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Chang CH, Ost DE, Jimenez CA, Saltijeral SN, Eapen GA, Casal RF, Sabath BF, Lin J, Cerrillos E, Nevarez Tinoco T, Grosu HB. Outcomes of Pleural Space Infections in Patients With Indwelling Pleural Catheters for Active Malignancies. J Bronchology Interv Pulmonol 2024; 31:155-159. [PMID: 37982602 DOI: 10.1097/lbr.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 09/15/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Pleural infections related to indwelling pleural catheters (IPCs) are an uncommon clinical problem. However, management decisions can be complex for patients with active malignancies due to their comorbidities and limited life expectancies. There are limited studies on the management of IPC-related infections, including whether to remove the IPC or use intrapleural fibrinolytics. METHODS We conducted a retrospective cohort study of patients with active malignancies and IPC-related empyemas at our institution between January 1, 2005 and May 31, 2021. The primary outcome was to evaluate clinical outcomes in patients with malignant pleural effusions and IPC-related empyemas treated with intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) compared with those treated with tPA alone or no intrapleural fibrinolytic therapy. The secondary outcome evaluated was the incidence of bleeding complications. RESULTS We identified 69 patients with a malignant pleural effusion and an IPC-related empyema. Twenty patients received tPA/DNase, 9 received tPA alone, and 40 were managed without fibrinolytics. Those treated with fibrinolytics were more likely to have their IPCs removed as part of the initial management strategy ( P =0.004). The rate of surgical intervention and mortality attributable to the empyema were not significantly different between treatment groups. There were no bleeding events in any group. CONCLUSION In patients with IPC-related empyemas, we did not find significant differences in the rates of surgical intervention, empyema-related mortality, or bleeding complications in those treated with intrapleural tPA/DNase, tPA alone, or no fibrinolytics. More patients who received intrapleural fibrinolytics had their IPCs removed, which may have been due to selection bias.
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Affiliation(s)
- Christopher H Chang
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sahara N Saltijeral
- Department of Internal Medicine, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Mexico
| | - Georgie A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce F Sabath
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Julie Lin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eben Cerrillos
- Department of Internal Medicine, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Mexico
| | - Tamara Nevarez Tinoco
- Department of Internal Medicine, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Mexico
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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de Groot PM, Jimenez CA, Godoy MCB, Wu CC. Pleural Effusions: Clues for Diagnosis and Characterization. Semin Roentgenol 2023; 58:431-439. [PMID: 37973272 DOI: 10.1053/j.ro.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/06/2023] [Accepted: 06/26/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Patricia M de Groot
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Myrna C B Godoy
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carol C Wu
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
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3
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Sarkiss M, Jimenez CA. The evolution of anesthesia management of patients with anterior mediastinal mass. Mediastinum 2023; 7:16. [PMID: 37261097 PMCID: PMC10226893 DOI: 10.21037/med-22-37] [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] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 02/23/2023] [Indexed: 06/02/2023]
Abstract
Anesthesia management of patients with mediastinal mass compressing the central airway is considered challenging. It is widely believed that general anesthesia induction in patients with mediastinal mass is associated with airway collapse, difficulty in ventilation and hemodynamic compromise. Additionally, several case reports and case series described patients demise after induction of general anesthesia. This has led to the strong recommendations to use inhalation induction, avoid the use of muscle relaxant and maintenance of spontaneous ventilation. Recent studies shed new light on our understanding of airway changes associated with mediastinal mass by directly visualizing and measuring the actual changes of the airway caliber and the variation in the peak inspiratory flow (PIF) and peak expiratory flow (PEF) in patients with mediastinal mass. These studies describe the changes in airway mechanics in different states e.g., awake and anesthetized, spontaneous and positive pressure ventilated with or without muscle relaxation. Interesting new findings in these recent publications show that general anesthesia with and without muscle relaxation does not worsen a pre-existing narrowing of the airway compressed by mediastinal mass. Moreover, it was discovered that the addition of positive pressure ventilation, positive end-expiratory pressure (PEEP) and muscle relaxation in an anesthetized patient were associated with improvement in the airway caliber and airflow in these patient's population. This new understanding of the mechanics of airway obstruction and the effects of anesthesia and mechanical ventilation on patients with mediastinal mass challenges our current anesthesia practices and leads us to consider a new approach to anesthetize and ventilate these patients. This article will review the past literature that led to the widely practiced current anesthesia techniques and how it is challenged with the new research. The author will also provide a new perspective and anesthesia technique that align with the new research findings for safe induction and maintenance of general anesthesia in patients with mediastinal mass.
