N3 hilar sampling decision in the staging of mediastinal lung cancer.

There is insufficient evidence for the sampling of morphometabolically normal N3 hilar lymph nodes https://bit.ly/3gWcar7.

Silicone Stent Versus Fully Covered Metallic Stent in Malignant Central Airway Stenosis.

BACKGROUND: Airway stenting to restore airway patency in cases of malignant central airway obstruction is an effective palliation treatment. Our goal was to compare the efficacy after deployment and complications of a fully covered self-expandable metal stent (SEMS) (Aerstent) and a silicone stent (Dumon). METHODS: This was a retrospective cohort of 2 similar groups of patients with malignant central airway obstruction treated with stents between August 2012 and July 2017. Complications were assessed bronchoscopically. A competing risk for death analysis was performed to adjust the probability of developing a complication. RESULTS: Seventy patients (29 with silicone stents and 41 with SEMS) were included. Stent insertion was successful in all cases. Mucus retention was the most frequent complication (75.9% with silicone stents and 84.8% with SEMS; P = .51), followed by granulation tissue (51.7% with silicone stents and 41.3% with SEMS; P = .52) and migration (6.9% with silicone stents and 13.0% with SEMS; P = .47). In the first month, the cumulative incidence of a complication was 36.7% for silicone stents and 41.3% for SEMS and increased to 90.0% and 97.8% after 6 months, respectively (hazard ratio = 1.66; P = .04). A competing risk for death analysis showed an adjusted hazard ratio of 1.41 (P = .49) indicating no differences in overall complications between stents. CONCLUSIONS: Both stents were equally successful and safe. The incidence of complications increased over time to 90% at 6 months for both stents. The risk of overall complications was higher for SEMS; nevertheless, when mortality was measured in a competitive risk analysis, no differences were found between SEMS and silicone stents.

Ultrathin Bronchoscopy with and without Virtual Bronchoscopic Navigation: Influence of Segmentation on Diagnostic Yield.

BACKGROUND: Bronchoscopy is a safe technique for diagnosing peripheral pulmonary lesions (PPLs), and virtual bronchoscopic navigation (VBN) helps guide the bronchoscope to PPLs. OBJECTIVES: We aimed to compare the diagnostic yield of VBN-guided and unguided ultrathin bronchoscopy (UTB) and explore clinical and technical factors associated with better results. We developed a diagnostic algorithm for deciding whether to use VBN to reach PPLs or choose an alternative diagnostic approach. METHODS: We compared diagnostic yield between VBN-UTB (prospective cases) and unguided UTB (historical controls) and analyzed the VBN-UTB subgroup to identify clinical and technical variables that could predict the success of VBN-UTB. RESULTS: Fifty-five cases and 110 controls were included. The overall diagnostic yield did not differ between the VBN-guided and unguided arms (47 and 40%, respectively; p = 0.354). Although the yield was slightly higher for PPLs ≤20 mm in the VBN-UTB arm, the difference was not significant (p = 0.069). No other clinical characteristics were associated with a higher yield in a subgroup analysis, but an 85% diagnostic yield was observed when segmentation was optimal and the PPL was endobronchial (vs. 30% when segmentation was suboptimal and 20% when segmentation was optimal but the PPL was extrabronchial). CONCLUSIONS: VBN-guided UTB is not superior to unguided UTB. A greater impact of VBN-guided over unguided UTB is highly dependent on both segmentation quality and an endobronchial location of the PPL. Segmentation quality should be considered before starting a procedure, when an alternative technique that may improve yield can be chosen, saving time and resources.

Positive Airway Pressure to Enhance Computed Tomography Imaging for Airway Segmentation for Virtual Bronchoscopic Navigation.

