Histogram-based quantitative evaluation of endobronchial ultrasonography images of peripheral pulmonary lesion

BACKGROUND

Endobronchial ultrasonography using a guide sheath (EBUS-GS) is an increasingly common bronchoscopic technique, but currently, no methods have been established to quantitatively evaluate EBUS images of peripheral pulmonary lesions.

OBJECTIVES

The purpose of this study was to evaluate whether histogram data collected from EBUS-GS images can contribute to the diagnosis of lung cancer.

METHODS

Histogram-based analyses focusing on the brightness of EBUS images were retrospectively conducted: 60 patients (38 lung cancer; 22 inflammatory diseases), with clear EBUS images were included. For each patient, a 400-pixel region of interest was selected, typically located at a 3- to 5-mm radius from the probe, from recorded EBUS images during bronchoscopy. Histogram height, width, height/width ratio, standard deviation, kurtosis and skewness were investigated as diagnostic indicators.

RESULTS

Median histogram height, width, height/width ratio and standard deviation were significantly different between lung cancer and benign lesions (all p < 0.01). With a cutoff value for standard deviation of 10.5, lung cancer could be diagnosed with an accuracy of 81.7%. Other characteristics investigated were inferior when compared to histogram standard deviation.

CONCLUSIONS

Histogram standard deviation appears to be the most useful characteristic for diagnosing lung cancer using EBUS images.

Broncholithiasis Assessed by Bronchoscopic Saline Solution Injection

A 68-year-old man was admitted with hemoptysis. Bronchoscopy showed bronchial obstruction at the right B(3)bii proximal to the broncholith. The distal end of the bronchoscope was placed in a wedge position at the right B(3)bii. After repeated injection of saline solution through the working channel of the bronchoscope, we observed that the broncholith was freed from the bronchial wall. The broncholith was easily removed with forceps through the working channel of the bronchoscope. Bronchoscopic saline solution injection was safe and effective in confirming the mobility of the broncholith as bronchoscopy alone could not detect the broncholiths due to bronchial occlusion.

Intractable pneumothorax managed by talc pleurodesis and bronchial occlusion with spigots

Three cases of inoperable secondary spontaneous pneumothorax were diagnosed in patients with chronic obstructive pulmonary disease. Two cases initially underwent bronchial occlusion with endobronchial Watanabe spigot (EWS), while one underwent talc poudrage with pleuroscopy. As air leaks were not stopped completely in all cases with the initial procedures, we performed additional interventional treatments: pleuroscopic talc poudrage in cases when bronchial occlusion was performed first; and bronchial occlusion with EWS for a case that initially underwent talc pleurodesis. The air leaks ceased in all cases without complication. We successfully removed chest tubes 2–10 days after secondary procedure, which was 10–23 days after the first procedure. The combination of talc pleurodesis and bronchial occlusion with EWS, when a single, initial interventional treatment fails, can be considered in cases of intractable, inoperable secondary pneumothorax.

[Efficacy of omalizumab in patients with severe asthma using the asthma health questionnaire and asthma control test]

BACKGROUND

The efficacy of anti-IgE antibody, omalizumab, was studied in patients with severe bronchial asthma. There have been reports stating that although omalizumab could not improve objective results, it has shown improvements in subjective symptoms of patients. The aim of this study is to evaluate the efficacy of omalizumab in severe bronchial asthma.

METHODS

Thirteen patients were enrolled. Omalizumab was administered subcutaneously every 2 or 4 weeks based on serum IgE level and body weight of each patient. Pulmonary function tests, Asthma Control Test (ACT), Asthma Health Questionnaire-JAPAN (AHQ-JAPAN), number of emergency visits and dosage of methylprednisolone during a 16-week period were compared to the previous year. We examined the correlations between respiratory function, and ACT and AHQ-JAPAN.

