The location, histologic type, and stage of lung cancer are associated with bleeding during endobronchial biopsy

Risk and adverse clinical outcomes of thrombocytopenia among patients with solid tumors-a Danish population-based cohort study

BACKGROUND

Knowledge about thrombocytopenia among patients with solid tumors is scarce. We examined the risk of thrombocytopenia among patients with solid tumors and its association with adverse outcomes.

METHODS

Using Danish health registries, we identified all patients with incident solid tumors from 2015-2018 (n = 52,380) and a platelet count measurement within 2 weeks prior to or on their cancer diagnosis date. The risk of thrombocytopenia was categorized as grades 0 (any platelet count × 109/L): <150; 1: <100; 2: <75; 3: <50; 4: <25, and 5: <10. To study the outcomes, each patient with thrombocytopenia was matched with up to five cancer patients without thrombocytopenia by age, sex, cancer type, and stage. Cox regression was used to compute hazard ratios (HRs) of bleeding, transfusion, or death, adjusting for confounding factors.

RESULTS

The 1-year risk of thrombocytopenia was 23%, increasing to 30% at 4 years. This risk was higher in patients receiving chemotherapy (43% at 1 year and 49% at 4 years). Overall, patients with thrombocytopenia had higher 30-days rates of bleeding (HR = 1.72 [95% confidence interval, CI: 1.41-2.11]). Thrombocytopenia was also associated with an increased rate of transfusion, and death, but some of the risk estimates were imprecise.

CONCLUSIONS

The risk of thrombocytopenia was substantial among patients with solid tumors and associated with adverse outcomes.

In Search of the Perfect Thrombosis and Bleeding-Associated Cancer Scale

Thrombosis and bleeding are commonly observed in cancer patients, and their management is crucial for positive patient outcomes. A comprehensive, prophylactic, and therapeutic management of venous thrombosis should focus on identifying the patients who would benefit most from treatment to reduce mortality and minimize the risk of thrombosis recurrence without significantly increasing the risk of bleeding. Existing cancer scales provide valuable information for assessing the overall burden of cancer and guiding treatment decisions, but their ability to predict thrombotic and bleeding events remains limited. With increasing knowledge of the pathophysiology of cancer and the availability of advanced anticancer therapies, new risk factors for cancer-associated thrombosis and bleeding are being identified. In this report, we analyze the current literature and identify new risk factors for venous thrombosis and bleeding which are not included in routinely used risk scores. While some existing cancer scales partially capture the risk of thrombosis and bleeding, there is a need for more specific and accurate scales tailored to these complications. The development of such scales could improve risk stratification, aid in treatment selection, and enhance patient care. Therefore, further research and development of novel cancer scales focused on thrombosis and bleeding are warranted to optimize patient management and outcomes.

Lung isolation-a personalized and clinically adapted approach to control bronchoscopy-associated acute massive airway hemorrhage

BACKGROUND

The current concept of bronchoscopy-associated massive airway hemorrhage is not accurate enough, and the amount of bleeding as the only evaluation criterion cannot comprehensively evaluate magnitude of the effects and the severity.

OBJECTIVE

To propose the concept of bronchoscopy-associated acute massive airway hemorrhage, analyze its impact on patients and highlight the treatment approach of acute massive airway hemorrhage without ECMO support.

DESIGNS

A retrospective cohort study.

SETTING

Include all patients who received bronchoscopy intervention therapy at Interventional Pulmonology Center of Emergency General Hospital from 2004 to December 2021.

PATIENTS

223 patients met the inclusion criteria.

INTERVENTION

Patients were divided into two groups: acute massive airway hemorrhage group (n = 29) and non-acute massive airway hemorrhage group (n = 194).

MAIN OUTCOME MEASURES

Perioperative adverse events between two groups were the main outcome. Secondary outcome was the impact of lung isolation on patient in group Acute.

RESULTS

The incidence of acute massive airway hemorrhage was 0.11%, and the incidence of non-acute massive airway hemorrhage was 0.76% in this study. There were significant differences in the incidence of intraoperative hypoxemia, lowest SpO2, hemorrhagic shock, cardiopulmonary resuscitation, intraoperative mortality, and transfer to ICU between acute group and non-acute group (P<0.05, respectively). Lung isolation was used in 12 patients with acute massive airway hemorrhage, and only 2 patients died during the operation.

