Localization Technique Using Mixture of Indigo Carmine and Lipiodol of Pulmonary Nodule via Bronchoscopic Navigation.

Background and Objectives: As the number of minimally invasive surgeries, including video-assisted thoracoscopic surgery, increases, small, deeply located lung nodules are difficult to visualize or palpate; therefore, localization is important. We studied the use of a mixture of indigo-carmine and lipiodol, coupled with a transbronchial approach-to achieve accurate localization and minimize patient discomfort and complications. Materials and Methods: A total of 60 patients were enrolled from May 2019 to April 2022, and surgery was performed after the bronchoscopy procedure. Wedge resection or segmentectomy was performed, depending on the location and size of the lesion. Results: In 58/60 (96.7%) patients, the localization of the nodules was successful after localization, and 2/60 required c-arm assistance. None of the patients complained of discomfort during the procedure; in all cases, margins were found to be free from carcinoma, as determined by the final pathology results. Conclusions: We recommend this localization technique using mixture of indigo carmine and lipiodol, in concert with the transbronchial approach, because the procedure time is short, patient's discomfort is low, and success rate is high.

Feasibility of Ultra-Low-Dose CT for Bronchoscopy of Peripheral Lung Lesions.

Background and objectives: Thin-section computed tomography (CT) is essential for identifying small bronchi during bronchoscopy using radial endobronchial ultrasound. Some patients should receive an additional CT for a thin-section image. We performed a retrospective study with a prospectively collected database to identify the optimal radiation dose for thin-section CT during peripheral bronchoscopy. Materials and Methods: In total, 91 patients with peripheral lung lesions underwent thin-section CT (both standard CT as a reference and ultra-low-dose CT (ultra-LDCT)). The patients were randomly assigned to one of four groups according to the ultra-LDCT parameters: group 1 = 120 kVp, 25 mAs; group 2 = 100 kVp, 15 mAs; group 3 = 120 kVp, 5 mAs; and group 4 = 100 kVp, 5 mAs. Two radiologists and two physicians analyzed both the standard CT and ultra-LDCT. Results: The effective doses (EDs) of ultra-LDCT significantly differed among the four groups (median EDs were 0.88, 0.34, 0.19, and 0.12 mSv for groups 1-4, respectively; p < 0.001). Median differences in peripheral airway wall thickness were higher in group 4 than in other groups (differences in median wall thickness measured by two radiologists were 0.4-0.5 mm and 0.8-0.9 mm for groups 1-3 and group 4, respectively). Bronchus signs on ultra-LDCT in groups 1 and 2 were well correlated with those of the standard-dose CT (accuracies of two radiologists and two pulmonary physicians were 95-100%). Conclusions: Our results indicate that ultra-LDCT with ED of >0.34 mSv (ED of group 2) is feasible for peripheral bronchoscopy.

Bronchoscopic management of solitary bronchial myelolipoma: a case report.

BACKGROUND: Myelolipoma is a rare benign tumor composed of mature adipose and hematopoietic tissues. Most myelolipomas are found in the adrenal glands, whereas intrathoracic myelolipoma is extremely rare. In particular, bronchial myelolipoma without the involvement of lung parenchyma has never been reported. CASE PRESENTATION: A previously healthy 38-year-old male developed dyspnea and a productive cough. Computed tomography revealed an endobronchial mass at the right bronchus intermedius and subsequent atelectasis of the right middle and lower lobes. Flexible bronchoscopy found a total obstruction of the right bronchus intermedius due to an endobronchial tumor. Using a rigid bronchoscope, the endobronchial tumor was resected and the base of the tumor was additionally ablated with a diode laser to prevent recurrence. The removed endobronchial tumor was a 13 mm × 20 mm-sized oval-shaped mass and was pathologically diagnosed as bronchial myelolipoma. Chest radiographs, obtained on the day following the procedure, showed an improvement of atelectasis, and accompanying symptoms were immediately improved. Follow-up bronchoscopy performed after 12 months evidenced no recurrence of the bronchial myelolipoma. CONCLUSIONS: We used bronchoscopic intervention in patients with solitary bronchial myelolipoma and there was no evidence of recurrence.

Development of the Korean Association for Lung Cancer Clinical Practice Guidelines: Recommendations on Radial Probe Endobronchial Ultrasound for Diagnosing Lung Cancer - An Updated Meta-Analysis.

