Pathologic Criteria for the Diagnosis of Usual Interstitial Pneumonia vs Fibrotic Hypersensitivity Pneumonitis in Transbronchial Cryobiopsies

Transbronchial cryobiopsy (TBCB) is increasingly used for the diagnosis of fibrosing interstitial pneumonias, but there are few detailed descriptions of the pathologic findings in such cases. It has been proposed that a combination of patchy fibrosis and fibroblast foci with an absence of alternative features is diagnostic of usual interstitial pneumonia (UIP; ie, idiopathic pulmonary fibrosis [IPF]) in TBCB. In this study, we reviewed 121 TBCB in which a diagnosis of fibrotic hypersensitivity pneumonitis (FHP; n = 83) or IPF (n = 38) was made by multidisciplinary discussion and evaluated a range of pathologic features. Patchy fibrosis was found in 65 of 83 (78%) biopsies from FHP and 32of 38 (84%) biopsies from UIP/IPF cases. Fibroblast foci were present in 47 of 83 (57%) FHP and 27 of 38 (71%) UIP/IPF cases. Fibroblast foci/patchy fibrosis combined did not favor either diagnosis. Architectural distortion was seen in 54 of 83 (65%) FHP and 32 of 38 (84%) UIP/IPF cases (odds ratio [OR] for FHP, 0.35; P = .036) and honeycombing in 18 of 83 (22%) and 17 of 38 (45%), respectively (OR, 0.37; P = .014). Airspace giant cells/granulomas were present in 13 of 83 (20%) FHP and 1 of 38 (2.6%) UIP/IPF cases (OR for FHP, 6.87; P = .068), and interstitial giant cells/granulomas in 20 of 83 (24%) FHP and 0 of 38 (0%) UIP/IPF (OR, 6.7 x 106; P = .000). We conclude that patchy fibrosis plus fibroblast foci can be found in TBCB from both FHP and UIP/IPF. The complete absence of architectural distortion/honeycombing favors a diagnosis of FHP, as does the presence of airspace or interstitial giant cells/granulomas, but these measures are insensitive, and many cases of FHP cannot be separated from UIP/IPF on TBCB.

Indwelling pleural catheters for persistent pleural effusions secondary to post lung resection for malignancies

Background

Malignant and nonmalignant pleural effusions (NMPEs) such as those due to hepatic hydrothorax have been successfully treated with an indwelling pleural catheter (IPC) with a low complication rate. There is no literature on the utility or safety of this treatment modality for NMPE post lung resection. We aimed to assess the utility of IPC for recurrent symptomatic NMPE secondary to post lung resection in lung cancer patients over a period of 4 years.

Methods

Patients who underwent lobectomy or segmentectomy as part of the treatment plan for lung cancer between January 2019 and June 2022 were identified, these patients were screened for post-surgical pleural effusion. A total of 422 underwent lung resection, of which 12 had recurrent symptomatic pleural effusions requiring IPC placement and were selected for final analysis. The primary end points were improved symptomatology and successful pleurodesis.

Results

Mean time to IPC placement was 78.4 days post-surgery. The mean length of IPC catheter was 77.7 days standard deviation (SD) 23.8. All 12 patients achieved spontaneous pleurodesis (SP), there was no second pleural intervention or re-accumulation of fluid on follow up imaging in any of the subjects after IPC removal. Two patients (16.7%) had skin infection related to catheter placement that was managed with oral antibiotics, there were no cases of pleural infections that required catheter removal.

Conclusions

IPC is a safe and effective alternative in managing recurrent NMPE post lung cancer surgery with high rate of pleurodesis and acceptable complication rates.

The Role of Surgery in Stage I Small Cell Lung Cancer: A National VA Database Analysis

BACKGROUND

Historically, limited stage Small Cell Lung Cancer (SCLC) has been treated with concurrent chemoradiation (CRT). While current NCCN guidelines recommend consideration of lobectomy in node-negative cT1-T2 SCLC, data regarding the role of surgery in very limited SCLC is lacking.

METHODS

Data from the National VA Cancer Cube were compiled. A total of 1,028 patients with pathologically confirmed stage I SCLC were studied. Only 661 patients that either received surgery or CRT were included. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median overall survival (OS) and hazard ratio (HR), respectively. Two survival curves were compared by a Wald test. Subset analysis was performed based on the location of the tumor in the upper vs. lower lobe as delineated by ICD-10 codes C34.1 and C34.3.

RESULTS

Four-hundred and forty-six patients received concurrent CRT; while 223 underwent treatment that contained surgery (93 surgery only, 87 surgery/chemo, 39 surgery/chemo/radiation and 4 surgery/radiation). The median OS for the surgery-inclusive treatment was 3.87 years (95% CI 3.21-4.48) while median OS for the CRT cohort was 2.45 years (95% CI 2.17-2.74). HR of death for surgery-inclusive treatment when compared to CRT is 0.67 (95% CI 0.55-0.81; P < .001). Subset analysis based on the location of the tumor in both the upper or lower lobes showed improved survival with surgery as compared to CRT regardless of the location. HR for the upper lobe was 0.63 (95% CI 0.50-0.80; P < .001) and lower lobe 0.61 (95% CI 0.42-0.87; P = .006). Multivariable regression analysis accounting for age and ECOG-PS shows a HR 0.60 (95% CI 0.43-0.83; P = .002) favoring surgery.

CONCLUSIONS

Surgery was used in less than a third of patients with stage I SCLC who received treatment. Surgery-inclusive multimodality treatment was associated with a longer overall survival as compared to chemoradiation, independent of age, performance status or tumor location. Our study suggests a more expansive role for surgery in stage I SCLC.

Safety and Feasibility of Photodynamic Therapy for Ablation of Peripheral Lung Tumors

BACKGROUND

Newer navigational bronchoscopy technologies render peripheral lung lesions accessible for biopsy and potential treatment. We investigated whether photodynamic therapy (PDT) delivered via navigational bronchoscopy is feasible and safe for ablation of peripheral lung tumors.