RESULTS

Treatment with omalizumab did not improve lung function. AHQ and ACT over the 16-week period significantly improved compared to baseline (p<0.01). The number of emergency visit and doses of methylprednisolone were significantly reduced compared to the previous year (p<0.01).

CONCLUSION

Although treatment with omalizumab could not improve lung function, AHQ and ACT during the 16-week study period had significantly improved compared to baseline. Omalizumab significantly reduced the number of emergency visits and dosages of methylprednisolone.

Severe tracheal stenosis with tracheopathia osteoplastica-like changes due to traumatic blunt injury

A 17-year-old man was injured in a motorcycle accident, leading to a complex cerebral contusion and hepatic injury. Approximately one month after being discharged from the hospital, the patient experienced gradually progressive dyspnea on exertion. Chest computed tomography revealed severe upper tracheal stenosis; thus, emergency tracheotomy and subsequent tracheoplasty were performed. Microscopically, the deformation of tracheal cartilage and extensive interstitial ossification/fibro-elastic changes were observed. To our knowledge, this is the first report documenting the ossification of the trachea that rapidly progressed after injury, which was confirmed by surgical resection of the upper trachea.

The correlation between lung sound distribution and pulmonary function in COPD patients

Background

Regional lung sound intensity in chronic obstructive pulmonary disease (COPD) patients is influenced by the severity and distribution of emphysema, obstructed peripheral airways, and altered ribcage and diaphragm configurations and movements due to hyperinflation. Changes in the lung sound distribution accompanied by pulmonary function improvements in COPD patients were observed after bronchodilator inhalation. We investigated the association of lung sound distribution with pulmonary functions, and the effects of emphysematous lesions on this association. These studies were designed to acquire the basic knowledge necessary for the application of lung sound analysis in the physiological evaluation of COPD patients.

Methods

Pulmonary function tests and the percentage of upper- and lower-lung sound intensity (quantitative lung data [QLD]) were evaluated in 47 stable male COPD patients (54 - 82 years of age). In 39 patients, computed tomography taken within 6 months of the study was available and analyzed.

Results

The ratio of lower QLD to upper QLD showed significant positive correlations with FEV₁ %predicted (%FEV₁; ρ = 0.45, p<0.005) and MEF₅₀ %predicted (%MEF₅₀; ρ = 0.46, p<0.005). These correlations were not observed in COPD patients with dominant emphysema (% low attenuation area >40%, n = 20) and were stronger in less emphysematous patients (n = 19, %FEV₁; ρ = 0.64, p<0.005, %MEF₅₀; ρ = 0.71, p<0.001).

Conclusions

In COPD patients, the ratio of lower- to upper-lung sound intensities decreased according to the severity of obstructive changes, although emphysematous lesions considerably affected lung sound distribution.

Left and right lung asynchrony as a physiological indicator for unilateral bronchial obstruction in interventional bronchoscopy

BACKGROUND

In patients with bronchial obstruction, pulmonary function tests may not change significantly after intervention. The airflow asynchrony in both lungs due to unilateral bronchial obstruction may be applicable as a physiological indicator. The airflow asynchrony is reflected by the difference in the left and right lung sound development at tidal breathing.

OBJECTIVES

To investigate the usefulness of left and right lung asynchrony due to unilateral bronchial obstruction as a physiological indicator for interventional bronchoscopy.

METHODS

Fifty cases with central airway obstruction were classified into three groups: tracheal, bronchial and extensive obstruction. The gap index was defined as the absolute value of the average of gaps between the left and right lung sound intensity peaks for a 12-second duration.

RESULTS

Before interventional bronchoscopy, the gap index was significantly higher in the bronchial (p<0.05) and extensive obstruction groups (p<0.05) than in the tracheal group. The gap index in cases with unilateral bronchial obstruction of at least 80% (0.18±0.04 seconds) was significantly higher than in cases with less than 80% obstruction (0.02±0.01 seconds, p<0.05). After intervention for bronchial obstruction, the dyspnea scale (p<0.001) and gap index significantly improved (p<0.05), although no significant improvements were found in spirometric assessments. The responder rates for dyspnea were 79.3% for gap indexes over 0.06 seconds and 55.6% for gap indexes of 0.06 seconds or under.