PURPOSE: Radial probe endobronchial ultrasound (RP-EBUS) accurately locates peripheral lung lesions (PLLs) during transbronchial biopsy (TBB). We performed an updated meta-analysis of the diagnostic yield of TBB for PLLs using RP-EBUS to generate recommendations for the development of the Korean Association of Lung Cancer guidelines. MATERIALS AND METHODS: We systematically searched MEDLINE and EMBASE (from January 2013 to December 2022), and performed a meta-analysis using R software. The diagnostic yield was evaluated by dividing the number of successful diagnoses by the total lesion number. Subgroup analysis was performed to identify related factors. RESULTS: Forty-one studies with a total of 13,133 PLLs were included. The pooled diagnostic yield of RP-EBUS was 0.72 (95% confidence interval [CI], 0.70 to 0.75). Significant heterogeneity was observed among studies (χ2=292.38, p < 0.01, I2=86.4%). In a subgroup analysis, there was a significant difference in diagnostic yield based on RP-EBUS findings (within, adjacent to, invisible), with a risk ratio of 1.45 (95% CI, 1.23 to 1.72) between within and adjacent to, 4.20 (95% CI, 1.89 to 9.32) between within and invisible, and 2.59 (95% CI, 1.32 to 5.01) between adjacent to and invisible. There was a significant difference in diagnostic yield based on lesion size, histologic diagnosis, computed tomography (CT) bronchus sign, lesion character, and location from the hilum. The overall complication rate of TBB with RP-EBUS was 6.8% (bleeding, 4.5%; pneumothorax, 1.4%). CONCLUSION: Our study showed that TBB with RP-EBUS is an accurate diagnostic tool for PLLs with good safety profiles, especially for PLLs with within orientation on RP-EBUS or positive CT bronchus sign.

Performance of the galactomannan test for the diagnosis of invasive pulmonary aspergillosis using non-invasive proximal airway samples.

OBJECTIVE: To diagnose invasive pulmonary aspergillosis (IPA), galactomannan (GM) detection in serum or bronchoalveolar lavage fluid (BALF) is widely used. However, the utility of proximal airway GM test (from induced sputum or tracheal aspirate) has not been well elucidated. METHODS: In this retrospective cohort study, we evaluated the diagnostic performance of proximal airway GM in diagnosis of IPA including COVID-19 associated pulmonary aspergillosis (CAPA). Between January 2022 and January 2023, patients who had been tested for GM with clinical suspicion or for surveillance from any specimen (serum, induced sputum, tracheal aspirate, and BALF) were screened. IPA was diagnosed using EORTC/MSGERC criteria, and CAPA was diagnosed following the 2020 ECMM/ISHAM consensus criteria. RESULTS: Of 624 patients with GM results, 70 met the criteria for proven/probable IPA and 427 had no IPA. The others included possible IPA and chronic form of aspergillosis. The sensitivities and specificities of serum, proximal airway, and BALF GM for proven/probable IPA versus no IPA were 78.9% and 70.6%, 93.1% and 78.7%, and 78.6% and 91.0%, respectively. Areas under the receiver operating characteristic curve (AUCs) were 0.742 for serum GM, 0.935 for proximal airway GM, and 0.849 for BALF GM (serum GM vs proximal airway GM, p = 0.014; proximal airway GM vs BALF GM, p = 0.334; serum GM vs BALF GM, p = 0.286). CONCLUSION: This study demonstrates that the performance of GM test from non-invasive proximal airway samples is comparable or even better than those from serum and distal airway sample (BALF).

Prediction Models for Mediastinal Metastasis and Its Detection by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Potentially Operable Non-Small Cell Lung Cancer: A Prospective Study.