METHODS

Two studies evaluated PDT in patients with solid peripheral lung tumors followed by clinical follow-up (nonresection study, N=5) or lobectomy (resection study, N=10). Porfimer sodium injection was administered 40 to 50 hours before navigational bronchoscopy. Lesion location was confirmed by radial probe endobronchial ultrasonography. An optical fiber diffuser was placed within or adjacent to the tumor under fluoroscopic guidance; laser light (630 nm wavelength) was applied at 200 J/cm of diffuser length for 500 seconds. Tumor response was assessed by modified Response Evaluation Criteria in Solid Tumors at 3 and 6 months postprocedure (nonresection study) and pathologically (resection study).

RESULTS

There were no deaths, discontinuations for adverse events, or serious or grade ≥3 adverse events related to study treatments. Photosensitivity reactions occurred in 8 of 15 patients: 6 mild, 1 moderate, 1 severe (elevated porphyrins noted in blood after treatment). Among 5 patients with clinical follow-up, 1 had complete response, 3 had stable disease, and 1 had progressive disease at 6 months follow-up. Among 10 patients who underwent lobectomy, 1 had no evidence of tumor at resection (complete response), 3 had 40% to 50% tumor cell necrosis, 2 had 20% to 35%, and 4 had 5% to 10%.

CONCLUSION

PDT for nonthermal ablation of peripheral lung tumors was feasible and safe in this small study. Further study is warranted to evaluate efficacy and corroborate the safety profile.

Role of Transbronchial Lung Cryobiopsy in the Diagnosis of Interstitial Lung Disease: A Meta-analysis of 68 Studies and 6300 Patients

BACKGROUND

Diagnosis of interstitial lung disease (ILD) is based on multidisciplinary team discussion (MDD) with the incorporation of clinical, radiographical, and histopathologic information if available. We aim to evaluate the diagnostic yield and safety outcomes of transbronchial lung cryobiopsy (TBLC) in the diagnosis of ILD.

METHODS

We conducted a meta-analysis by comprehensive literature search to include all studies that evaluated the diagnostic yields and/or adverse events with TBLC in patients with ILD. We calculated the pooled event rates and their 95% confidence intervals (CIs) for the diagnostic yield by MDD, histopathologic diagnostic yield, and various clinical adverse events.

RESULTS

We included 68 articles (44 full texts and 24 abstracts) totaling 6386 patients with a mean age of 60.7±14.1 years and 56% men. The overall diagnostic yield of TBLC to achieve a definite or high-confidence diagnosis based on MDD was 82.3% (95% CI: 78.9%-85.2%) and histopathologic diagnosis of 72.5% (95% CI: 67.7%-76.9%). The overall rate of pneumothorax was 9.6% (95% CI: 7.9%-11%), while the rate of pneumothorax requiring drainage by a thoracostomy tube was 5.3% (95% CI: 4.1%-6.9%). The rate of moderate bleeding was 11.7% (95% CI: 9.1%-14.9%), while the rate of severe bleeding was 1.9% (95% CI: 1.4%-2.6%). The risk of mortality attributed to the procedure was 0.9% (95% CI: 0.7%-1.3%).

CONCLUSION

Among patients with undiagnosed or unclassified ILD requiring tissue biopsy for diagnosis, transbronchial cryobiopsy represents a reliable alternative to surgical lung biopsy with decreased incidence of various clinical adverse events.

Survival Differences by Comorbidity Burden among Patients with Stage I/II Non-Small-Cell Lung Cancer after Thoracoscopic Resection

We sought to compare overall survival (OS) by comorbidity burden among patients with stage I/II non-small cell lung cancer (NSCLC) who received thoracoscopic resection. Utilizing data from the National Cancer Database, we conducted a survival analysis among patients aged 50+ with stage I/II NSCLC who received thoracoscopic resection between 2010 and 2017. The comorbidity burden was measured by the Charlson comorbidity index (CCI, 0, 1, 2+). Multivariable Cox proportional hazard models were used to compare overall survival relative to the CCI (CCI of 0 as the referent). Subgroup analyses were conducted considering sex, age groups, days from diagnosis to surgery, facility type, laterality, and type of surgery. For this study, 61,760 patients were included, with a mean age of 69.1 years (SD: 8.5). Notably, 51.2% had a CCI of 0, 31.8% had a CCI of 1, and 17.0% had a CCI of 2+. Most participants were non-Hispanic White (87.5%), and 56.9% were female. We found that an increase in the CCI was associated with a higher risk of all-cause mortality (CCI 1 vs. 0 aHR: 1.24, 95% CI: 1.20–1.28; CCI 2+ vs. 0 aHR: 1.51, 95% CI: 1.45–1.57; p-trend < 0.01). Our subgroup analysis according to sex suggested that the association between CCI and risk of death was stronger in women.

A Preliminary Study of Extracting Pulmonary Nodules and Nodule Characteristics from Radiology Reports Using Natural Language Processing

This study aims to develop a natural language processing (NLP) tool to extract the pulmonary nodules and nodule characteristics information from free-text clinical narratives. We identified a cohort of 3,080 patients who received low dose computed tomography (LDCT) at the University of Florida health system and collected their clinical narratives including radiology reports in their electronic health records (EHRs). Then, we manually annotated 394 reports as the gold-standard corpus and explored three state-of-the-art transformer-based NLP methods. The best model achieved an F1-score of 0.9279.

Procedural complications associated with invasive diagnostic procedures after lung cancer screening with low-dose computed tomography

INTRODUCTION

Although the National Lung Screening Trial (NLST) has proven low-dose computed tomography (LDCT) is effective for lung cancer screening, little is known about complication rates from invasive diagnostic procedures (IDPs) after LDCT in real-world settings. In this study, we used the real-world data from a large clinical research network to estimate the complication rates associated with IDPs after LDCT.

METHODS

Using 2014-2021 electronic health records and claims data from the OneFlorida clinical research network, we identified case individuals who underwent an IDP (i.e., cytology or needle biopsy, bronchoscopy, thoracic surgery, and other surgery) within 12 months of their first LDCT. We matched each case with one control individual who underwent an LDCT but without any IDPs. We calculated 3-month incremental complication rates as the difference in the complication rate between the case and control groups by IDP and complication severity.