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Affiliation(s)
- Mona Sarkiss
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos A. Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Salahuddin M, Sarkiss M, Sagar AES, Vlahos I, Chang CH, Shah A, Sabath BF, Lin J, Song J, Moon T, Norman PH, Eapen GA, Grosu HB, Ost DE, Jimenez CA, Chintalapani G, Casal RF. Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia: A Multicenter Randomized Controlled Trial (Ventilatory Strategy to Prevent Atelectasis -VESPA- Trial). Chest 2022; 162:1393-1401. [PMID: 35803302 DOI: 10.1016/j.chest.2022.06.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [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: 03/16/2022] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images. RESEARCH QUESTION Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio2, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio2 titration (< 100%), and PEEP of 8 to 10 cm H2O. All patients underwent chest CT imaging and a survey for atelectasis with RP-EBUS bilaterally on bronchial segments 6, 9, and 10 after artificial airway insertion (time 1) and 20 to 30 min later (time 2). Chest CT scans were reviewed by a blinded chest radiologist. RP-EBUS images were assessed by three independent, blinded readers. The primary end point was the proportion of patients with any atelectasis (either unilateral or bilateral) at time 2 according to chest CT scan findings. RESULTS Seventy-six patients were analyzed, 38 in each group. The proportion of patients with any atelectasis according to chest CT scan at time 2 was 84.2% (95% CI, 72.6%-95.8%) in the control group and 28.9% (95% CI, 15.4%-45.9%) in the VESPA group (P < .0001). The proportion of patients with bilateral atelectasis at time 2 was 71.1% (95% CI, 56.6%-85.5%) in the control group and 7.9% (95% CI, 1.7%-21.4%) in the VESPA group (P < .0001). At time 2, 3.84 ± 1.67 (mean ± SD) bronchial segments in the control group vs 1.21 ± 1.63 in the VESPA group were deemed atelectatic (P < .0001). No differences were found in the rate of complications. INTERPRETATION VESPA significantly reduced the incidence of atelectasis, was well tolerated, and showed a sustained effect over time despite bronchoscopic nodal staging maneuvers. VESPA should be considered for bronchoscopy when atelectasis is to be avoided. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04311723; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Moiz Salahuddin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mona Sarkiss
- Department of Anesthesia and Peri-Operative MedicineThe University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ala-Eddin S Sagar
- Department of Onco-Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Ioannis Vlahos
- Thoracic Imaging Department, Division of Diagnostic Imaging, Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher H Chang
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Archan Shah
- Department of Onco-Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Bruce F Sabath
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Julie Lin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Teresa Moon
- Department of Anesthesia and Peri-Operative MedicineThe University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peter H Norman
- Department of Anesthesia and Peri-Operative MedicineThe University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Godoy MCB, Truong MT, Jimenez CA, Shroff GS, Vlahos I, Casal RF. Imaging of therapeutic airway interventions in thoracic oncology. Clin Radiol 2021; 77:58-72. [PMID: 34736758 DOI: 10.1016/j.crad.2021.09.012] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/16/2021] [Indexed: 11/17/2022]
Abstract
Tracheobronchial obstruction, haemoptysis, and airway fistulas caused by airway involvement by primary or metastatic malignancies may result in dyspnoea, wheezing, stridor, hypoxaemia, and obstructive atelectasis or pneumonia, and can lead to life-threatening respiratory failure if untreated. Complex minimally invasive endobronchial interventions are being used increasingly to treat cancer patients with tracheobronchial conditions with curative or, most often, palliative intent, to improve symptoms and quality of life. The selection of the appropriate treatment strategy depends on multiple factors, including tumour characteristics, whether the lesion is predominately endobronchial, shows extrinsic compression, or a combination of both, the patient's clinical status, the urgency of the clinical scenario, physician expertise, and availability of tools. Pre-procedure multidetector computed tomography (MDCT) imaging can aid in the most appropriate selection of bronchoscopic treatment. Follow-up imaging is invaluable for the early recognition and management of any potential complication. This article reviews the most commonly used endobronchial procedures in the oncological setting and illustrates the role of MDCT in planning, assisting, and follow-up of endobronchial therapeutic procedures.