RATIONALE: Virtual bronchoscopic navigation (VBN) guidance to peripheral pulmonary lesions is often limited by insufficient segmentation of the peripheral airways. OBJECTIVES: To test the effect of applying positive airway pressure (PAP) during CT acquisition to improve segmentation, particularly at end-expiration. METHODS: CT acquisitions in inspiration and expiration with 4 PAP protocols were recorded prospectively and compared to baseline inspiratory acquisitions in 20 patients. The 4 protocols explored differences between devices (flow vs. turbine), exposures (within seconds vs. 15-min) and pressure levels (10 vs. 14 cmH2O). Segmentation quality was evaluated with the number of airways and number of endpoints reached. A generalized mixed-effects model explored the estimated effect of each protocol. MEASUREMENTS AND MAIN RESULTS: Patient characteristics and lung function did not significantly differ between protocols. Compared to baseline inspiratory acquisitions, expiratory acquisitions after 15 min of 14 cmH2O PAP segmented 1.63-fold more airways (95% CI 1.07-2.48; p = 0.018) and reached 1.34-fold more endpoints (95% CI 1.08-1.66; p = 0.004). Inspiratory acquisitions performed immediately under 10 cmH2O PAP reached 1.20-fold (95% CI 1.09-1.33; p < 0.001) more endpoints; after 15 min the increase was 1.14-fold (95% CI 1.05-1.24; p < 0.001). CONCLUSIONS: CT acquisitions with PAP segment more airways and reach more endpoints than baseline inspiratory acquisitions. The improvement is particularly evident at end-expiration after 15 min of 14 cmH2O PAP. Further studies must confirm that the improvement increases diagnostic yield when using VBN to evaluate peripheral pulmonary lesions.

Successful Healing of Tracheal Radionecrosis: Role of Hyperbaric Oxygen Therapy.

Hyperbaric oxygen therapy, the administration of 100% oxygen at pressures > 1 atm, is believed to promote wound healing by increasing angiogenesis and collagen synthesis. To our knowledge, this treatment modality has never been described in patients with tracheal radionecrosis. Here, we report the case of a 55-year-old man diagnosed with stage IIIB lung adenocarcinoma who was treated with chemotherapy and concomitant external intensity-modulated radiotherapy involving the left lung and mediastinum. Nine months later, he presented with neck pain, cough with mucopurulent sputum, and fever. A PET-CT scan revealed a fissure in the posterior wall of the left upper trachea. Flexible bronchoscopy showed a tracheal ulceration with a small left posterior wall fissure that extended into the mediastinum. To our knowledge, this is the first report in the literature that suggests that treatment with hyperbaric oxygen therapy, local debridement, and antibiotics is a feasible and successful management option for patients with complicated tracheal radionecrosis.

Colchicine Treatment for Tracheobronchial Amyloidosis.

Tracheobronchial amyloidosis is an infrequent disease characterized by the deposition of proteinaceous material in the tracheobronchial tree. The disease generally has a high morbidity and variable mortality in the years following diagnosis. There is no consensus on the optimal treatment. We report a case of a 63-year-old woman who presented with a diffuse tracheobronchial amyloidosis associated with laryngeal involvement, which required a percutaneous tracheostomy due to high-grade subglottic stenosis, with no evidence of systemic amyloidosis. After treatment exclusively with colchicine, she had a complete resolution of the stenotic area, with a very good response from the tracheobronchial amyloidosis disease, with only minor yellow plaques persisting. The patient has remained asymptomatic in the next 4 years of follow-up, with no evidence of endoscopic progression. This is the first documented case of this kind of response of tracheobronchial amyloidosis to colchicine treatment alone. A review of the available literature is presented.

Combined Bronchial Artery Embolization and Endobronchial Resection for Bronchial Carcinoid: A Safety and Feasibility Pilot Study.

BACKGROUND: There is growing evidence to support bronchoscopic resection of well-circumscribed typical carcinoids. However, massive bleeding and risk of recurrence can potentially complicate this approach. OBJECTIVES: The aim of this study was to assess the safety and feasibility of endobronchial resection of carcinoids preceded by bronchial artery embolization. METHODS: Five patients with centrally located typical carcinoids were recruited, 4 with a curative intent and 1 for palliation of a carcinoid with mediastinal invasion. All patients underwent selective embolization of the feeding bronchial artery 24-48 h prior to endobronchial resection, which was performed with a rigid bronchoscope and neodymium:yttrium-aluminium-perovskite laser. RESULTS: Minimal bleeding was noted during tumour resection. After a median (range) follow-up of 20 (14-48) months, only the case with segmental extension of the tumour had local recurrence, which was treated successfully using cryotherapy (with negative endobronchial biopsies since), and no cases of metastatic spread occurred. One patient, in whom the histopathological diagnosis was changed from typical to atypical carcinoid following resection, went on to have a surgical bilobectomy 3 months later. Extensive fibrosis was noted at the site of original tumour resection with no evidence of residual disease. CONCLUSIONS: Bronchial artery embolization prior to endobronchial resection of centrally located carcinoids is feasible and safe. The reduction in bleeding may facilitate and simplify the procedure. The possible application of this combined therapy to the management of atypical carcinoids warrants the design of a larger prospective clinical trial.

