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Gong Y, Chen Y, Li J, Xu G, Luo G. Endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing intrathoracic lymphadenopathy in patients with nasopharyngeal cancer. Am J Transl Res 2024; 16:1757-1768. [PMID: 38883364 PMCID: PMC11170604 DOI: 10.62347/gdmg9203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/24/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE This study aimed to assess the efficacy of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in detecting intrathoracic lymph nodes in patients with nasopharyngeal carcinoma (NPC). METHODS Retrospective data analysis was conducted on individuals who underwent EBUS-TBNA between June 2015 and June 2022. Patients with NPC and enlarged intrathoracic lymph nodes were included. Specimens were categorized as malignant or non-malignant, with final non-malignancy confirmation procedures, or 12 months of clinical follow-up. RESULTS Among 97 patients, 59 (60.8%) had NPC with intrathoracic lymph node metastasis, 3 (3.1%) had primary lung cancer involving nodes, and 25 (25.8%) showed benign characteristics. Ten cases (10.3%) were false-negative on initial EBUS-TBNA but confirmed as metastatic on follow-up. For NPC patients with intrathoracic lymphadenopathy, EBUS-TBNA exhibited 86.1% sensitivity (62/72), 71.4% negative predictive value (25/35), and 89.7% accuracy (87/97). Multivariate analysis identified increased lymph node short axis (OR: 1.200, 95% CI: 1.024-1.407; P = 0.041), metachronous NPC (OR: 11.274, 95% CI: 2.289-55.528; P = 0.003), and synchronous lung lesions (OR: 19.449, 95% CI: 1.875-201.753; P = 0.001) as independent predictors of malignant intrathoracic lymphadenopathy. Longer lymph node short axis (OR: 1.305, 95% CI: 1.044-1.631; P = 0.019) was independently associated with EBUS-TBNA accuracy. CONCLUSION EBUS-TBNA effectively diagnoses intrathoracic lymphadenopathy in NPC patients.
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Affiliation(s)
- Yu Gong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou 510060, Guangdong, The People's Republic of China
- Department of Endoscopy, Sun Yat-sen University Cancer Center No. 651 Dongfeng Road East, Guangzhou 510060, Guangdong, The People's Republic of China
| | - Yufan Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou 510060, Guangdong, The People's Republic of China
- Department of Endoscopy, Sun Yat-sen University Cancer Center No. 651 Dongfeng Road East, Guangzhou 510060, Guangdong, The People's Republic of China
| | - Jianjun Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou 510060, Guangdong, The People's Republic of China
- Department of Endoscopy, Sun Yat-sen University Cancer Center No. 651 Dongfeng Road East, Guangzhou 510060, Guangdong, The People's Republic of China
| | - Guoliang Xu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou 510060, Guangdong, The People's Republic of China
- Department of Endoscopy, Sun Yat-sen University Cancer Center No. 651 Dongfeng Road East, Guangzhou 510060, Guangdong, The People's Republic of China
| | - Guangyu Luo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine Guangzhou 510060, Guangdong, The People's Republic of China
- Department of Endoscopy, Sun Yat-sen University Cancer Center No. 651 Dongfeng Road East, Guangzhou 510060, Guangdong, The People's Republic of China
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Wang Y, Ning W, Liu C, Su N, Zhu Q, Chen Y, Chen C. Additional EBUS-guided intralesional amphotericin B injection combined systemic intravenous therapy in pulmonary mucormycosis: a case report. Ther Adv Respir Dis 2024; 18:17534666241267242. [PMID: 39113423 PMCID: PMC11311181 DOI: 10.1177/17534666241267242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 06/19/2024] [Indexed: 08/11/2024] Open
Abstract
Mucormycosis is an invasive fungal infection that can result in severe lung infections, with pulmonary mucormycosis (PM) being one of the most prevalent manifestations. Prompt diagnosis is crucial for patient survival, as PM often exhibits rapid clinical progression and carries a high fatality rate. Broncho-alveolar lavage fluid or endobronchial biopsy (EBB) has been commonly employed for diagnosing PM, although there is limited mention of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the literature. In this report, we present a case of PM in a patient with diabetes. While EBB did not yield evidence of Rhizopus infection, a definitive diagnosis was obtained through EBUS-TBNA. The patient underwent combination therapy, including oral medication, nebulization, and EBUS-guided intrafocal amphotericin B injection, which resulted in significant improvement following the failure of initial therapy with amphotericin B injection cholesterol sulfate complex. Our case highlights the potential of EBUS-TBNA not only for mediastinal lymphadenopathy but also for obtaining extraluminal lesion specimens. Furthermore, for patients with an inadequate response to mono-therapy and no access to surgical therapy, the addition of EBUS-guided intralesional amphotericin B injection to systemic intravenous therapy may yield unexpected effects.
