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Yo SW, Joosten SA, Wimaleswaran H, Mansfield D, Thomson L, Landry SA, Edwards BA, Hamilton GS. Body position during laboratory and home polysomnography compared to habitual sleeping position at home. J Clin Sleep Med 2022; 18:2103-2111. [PMID: 35459447 PMCID: PMC9435326 DOI: 10.5664/jcsm.9990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Supine-predominant obstructive sleep apnea (OSA) is highly prevalent. The proportion of time spent in the supine position may be overrepresented during polysomnography, which would impact on the apnea-hypopnea index (AHI) and have important clinical implications. We aimed to investigate the difference in body position during laboratory or home polysomnography compared to habitual sleep and estimate its effect on OSA severity. Secondary aims were to evaluate the consistency of habitual sleeping position and accuracy of self-reported sleeping position. METHODS Patients undergoing diagnostic laboratory or home polysomnography were recruited. Body position was recorded using a neck-worn device. Habitual sleeping position was the average time spent supine over 3 consecutive nights at home. Primary outcomes were the proportion of sleep time spent supine (% time supine) and AHI adjusted for habitual sleeping position. RESULTS Fifty-seven patients who underwent laboratory polysomnography and 56 who had home polysomnography were included. Compared to habitual sleep, % time supine was higher during laboratory polysomnography (mean difference 14.1% [95% confidence interval: 7.2-21.1]; P = .0002) and home polysomnography (7.1% [95% confidence interval 0.9-13.3]; P = .03). Among those with supine-predominant OSA, there was a trend toward lower adjusted AHI than polysomnography-derived AHI (P = .07), changing OSA severity in 31.6%. There was no significant between-night difference in % time supine during habitual sleep (P = .4). Self-reported % time supine was inaccurate (95% limits of agreement -49.2% to 53.9%). CONCLUSIONS More time was spent in the supine position during polysomnography compared to habitual sleep, which may overestimate OSA severity for almost one-third of patients with supine-predominant OSA. CLINICAL TRIAL REGISTRATION Registry: Australia and New Zealand Clinical Trials Registry (ANZCTR); Title: Sleeping position during sleep tests and at home; Identifier: ACTRN12618000628246; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374873&isReview=true. CITATION Yo SW, Joosten SA, Wimaleswaran H, et al. Body position during laboratory and home polysomnography compared to habitual sleeping position at home. J Clin Sleep Med. 2022;18(9):2103-2111.
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Affiliation(s)
- Shaun W. Yo
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
| | - Simon A. Joosten
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Hari Wimaleswaran
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
| | - Darren Mansfield
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
| | - Luke Thomson
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
| | - Shane A. Landry
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
| | - Bradley A. Edwards
- Department of Physiology Biomedicine Discovery Institute, Monash University, Melbourne, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia
| | - Garun S. Hamilton
- Monash Lung, Sleep, Allergy & Immunology, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
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2
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Habteslassie D, McMahon M, Wimaleswaran H. Can insomnia be fatal? An Australian case of fatal familial insomnia. Intern Med J 2022; 52:667-670. [PMID: 35419959 DOI: 10.1111/imj.15737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 10/28/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Abstract
Fatal familial insomnia (FFI) is a rare prion disease with autosomal dominant inheritance. Currently, there is only one published case study of FFI in Australia. FFI is universally fatal, with the disease duration ranging from 8 to 72 months. Clinically, it manifests with disordered sleep-wake cycle, dysautonomia, motor disturbances and neuropsychiatric disorders. We describe a case of FFI detailing the investigative process, including the importance of sleep assessment and polysomnography in obtaining a diagnosis.