CONCLUSION

Bronchoscopy-associated acute massive airway hemorrhage had more serious impact on patients due to rapid bleeding, blurred vision of bronchoscopy, inability to stop bleeding quickly, blood filling alveoli, and serious impact on oxygenation of the lung lobes. Polyvinyl chloride single-lumen endotracheal intubation for lung isolation, with its characteristics of low difficulty, wide applicability and available in most hospitals, may reduce the intraoperative mortality of patients with bronchoscopy-associated acute massive airway hemorrhage.

TRIAL REGISTRATION

Chinese Clinical Trial Registry on 13/03/2022.

REGISTRATION NUMBER

ChiCTR2200057470.

Clinical and Paraclinical Characteristics of Endobronchial Pulmonary Squamous Cell Carcinoma-A Brief Review

BACKGROUND

Endobronchial squamous cell carcinoma is one of the most common types of tumors located inside the tracheobronchial tree. Patients often present in advanced stages of the disease, which most often leads to a targeted therapeutic attitude of pneumonectomy. Practicing lung parenchyma-preserving surgery led us to undertake this review.

MATERIALS AND METHODS

We used three search platforms-SCIENCE, MEDLINE, and PubMed-in order to identify studies presenting case reports, investigations, and reviews on endobronchial squamous cell carcinoma. We identified the clinical and paraclinical features of endobronchial squamous cell carcinoma. All the selected articles were in English and addressed the clinical criteria of endobronchial squamous cell carcinoma, autofluorescence bronchoscopy in endobronchial squamous cell carcinoma, imaging features of endobronchial squamous cell carcinoma, blood tumor markers specific to lung squamous cell carcinoma, and histopathological features of endobronchial squamous cell carcinoma.

RESULTS

In total, 73 articles were analyzed, from which 48 articles were selected as bibliographic references. We present the criteria used for the identification of endobronchial squamous cell carcinoma in order to highlight its main characteristics and the most reliable technologies that can be used for the detection of this type of cancer.

CONCLUSIONS

The current literature review highlights the clinical and paraclinical characteristics of endobronchial squamous cell carcinoma. It aims to open new paths for research and early detection with respect to the frequent practice of lung parenchymal preservation surgery.

Association between blood pressure and the risk of biopsy-induced endobronchial hemorrhage during bronchoscopy

BACKGROUND

Hemorrhage is one of the most common complications of bronchoscopy. Although several hemorrhage risk factors have been proposed, it remains unclear whether blood pressure affects the onset of biopsy-induced endobronchial hemorrhage.

METHODS

We conducted a retrospective cohort study of 643 consecutive adults with lung cancer over an approximately 4-year period (from January 2014 to February 2018) at a large tertiary care hospital. Patients were divided into the hemorrhage group and the non-hemorrhage group based on endobronchial biopsy (EBB) findings. The association between systolic pressure (SP), diastolic pressure (DP), mean arterial pressure (MAP), pulse pressure (PP), PP to DP ratio (PP/DP) and the risk of EBB-induced hemorrhage was evaluated using multivariate regression analysis and smooth curve fitting adjusted for potential confounding factors.

RESULTS

The EBB-induced bleeding incidence was 37.8% (243/643) in our cohort. An independent association was found between PP/PD and the EBB-induced hemorrhage risk (per 1 SD, adjusted odds ratio, 0.788; 95% confidence interval, 0.653-0.951). The multivariate regression analysis performed using quartiles of PP/DP revealed that lower level of PP/DP ratio was related to a higher risk of EBB-induced hemorrhage (P for trend <0.05) after adjustment for potential confounders. However, no association was observed between SP, DP, MAP, PP and EBB-induced hemorrhage.

CONCLUSIONS

Low PP/DP was the independent risk factor for biopsy-induced endobronchial hemorrhage during bronchoscopy in patients with lung cancer.