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Affiliation(s)
- Yang Wang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weiwei Ning
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Chao Liu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Nan Su
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qingqing Zhu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yanbin Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Pinghai Road No. 899, Suzhou 215000, China
| | - Cheng Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Pinghai Road No. 899, Suzhou 215000, China
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Gürün Kaya A, Doğan D. The evolution of endobronchial ultrasound usage in modern era. Tuberk Toraks 2023; 71:299-307. [PMID: 37740633 PMCID: PMC10795244 DOI: 10.5578/tt.20239711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Abstract
Over the past two decades, endobronchial ultrasound (EBUS) has become a crucial tool for diagnosing pulmonary diseases. The most common indication of EBUS usage is the diagnosis and staging of lung cancer. Additionally, there have been significant improvements in the application of convex probe EBUS in line with the increase in experience and knowledge about EBUS and the developments in medicine and technology. To enhance diagnostic accuracy and acquire larger tissue samples, techniques such as cryo-biopsy guided by endobronchial ultrasound (EBUS) and intranodal forceps biopsy have been developed. Additionally, elastography functionality has been integrated into the EBUS application to improve the assessment of targeted lesions. Moreover, its utilization for evaluating and sampling pulmonary vascular structures has expanded. It has also found applications in guiding intratumoral therapy, positioning fiducial markers, and facilitating the drainage of pleural or pericardial effusions. This review aims to provide an overview of the extended applications of convex probe EBUS beyond its conventional uses.
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Affiliation(s)
- Aslıhan Gürün Kaya
- Department of Chest Diseases, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Deniz Doğan
- Department of Chest Diseases, University of Health Sciences, Gülhane Faculty of Medicine, Ankara, Türkiye
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Kalchiem-Dekel O, Hossain S, Gauran C, Beattie JA, Husta BC, Lee RP, Chawla M. An evolving role for endobronchial ultrasonography in the intensive care unit. J Thorac Dis 2021; 13:5183-5194. [PMID: 34527358 PMCID: PMC8411164 DOI: 10.21037/jtd-2019-ipicu-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/21/2020] [Indexed: 11/06/2022]
Abstract
Endobronchial ultrasound (EBUS) bronchoscopy is an established minimally-invasive modality for visualization, characterization, and guidance of sampling of paratracheal and parabronchial structures and tissues. In the intensive care unit (ICU), rapidly obtaining an accurate diagnosis is paramount to the management of critically ill patients. In some instances, diagnosing and confirming terminal illness in a critically ill patient provides needed closure for patients and their loved ones. Currently available data on feasibility, safety, and yield of EBUS bronchoscopy in critically ill patients is based on single center experiences. These data suggest that in select ICU patients convex and radial probe-EBUS bronchoscopy can serve as useful tools in the evaluation of mediastinal lymphadenopathy, central airway obstruction, pulmonary embolism, and peripheral lung lesions. Barriers to the use of EBUS bronchoscopy in the ICU include: (I) requirement for dedicated equipment, prolonged procedure time, and bronchoscopy team expertise that may not be available; (II) applicability to a limited number of patients and conditions in the ICU; and (III) technical difficulty related to the relatively large outer diameter of the convex probe-EBUS bronchoscope and an increased risk for adverse cardiopulmonary consequences due to intermittent obstruction of the artificial airway. While the prospects for EBUS bronchoscopy in critically ill patients appear promising, judicious patient selection in combination with bronchoscopy team expertise are of utmost importance when considering performance of EBUS bronchoscopy in the ICU setting.
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Affiliation(s)
- Or Kalchiem-Dekel
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Saamia Hossain
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cosmin Gauran
- Department of Anesthesia and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason A Beattie
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bryan C Husta
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert P Lee
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mohit Chawla
- Section of Interventional Pulmonology, Pulmonary Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Wu J, Wu C, Zhou C, Zheng W, Li P. Recent advances in convex probe endobronchial ultrasound: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:419. [PMID: 33842640 PMCID: PMC8033319 DOI: 10.21037/atm-21-225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Convex probe endobronchial ultrasound (CP-EBUS) has been widely used in the lymph node staging and restaging of lung tumors and the diagnosis of mediastinal diseases. Recent years have seen continuous progress in this technology. For diagnosis, elastography technology can preliminarily distinguish between benign and malignant lesions, so that reduce the number of punctures. CP-EBUS can also be used as an endoscopic ultrasound (EUS) to guide needle aspirations of liver lesions, retroperitoneal lymph nodes and left adrenal gland (LAG) lesions sometimes. Some advances help diagnosing more accurately and effectively, such as the intranodal forceps biopsy (IFB), the new type of 22G needle, the rapid on-site evaluation (ROSE) and the cancer gene methylation, etc. In addition, special advances are being made in diagnosis using artificial intelligence (AI). For treatment, CP-EBUS has yielded novel research results when applied to transbronchial needle injection (TBNI) and radioactive seed implantation in clinical cases, and blocking of the cardiac plexus in animal studies. The next-generation CP-EBUS is also ready for use in the clinic and the technology will be improving continuously. Through this review, we hope to educate clinicians on the latest uses of CP-EBUS and open up further research ideas for readers interested in this technology.