BACKGROUND: Prediction models for mediastinal metastasis and its detection by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) have not been developed using a prospective cohort of potentially operable patients with non-small cell lung cancer (NSCLC). RESEARCH QUESTION: Can mediastinal metastasis and its detection by EBUS-TBNA be predicted with prediction models in NSCLC? STUDY DESIGN AND METHODS: For the prospective development cohort, 589 potentially operable patients with NSCLC were evaluated (July 2016-June 2019) from five Korean teaching hospitals. Mediastinal staging was performed using EBUS-TBNA (with or without the transesophageal approach). Surgery was performed for patients without clinical N (cN) 2-3 disease by endoscopic staging. The prediction model for lung cancer staging-mediastinal metastasis (PLUS-M) and a model for mediastinal metastasis detection by EBUS-TBNA (PLUS-E) were developed using multivariable logistic regression analyses. Validation was performed using a retrospective cohort (n = 309) from a different period (June 2019-August 2021). RESULTS: The prevalence of mediastinal metastasis diagnosed by EBUS-TBNA or surgery and the sensitivity of EBUS-TBNA in the development cohort were 35.3% and 87.0%, respectively. In PLUS-M, younger age (< 60 years and 60-70 years compared with ≥ 70 years), nonsquamous histology (adenocarcinoma and others), central tumor location, tumor size (> 3-5 cm), cN1 or cN2-3 stage by CT, and cN1 or cN2-3 stage by PET-CT were significant risk factors for N2-3 disease. Areas under the receiver operating characteristic curve (AUCs) for PLUS-M and PLUS-E were 0.876 (95% CI, 0.845-0.906) and 0.889 (95% CI, 0.859-0.918), respectively. Model fit was good (PLUS-M: Hosmer-Lemeshow P = .658, Brier score = 0.129; PLUS-E: Hosmer-Lemeshow P = .569, Brier score = 0.118). In the validation cohort, PLUS-M (AUC, 0.859 [95% CI, 0.817-0.902], Hosmer-Lemeshow P = .609, Brier score = 0.144) and PLUS-E (AUC, 0.900 [95% CI, 0.865-0.936], Hosmer-Lemeshow P = .361, Brier score = 0.112) showed good discrimination ability and calibration. INTERPRETATION: PLUS-M and PLUS-E can be used effectively for decision-making for invasive mediastinal staging in NSCLC. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02991924; URL: www. CLINICALTRIALS: gov.

Combined procedure with radial probe and convex probe endobronchial ultrasound.

BACKGROUND: Concurrent bronchoscopy using radial probe and convex endobronchial ultrasound (RP- and CP-EBUS) is used to simultaneously evaluate both peripheral lung lesions for the histological diagnosis of the primary tumor and mediastinal lymph nodes for mediastinal staging. So far, little is known about the combined procedure with RP- and CP-EBUS. METHODS: Between January 2020 and March 2021, the bronchoscopy database was reviewed to identify the clinical outcomes of the combined procedure with RP- and CP-EBUS. Patients who underwent transbronchial biopsy using RP-EBUS alone were classified as the RP-EBUS group, while those who underwent a combined procedure with RP- and CP-EBUS were classified as the combination group. RESULTS: The overall diagnostic yield of the bronchoscopic procedure in the combination group was significantly higher than the RP-EBUS group (90.7% vs. 70.0%, p < 0.001). CP-EBUS increased the diagnostic yield of the bronchoscopic procedure in the combination group by 9.3%. Although the mean procedure time was significantly longer, and the mean doses of midazolam and fentanyl were significantly higher in the combination group (p < 0.001), there were no differences in the overall complication rates between the two study groups (1.4% and 1.0% for the RP-EBUS and combination groups, respectively, p = 0.766). CONCLUSIONS: Combined bronchoscopy using RP- and CP-EBUS is feasible and safe. In addition to mediastinal staging, CP-EBUS increased the overall diagnostic yield of the bronchoscopic procedure by 9.3%.

Linezolid-induced black hairy tongue in a patient with multidrug-resistant tuberculosis: A case report.

The revised World Health Organization guidelines on multidrug-resistant tuberculosis include linezolid in the core drugs group. Consequently, the use of linezolid for patients with multidrug-resistant tuberculosis is increasing. Common adverse events of long-term linezolid use include bone marrow suppression and neuropathies. However, there is limited information on a rare adverse event, black hairy tongue. Here, we report a case of linezolid-induced black hairy tongue in a patient with multidrug-resistant tuberculosis. The etiology, pathogenesis, diagnosis, and treatment of black hairy tongue are also discussed.

Unexpected exposure to Mycobacterium tuberculosis during bronchoscopy using radial probe endobronchial ultrasound.