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Affiliation(s)
- M C B Godoy
- Department of Thoracic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
| | - M T Truong
- Department of Thoracic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - C A Jimenez
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - G S Shroff
- Department of Thoracic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - I Vlahos
- Department of Thoracic Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - R F Casal
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Lin J, Jimenez CA. Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review. Semin Diagn Pathol 2021; 39:113-119. [PMID: 34176697 DOI: 10.1053/j.semdp.2021.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 11/11/2022]
Abstract
Acute mediastinitis is a rare infection that carries high morbidity and mortality. They are complications seen most often with deep sternal wound infections from surgeries with median sternotomies, oropharyngeal and odontogenic infections and esophageal perforations. These conditions should be promptly recognized and treated. Mediastinal granulomas are focal, mass-like lesions commonly resulting from prior granulomatous infections. They are regarded as benign, self-resolving lesions however can cause complications by compression of adjacent mediastinal structures. Chronic fibrosing mediastinitis is a rare, diffuse fibroinflammatory process most often seen with granulomatous infections and carries a worse prognosis than mediastinal granulomas especially when adjacent mediastinal structures are compromised. In this review, we discuss the epidemiology, etiology, clinical presentation, treatment and prognosis of acute mediastinitis, mediastinal granulomas, and chronic fibrosing mediastinitis.
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Affiliation(s)
- Julie Lin
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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7
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Martinez-Zayas G, Almeida FA, Yarmus L, Steinfort D, Lazarus DR, Simoff MJ, Saettele T, Murgu S, Dammad T, Duong DK, Mudambi L, Filner JJ, Molina S, Aravena C, Thiboutot J, Bonney A, Rueda AM, Debiane LG, Hogarth DK, Bedi H, Deffebach M, Sagar AES, Cicenia J, Yu DH, Cohen A, Frye L, Grosu HB, Gildea T, Feller-Kopman D, Casal RF, Machuzak M, Arain MH, Sethi S, Eapen GA, Lam L, Jimenez CA, Ribeiro M, Noor LZ, Mehta A, Song J, Choi H, Ma J, Li L, Ost DE. Predicting Lymph Node Metastasis in Non-small Cell Lung Cancer: Prospective External and Temporal Validation of the HAL and HOMER Models. Chest 2021; 160:1108-1120. [PMID: 33932466 DOI: 10.1016/j.chest.2021.04.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Two models, the Help with the Assessment of Adenopathy in Lung cancer (HAL) and Help with Oncologic Mediastinal Evaluation for Radiation (HOMER), were recently developed to estimate the probability of nodal disease in patients with non-small cell lung cancer (NSCLC) as determined by endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA). The objective of this study was to prospectively externally validate both models at multiple centers. RESEARCH QUESTION Are the HAL and HOMER models valid across multiple centers? STUDY DESIGN AND METHODS This multicenter prospective observational cohort study enrolled consecutive patients with PET-CT clinical-radiographic stages T1-3, N0-3, M0 NSCLC undergoing EBUS-TBNA staging. HOMER was used to predict the probability of N0 vs N1 vs N2 or N3 (N2|3) disease, and HAL was used to predict the probability of N2|3 (vs N0 or N1) disease. Model discrimination was assessed using the area under the receiver operating characteristics curve (ROC-AUC), and calibration was assessed using the Brier score, calibration plots, and the Hosmer-Lemeshow test. RESULTS Thirteen centers enrolled 1,799 patients. HAL and HOMER demonstrated good discrimination: HAL ROC-AUC = 0.873 (95%CI, 0.856-0.891) and HOMER ROC-AUC = 0.837 (95%CI, 0.814-0.859) for predicting N1 disease or higher (N1|2|3) and 0.876 (95%CI, 0.855-0.897) for predicting N2|3 disease. Brier scores were 0.117 and 0.349, respectively. Calibration plots demonstrated good calibration for both models. For HAL, the difference between forecast and observed probability of N2|3 disease was +0.012; for HOMER, the difference for N1|2|3 was -0.018 and for N2|3 was +0.002. The Hosmer-Lemeshow test was significant for both models (P = .034 and .002), indicating a small but statistically significant calibration error. INTERPRETATION HAL and HOMER demonstrated good discrimination and calibration in multiple centers. Although calibration error was present, the magnitude of the error is small, such that the models are informative.