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Affiliation(s)
- Jian Wu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Cen Wu
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chuming Zhou
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wei Zheng
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Li
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
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The role of endobronchial ultrasonography elastography for predicting malignancy. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:158-165. [PMID: 32175157 DOI: 10.5606/tgkdc.dergisi.2020.18508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 09/05/2019] [Indexed: 12/25/2022]
Abstract
Background This study aims to investigate the role of endobronchial ultrasonography elastography in predicting malignancy. Methods Between January 2016 and December 2016, a total of 221 lymph nodes were biopsied using the endobronchial ultrasonography-guided transbronchial needle aspiration from 119 consecutive patients (69 males, 50 females; mean age 63.2±12.4 years; range, 16 to 86 years) were included. Lymph nodes were scored by elastography according to their colors in four categories before the procedure. The strain ratio was calculated based on the region of interest after three measurements. Results Of the patients, 93 were diagnosed with a malignancy through endobronchial ultrasonography-guided transbronchial needle aspiration biopsy. The mean lymph node score of benign versus malignant lesions was 2.2±1.0 and 3.2±1, respectively (p<0.001). There was a positive correlation between the lymph node scores and lymph node diameter, strain ratio, ≥3 of lymph node scoring, the sensitivity for malignancy was 79% and specificity was 60%. The mean strain ratio for malignant and benign lymph nodes was 22.2±30.1 and 5.2±1.7, respectively (p<0.001). With a cut-off value of ≥2.47 of strain ratio, the sensitivity for malignancy was 75% and specificity was 65%. The combined use of positron emission tomography and lymph node score or strain ratio yielded 80.4% and 61.2% sensitivity and 80% and 70.3% specificity for malignancy, respectively. Conclusion Endobronchial ultrasonography elastography is useful in predicting malignancy of the lymph nodes. When combined with positron emission tomography, specificity and positive predictive value for malignancy increase.
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Role of Convex Probe Endobronchial Ultrasound in the Diagnosis and Treatment of Nonmalignant Diseases. Pulm Med 2019; 2019:6838439. [PMID: 31316830 PMCID: PMC6601475 DOI: 10.1155/2019/6838439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 05/31/2019] [Accepted: 06/07/2019] [Indexed: 01/08/2023] Open
Abstract
Here we present a comprehensive review of the literature concerning the utility of convex probe endobronchial ultrasound (CP-EBUS) in the diagnosis and treatment of nonmalignant conditions and discuss the associated complications. CP-EBUS has been conventionally used for the staging of lung cancer and sampling of mediastinal and hilar nodes. However, its application is not limited to malignant conditions, and it is gaining acceptance as a diagnostic modality of choice for nonmalignant conditions such as tuberculosis, sarcoidosis, pulmonary embolism, thyroid lesions, and cysts. Moreover, its therapeutic value allows for extended applications such as mediastinal and thyroid cyst drainage, fiducial marker placement for radiation therapy, and transbronchial needle injection. The noninvasiveness, low complication rate, high diagnostic yield, and satisfactory sensitivity and specificity values are the main attributes that lend credence to the use of CP-EBUS as a standalone primary diagnostic and therapeutic tool in pulmonary medicine in the foreseeable future.
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Li P, Wu C, Zheng W, Zhao L. Pathway and application value of exploration of the pulmonary artery by endobronchial ultrasound. J Thorac Dis 2017; 9:5345-5351. [PMID: 29312744 DOI: 10.21037/jtd.2017.12.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The current standard methods for detecting pulmonary artery diseases are pulmonary artery enhanced computed tomography (CT) scan and pulmonary arteriography. However, some patients cannot tolerate these procedures for various reasons. The present study aimed to investigate the feasibility and operation process of endobronchial ultrasound (EBUS) in exploring the pulmonary artery. Methods Based on normal contrast-enhanced chest CT images, the sites and process for exploring the pulmonary arteries were established. Then the feasibility of the exploration by the convex probe EBUS were evaluated, and roadmaps for exploration of the pulmonary arteries were drawn. Results Among patients who underwent pulmonary artery exploration, sonograms of the left and right pulmonary artery were obtained by the convex probe EBUS. The above-mentioned pulmonary artery branches can be positioned by means of anatomical markers under the bronchoscopic view and follow a certain route for continuous exploration. Sonograms had a certain degree of identification and can be used as an auxiliary tool for pulmonary artery exploration. Conclusions EBUS can be used to explore the main branches of the pulmonary artery continuously. Therefore, EBUS could be considered as a candidate for the diagnosis of pulmonary artery diseases in a selected group of patients, i.e., patient with contrast allergy or renal failure.