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Affiliation(s)
- Daniel Habteslassie
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Marcus McMahon
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Hari Wimaleswaran
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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3
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Aloe CA, Leong TLT, Wimaleswaran H, Papagianis PC, McQualter JL, McDonald CF, Khor YH, Hoy RF, Ingle A, Bansal V, Goh NSL, Bozinovski S. Excess iron promotes emergence of foamy macrophages that overexpress ferritin in the lungs of silicosis patients. Respirology 2022; 27:427-436. [PMID: 35176813 PMCID: PMC9303595 DOI: 10.1111/resp.14230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/18/2022] [Accepted: 02/02/2022] [Indexed: 01/09/2023]
Abstract
Background and objective Inhalation of high concentrations of respirable crystalline silica (RCS) can lead to silicosis. RCS contains varying levels of iron, which can cause oxidative stress and stimulate ferritin production. This study evaluated iron‐related and inflammatory markers in control and silicosis patients. Methods A cohort of stone benchtop industry workers (n = 18) were radiologically classified by disease severity into simple or complicated silicosis. Peripheral blood and bronchoalveolar lavage (BAL) were collected to measure iron, ferritin, C‐reactive protein, serum amyloid A and serum silicon levels. Ferritin subunit expression in BAL and transbronchial biopsies was analysed by reverse transcription quantitative PCR. Lipid accumulation in BAL macrophages was assessed by Oil Red O staining. Results Serum iron levels were significantly elevated in patients with silicosis, with a strong positive association with serum ferritin levels. In contrast, markers of systemic inflammation were not increased in silicosis patients. Serum silicon levels were significantly elevated in complicated disease. BAL macrophages from silicosis patients were morphologically consistent with lipid‐laden foamy macrophages. Ferritin light chain (FTL) mRNA expression in BAL macrophages was also significantly elevated in simple silicosis patients and correlated with systemic ferritin. Conclusion Our findings suggest that elevated iron levels during the early phases of silicosis increase FTL expression in BAL macrophages, which drives elevated BAL and serum ferritin levels. Excess iron and ferritin were also associated with the emergence of a foamy BAL macrophage phenotype. Ferritin may represent an early disease marker for silicosis, where increased levels are independent of inflammation and may contribute to fibrotic lung remodelling. Silicosis is an aggressive and incurable lung disease. In this study, serum iron levels were increased in silicosis patients, and these levels were strongly associated with serum ferritin levels. Lipid‐laden bronchoalveolar lavage macrophages were identified as a major source of ferritin, whereas markers of inflammation were not increased. See relatedEditorial
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Affiliation(s)
| | - Tracy Li-Tsein Leong
- Department of Respiratory Medicine, Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Hari Wimaleswaran
- Department of Respiratory Medicine, Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | | | | | - Christine Faye McDonald
- Department of Respiratory Medicine, Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Yet Hong Khor
- Department of Respiratory Medicine, Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ryan Francis Hoy
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Aviraj Ingle
- Sir Ian Potter NanoBioSensing Facility, NanoBiotechnology Research Laboratory, School of Science, RMIT University, Melbourne, Victoria, Australia
| | - Vipul Bansal
- Sir Ian Potter NanoBioSensing Facility, NanoBiotechnology Research Laboratory, School of Science, RMIT University, Melbourne, Victoria, Australia
| | - Nicole Soo Leng Goh
- Department of Respiratory Medicine, Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Steven Bozinovski
- School of Health & Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
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Robinson DH, Wimaleswaran H, McDonald CF, Howard ME, Willcox A. Pulmonary embolus in patients with COVID-19: an Australian perspective. Intern Med J 2021; 51:1324-1327. [PMID: 34423548 PMCID: PMC8653313 DOI: 10.1111/imj.15405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/11/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022]
Abstract
Pulmonary embolus (PE) is a known complication of coronavirus disease 2019 (COVID‐19). The diagnosis of PE in our hospitalised patients with COVID‐19 correlated with more severe disease and occurred despite the use of routine thromboprophylaxis. Higher D‐dimers were seen on admission in patients who developed PE and rose at PE diagnosis, suggesting a role for D‐dimer in risk stratification.