BACKGROUND: Bronchoscopy using radial probe endobronchial ultrasound (EBUS) is performed when a peripheral lung lesion (PLL) is suspected to be malignant. However, pulmonary tuberculosis is diagnosed in some patients, and healthcare workers could therefore be exposed to tuberculosis if sufficient precautions are not taken. In this study, we examined the proportion of and factors associated with unexpected exposure to Mycobacterium tuberculosis during bronchoscopy using radial probe EBUS. METHODS: This retrospective study included 970 patients who received bronchoscopy using radial probe EBUS between December 2015 and November 2018. Clinical, histological, radiological, and microbiological data were reviewed. RESULTS: Pulmonary tuberculosis was diagnosed in 31 patients (3.2%) during bronchoscopy using radial probe EBUS. Patients with a lower age were significantly more likely to be diagnosed with tuberculosis than elderly patients (odds ratio [OR], 0.951; 95% confidence interval [CI], 0.924-0.978; P = 0.001). Among the various CT findings, a low HUs difference between pre- and post-enhanced CT (OR, 0.976; 95% CI, 0.955-0.996; P = 0.022), the presence of concentric cavitation (OR, 5.211; 95% CI, 1.447-18.759; P = 0.012), and the presence of satellite centrilobular nodules (OR, 22.925; 95% CI, 10.556-49.785; P < 0.001) were independently associated with diagnosis of tuberculosis. CONCLUSIONS: The proportion of unexpected exposure to Mycobacterium tuberculosis during bronchoscopy using radial probe EBUS was 3.2%. A higher risk was independently associated with a younger age and CT findings of a small difference in HUs between pre- and post-enhancement images, concentric cavitation, and the presence of a satellite centrilobular nodule.

Sequential Organ Failure Assessment score as a predictor of mortality in ventilated patients with multidrug-resistant bacteremia.

BACKGROUND: The occurrence of multidrug-resistant (MDR) bacteremia in ventilated patients may be associated with a high mortality rate. We evaluated whether Sequential Organ Failure Assessment (SOFA) score on the day of bacteremia could predict 90-day mortality in these patients. METHODS: Data were obtained retrospectively from 202 patients (male, 60.4%; median age, 64 years) hospitalized at a single university-affiliated tertiary care hospital. All adult patients who had were ventilated and had one of the following six MDR bacteremias between March 2011 and February 2018 were enrolled: methicillin-resistant Staphylococcus aureus, extended-spectrum ß-lactamase-producing Gram-negative bacteria (Escherichia coli and Klebsiella pneumonia), carbapenem-resistant Gram-negative rods (Acinetobacter baumannii and Pseudomonas aeruginosa), or vancomycin-resistant Enterococcus faecium. RESULTS: The overall 90-day mortality rate after the day of bacteremia was 59.9%. The areas under the receiver operating characteristic curves for the SOFA and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 0.732 (95% confidence interval [CI], 0.666 to 0.792; P<0.001) and 0.662 (95% CI, 0.593 to 0.727; P<0.001), respectively, with no difference between the two (P=0.059). Also, the cutoff value of the SOFA score was 9 (based on Youden's index). Multivariate Cox regression analysis showed that this cut-off value was significantly associated with higher mortality rate (hazard ratio, 2.886; 95% CI, 1.946 to 4.221; P<0.001). CONCLUSIONS: SOFA score measured on the day of bacteremia may be a useful prognostic indicator of 90-day mortality in ventilated patients with MDR bacteremia.

Appropriate amounts proportions of lidocaine gel, indigo carmine and lipiodol mixture for preoperative marking in video-assisted thoracic surgery.

Preoperative marking is necessary in thoracoscopic wedge resections of lung nodules expected to be invisible or nonpalpable during surgery. Recently, lidocaine gel was added to a dye solution containing indigo carmine and lipiodol to promote micelle formation, but the optimal mixing ratio was not determined. Thus, an in vitro experiment was performed to identify the optimal mixing ratio of lidocaine gel, indigo carmine and lipiodol. To fixed volumes of indigo carmine and lipiodol of 0.5 ml each, 0.1, 0.2, 0.3, 0.4 and 0.5 ml of lidocaine gel was added. Changes were examined every 2 h. No changes were seen in the mixtures containing 0.1 and 0.2 ml of lidocaine gel, whereas those with 0.3, 0.4 and 0.5 ml had clearly separated after 2 h. Our findings suggest that the ideal proportion of indigo carmine, lipiodol and lidocaine gel for use in preoperative marking is 5:5:2.