CONCLUSIONS

Assessment of left and right lung asynchrony in central airway obstruction with bronchial involvement may provide useful physiological information for interventional bronchoscopy.

Bronchoscopic interventions for chronic obstructive pulmonary disease

Over the past decade, several non-surgical and minimally invasive bronchoscopic lung volume reduction (BLVR) techniques have been developed to treat patients with severe chronic obstructive pulmonary disease (COPD). BLVR can be significantly efficacious, suitable for a broad cohort of patients, and associated with a solid safety profile at a reasonable expense. The introduction of BLVR is also expected to accelerate the further development of interventional pulmonology worldwide. Recently, results from clinical studies on BLVR techniques have been published, providing valuable information about the procedure's indications, contraindications, patient-selection criterion and outcomes. BLVR utilizing one-way endobronchial valves is gaining momentum as an accepted treatment in regular medical practice because of the identification of best responders. Patients with a heterogeneous emphysema distribution and without inter-lobar collateral ventilation show encouraging results. Furthermore, for patients with collateral ventilation, who are not considered candidates for valve treatment, and for patients with homogeneous emphysema, the introduction of lung volume reduction coil treatment is a promising solution. Moreover, with the development of newer treatment modalities, that is, biochemical sealant and thermal water vapor, the potential to treat emphysema irrespective of collateral flow, may be further increased. Nevertheless, patient selection for BLVR treatment will be crucial for the procedure's success and should be performed using a multidisciplinary team approach. Consequently, BLVR needs to be concentrated in high-volume centres that will offer better quality and experience with treatment challenges and adverse events. This review gives a general overview of BLVR from an expert and scientific perspective.

Role of narrowband imaging in assessing endobronchial cryptococcosis

Endobronchial cryptococcosis can cause tracheobronchitis with granulomatous changes. In this patient under steroid therapy, bronchoscopic images revealed elevated white patchy lesion on the posterior longitudinal folds of the lower trachea. Bronchoscopy with narrowband imaging (NBI) revealed opaque bronchial subepithelial vessels. Endobronchial biopsy confirmed Cryptococcus neoformans infection in the subepithelial layer. Following treatment with fluconazole, bronchoscopy with NBI revealed the disappearance of elevated lesion and regrowth of vessels of regular caliber. NBI might be useful to assess and follow-up endobronchial fungal infection and other inflammatory processes.

Assessment of central airway obstruction using impulse oscillometry before and after interventional bronchoscopy

BACKGROUND

Spirometry is used to physiologically assess patients with central airway obstruction (CAO) before and after interventional bronchoscopy, but is not always feasible in these patients, does not localize the anatomic site of obstruction, and may not correlate with the patient's functional impairment. Impulse oscillometry may overcome these limitations. We assessed the correlations between impulse oscillometry measurements, symptoms, and type of airway narrowing, before and after interventional bronchoscopy, and whether impulse oscillometry parameters can discriminate between fixed and dynamic CAO.

METHODS

Twenty consecutive patients with CAO underwent spirometry, impulse oscillometry, computed tomography, dyspnea assessment, and bronchoscopy, before and after interventional bronchoscopy. The collapsibility index (the percent difference in airway lumen diameter during expiration versus during inspiration) was calculated using morphometric bronchoscopic images during quiet breathing. Variable CAO was defined as a collapsibility index of > 50%. Fixed CAO was defined as a collapsibility index of < 50%. The degree of obstruction was analyzed with computed tomography measurements.