RESULTS

Among 7,041 individuals who underwent an LDCT, 301 (4.3%) subsequently had an IDP within 12 months following the LDCT. The overall 3-month incremental complication rate was 16.6% (95% confidence interval [CI]: 9.9% - 23.1%), higher than that reported in the NLST (9.4%). The overall incremental complication rate was 5.6% (95% CI: 1.9% - 9.6%) for major, 8.6% (95% CI: 3.1% - 14.1%) for intermediate, and 13.2% (95% CI: 8.1% - 18.5%) for minor complications.

CONCLUSIONS

It is important to ensure adherence to clinical guidelines for nodule management and downstream work-up to minimize potential harms from screening.

A computational modeling approach for dosing endoscopic intratumoral chemotherapy for advanced non-small cell lung cancer

We recently developed a computational model of cisplatin pharmacodynamics in an endobronchial lung tumor following ultrasound-guided transbronchial needle injection (EBUS-TBNI). The model suggests that it is more efficacious to apportion the cisplatin dose between injections at different sites rather than giving it all in a single central injection, but the model was calibrated only on blood cisplatin data from a single patient. Accordingly, we applied a modified version of our original model in a set of 32 patients undergoing EBUS-TBNI for non-small cell lung cancer (NSCLC). We used the model to predict clinical responses and compared them retrospectively to actual patient outcomes. The model correctly predicted the clinical response in 72% of cases, with 80% accuracy for adenocarcinomas and 62.5% accuracy for squamous-cell lung cancer. We also found a power-law relationship between tumor volume and the minimal dose needed to induce a response, with the power-law exponent depending on the number of injections administered. Our results suggest that current injection strategies may be significantly over- or under-dosing the agent depending on tumor size, and that computational modeling can be a useful planning tool for EBUS-TBNI of cisplatin in lung cancer.

ACR Appropriateness Criteria® Suspected Retroperitoneal Bleed

The initial diagnosis of retroperitoneal bleeding can be challenging by physical examination and clinical presentation. Prompt imaging can make the diagnosis and be lifesaving. When selecting appropriate imaging for these patient's, consideration must be made for sensitivity and ability to image the retroperitoneum, as well as speed of imaging.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Prevention of acute exacerbation of chronic obstructive pulmonary disease after bronchoscopic lung volume reduction with endobronchial valves

INTRODUCTION

Bronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBVs) has emerged as an important treatment method for patients with severe chronic obstructive pulmonary disease (COPD). Acute exacerbations of COPD (AECOPD) are a frequent complication following BLVR with EBV. However, there is no consensus on the prevention of AECOPD.

OBJECTIVES

Our study aims to compare the outcomes of different prophylactic measures on the occurrence of AECOPD after BLVR with EBV.

METHODS

We conducted a multicenter, retrospective study of patients who underwent BLVR with EBV at six different institutions. Emphasis was directed towards the specific practices aimed at preventing AECOPD: antibiotics, steroids, antibiotics plus steroids, or no prophylaxis. Subgroups were compared, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 170 patients were reviewed. The rate of AECOPD was 21.2% for the full cohort. Patients who received prophylaxis had a significantly lower rate of AECOPD compared with those who did not (16.7% vs. 46.2%; p = 0.001). The rate was lowest in patients who received antibiotics alone (9.2%). There was no significant difference in the rate of AECOPD between patients who received steroids alone or antibiotics plus steroids, compared with the other subgroups. The OR for AECOPD was 4.3 (95% CI: 1.8-10.4; p = 0.001) for patients not receiving prophylaxis and 3.9 (95% CI: 1.5-10.1; p = 0.004) for prophylaxis other than antibiotics alone.

CONCLUSIONS

Administration of antibiotics after BLVR with EBV was associated with a lower rate of AECOPD. This was not observed with the use of steroids or in combination with antibiotics.

Utility of bronchoscopic intra-tumoral alcohol injection to restore airway patency

Background

In cases of malignant airway obstruction, achieving airway patency using conventional bronchoscopic modalities can be challenging and may not be satisfactory. We aim to present our experience of using intra-tumoral alcohol injection (ITAI) to help achieve airway patency in malignant airway obstruction.

Methods

A retrospective study of adult patients presenting with malignant airway obstruction who underwent bronchoscopy with ITAI at a university center between 2015 and 2020 was conducted. We present procedural and patients' characteristics along with any additional bronchoscopic or systemic interventions received. Patients were classified based on airway patency response (assessed qualitatively by an interventional pulmonologist) into those with good response (≥50% improvement in airway patency) vs. those with low response (<50% improvement in airway patency).

Results

Forty-two patients underwent ITAI, of which 34 (81%) had at least two bronchoscopies to evaluate response. The patient median age was 65.5 [interquartile range (IQR) 57.8-72]. Most patients had stage IV malignancy at the time of the bronchoscopy (57.1%) and had Eastern Cooperative Oncology Group (ECOG) performance status score of between 2-3. Eighty-two percent of the patients achieved good airway patency response at the conclusion of the procedures. The procedures were generally well-tolerated and only one patient had significant bleeding that was not directly related to ITAI and required intensive care unit monitoring for 24 hours after the procedure.

Conclusions

Dehydrated alcohol is readily available, inexpensive and a safe drug that can be potentially injected directly in malignant airway obstructive lesions in a multimodality approach to achieve airway patency when traditional modalities reach their limitation. Further studies are warranted to determine whether ITAI is superior to other interventional methods, explore its utilization to treat peripheral malignant tumors, as well as to standardize the treatment protocol and determine the effects of ITAI on patient symptoms and quality of life.

A 57-Year-Old Man With Stridor and Critical Tracheal Narrowing

CASE PRESENTATION

A 57-year-old man with a history of polysubstance use presented with shortness of breath, wheezing, productive cough, subjective fever, and chills of 3-day duration. Additionally, he reported worsening shortness of breath for the last 3 months. Of note, the patient was reported to have had, in the previous 6 months, two episodes of pneumonia that was treated with antibiotics and steroids. He was also diagnosed several years prior with adult-onset asthma due to intermittent wheezing and was prescribed an albuterol inhaler. The albuterol did not help relieve his wheezing, and he stopped refilling it.