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Affiliation(s)
- Peng Li
- The 1st Department of Respiratory Medicine and Medical Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Cen Wu
- The 1st Department of Respiratory Medicine and Medical Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Wei Zheng
- The 1st Department of Respiratory Medicine and Medical Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Li Zhao
- The 1st Department of Respiratory Medicine and Medical Intensive Care Unit, Shengjing Hospital of China Medical University, Shenyang 110004, China
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Kattoor AJ, Rochlani YM, Kuriakose K, Meena NK. Mitral valve vegetation diagnosed with oesophageal ultrasound with bronchoscope (EUS-B). BMJ Case Rep 2017; 2017:bcr-2016-218849. [PMID: 28512099 DOI: 10.1136/bcr-2016-218849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Oesophageal ultrasound with bronchoscope (EUS-B) is designed to evaluate mediastinal structures. We describe a case of a 78-year-old woman who presented with altered mental status for 2 weeks. CT head revealed a subacute infarct in the right middle cerebral artery distribution. She was also found to have a lung mass on chest imaging. EUS-B-guided fine needle aspiration demonstrated the presence of adenocarcinoma in station 7 lymph node and in the mass. Immunohistochemistry confirmed it to be a lung primary as the Thyroid Transcription Factor-1 (TTF-1) was strongly positive. During the procedure, the cardiac valves were evaluated, and a mitral valve vegetation was noted. Formal echocardiography confirmed the presence of the vegetation. During hospital stay, the patient developed fever. Her blood cultures grew oxacillin-resistant Staphylococcus aureus. She was subsequently treated for infective endocarditis. We suggest that the use of EUS-B to routinely scan adjacent structures during a procedure may help obtain additional clinical information that may be critical to patient management.
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Affiliation(s)
- Ajoe John Kattoor
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Yogita M Rochlani
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kevin Kuriakose
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nikhil K Meena
- Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Tertemiz KC, Alpaydin AO, Karacam V. The role of endobronchial ultrasonography for mediastinal lymphadenopathy in cases with extrathoracic malignancy. Surg Endosc 2016; 31:2829-2836. [PMID: 27770251 DOI: 10.1007/s00464-016-5293-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 10/13/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Many extrathoracic malignancies can metastasize to lungs and mediastinal lymph nodes. Whether mediastinal lesions are metastasis in these patients changes staging, prognosis, and treatment strategy. In this study, we aimed to find out the contribution of EBUS-TBNA to the diagnosis in cases with extrathoracic malignancy. MATERIALS AND METHODS Patients who had been previously diagnosed as extrapulmonary solid organ malignancy and in whom mediastinal or hilar lymphadenopathy developed during their follow-up and EBUS-TBNA was applied for diagnostic purposes were retrospectively included in this study. RESULTS A total of 91 patients consisting of 35 females (38.5 %) and 56 males (61.5 %) were included in the study. The mean age of the patients was 60.5 (±11.4). Malignancy was not observed in 54 (59.3 %) patients; primary malignancy metastasis was detected in 33 (36.3 %) patients, and primary lung cancer was detected in 4 (4.4 %) patients with EBUS-TBNA. The sensitivity of EBUS-TBNA in extrathoracic malignancies was determined as 90.2 %; its specificity was determined as 100 %, its negative predictive value as 92.5 %, its positive predictive value as 100 %, and its diagnostic accuracy as 95.6 %. The highest rate was determined in the left lower paratracheal lymph node when they were examined in terms of malignancy detection rate in lymph node stations. CONCLUSION EBUS-TBNA is a minimally invasive method with quite a low complication rate that does not require general anesthesia. It should be the first step method to be used in the diagnosis of mediastinal and hilar lymphadenopathies seen in extrathoracic malignancies since it has high diagnostic accuracy, sensitivity, and specificity. EBUS-TBNA significantly reduces the need for surgical intervention. Further surgical interventions can be planned in patients in whom diagnostic competence is not ensured.
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Affiliation(s)
- Kemal Can Tertemiz
- Department of Pulmonary Diseases, Dokuz Eylul University Medical Faculty, 35340, Balcova, Izmir, Turkey.
| | - Aylin Ozgen Alpaydin
- Department of Pulmonary Diseases, Dokuz Eylul University Medical Faculty, 35340, Balcova, Izmir, Turkey
| | - Volkan Karacam
- Thoracic Surgery, Dokuz Eylul University Medical Faculty, Balcova, Izmir, Turkey
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