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Affiliation(s)
- Gabriela Martinez-Zayas
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Daniel Steinfort
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Donald R Lazarus
- Department of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, TX
| | - Michael J Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Timothy Saettele
- Department of Pulmonary Disease and Critical Care Medicine, Saint Luke's Hospital of Kansas City, Kansas City, MO
| | - Septimiu Murgu
- Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Tarek Dammad
- Department of Pulmonary Medicine, University of New Mexico, Albuquerque, NM; Department of Pulmonary and Critical Care Medicine, CHRISTUS St. Vincent Medical Center, Santa Fe, NM
| | - D Kevin Duong
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University Medical Center and School of Medicine, Stanford, CA
| | - Lakshmi Mudambi
- Division of Pulmonary and Critical Care, VA Portland Health Care System, Oregon Health and Science University, Portland, OR
| | - Joshua J Filner
- Department of Pulmonary Medicine, Northwest Permanente and The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Sofia Molina
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos Aravena
- Department of Respiratory Diseases, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Jeffrey Thiboutot
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Asha Bonney
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Adriana M Rueda
- Department of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, TX
| | - Labib G Debiane
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - D Kyle Hogarth
- Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL
| | - Harmeet Bedi
- Department of Pulmonary, Allergy and Critical Care Medicine, Stanford University Medical Center and School of Medicine, Stanford, CA
| | - Mark Deffebach
- Division of Pulmonary and Critical Care, VA Portland Health Care System, Oregon Health and Science University, Portland, OR
| | - Ala-Eddin S Sagar
- Department of Pulmonary Medicine, Banner MD Anderson Cancer Center, Gilbert, AZ
| | - Joseph Cicenia
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Diana H Yu
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Avi Cohen
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Laura Frye
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin, Madison, WI
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas Gildea
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Machuzak
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Muhammad H Arain
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sonali Sethi
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Louis Lam
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Manuel Ribeiro
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Laila Z Noor
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Atul Mehta
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Humberto Choi
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Junsheng Ma
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Sheshadri A, Keus L, Blanco D, Lei X, Kellner C, Shannon VR, Balachandran DD, Jimenez CA, Bashoura L, Faiz SA. Pulmonary Function Testing in Patients with Tracheostomies: Feasibility and Technical Considerations. Lung 2021; 199:307-310. [PMID: 33779802 DOI: 10.1007/s00408-021-00441-x] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/18/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Pulmonary function testing (PFT) in patients with tracheostomies has been perceived as difficult to perform and clinically unreliable. We studied the feasibility, quality, repeatability and clinical significance of PFT. METHODS Patients with tracheostomies that underwent PFT from January 1, 2010 to February 29, 2012 were identified. Clinical history and PFT data were reviewed retrospectively. RESULTS Fifty patients (88% men) were identified. Forty-seven (94%) patients were able to perform PFT. Acceptable repeatability was obtained for FVC in 39 (83%) and for FEV1 in 41 (87%). Patients with tracheostomies showed difficulty in meeting ATS end-of-test criteria; only 9 (19%) met plateau criteria and 25 (53%) had exhalation times of greater than 6 s. Obstructive pattern was observed in 30 (64%) and restrictive pattern in 9 (19%). DLCO measurements were attempted in 43 patients and satisfactorily obtained in 34 (79%). CONCLUSIONS PFT can be performed with reliability in patients with tracheostomies, and they are useful for detecting and classifying types of lung dysfunction.