The Posterior Pericardial Recess: Potential for Confusion at Endobronchial Ultrasound.

Pericardial recesses are formed at sites of reflection of the visceral to parietal pericardium around the great vessels of the mediastinum. Identification at endobronchial ultrasound (EBUS) of a "high-riding" superior pericardial recess, masquerading as a lower paratracheal lymph node, has previously been reported. Although the potential for the posterior pericardial recess to be seen in the subcarinal region on computed tomography has been described in the radiology literature, its identification with EBUS has not. We report a case where the posterior pericardial recess was seen with EBUS in the lower subcarinal region adjacent to the bronchus intermedius. It can be clearly differentiated from a lymph node or vascular structure due to its hypoechoic appearance and lack of a color Doppler signal. Bronchoscopists should be aware of the potential to image the posterior pericardial recess with EBUS in the subcarinal region, to avoid confusion at the time of endoscopy.

Tratamiento endoscópico de la fuga aérea persistente alveolo-pleural con una válvula endobronquial unidireccional / Endoscopic Treatment of Persistent Alveolar-Pleural Air Leaks with a Unidirectional Endobronchial Valve

La fuga aérea persistente por fístula alveolopleural no es una complicación infrecuente del neumotórax,sobretodo de los secundarios. Las válvulas endobronquiales de flujo unidireccional diseñadas para lareducción del volumen pulmonar son la última incorporación en el arsenal terapéutico.Se presenta el caso de un paciente con enfermedad pulmonar obstructiva crónica (EPOC), con unneumotórax persistente a pesar del tratamiento con tres pleurodesis, y que pudo resolverse con laimplantación de dos válvulas tipo IBV(AU)

Persistent air leaks due to alveolopleural fistula are not an uncommon complication of pneumothorax,particularly secondary ones. Unidirectional flow endobronchial valves designed for lung volumereduction are the latest incorporation to the therapeutic armamentarium.We present the case of a patient with chronic obstructive pulmonary disease (COPD) with persistentpneumothorax in spite of treatment with three pleurodesis which was able to be resolved with theplacement of two IBVTM valves(AU)

Endoscopic treatment of persistent alveolar-pleural air leaks with a unidirectional endobronchial valve.

The persistent air leaks due to alveolopleural fistula are not an uncommon complication of pneumothorax, particularly secondary ones. Unidirectional flow endobronchial valves designed for lung volume reduction are the latest incorporation to the therapeutic armamentarium. We present the case of a patient with chronic obstructive pulmonary disease (COPD) with persistent pneumothorax in spite of treatment with three pleurodesis which was able to be resolved with the placement of two IBV™ valves.

Chorea-ballism associated with familial amyotrophic lateral sclerosis. A clinical, genetic, and neuropathological study.

Hyperkinetic movements in amyotrophic lateral sclerosis (ALS) are extremely rare. We present clinical, neuropathological, and genetic data for a 53-year-old woman with spinal onset ALS presenting chorea affecting the face, mouth, neck, and hands, and ballism in both arms 31 months after leg weakness onset. Her father and older sister had ALS, but had no movement disorders. As well as the typical neuropathological findings of ALS (marked upper and lower motor neuron loss), post-mortem examination showed prominent neuronal loss and gliosis in the subthalamus, and in the internal globus pallidus, substantia nigra pars compacta, and red nucleus. No abnormalities were found in the caudate, putamen, and thalamus. No defects were found in the SOD1, HD, and DRPLA genes. These data support the idea that choreo-ballism in ALS Plus may be the result of pallido-luyso-rubro-nigral atrophy, despite not being the result of concomitant DRPLA based on neuropathological and genetic criteria.