampling, which showed malignant cells. Eight days after the procedure the patient developed fever and was diagnosed with mediastinal abscess. The second patient was treated with antibiotics and several debridements; however, he was eventually transitioned to hospice care because of a continued spread of his cancer. Although rare, mediastinal infection is a complication of endoscopic mediastinal needle aspiration.

Intrapulmonary bronchogenic cyst and cerebral gas embolism in an aircraft flight passenger.

Although it is estimated that > 1 billion passengers travel by air worldwide each year, the incidence of in-flight emergencies is low. However, due to nonstandardized reporting requirements for in-flight medical emergencies, the true incidence of pulmonary barotrauma in airplane passengers is unknown. We describe the case of a passenger with an asymptomatic intrapulmonary cyst in whom a severe case of cerebral gas embolism developed during an aircraft flight. The decrease in ambient pressure during the aircraft climb resulted in expansion of the cyst volume based on Boyle's law (pressure x volume = constant). Due to the cyst expansion, we believe tears in the wall led to the leakage of air into the surrounding vessels followed by brain gas emboli. Adult patients with intrapulmonary cysts should be strongly considered for cyst resection or should at least be advised to abstain from activities leading to considerable changes in ambient pressure.

Coexistent sarcoidosis and HIV infection: an immunological paradox?

The CD4 lymphocyte plays a pivotal role in both sarcoidosis and HIV infection. Caring for a patient with both conditions represents a diagnostic and therapeutic challenge. We describe a patient, previously diagnosed with sarcoidosis, who subsequently contracted HIV infection. Manifestations of sarcoidosis were clinically silent until highly active anti-retroviral therapy was instituted. Her condition improved with the institution of corticosteroids. The diagnostic and therapeutic dilemmas encountered in patients with both conditions will be discussed including a complete review of the literature.

Indução de brotações em explantes de segmentos de folhas de plântulas de urucueiro em diferentes citocininas / Induction of shoot buds in leaf explants of annatto seedlings in differents cytokinins

Segmentos de folhas de plântulas de urucum (Bixa orellana L), foram cultivados in vitro, em um meio básico idealizado por Murashige & Skoog (1962), suplementado com 0,5mg/l dos reguladores do crescimento, benzilaminopurina (BAP), cinetina (KN) e isopentenil-adenina (2iP), isolados ou combinados entre si, com o objetivo de avaliar qual a melhor citocinina ou combinação destas para indução de brotações de boa qualidade visando à micropropagação. Após 60 dias de cultivo, as gemas obtidas foram transferidas para um meio MS modificado, contendo a metade da formulação de sais minerais, sem a suplementação de reguladores do crescimento. Gemas de melhor qualidade foram obtidas nos tratamentos onde a KN e o BAP estavam em combinação. A KN sozinha não foi eficiente na indução de brotações. O maior número de gemas por explante foi obtido com KN, BAP e 2iP e no tratamento com apenas BAP.

Excised leaf explants of annatto (Bixa orellana L.) seedlings were cultivated on a Murashige & Skoog basal medium containing benzylaminopurine (BAP), kinetin (KN) and isopentenyl-adenine (2iP) individually or in combination, each at concentration of 0.5mg/l, with the purpose of evaluated the best cytokinins or cytokinins combination for shoot bud formation. After 60 days, regenerated shoots were transferred to half strenght MS medium without growth regulators. Best shoots were observed where KN and BAP were added in combination. Isolated KN was ineffective for shoot bud formation. The maximum average number of shoot buds per leaf explant was obtained on medium with BAP, KN and 2iP in combination and on medium supplied of isolated BAP.