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Affiliation(s)
- Ajay Sheshadri
- Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Leendert Keus
- Cardiopulmonary Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Blanco
- Cardiopulmonary Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cheryl Kellner
- Cardiopulmonary Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vickie R Shannon
- Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Diwakar D Balachandran
- Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, Unit 1462, The University of Texas MD Anderson Cancer Center, P.O. Box 301402, Houston, TX, 77030-1402, USA.
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9
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Schwalk AJ, Ost DE, Saltijeral SN, De La Garza H, Casal RF, Jimenez CA, Eapen GA, Lewis J, Rinsurongkawong W, Rinsurongkawong V, Lee J, Elamin Y, Zhang J, Roth JA, Swisher S, Heymach JV, Grosu HB. Risk Factors for and Time to Recurrence of Symptomatic Malignant Pleural Effusion in Patients With Metastatic Non-Small Cell Lung Cancer with EGFR or ALK Mutations. Chest 2020; 159:1256-1264. [PMID: 33217413 DOI: 10.1016/j.chest.2020.10.081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/12/2020] [Revised: 09/21/2020] [Accepted: 10/29/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The main goal of management in patients with non-small cell lung cancer (NSCLC) and malignant pleural effusion (MPE) is palliation. Patients with MPE and actionable mutations, because their disease is expected to respond quickly and markedly to targeted therapy, are less likely than those without actionable mutations to receive definitive MPE management. Whether such management is indicated in these patients is unclear. RESEARCH QUESTIONS What is the time to ipsilateral MPE recurrence requiring intervention in patients with metastatic NSCLC by mutation status? What are the risk factors for MPE recurrence? STUDY DESIGN AND METHODS Retrospective cohort study of consecutive patients who underwent initial thoracentesis for MPE. We used a Fine-Gray subdistribution hazard model to calculate the time to ipsilateral MPE recurrence requiring intervention within 100 days of initial thoracentesis and to identify variables associated with time to pleural fluid recurrence. RESULTS A total of 396 patients, comprising 295 (74.5%) without and 101 (25.5%) with actionable mutations, were included. Most patients with actionable mutations (90%) were receiving targeted treatment within 30 days of initial thoracentesis. On univariate analysis, patients with actionable mutations showed a significantly higher hazard of MPE recurrence. On multivariate analysis, this difference was not significant. Larger pleural effusion size on chest radiography (P < .001), higher pleural fluid lactate dehydrogenase (P < .001), and positive cytologic examination results (P = .008) were associated with an increased hazard of recurrence. INTERPRETATION Our findings indicate that patients with actionable mutations have a similar risk of MPE recurrence when compared with patients without mutations and would benefit from a similar definitive management approach to MPE.
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Affiliation(s)
- Audra J Schwalk
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Georgie A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeff Lewis
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Waree Rinsurongkawong
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yasir Elamin
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jianjun Zhang
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen Swisher
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John V Heymach
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Sagar AES, Sabath BF, Eapen GA, Song J, Marcoux M, Sarkiss M, Arain MH, Grosu HB, Ost DE, Jimenez CA, Casal RF. Incidence and Location of Atelectasis Developed During Bronchoscopy Under General Anesthesia: The I-LOCATE Trial. Chest 2020; 158:2658-2666. [PMID: 32561439 DOI: 10.1016/j.chest.2020.05.565] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [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: 02/13/2020] [Revised: 05/25/2020] [Accepted: 05/31/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite the many advances in peripheral bronchoscopy, its diagnostic yield remains suboptimal. With the use of cone-beam CT imaging we have found atelectasis mimicking