Abstract PO-092: Developing a computable phenotype to identify populations eligible/ineligible for lung cancer screening

Introduction Seventy percent of lung cancer patients are diagnosed at advanced stages. Lung cancer screening (LCS) can potentially produce a stage-shift through early detection of the disease. The 2013 LCS guideline from the U.S. Preventive Services Task Force (USPSTF) recommended screening with low-dose computed tomography (LDCT) for individuals aged between 55 and 80 with 30 pack-year smoking history (i.e., current smoker or had quit smoking within 15 years). However, the high false-positive rate of LCS with LDCT is one of the concerns that hinders the uptake of LCS in real-world settings. An electronic health record (EHR)-based computable phenotyping (CP) algorithm that accurately identifies patients who meet the LCS eligibility criteria can potentially improve the reach of screening eligible population and thereby increase the uptake of LCS. Objective To develop an EHR-based CP algorithm to identify patients eligible for LCS. Method The LCS CP algorithm was developed to extract quantitative smoking information (i.e., pack-years, smoking years, quit year) using both structured EHR and unstructured clinical notes, enabled by advanced natural language processing (NLP) methods. The study cohort consisted of 3,080 patients who received LCS with LDCT based on procedure codes, as documented in EHR data from the UF Health Integrated Data Repository (IDR). The EHR-based LCS CP algorithm included two modules, one to extract smoking information from both structured EHR data and clinical notes using NLP techniques, and the other to integrate the extracted results based on the CP rules (e.g., pack-year &gt; 30; quit year within 15 years; age 55-80) to determine whether a patient is eligible for LCS. For initial evaluation, we conducted a chart review of 20 randomly selected patients and compared the CP algorithm outcomes with the chart review results. Results and Discussion The manual chart review of the 20 patients who underwent LCS with LDCT identified 13 patients were qualified for LCS, 6 patients were not qualified for LCS, and 1 patient was undecidable. Based on this gold standard dataset, the CP algorithm achieved a specificity of 1.00 and a sensitivity of 0.92. Without smoking information extracted from clinical notes using NLP, the specificity score dropped to 0.80. Our results indicate that clinical notes are an important source of information on smoking histories. For all smoking-related information extracted from the clinical notes, smoking history was consistent with the structured EHR in 60% of cases, inconsistent in 10% cases, with the remaining 30% missing. Our results point to (1) suboptimal documentation of smoking information in EHRs, (2) added value of artificial intelligence methods such as NLP in improving CP performance, and (3) potential of an EHR-based CP to accurately identify patients eligible for LCS, and potential relevance to clinical decision support. As the upcoming USPSTF LCS guideline is changing (i.e., from 30 pack-year to 20 pack-year), the CP needs be refined to reflect the changes.

Citation Format: Shuang Yang, Tianchen Lyu, Xi Yang, Yonghui Wu, Yi Guo, Michelle Alvarado, Hiren J. Mehta, Ramzi G. Salloum, Dejana Braithwaite, Jinhai Huo, Ya-Chen Tina Shih, Jiang Bian. Developing a computable phenotype to identify populations eligible/ineligible for lung cancer screening [abstract]. In: Proceedings of the AACR Virtual Special Conference on Artificial Intelligence, Diagnosis, and Imaging; 2021 Jan 13-14. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(5_Suppl):Abstract nr PO-092.

Sensitivity and Safety of Electromagnetic Navigation Bronchoscopy for Lung Cancer Diagnosis: Systematic Review and Meta-analysis

BACKGROUND

Bronchoscopy is a useful tool for the diagnosis of lesions near central airways; however, the diagnostic accuracy of these procedures for peripheral pulmonary lesions (PPLs) is a matter of ongoing debate. In this setting, electromagnetic navigation bronchoscopy (ENB) is a technique used to navigate and obtain samples from these lesions. This systematic review and meta-analysis aims to explore the sensitivity of ENB in patients with PPLs suspected of lung cancer.

RESEARCH QUESTION

In patients with peripheral pulmonary lesion suspected of lung cancer, what is the sensitivity and safety of electromagnetic navigation bronchoscopy compared to surgery or longitudinal follow up?

STUDY DESIGN AND METHODS

A comprehensive search of several databases was performed. Extracted data included sensitivity of ENB for malignancy, adequacy of the tissue sample, and complications. The study quality was assessed using the QUADAS-2 tool, and the combined data were meta-analyzed using a bivariate method model. A summary receiver operatic characteristic curve (sROC) was created. Finally, the quality of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Forty studies with a total of 3,342 participants were included in our analysis. ENB reported a pooled sensitivity of 77% (95% CI, 72%-82%; I² = 80.6%) and a specificity of 100% (95% CI, 99%-100%; I² = 0%) for malignancy. The sROC showed an area under the curve of 0.955 (P = .03). ENB achieved a sufficient sample for ancillary tests in 90.9% (95% CI, 84.8%-96.9%; I² = 80.7%). Risk of pneumothorax was 2.0% (95% CI, 1.0-3.0; I² = 45.2%). We found subgroup differences according to the risk of bias and the number of sampling techniques. Meta-regression showed an association between sensitivity and the mean distance of the sensor tip to the center of the nodule, the number of tissue sampling techniques, and the cancer prevalence in the study.

INTERPRETATION

ENB is very safe with good sensitivity for diagnosing malignancy in patients with PPLs. The applicability of our findings is limited because most studies were done with the superDimension navigation system and heterogeneity was high.

TRIAL REGISTRY

PROSPERO; No.: CRD42019109449; URL: https://www.crd.york.ac.uk/prospero/.

Repositioning of migrated self-expanding metallic tracheobronchial stent: predictors of a successful maneuver and its impact on survival

Background

Endobronchial stents that are used to treat airway obstruction may migrate over time. These stents can be repositioned. However, not much has been reported about this technique. We retrospectively reviewed our experience with self-expanding metallic stents (SEMS) and attempted to determine—(I) factors related to successful stent repositioning; (II) determine its impact on survival.

Methods

Demographic, medical history, and stent-related procedure factors were extracted from the electronic health record. Primary outcomes were bronchial stent repositioning success and survival (days until death). As validation of successful repositioning, the durations of successful and failed repositioning procedures were compared using an independent t-test.