RESULTS

After interventional bronchoscopy, all impulse oscillometry measurements significantly improved, especially resistance at 5 Hz, which decreased from 0.67 ± 0.29kPa/L/s to 0.38 ± 0.17kPa/L/s (P < .001), and reactance at 20 Hz, which increased from -0.09 ± 0.11 to 0.03 ± 0.08 (P < .001). Changes in dyspnea score correlated with resistance at 5 Hz, the difference between the resistance at 5 Hz and the resistance at 20 Hz, and the reactance at 5 Hz, but not with spirometry measurements. The type of obstruction also correlated with dyspnea score, and showed distinct impulse oscillometry measurements.

CONCLUSIONS

Impulse oscillometry measurements correlate with symptom improvements after interventional bronchoscopy. Impulse oscillometry might be useful to discriminate variable from fixed central airway obstruction. (University Hospital Medical Information Network, http://www.umin.ac.jp/english, ID000005322).

Vibration response imaging in healthy Japanese subjects

BACKGROUND

Vibration response imaging (VRI) records the intensity and distribution of lung sounds during the respiration cycle. Our objective was to analyze VRI findings in healthy Japanese adults.

METHODS

VRI images of 106 healthy subjects (33.7±9.6 years, 52 male and 54 female), including 67 nonsmokers and 39 asymptomatic smokers, were recorded. The regional intensity of vibrations was assessed using quantitative lung data (QLD), and VRI dynamic images by rater assessment, left and right lung asynchrony (gap index), and regional lung asynchrony (asynchrony score).

RESULTS

A dominance of total left lung QLD was observed in all subjects, and this phenomenon was more prominent in female subjects. However, there was no significant difference between the total left and total right lung QLD in smokers. Rater assessments showed that 81.1% of all subjects had a normal final assessment. Male subjects had a significantly higher percentage of good or normal assessments for all image scores, except dynamic image scoring. The asynchrony score was significantly higher in female subjects. There were no significant differences in these qualitative assessments between non-smokers and smokers.

CONCLUSIONS

Although our QLD results were similar to those of a previous report, there were discrepancies between sexes for the qualitative assessments. A significantly higher number of female subjects had abnormal images as assessed by the raters. Furthermore, significantly higher asynchrony scores were observed in female subjects. The VRI variability in sex may be considered normal among the Japanese population. This study is registered with UMIN-CTR under registration number UMIN000002355.

Cell therapy with adipose tissue-derived stem/stromal cells for elastase-induced pulmonary emphysema in rats

AIMS

The purpose of this study was to elucidate the mechanism underlying the effects of adipose tissue-derived stem/stromal cell (ASC) transplantation on porcine pancreatic elastase-induced emphysema.

MATERIALS & METHODS

ASCs (2.5 × 10(6)) were transplanted into pancreatic elastase (250 U/kg)-treated rats, after which gas exchange and growth factor/cytokine levels in lung tissue were determined.

RESULTS

ASC transplantation restored pulmonary function (arterial oxygen tension and alveolar-arterial oxygen tension difference) almost to that of normal animals. Enlargement of the alveolar airspaces was inhibited. HGF and CINC-1 levels were significantly higher in the ASC group even at 2 weeks after transplantation. Sponge implantation with CINC-1 induced neovascular formation with increased HGF. In vitro secretion of HGF and CINC-1 from ASCs was promoted in the presence of IL-1β.

CONCLUSION

Not only HGF, but also CINC-1, secreted from transplanted and viable ASCs presumably contributed to lung repair through angiogenesis.

Talc pleurodesis for the management of malignant pleural effusions in Japan

OBJECTIVE

Malignant pleural effusions are commonly treated with tube drainage followed by chemical pleurodesis to maintain the patient's quality of life. While talc is now accepted to be a worldwide gold-standard sclerosing agent for treating malignant pleural effusion, it is not yet approved in Japan. Instead, many patients are administered OK-432 for pleurodesis, which carries the risk of complications such as high-grade fever, chest pain, anaphylactic shock, interstitial pneumonia and acute renal failure. To assess the efficacy and safety of talc as a sclerosing agent in the management of malignant pleural effusions in Japanese patients.