lung tumors or obscuring them when using radial-probe endobronchial ultrasound (RP-EBUS), but its incidence remains unknown. RESEARCH QUESTION What are the incidence, anatomic location, and risk factors for developing atelectasis during bronchoscopy under general anesthesia? STUDY DESIGN AND METHODS We performed a prospective observational study in which patients undergoing peripheral bronchoscopy under general anesthesia were subject to an atelectasis survey carried out by RP-EBUS under fluoroscopic guidance. The following dependent segments were evaluated: right bronchus 2 (RB2), RB6, RB9, and RB10; and left bronchus 2 (LB2), LB6, LB9, and LB10. Images were categorized either as aerated lung ("snowstorm" pattern) or as having a nonaerated/atelectatic pattern. Categorization was performed by three independent readers. RESULTS Fifty-seven patients were enrolled. The overall intraclass correlation agreement among readers was 0.82 (95% CI, 0.71-0.89). Median time from anesthesia induction to atelectasis survey was 33 min (range, 3-94 min). Fifty-one patients (89%; 95% CI, 78%-96%) had atelectasis in at least one of the eight evaluated segments, 45 patients (79%) had atelectasis in at least three, 41 patients (72%) had atelectasis in at least four, 33 patients (58%) had atelectasis in at least five, and 18 patients (32%) had atelectasis in at least six segments. Right and left B6, B9, and B10 segments showed atelectasis in > 50% of patients. BMI and time to atelectasis survey were associated with increased odds of having more atelectatic segments (BMI: OR, 1.13 per unit change; 95% CI, 1.034-1.235; P = .007; time to survey: OR, 1.064 per minute; 95% CI, 1.025-1.105; P = .001). INTERPRETATION The incidence of atelectasis developing during bronchoscopy under general anesthesia in dependent lung zones is high, and the number of atelectatic segments is greater with higher BMI and with longer time under anesthesia. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT03523689; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Ala-Eddin S Sagar
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bruce F Sabath
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juhee Song
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mathieu Marcoux
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mona Sarkiss
- Department of Anesthesia and Peri-Operative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Muhammad H Arain
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roberto F Casal
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.
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Sagar AES, Landaeta MF, Adrianza AM, Aldana GL, Pozo L, Armas-Villalba A, Toquica CC, Larson AJ, Vial MR, Grosu HB, Ost DE, Eapen GA, Sheshadri A, Morice RC, Shannon VR, Bashoura L, Balachandran DD, Almeida FA, Uzbeck MH, Casal RF, Faiz SA, Jimenez CA. Complications following symptom-limited thoracentesis using suction. Eur Respir J 2020; 56:13993003.02356-2019. [DOI: 10.1183/13993003.02356-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/27/2020] [Indexed: 11/05/2022]
Abstract
BackgroundThoracentesis using suction is perceived to have increased risk of complications, including pneumothorax and re-expansion pulmonary oedema (REPO). Current guidelines recommend limiting drainage to 1.5 L to avoid REPO. Our purpose was to examine the incidence of complications with symptom-limited drainage of pleural fluid using suction and identify risk factors for REPO.MethodsA retrospective cohort study of all adult patients who underwent symptom-limited thoracentesis using suction at our institution between January 1, 2004 and August 31, 2018 was performed, and a total of 10 344 thoracenteses were included.ResultsPleural fluid ≥1.5 L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%) and persistent cough (13%). Pneumothorax based on chest radiography was detected in 3.98%, but only 0.28% required intervention. The incidence of REPO was 0.08%. The incidence of REPO increased with Eastern Cooperative Oncology Group performance status (ECOG PS) ≥3 compounded with ≥1.5 L (0.04–0.54%; 95% CI 0.13–2.06 L). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (p<0.01).ConclusionsSymptom-limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPO are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPO increased with poor ECOG PS and drainage ≥1.5 L. Symptom-limited drainage using suction without pleural manometry is safe.