Results

Seventy-six patients underwent stent repositioning, of which, 55.3% (n=42) were successfully repositioned. The probability of success in repositioning procedures was accounted for by patient sex, stent location, and stent diameter. Females were more likely to have a successful repositioning compared to males. Stent repositioning in the LMS was more likely to be successful and stents larger in diameter tended to increase the likelihood of successful repositioning. Long-term survival was higher for those who had a successful procedure. Stent location and disease subgroups predicted average length of survival.

Conclusions

Repositioning of migrated stents can be successfully performed regardless of the reasons for initial placement, duration of stenting and degree of original obstruction. Larger stents are easier to reposition and so were stents in the left main stem (LMS) airway. A successful stent repositioning maneuver improved long-term survival although did not have any impact survival in the immediate post-procedural period.

Chloroquine and hydroxychloroquine in the context of COVID-19

Chloroquine and closely related structural analogs, employed initially for the treatment of malaria, are now gaining worldwide attention due to the rapidly spreading pandemic caused by severe acute respiratory syndrome-coronavirus-2, named coronavirus disease (COVID) of 2019 (COVID-19). Although much of this attention has a mechanistic basis, the hard efficacy data for chloroquine/hydroxychloroquine in the management of the clinical syndrome of COVID-19 have been limited thus far. This review aims to present the available in vitro and clinical data for the role of chloroquine/hydroxychloroquine in COVID-19 and attempts to put them into perspective, especially in relation to the different risks/benefits particular to each patient who may require treatment.

[Airway tridimensional printing]

Tridimensional printing is becoming relevant in medicine, specially in surgical and interventional specialties. We review the technical aspects and clinical application of airway tridimensional printing. Using this technique, simulation models for bronchoscopy and models for diagnostic and therapeutic procedures such as stent design, tracheal reconstruction and airway models can be created.

Single-center In-hospital Cardiac Arrest Outcomes

BACKGROUND

This study was designed to evaluate the patient characteristics and outcomes of in-hospital cardiac arrest (IHCA).

MATERIALS AND METHODS

We carried out a single-center, 5-year, retrospective chart review and analysis of resuscitation data for age, gender, body mass index (BMI), length of stay (LOS) until cardiac arrest, survival of initial IHCA, survival to hospital discharge, primary medical service, and determination of the etiology of cardiac arrest.

RESULTS

A total of 500 cases occurred with a mean LOS of 8.5 days until the initial IHCA. Overall, 79.5% survived the initial IHCA and 32.4% survived to discharge. As LOS increased, there was an increase in the proportion of pulmonary and metabolic etiologies. Logistic regression analysis adjusting for BMI, gender, age, LOS, and primary medical service were on a surgical service significant for survival to discharge (p = 0.0007) and LOS <9 days significant for survival of IHCA (p = 0.018).

CONCLUSION

There are a number of causes of IHCA, and the incidence of death and respiratory related IHCA etiologies increase with LOS. Length of stay carries the highest weight when predicting survival of IHCA. Also, there is a higher rate of survival to discharge when on a primary surgical service.

HOW TO CITE THIS ARTICLE

Riley LE, Mehta HJ, Lascano J. Single-center In-hospital Cardiac Arrest Outcomes. Indian J Crit Care Med 2020;24(1):44-48.

Efficacy of the Spiration Valve System in Patients with Severe Heterogeneous Emphysema: A Systematic Review and Meta-Analysis

BACKGROUND

Spiration Valve System (SVS) is an alternative for patients with severe heterogeneous emphysema; however, data about efficacy from randomized controlled trials (RCT) are unclear.

OBJECTIVES

To explore both efficacy and safety of SVS in patients with severe emphysema and hyperinflation.

METHODS

We included PubMed, EMBASE, Coch-rane database. All searches were performed until August 2019. Only RCTs were included for analysis. Risk of bias was assessed using Cochrane risk of bias tool. A meta-analysis evaluated change in forced expiratory volume in 1 s (FEV1), 6-min walking test (6MWT), residual volume, modified medical research council (mMRC) and Saint George respiratory questionnaire (SGRQ), all-cause mortality, risk of pneumothorax, and risk of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Quality of the evidence was rated using GRADE approach.

RESULTS

Four RCTs including 629 subjects were included. SVS showed an overall change of 0.03 L (-0.07 to 0.13, I2 = 90%) in the in FEV1 (L) and a 2.03% (-2.50 to 6.57, I2 = 96%) in the predicted FEV1 (%) compared to baseline; however, studies without collateral ventilation (CV) showed an improvement of 0.12 L (95% CI 0.09-0.015, I2 = 0%), This subgroup also reported better results in SGRQ -12.27 points (95% CI -15.84 to -8.70, I2 = 0%) and mMRC -0.54 (95% CI -0.74 to -0.33, I2 = 0%). We found no benefit in 6MWT mean difference = 4.56 m (95% CI -21.88 to 31.00, I2 = 73%). Relative risk of mortality was 2.54 (95% CI 0.81-7.96, I2 = 0%), for pneumothorax 3.3 (95% CI 0.61-18.12, I2 = 0%) and AECOPD 1.68 (95% CI 1.04-2.70, I2 = 0%).

CONCLUSION

In patients with severe heterogeneous emphysema and hyperinflation without CV, SVS is an alternative that showed an improvement in pulmonary function, quality of life, and dyspnea score with an acceptable risk profile.

Association between inflammatory bowel disease and chronic obstructive pulmonary disease: a systematic review and meta-analysis

INTRODUCTION

There is evidence of an association between inflammatory bowel disease (IBD) and lung conditions such as chronic obstructive pulmonary disease (COPD). This systematic review and meta-analysis explored the risk of new onset IBD in patients with COPD and new onset COPD in IBD patients.

METHODS

We performed a systematic review of observational studies exploring the risk of both associations. Two independent reviewers explored the EMBASE, MEDLINE, LILACS and DOAJ databases, and the risk of bias was evaluated using the ROBBINS-I tool. Data from included studies was pooled in a random effect meta-analysis following a DerSimonian-Laird method. The quality of the evidence was ranked using GRADE criteria.