Flexible bronchoscopy in a tertiary healthcare facility: a review of indications and outcomes

Objectives

Flexible Fibreoptic bronchoscopy (FFB) is a major diagnostic and therapeutic tool employed largely in respiratory medicine but its use in our country has been quite limited. We performed a retrospective review of the indications, overall diagnostic yield and safety of FFB at the Korle-Bu Teaching Hospital (KBTH).

Study Design

Retrospective study.

Study Setting

Cardiothoracic Unit, Korle-Bu Teaching Hospital.

Study Participants

All bronchoscopy records from January 2017 - December 2018.

Interventions

Eight-five bronchoscopy reports generated over a 2-year period were reviewed. Using a data extraction form, patient's demographic details, indications for FFB, sedation given, specimen obtained and results of investigation, and complications encountered were recorded and entered into SPSS version 22. Descriptive analysis was performed and presented as means and percentages.

Results

Suspected lung cancer was the predominant indication for bronchoscopy requests (55.3%). Diagnostic yield of endobronchial biopsy was 86.7% increased to 93.3% when biopsy was combined with bronchial washing cytology. Bronchial washing geneXpert was positive in 20.8% of sputum negative cases, and 20.7% of patients with unresolved pneumonia and bronchiectasis had a positive microbial yield. Overall mild complications occurred in 5.9% of patients with no mortality.

Conclusion

Flexible bronchoscopy has a significantly high diagnostic yield, particularly in evaluating lung cancers and undiagnosed lung infections with minimal associated complications, hence increasing its availability in the country and widening the diagnostic scope at the cardiothoracic unit of the Korle-Bu Teaching Hospital.

Funding

None declared.

Low-density lipoprotein cholesterol levels are positively associated with the risk of endobronchial biopsy-induced refractory hemorrhage in patients with lung cancer

Background

Lipoprotein concentrations have been associated with the major risk of bleeding events. However, whether plasma levels of LDL-C are associated with the risk of biopsy-related endobronchial hemorrhage remain elusive. Therefore, the present study was initiated to investigate the explicit association of low-density lipoprotein cholesterol (LDL-C) with endobronchial biopsy (EBB)-induced refractory hemorrhage in patients with lung cancer.

Methods

This retrospective study included a total of 659 consecutive patients with lung cancer who had undergone EBB at a tertiary hospital between January 2014 and April 2018. Using multiple regression analysis, the association between LDL-C and the risk of EBB-induced refractory hemorrhage was assessed after adjusting for potential confounding factors.

Results

A significant proportion (13.8%, 91/659) of the patients experienced refractory hemorrhage following EBB. In multivariate regression analysis, higher plasma LDL-C concentrations were associated with increased risk of EBB-induced refractory hemorrhage in patients with lung cancer after adjusting for potential confounders (P < 0.05). Using the lowest quartile of plasma LDL-C as the reference group, the odds ratio (95% confidence interval) of Q2, Q3, and Q4 were 2.32 (1.07, 5.03), 2.37 (0.94, 5.95), and 3.65 (1.16, 11.51), respectively (P for trend < 0.05). Moreover, this association was noticeably more pronounced in male patients with lung cancer in the subgroup analysis (P < 0.05).

Conclusions

Plasma LDL-C was positively correlated with the increased risk of EBB-induced refractory hemorrhage in patients with lung cancer; predominantly, the associated risk was more pronounced in male patients with lung cancer.

Development of a Predictive Model of Difficult Hemostasis following Endobronchial Biopsy in Lung Cancer Patients