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Martinez-Zayas G, Almeida FA, Simoff MJ, Yarmus L, Molina S, Young B, Feller-Kopman D, Sagar AES, Gildea T, Debiane LG, Grosu HB, Casal RF, Arain MH, Eapen GA, Jimenez CA, Noor LZ, Baghaie S, Song J, Li L, Ost DE. A Prediction Model to Help with Oncologic Mediastinal Evaluation for Radiation: HOMER. Am J Respir Crit Care Med 2020; 201:212-223. [PMID: 31574238 PMCID: PMC6961739 DOI: 10.1164/rccm.201904-0831oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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] [Indexed: 02/06/2023] Open
Abstract
Rationale: When stereotactic ablative radiotherapy is an option for patients with non–small cell lung cancer (NSCLC), distinguishing between N0, N1, and N2 or N3 (N2|3) disease is important. Objectives: To develop a prediction model for estimating the probability of N0, N1, and N2|3 disease. Methods: Consecutive patients with clinical-radiographic stage T1 to T3, N0 to N3, and M0 NSCLC who underwent endobronchial ultrasound–guided staging from a single center were included. Multivariate ordinal logistic regression analysis was used to predict the presence of N0, N1, or N2|3 disease. Temporal validation used consecutive patients from 3 years later at the same center. External validation used three other hospitals. Measurements and Main Results: In the model development cohort (n = 633), younger age, central location, adenocarcinoma, and higher positron emission tomography–computed tomography nodal stage were associated with a higher probability of having advanced nodal disease. Areas under the receiver operating characteristic curve (AUCs) were 0.84 and 0.86 for predicting N1 or higher (vs. N0) disease and N2|3 (vs. N0 or N1) disease, respectively. Model fit was acceptable (Hosmer-Lemeshow, P = 0.960; Brier score, 0.36). In the temporal validation cohort (n = 473), AUCs were 0.86 and 0.88. Model fit was acceptable (Hosmer-Lemeshow, P = 0.172; Brier score, 0.30). In the external validation cohort (n = 722), AUCs were 0.86 and 0.88 but required calibration (Hosmer-Lemeshow, P < 0.001; Brier score, 0.38). Calibration using the general calibration method resulted in acceptable model fit (Hosmer-Lemeshow, P = 0.094; Brier score, 0.34). Conclusions: This prediction model can estimate the probability of N0, N1, and N2|3 disease in patients with NSCLC. The model has the potential to facilitate decision-making in patients with NSCLC when stereotactic ablative radiotherapy is an option.
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Affiliation(s)
- Gabriela Martinez-Zayas
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico.,Department of Pulmonary Medicine and
| | | | - Michael J Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland; and
| | - Sofia Molina
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico.,Department of Pulmonary Medicine and
| | - Benjamin Young
- Division of Pulmonary and Critical Care Medicine, University Hospitals, Cleveland, Ohio
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland; and
| | | | - Thomas Gildea
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Labib G Debiane
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland; and
| | | | | | | | | | | | | | | | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Styskel BA, Lopez-Mattei J, Jimenez CA, Stewart J, Hagemeister FB, Faiz SA. Ibrutinib-associated Serositis in Mantle Cell Lymphoma. Am J Respir Crit Care Med 2019; 199:e43-e44. [PMID: 30802411 DOI: 10.1164/rccm.201809-1738im] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Brett A Styskel
- 1 Department of Internal Medicine, Baylor College of Medicine, Houston, Texas; and
| | | | | | | | - Fredrick B Hagemeister
- 5 Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Affiliation(s)
| | | | | | | | - Jorge E Cortes
- 2 Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Coral-Casas J, Ricaurte-Fajardo A, McCormick SJ, Baracaldo I, Jimenez CA, Mejia JA. [Reversible cerebral vasoconstriction syndrome associated with anastrozole: an unusual cause of high impact]. Rev Neurol 2019; 68:250-254. [PMID: 30855709 DOI: 10.33588/rn.6806.2018373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Reversible cerebral vasoconstriction syndrome (RCVS) is a low incidence disability with a multifactorial etiology and a wide array of symptoms. The main symptom is a thunderclap headache, accompanied sometimes with various neurological deficits that can lead to death. RCVS is usually diagnosed through radiological imaging technology. The treatment includes adopting general measures of monitoring, symptomatic management, identifying the etiology and acting on it to avoid recurrence. CASE REPORT A 71-year-old woman with a history of breast cancer originally treated with tamoxifen. Due to urticaria, the anastrozole management was staggered. She was admitted for aphasia, drowsiness and a thunderclap headache. The patient reported a similar event two weeks prior admission. In brain resonance, there was evidence of small sub-arachnoidal haemorrhage (SAH) of the left parietal temporal convexity and cerebral angiography. As well as documented vasospasm in the posterior parietal region confirming the diagnosis of RCVS plus SAH. During the stay, she presented three events with the same characteristics, requiring intensive monitoring and two therapeutic panangiographies with intra-arterial nimodipine with subsequent resolution of the vessel spasm. The patient remains asymptomatic six months later. CONCLUSION RCVS is difficult to diagnose given its wide array of symptoms and multifactorial etiology. In this case, RCVS plus SAH is associated with the use of anastrozole. So far there are no reported cases of aromatase inhibitors associated with this pathology and should be reported in the literature for pharmacovigilance.