RESULTS

Four studies including a pooled population of 1355 new cases were included. We found association between new onset IBD in COPD population. The risk of bias was low in most of them. Only one study reported tobacco exposure as a potential confounding factor. The pooled risk ratio (RR) for a new diagnosis of IBD in COPD patients was 2.02 (CI, 1.56 to 2.63), I2 = 72% (GRADE: low). The subgroup analyses for Crohn's disease and ulcerative colitis yielded RRs of 2.29 (CI, 1.51 to 3.48; I2 = 62%), and 1.79 (CI, 1.39 to 2.29; I2 = 19%.), respectively.

DISCUSSION

According to our findings, the risk of new onset IBD was higher in populations with COPD compared to the general population without this condition. Based on our analysis, we suggest a potential association between IBD and COPD; however, further research exploring the potential effect of confounding variables, especially cigarette smoking, is still needed. REVIEW REGISTER: (PROSPERO: CRD42018096624).

A 62-Year-Old Woman With Refractory Wheezing

CASE PRESENTATION

A 62-year-old Hispanic woman, a resident of Puerto Rico, presented with symptoms of chronic cough and shortness of breath for the past 2 years that were slowly and progressively getting worse. She received a diagnosis of asthma on the basis of her history of symptomatic "wheezing" and had been on treatment with inhaled bronchodilators and corticosteroids with minimal symptomatic improvement. The peculiarity of her symptoms was that her dyspnea was worse when she was reclining in bed and she would often hear a "whistling" noise in her throat during those times. Additionally, she reported difficulty swallowing and would often drink water to aid in swallowing food. There was no prior history of endotracheal intubations or surgeries. She denied any history of joint pain, skin rashes, eye pain, hair loss, mouth ulcers, photosensitivity, diarrhea, blood-mixed stool, or blood in the urine.

SMARCA4-Deficient Thoracic Sarcoma: A Case Report and Review of Literature

SMARCA4-deficient thoracic sarcoma (SMARCA4-DTS) is a recently described entity with a poor prognosis that is defined by certain genetic alterations in the BAF chromatin remodeling complex, specifically SMARCA4 and SMARCA2. We present a case of a SMARCA4-DTS in a 59 year-old male with a heavy smoking history who was found to have an unexpected right upper lobe lung mass on routine chest radiograph after a visit to his primary care physician. This led to a biopsy with a diagnosis of poorly differentiated carcinoma at an outside institution. The patient was subsequently seen at our facility for surgical intervention. The right upper lobectomy contained a 7.2-cm poorly differentiated malignancy with slightly discohesive cells arranged in sheets and nests, abundant geographic necrosis, and with many areas showing rhabdoid morphology. The tumor was focally reactive for CK7, AE1/3, Cam5.2, and SALL4 and showed scattered reactivity for CD34 and SOX2. There was complete loss of reactivity for both SMARCA4 and SMARCA2. The histology and immunophenotype were all consistent with the diagnosis of a SMARCA4-DTS. Next-generation sequencing showed a frameshift mutation in the SMARCA4 gene and no abnormality with the SMARCA2 gene. Interestingly, this tumor was confined to the pulmonary parenchyma with no invasion of the visceral pleura nor the mediastinum and with no clinically apparent metastases at the time of presentation. This case is presented to add to the cohort of cases described to date and to discuss the immunohistochemical and molecular findings with regard to SMARCA2.

Bronchoscopic Lung Volume Reduction with Endobronchial Zephyr Valves for Severe Emphysema: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic lung volume reduction using Zephyr® valves has been recently adopted as a treatment option for patients with severe emphysema without collateral ventilation (CV).

OBJECTIVES

To assess the efficacy and safety of Zephyr valves in such a population.

METHODS

Studies were identified from MEDLINE and EMBASE databases. All searches were current until June 2018. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy and safety of Zephyr. We defined as outcome: change in forced expiratory volume in 1 s (FEV1), in the 6-min walking test (6MWT), in the St George's Respiratory Questionnaire (SGRQ), and in residual volume (RV). Safety analysis included relative risk (RR) of pneumothorax. We assessed the quality of the evidence using GRADE.

RESULTS

7 RCTs reported on Zephyr valves and 5 RCTs included only patients without CV. Zephyr improved FEV1 with a mean difference (MD) of 17.36% (CI, 9.28-25.45, I2 = 78%). Subgroup analysis showed significant FEV1 improvement following Zephyr placement in patients with heterogeneous distribution: MD = 21.78% (CI, 8.70-34.86, I2 = 89%) and 16.27% (CI, 8.78-23.76, I2 = 0%) in patients with homogeneous emphysema. Studies with a follow-up of 3 months reported FEV1 MD = 17.19% (CI, 3.16-31.22, I2 = 89%) compared to studies with a follow-up of 6-12 months, which showed a consistent improvement of FEV1 MD = 17.90% (CI, 11.47-24.33, I2 = 0%). Zephyr also showed improvement of SGRQ, 6MWT, and RV. RR of pneumothorax was 6.32 (CI, 3.74-10.67, I2 = 0%).

CONCLUSION

In this population, Zephyr valves provided significant and clinically meaningful short-term improvements in either homogeneous or heterogeneous emphysema without CV but with an increase in adverse events.

Oncolytic virotherapy for small-cell lung cancer induces immune infiltration and prolongs survival

Oncolytic virotherapy has been proposed as an ablative and immunostimulatory treatment strategy for solid tumors that are resistant to immunotherapy alone; however, there is a need to optimize host immune activation using preclinical immunocompetent models in previously untested common adult tumors. We studied a modified oncolytic myxoma virus (MYXV) that shows high efficiency for tumor-specific cytotoxicity in small-cell lung cancer (SCLC), a neuroendocrine carcinoma with high mortality and modest response rates to immune checkpoint inhibitors. Using an immunocompetent SCLC mouse model, we demonstrated the safety of intrapulmonary MYXV delivery with efficient tumor-specific viral replication and cytotoxicity associated with induction of immune cell infiltration. We observed increased SCLC survival following intrapulmonary MYXV that was enhanced by combined low-dose cisplatin. We also tested intratumoral MYXV delivery and observed immune cell infiltration associated with tumor necrosis and growth inhibition in syngeneic murine allograft tumors. Freshly collected primary human SCLC tumor cells were permissive to MYXV and intratumoral delivery into patient-derived xenografts resulted in extensive tumor necrosis. We confirmed MYXV cytotoxicity in classic and variant SCLC subtypes as well as cisplatin-resistant cells. Data from 26 SCLC human patients showed negligible immune cell infiltration, supporting testing MYXV as an ablative and immune-enhancing therapy.