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Affiliation(s)
- Danielle H Robinson
- Department of Clinical Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Hari Wimaleswaran
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Mark E Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Abbey Willcox
- Department of Clinical Haematology, Austin Health, Melbourne, Victoria, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Drewett GP, Chan RK, Jones N, Wimaleswaran H, Howard ME, McDonald CF, Kwong J, Smibert O, Holmes NE, Trubiano JA. Risk factors for readmission following inpatient management of COVID-19 in a low-prevalence setting. Intern Med J 2021; 51:821-823. [PMID: 34047021 PMCID: PMC8206980 DOI: 10.1111/imj.15218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- George P Drewett
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - R Kimberley Chan
- Department of General Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Nicholas Jones
- Department of General Medicine, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, VIC, Australia
| | - Hari Wimaleswaran
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Heidelberg, VIC, Australia
| | - Mark E Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, VIC, Australia
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, VIC, Australia.,Institute for Breathing and Sleep, Heidelberg, VIC, Australia
| | - Jason Kwong
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,Department of Microbiology & Immunology, University of Melbourne, VIC, Australia
| | - Olivia Smibert
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,Dept of Oncology, Peter McCallum Cancer Centre, University of Melbourne, VIC, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Parkville, VIC, Australia.,Data Analytics Research and Evaluation (DARE) Centre, Austin Health and The University of Melbourne, VIC, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, VIC, Australia
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Wong E, Jeganathan V, Wreghitt S, Davis G, Wimaleswaran H, Howard ME. Worsening respiratory failure in an adult hydrocephalic patient with a ventriculo-pleural shunt. Respirol Case Rep 2020; 8:e00660. [PMID: 33005422 PMCID: PMC7519950 DOI: 10.1002/rcr2.660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022] Open
Abstract
Ventriculo-pleural (VPL) shunt insertion is performed in hydrocephalic patients when alternative sites of cerebrospinal fluid (CSF) diversion are contraindicated. These include patients with peritoneal complications from ventriculo-peritoneal shunts. Despite its utility, VPL shunts are uncommon. Hydrothoraces should be considered as a potential cause of dyspnoea in the setting of a VPL shunt. We present a case of worsening respiratory failure in the setting of a massive CSF hydrothorax in a hydrocephalic patient with a VPL shunt to highlight this potential complication of pleural CSF diversion, and present a potential management strategy in patients with premorbid underlying lung pathology. In this case, the hydrothorax was drained and the shunt was converted to ventriculo-atrial (VA) shunt.
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Affiliation(s)
- Edmond Wong
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
| | - Vishnu Jeganathan
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
- Institute for Breathing and SleepHeidelbergVICAustralia
| | - Samuel Wreghitt
- Department of NeurosurgeryAustin HealthHeidelbergVICAustralia
| | - Gavin Davis
- Department of NeurosurgeryAustin HealthHeidelbergVICAustralia
| | - Hari Wimaleswaran
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
- Institute for Breathing and SleepHeidelbergVICAustralia
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVICAustralia
| | - Mark E Howard
- Department of Respiratory and Sleep MedicineAustin HealthHeidelbergVICAustralia
- Institute for Breathing and SleepHeidelbergVICAustralia
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVICAustralia
- Turner Institute for Brain and Mental HealthMonash UniversityClaytonVICAustralia
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Sanderson E, Wimaleswaran H, Senko C, White S, McDonald CF. Durvalumab induced sarcoid-like pulmonary lymphadenopathy. Respirol Case Rep 2020; 8:e00542. [PMID: 32110415 PMCID: PMC7040456 DOI: 10.1002/rcr2.542] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 12/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have become pivotal in the treatment of lung cancer. An increasing number of immune-related adverse events (irAEs) have been recognized with their use. To our knowledge, this is the first published case of sarcoid-like pulmonary lymphadenopathy associated with durvalumab, a monoclonal antibody against programmed death ligand-1 (PD-L1). A 76-year-old woman received adjuvant durvalumab for Stage IIA pT2aN1M0 (American Joint Committee on Cancer, Seventh edition) poorly differentiated lung adenocarcinoma. After three cycles, a sarcoid-like granulomatous reaction was identified in mediastinal and hilar lymph nodes. Although the lymphadenopathy remained stable in size with the ongoing treatment, progressive intracranial metastases were identified after a further three cycles of durvalumab. Sarcoid-like inflammation with the formation of non-caseating granulomas in the absence of systemic sarcoidosis is an irAE which may mimic disease progression. Although a subset of patients who experience this reaction may have a favourable response to checkpoint inhibition, progression of disease may occur contemporaneously.