Endobronchial biopsy (EBB)-induced bleeding is fairly common; however, it can be potentially life-threatening due to difficult hemostasis following EBB. The aim of this study was to develop a predictive model of difficult hemostasis post-EBB. A total of 620 consecutive patients with primary lung cancer who had undergone EBB between 2014 and 2018 in a large tertiary hospital were enrolled in this retrospective single-center cohort study. Patients were classified into the difficult hemostasis group and the nondifficult hemostasis group according to hemostatic measures used following EBB. The LASSO regression method was used to select predictors and multivariate logistic regression was applied to develop the predictive model. The area under the curve (AUC) of the model was calculated. Bootstrapping method was applied for internal validation. Calibration curve analysis and decision curve analysis (DCA) were also performed. A nomogram was constructed to display the model. The incidence of difficult hemostasis post-EBB was 11.9% (74/620). Eight variables were selected by the LASSO regression analysis and seven (histological type of cancer, lesion location, neutrophil percentage, activated partial thromboplastin time, low density lipoprotein cholesterol, apolipoprotein-E, and pulmonary infection) of them were finally included in the predictive model. The AUC of the model was 0.822 (95% CI, 0.777-0.868), and it was 0.808 (95% CI, 0.761-0.856) in the internal validation. The predictive model was well calibrated and DCA indicated its potential clinical usefulness, which suggests that the model has great potential to predict lung cancer patients with a more difficult post-EBB hemostasis.

Non-linear association of plasma level of high-density lipoprotein cholesterol with endobronchial biopsy bleeding in patients with lung cancer

Background

Despite a large body of studies have demonstrated the multifaceted behavior of high-density lipoproteins (HDLs) in several physiological and pathological processes, the levels of plasma HDL-cholesterol (HDL-C) that may be associated with endobronchial biopsy (EBB)-related bleeding have never been examined.

Methods

We conducted a single-center retrospective cohort study of 628 consecutive patients with primary lung cancer who had undergone EBB at a large tertiary hospital between January 2014 and February 2018. Patients were divided into the bleeding group and the non-bleeding group according to the bronchoscopy report. The association between HDL-C levels and EBB-induced bleeding was evaluated using the LASSO regression analysis, multiple regression analysis and smooth curve fitting adjusted for potential confounders.

Results

There was an inverse association of plasma HDL-C concentration with the incidence of EBB-induced bleeding as assessed by univariate analysis (P < 0.05). However, in piecewise linear regression analysis, a non-linear relationship with threshold saturation effects was observed between plasma HDL-C concentrations and EBB-induced bleeding. The incidence of EBB-induced bleeding decreased with HDL-C concentrations from 1.5 mmol/L up to 2.0 mmol/L (adjusted OR, 0.39; 95% CI, 0.20–0.74), but increased with HDL-C levels above the inflection point (HDL-C = 2.0 mmol/L).

Conclusions

There was a non-linear association between plasma HDL-C concentrations and the risk of EBB-induced bleeding in patients with lung cancer. The plasma level of HDL-C above 2.0 mmol/L or below 1.5 mmol/L may increase the risk of EBB-induced bleeding.

Plasma apolipoprotein E level is associated with the risk of endobronchial biopsy-induced bleeding in patients with lung cancer

Background

Factors affecting the risk of bleeding by bronchoscopic biopsy in patients with lung cancer remain unclear. The levels of plasma apolipoprotein E (ApoE) that may be associated with endobronchial biopsy (EBB)-induced bleeding have never been examined.

Methods

This was a retrospective study using data collected from 615 consecutive patients who had undergone EBB and been diagnosed with primary lung cancer from January 2014 through February 2018. Patients were either classified as the bleeding group (n = 214) or the non-bleeding group (n = 391) based on the bronchoscopy report. Multiple regression analysis was done to estimate the independent relationship between ApoE levels and EBB-induced bleeding, with an adjustment for potential confounders.

Results

The mean plasma ApoE concentration was higher in the non-bleeding group compared to that in the bleeding group (P < 0.05). However, a non-linear relationship with threshold effects was observed between plasma ApoE levels and EBB-induced bleeding in a piecewise linear regression analysis. The risk of EBB-induced bleeding decreased with ApoE concentrations from 3.5 mg/dL up to 5.9 mg/dL (adjusted odds ratio, 0.64; 95% confidence interval, 0.43–0.94); however, the incidence of EBB-induced bleeding increased with ApoE levels above the turning point (ApoE = 5.9 mg/dL).

Conclusions

There was a non-linear association between plasma ApoE levels and the risk of EBB-induced bleeding. Higher plasma ApoE concentrations (> 5.9 mg/dL) are the independent risk factor for hemorrhage during EBB in patients with lung cancer.