Chronic obstructive pulmonary disease and lung cancer: inter-relationships

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is a well established risk factor for lung cancer. Newer studies reveal a myriad of other mechanisms, some proven and some putative, which may contribute to their association.

RECENT FINDINGS

There is an ever-growing bundle of evidence that suggests a close association between persistent chronic inflammation and lung cancer. A few potential targets of genetic susceptibility locus for COPD and lung cancer have been suggested. Better characterization of immune dysregulation and identification of signaling pathways may assist the development of strategies to reduce risk of developing lung cancer in patients with COPD. Current lung cancer screening strategies may exclude some patients at high risk of having lung cancer. Prospective studies indicate that a screening criterion that includes variables reflecting the severity of COPD may increase the sensitivity of the screening program and reduce 'over-diagnosis bias' of indolent lung cancers. Examples of such variables include the emphysema score generated from computed tomography scans and diffusion capacity for carbon monoxide derived from lung function tests.

SUMMARY

A better understanding of the inter-relationship between lung cancer pathogenesis and COPD has been described recently. Improving lung cancer screening strategies by incorporating markers of COPD severity has recently been proposed.

Diagnostic Yield of the Virtual Bronchoscopic Navigation System Guided Sampling of Peripheral Lung Lesions using Ultrathin Bronchoscope and Protected Bronchial Brush

OBJECTIVES

The use of an ultrathin bronchoscope (UB) to diagnose peripheral pulmonary lesions is described. A virtual bronchoscopic navigation system was used to direct the ultrathin scope to the nodule. One of the constraints of this technique was the inability to confirm the target lesion position during biopsy by using a conventional linear endobronchial ultrasound probe, since the probe does not fit into a 1.2 mm working channel of this bronchoscope. The aim of the study was to review our institutional experience with the use of a UB for sampling peripheral pulmonary lesions using the transbronchial brush guided by virtual bronchoscopy. We describe a technique wherein we attempt to brush all the visible bronchial sub-segments once the bronchoscope has reached close to the nodule.

MATERIALS AND METHODS

In total, 52 patients underwent the procedure between 2010 and 2017. A multiplanar computed tomography (CT) scan of the chest was obtained and subsequently uploaded to the Lung Point Virtual bronchoscopy navigation software. The UB was parked close to the lesion. All visible airway branches were then brushed using a protected bronchial brush. The data were retrospectively abstracted from the electronic medical records using standardized forms.

RESULTS

A total of 52 lesions (40 solid, 8 part-solid, 3 cavitary, and 1 ground-glass) were sampled using a transbronchial brush (median, 2; range, 1-8). Twenty-four lesions were under 2 cm in size. The overall success rates were 67.3%. The average diameter of nodules was 2.7±1.01 cm; 65% lesions were in the outer-third of the lungs. The cancer-specific sensitivity was 72.5%. The presence of bronchus sign; location of the lesion; and the characteristics, size, and stage of cancer did not have any impact on the diagnostic yield.

CONCLUSION

Virtual bronchoscopy-guided ultrathin bronchoscopy with bronchial brushing is safe and has a diagnostic yield comparable to other described techniques for evaluating peripheral pulmonary nodules.

The Prevalence of Rhesus-Negative Blood Group Among Patient With Small Cell Lung Cancer and Analysis of Its Effect on Overall Survival

A higher incidence of Rhesus group D (RHD)-negative blood group among patients with Small Cell Cancer of the lung (SCLC) had been previously reported but reproducibility was not confirmed, and clinical relevance is undefined. We tested 1,090 (SCLC; Adenocarcinoma: Squamous = 202:536:352) cases of lung cancer over a 3-year period at a single institution and noted a higher frequency RHD negative status among SCLC cases (19/89) compared with non-SCLC (61/480) that could not be explained by differences in ethnic background in the patient population. While we confirmed poor ECOG functional status, advanced stage, elevated alkaline phosphatase, and low albumin levels as independent and significant factors for reduced overall survival (OS), we did not detect any clinical outcome correlations with RHD status in our dataset. Patients with SCLC rarely undergo surgical resection resulting in limited data for blood group analyses. We have now detected a higher rate of RHD-negative status in patients with SCLC compared with all other subtypes of lung cancer. The clinical and biological basis for this observation is undefined and we feel that this may be explained by variations in ethnic background.

NUT (Nuclear Protein in Testis) Carcinoma: A Report of Two Cases With Different Histopathologic Features

NUT (nuclear protein in testis) carcinoma (NC) is an aggressive carcinoma characterized by rearrangements of the NUT gene on chromosome 15q14. Histologically, it is a poorly differentiated carcinoma composed of monotonous, medium-sized, round cells with scant amphophilic or eosinophilic cytoplasm. Foci of abrupt keratinization are often seen. In this report, we compare the morphology of 2 cases of NC. The first case shows characteristic features of uniform, round epithelioid cells admixed with foci of abrupt keratinization. The second case demonstrates nests of epithelioid-polygonal cells that appear to be loosely cribriform within a mucoid stroma. Although considered rare, the actual incidence of NC may be underestimated, as it is likely that many go undiagnosed because the morphology deviates from what is typical. Our report demonstrates that NC should always be considered in any case of an undifferentiated carcinoma and should not be excluded if typical histologic and immunohistochemical features of squamous differentiation are lacking.

Standard Bronchoscopy With Fluoroscopy vs Thin Bronchoscopy and Radial Endobronchial Ultrasound for Biopsy of Pulmonary Lesions: A Multicenter, Prospective, Randomized Trial

BACKGROUND

New technology has resulted in bronchoscopy being increasingly used for diagnosing pulmonary lesions. Reported yield from these procedures varies widely with few randomized clinical trials. This study compares the diagnostic yield of a thin bronchoscope and radial endobronchial ultrasound (R-EBUS) with standard bronchoscopy and fluoroscopy (SB-F) in lung lesions.