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Affiliation(s)
- Emma Sanderson
- Department of Respiratory and Sleep MedicineAustin HealthMelbourneVICAustralia
| | - Hari Wimaleswaran
- Department of Respiratory and Sleep MedicineAustin HealthMelbourneVICAustralia
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneMelbourneVICAustralia
| | - Clare Senko
- Department of Medical OncologyAustin HealthMelbourneVICAustralia
| | - Shane White
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneMelbourneVICAustralia
- Department of Medical OncologyAustin HealthMelbourneVICAustralia
| | - Christine F. McDonald
- Department of Respiratory and Sleep MedicineAustin HealthMelbourneVICAustralia
- Faculty of Medicine, Dentistry and Health SciencesUniversity of MelbourneMelbourneVICAustralia
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Yo S, Wimaleswaran H, Deshpande S, Cheung T, Buzacott H, Serraglio C, Wong AM, Landry S, Thomson L, Edwards B, Mansfield D, Joosten S, Hamilton G. Sleeping position during unattended home polysomnography compared to habitual sleeping position and the potential impact on measured sleep apnea severity. Sleep Med 2019. [DOI: 10.1016/j.sleep.2019.11.1213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wimaleswaran H, Farmer MW, Irving LB, Jennings BR, Steinfort DP. Pulmonologist-performed transoesophageal sampling for lung cancer staging using an endobronchial ultrasound video-bronchoscope: an Australian experience. Intern Med J 2017; 47:205-210. [PMID: 27860078 DOI: 10.1111/imj.13330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/16/2016] [Accepted: 11/03/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transoesophageal endobronchial ultrasound (EBUS) video-bronchoscope insertion provides pulmonologists access to conduct endoscopic fine-needle aspiration (EUS-B-FNA) of mediastinal lymph node (LN) lesions and also assist in lung cancer staging by sampling left adrenal gland (LAG) lesions. Limited literature has described additional diagnostic value whilst maintaining patient safety. To elicit whether combining endoscopic transoesophageal fine-needle aspiration using convex probe bronchoscope (EUS-B-FNA) and EBUS bronchoscopy enhances the diagnostic yield of mediastinal nodal staging in lung cancer, whilst maintaining safety. METHODS All eligible patients with paraoesophageal lesions on thoracic computed tomography (CT) underwent pulmonologist-performed EUS-B-FNA at two tertiary centres and were included in this prospective observational cohort study. RESULTS EUS-B-FNA sampling was performed at 69 mediastinal LN lesion sites, including 17 sites inaccessible to bronchoscopic sampling. Four LAG lesions were sampled via EUS-B-FNA. There were no complications. EBUS-TBNA was augmented by EUS-B-FNA because of accessibility of sampling lesions otherwise unamenable bronchoscopically, thereby increasing diagnostic utility. Diagnostic sensitivity of EUS-B-FNA for malignancy in mediastinal LN lesions was 88% (51 of 58). For mediastinal LN lesions not amenable to EBUS-TBNA, the sensitivity for diagnosis of malignancy via EUS-B-FNA was 88% (15 of 17). Diagnostic sensitivity of EUS-B-FNA for malignancy in LAG lesions was 50% (2 of 4). CONCLUSION EUS-B-FNA is a precise and safe approach in the evaluation and staging of lung cancer when performed by a pulmonologist. It complements and increases the diagnostic utility of EBUS-TBNA by further coverage of mediastinal LN stations and access to LAG lesions.
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Affiliation(s)
- Hari Wimaleswaran
- Deparment of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael W Farmer
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Louis B Irving
- Deparment of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Barton R Jennings
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Daniel P Steinfort
- Deparment of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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