Newer modalities in the work-up of peripheral pulmonary nodules

Diagnosis of Peripheral Pulmonary Lesions with Transbronchial Lung Cryobiopsy by Guide Sheath and Radial Endobronchial Ultrasonography: A Prospective Control Study

Objective

We design a prospective control study on the utilization of transbronchial cryobiopsy guided by EBUS-GS (EBUS-GS-TBCB) to diagnose PPLs.

Methods

PPLs were defined as pulmonary nodules or masses with a diameter from 10 mm to 50 mm. PPLs were randomly divided into group EBUS-GS-TBCB and transbronchial biopsy by forceps guided under EBUS-GS (EBUS-GS-TBB).

Results

28 cases were involved in group EBUS-GS-TBCB and 31 cases were in group EBUS-GS-TBB. The mean sizes of PPLs were 30.23 ± 11.10 mm in group EBUS-GS-TBCB and 28.69 ± 8.62 mm in group EBUS-GS-TBB (t = 0.600, p=0.551). The diagnostic yields of EBUS-GS-TBCB and EBUS-GS-TBB were 75% and 64.52% respectively, and the difference between the two groups was not significant (χ ² value = 0.137, p=0.711). If only the first specimen was taken into account, the diagnostic yields from EBUS-GS-TBCB and EBUS-GS-TBB were 64.29% (18/28 cases) and 35.48% (11/31 cases), respectively. The difference was statistically significant by Fisher's Exact Test (χ ² value = 4.883, p=0.038). The total incidence rates of bleeding were 21.43% and 6.45%, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB. The total incidence rates of pneumothorax were 7.14% and 0, respectively, in groups EBUS-GS-TBCB and EBUS-GS-TBB.

Conclusion

The diagnostic yield of EBUS-GS-TBCB was slightly higher than that of EBUS-GS-TBB for the diagnosis of PPLs. EBUS-GS-TBCB might be useful if only the first sample was taken into account.

Ultrathin bronchoscopy for solitary pulmonary lesions in a region endemic for tuberculosis: a randomised pilot trial

Background

The evaluation of solitary pulmonary lesions (SPL) requires a balance between procedure-related morbidity and diagnostic yield, particularly in areas where tuberculosis (TB) is endemic. Data on ultrathin bronchoscopy (UB) for this purpose is limited. To evaluate feasibility and safety of UB compared to SB for diagnosis of SPL in a TB endemic region.

Methods

In this prospective randomised trial we compared diagnostic yield and adverse events of UB with standard-size bronchoscopy (SB), both combined with fluoroscopy, in a cohort of patients with SPL located beyond the visible range of SB.

Results

We included 40 patients (mean age 55.2 years, 45 % male) with malignant SPL (n = 16; 40 %), tuberculous SPL (n = 11; 27.5 %) and other benign SPL (n = 13; 32.5 %). Mean procedure time in UB and SB was 30.6 and 26.0 min, respectively (p = 0.15). By trend, adverse events were recorded more often with UB than with SB (30.0 vs. 5.0 %, p = 0.091), including extensive coughing (n = 2), blocked working channel (n = 2), and arterial hypertension requiring therapeutic intervention (n = 1), all with UB. The overall diagnostic yield of UB compared to SB was 55.0 % vs. 80.0 %, respectively (p = 0.18). Sensitivity for the diagnosis of malignancy of UB and SB was 50.0 % and 62.5 %, respectively (p = 0.95).

Conclusion

UB is not superior to SB for the evaluation of SPL in a region endemic with tuberculosis, when combined with fluoroscopic guidance only.

Trial registration

ClinicalTrials.gov (Identifier: NCT02490059).

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0225-1) contains supplementary material, which is available to authorized users.

New Nodule-Newer Etiology

AIM: To evaluate frequency and temporal relationship between pulmonary nodules (PNs) and transbronchial biopsy (TBBx) among lung transplant recipients (LTR).

METHODS: We retrospectively reviewed 100 records of LTR who underwent flexible bronchoscopy (FB) with TBBx, looking for the appearance of peripheral pulmonary nodule (PPN). If these patients had chest radiographs within 50 d of FB, they were included in the study. Data was compared with 30 procedures performed among non-transplant patients. Information on patient’s demographics, antirejection medications, anticoagulation, indication and type of lung transplantation, timing of the FB and the appearance and disappearance of the nodules and its characteristics were gathered.

RESULTS: Nineteen new PN were found in 13 procedures performed on LTR and none among non-transplant patients. Nodules were detected between 4-47 d from the procedure and disappeared within 84 d after appearance without intervention.

CONCLUSION: FB in LTR is associated with development of new, transient PPN at the site of TBBx in 13% of procedures. We hypothesize that these nodules are related to local hematoma and impaired lymphatic drainage. Close observation is a reasonable management approach.

Diagnosis and management of pulmonary nodules

There are an increased number of pulmonary nodules discovered on CT scan images in part due to those performed for lung cancer screening. Risk stratification and patient involvement is critical in determining management ranging from interval imaging to invasive biopsy or surgery. A definitive diagnosis requires tissue biopsy. The choice of a particular biopsy technique depends on the risks/benefits of the procedure, the diagnostic yield and local expertise. This review will focus on the evaluation and management of pulmonary nodules based on the Fleischner Society and American College of Chest Physician guidelines. There have been recent changes to both societies' recommendations for incidental detection of solid and subsolid nodules, risk stratification, imaging, minimally invasive diagnostic techniques and definitive surgical options.