METHODS

Patients presenting for diagnostic bronchoscopic evaluation at five centers were randomized to undergo SB-F or R-EBUS with a thin bronchoscope (TB-EBUS). If SB-F was nondiagnostic, crossover to the TB-EBUS arm was allowed. Data on patient demographics, radiographic features, and final pathologic or radiographic follow-up were collected. Statistical comparisons were made by Fisher exact test, χ² test, and Student t test. Bivariate and multivariate analyses were performed to determine predictors of diagnostic yield.

RESULTS

One hundred and ninety-seven patients were included in the final analyses. There was no difference in demographics, lesion size, or location between study arms. The average lesion size was 31.2 mm (SD, 10.8 mm). Bronchoscopy was diagnostic in 87 patients (44%). Although the diagnostic yield was higher in the TB-EBUS arm compared with the SB-F arm (49% vs 37%), this difference was not statistically significant (P = .11). Among those with nondiagnostic bronchoscopic findings in the standard arm, 87% (n = 46) crossed over to TB-EBUS, resulting in a diagnosis in seven additional patients (15% of 46).

CONCLUSIONS

Bronchoscopy with or without a thin scope and R-EBUS had a poor diagnostic yield for pulmonary lesions. Future work should focus on improvements in technique and technology advances that ensure a higher likelihood of obtaining a diagnosis.

Clinical performance of endobronchial ultrasound-guided transbronchial needle aspiration for assessing programmed death ligand-1 expression in nonsmall cell lung cancer

BACKGROUND

Pembrolizumab was recently approved as a first line agent for metastatic NSCLC in patients with high programmed death-ligand 1 (PD-L1) expression.

OBJECTIVES

Since a significant portion of lung cancer is diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA); there is a need for PD-L1 testing in these specimens. However, to date few studies have evaluated performance of cytology specimens from EBUS TBNA for PD-L1 analysis.

METHODS

Patients who had a diagnosis of NSCLC and in whom ancillary testing, i.e., next generation sequencing (NGS), anaplastic lymphoma kinase (ALK), and PD-L1 expression was requested between January and May 2017 were reviewed.

RESULTS

Fifty of the 112 patients reviewed had the diagnosis of NSCLC for which ancillary testing was requested. Twelve patients (24%) had squamous cell carcinoma, twenty-seven had adenocarcinoma (54%), five had NSCLC favor adenocarcinoma (10%), two had NSCLC favor squamous cell cancer (4%), and four had NSCLC not otherwise specified (NOS) (8%). Size of the lymph nodes or lesion sampled ranged from 10 to 50 mm. Four (8%) patients had insufficient number of tumor cells in the cell block for any of the ancillary molecular testing. Forty-one (82%) patients had an adequate sample for all three ancillary tests. Satisfactory results for PD-L1 expression for all cases was 86% with 14 (32%) patients having levels of PD-L1 expression >50%.

CONCLUSION

EBUS TBNA is effective and has a high proportion of satisfactory results for testing PD-L1 expression on tumor cells in addition to NGS and ALK FISH.

[Endoscopic lung volume reduction in advanced pulmonary emphysema: initial experience in Chile]

Chronic obstructive pulmonary disease (COPD) has no curative treatment, and in moderate to advanced stages, functional parameters and quality of life are affected. Lung volume reduction improves respiratory parameters and quality of life of these patients. Endoscopic lung volume reduction is a minimally invasive procedure that uses endobronchial valves or coils. Valves are unidirectional, blocking the air from entering the target lobe during inspiration, allowing the exit of air and secretions during expiration. Complete fissure and absence of collateral ventilation are needed for an adequate functioning of endobronchial valves. Endobronchial coils cause mechanical retraction of the lung parenchyma. We report two patients who underwent endoscopic lung volume reduction by endobronchial valves. One patient was on continuous positive pressure non-invasive ventilation due to his severe emphysema.

Tracheobronchomalacia

The term tracheobronchomalacia refers to excessively compliant and collapsible central airways leading to symptoms. Although seen as a coexisting condition with various other pulmonary condition, it may cause symptoms by itself. The condition is often misdiagnosed as asthma, bronchitis or just chronic cough due to a lack of specific pathognomonic history and clinical findings. The investigation revolves around different modes of imaging, lung function testing and usually confirmed by flexible bronchoscopy. The treatment widely varies based on the cause, with most cases treated conservatively with non-invasive ventilation. Some may require surgery or stent placement. In this article, we aim to discuss the pathophysiology behind this condition and recognize the common symptoms and causes of tracheobronchomalacia. The article will highlight the diagnostic steps as well as therapeutic interventions based on the specific cause.

Endobronchial Ultrasound-guided Intratumoral Injection of Cisplatin for the Treatment of Isolated Mediastinal Recurrence of Lung Cancer

Isolated hilar and mediastinal recurrence (IMHR) following external beam radiation therapy (EBRT) in patients with lung cancer is common. These patients do not have many treatment options and are usually offered palliative chemotherapy or best supportive care. Endobronchial ultrasound (EBUS)-guided intratumoral injection of cisplatin (ITC) is a novel approach for these patients. The procedure is performed under conscious sedation. The lesion is located with a bronchoscopy using EBUS, and a 22-gauge EBUS needle is advanced through the working channel of the scope and locked in position. Under ultrasound guidance, the wall of the tracheobronchial tree is punctured and the needle is moved into the target lesion. The needle stylet is then removed and cisplatin (40 mg/40 mL) is injected into the lesion. One to two sites are treated per session. Details of the procedure are described in the protocol section of paper. At our center, 50 sites were treated in 36 patients (19 males, 17 females). The mean age of our cohort was 61.9 ±8.5 years. We performed final analyses on 35 patients and 41 sites. 24/35 (69%) had complete or partial response (responders), whereas 11/35 (31%) had stable or progressive disease (non-responders). Overall, survival in our group was 8 months (95% CI of 6-11 months), with patients who responded having significantly better survival than the ones who did not.