METHODS

Pleurodesis was performed using 4 g of sterile talc with thoracoscopic talc poudrage or the administration of talc slurry via a chest tube in patients with malignant pleural effusions.

RESULTS

A total of 57 patients were included. The success rate of pleurodesis assessed on chest radiography at 30, 90 and 180 days was 90.6%, 80.9% and 76.1%, respectively. Complications occurring after talc pleurodesis included fever in 10.5% of the patients and chest pain in 14.0% of the patients. No major complications were reported.

CONCLUSION

Talc pleurodesis is an effective and safe treatment for the management of malignant pleural effusion in Japanese patients.

Impacts of treatment lines and initiation timing of erlotinib for advanced non-small cell lung cancer

AIM

This study aimed to analyze whether or not the efficacy and safety of erlotinib are influenced by differences among treatment lines and initiation timing in advanced non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Stage III or IV NSCLC cases were retrospectively evaluated at three university hospitals. The primary outcome was progression-free survival (PFS).

RESULTS

Median PFSs of the second-, third- and fourth-line and over therapies were 138, 250 and 95 days; and median overall survivals (OSs) were 174, 260 and 270 days, respectively, with no significant differences. The response rates (RR) for the second-, third- and fourth-line and over therapies were 14%, 24% and 13%, respectively, with no significant differences. The toxicity profiles did not differ among the groups. The median PFSs and OSs according to initiation timing were not significantly different.

CONCLUSION

Differences in treatment lines and initiation timing affected neither efficacy nor safety in patients with advanced NSCLC.

Pleuroperitoneal shunt for chylothorax and chylopericardium in lung cancer: a case report

A 70-year-old man with T1N3M1 stage IV squamous cell carcinoma in the right upper lobe of the lung developed chylothorax and chylopericardium as rare simultaneous complications. Intravenous hyperalimentation, repeated pleurodesis, and ligation of the thoracic duct were all ineffective. A pleuroperitoneal shunt was inserted into the right pleural cavity from the fifth intercostal space, and a peritoneal catheter was placed in the abdominal cavity. Chylothorax was markedly improved, and the quality of life of the patient increased. This case indicates that a pleuroperitoneal shunt can be used for lung cancer-related chylothorax, as well as for malignant pleural effusion.

Narrow band imaging applied to pleuroscopy for the assessment of vascular patterns of the pleura

BACKGROUND

Narrow band imaging (NBI), which enhances blood vessels, is a new endoscopic technology for diagnosing malignancies, but it has not been investigated for pleuroscopy.

OBJECTIVES

To evaluate the efficacy of NBI applied to pleuroscopy for detecting malignant lesions by assessing vascular patterns of the pleura.

METHODS

From May 2006 to September 2008, 45 patients with undiagnosed pleural ef-fusion underwent pleuroscopy using a pleura-videoscope with white light (WL) and NBI under local anesthesia. For this prospective study, 73 biopsy specimens were obtained from sites where images under both WL and NBI were recorded and classified regarding vascular patterns.

RESULTS

Of the 73 lesions, WL showed blood vessels in 32 lesions, and NBI in 52 lesions (WL vs. NBI; p = 0.0014). The accuracy, sensitivity and specificity in the detection of irregular vascular patterns, e.g. blood vessels with irregular caliber or punctate vessels indicating malignant lesions, were 60.3, 76.5 and 55.4% in WL, and 80.8, 85.3 and 76.9% in NBI, respectively, resulting in a significant increase in NBI (p = 0.0106 for accuracy and p = 0.0494 for specificity). For flat lesions, NBI revealed a higher accuracy rate (90.6%) in the detection of irregular vascular patterns indicating malignant lesions.

CONCLUSION

Our study demonstrated that NBI applied to pleuroscopy displayed blood vessels significantly better than WL. NBI was useful to detect irregular vascular patterns suggesting malignant lesions, especially for flat lesions. Therefore, NBI was considered useful in the selection of optimal biopsy sites by assessing vascular patterns.