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Affiliation(s)
- J Coral-Casas
- Pontificia Universidad Javeriana, Bogota DC, Colombia
| | | | - S J McCormick
- Pontificia Universidad Javeriana, Bogota DC, Colombia
| | - I Baracaldo
- Pontificia Universidad Javeriana, Bogota DC, Colombia
| | - C A Jimenez
- Pontificia Universidad Javeriana, Bogota DC, Colombia
| | - J A Mejia
- Pontificia Universidad Javeriana, Bogota DC, Colombia
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Casal RF, Sepesi B, Sagar AES, Tschirren J, Chen M, Li L, Sunny J, Williams J, Grosu HB, Eapen GA, Jimenez CA, Ost DE. Centrally located lung cancer and risk of occult nodal disease: an objective evaluation of multiple definitions of tumour centrality with dedicated imaging software. Eur Respir J 2019; 53:13993003.02220-2018. [DOI: 10.1183/13993003.02220-2018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/08/2019] [Indexed: 12/25/2022]
Abstract
IntroductionCurrent guidelines recommend invasive mediastinal staging in patients with centrally located radiographic stage T1N0M0 nonsmall cell lung cancer (NSCLC). The lack of a specific definition of a central tumour has resulted in discrepancies among guidelines and heterogeneity in practice patterns.MethodsOur objective was to study specific definitions of tumour centrality and their association with occult nodal disease. Pre-operative chest computed tomography scans from patients with clinical (c) T1N0M0 NSCLC were processed with a dedicated software system that divides the lungs in thirds following vertical and concentric lines. This software accurately assigns tumours to a specific third based both on the location of the centre of the tumour and its most medial aspect, creating eight possible definitions of central tumours.Results607 patients were included in our study. Surgery was performed for 596 tumours (98%). The overall pathological (p) N disease was: 504 (83%) N0, 56 (9%) N1, 47 (8%) N2 and no N3. The prevalence of N2 disease remained relatively low regardless of tumour location. Central tumours were associated with upstaging from cN0 to any N (pN1/pN2). Two definitions were associated with upstaging to any N: concentric lines, inner one-third, centre of the tumour (OR 3.91, 95% CI 1.85–8.26; p<0.001) and concentric lines, inner two-thirds, most medial aspect of the tumour (OR 1.91, 95% CI 1.23–2.97; p=0.004).ConclusionsWe objectively identified two specific definitions of central tumours. While the rate of occult mediastinal disease was relatively low regardless of tumour location, central tumours were associated with upstaging from cN0 to any N.
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Casal RF, Sarkiss M, Jones AK, Stewart J, Tam A, Grosu HB, Ost DE, Jimenez CA, Eapen GA. Cone beam computed tomography-guided thin/ultrathin bronchoscopy for diagnosis of peripheral lung nodules: a prospective pilot study. J Thorac Dis 2018; 10:6950-6959. [PMID: 30746241 DOI: 10.21037/jtd.2018.11.21] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Despite advances in bronchoscopy, its diagnostic yield for peripheral lung lesions continues to be suboptimal. Cone beam computed tomography (CBCT) could be utilized to corroborate the accuracy of our bronchoscopic navigation and hopefully increase its diagnostic yield. However, data on radiation exposure and feasibility of CBCT-guided bronchoscopy is scarce. Methods Prospective pilot study of bronchoscopy for peripheral lung nodules under general anesthesia with thin/ultrathin bronchoscope, radial-probe endobronchial ultrasound (RP-EBUS), and CBCT. Main objective was to estimate radiation dose and secondary objective was the additional value of CBCT in terms of navigational and diagnostic yield. Results A total of 20 patients were enrolled. Median lesion size was 2.1 (range, 1.1-3) cm and distance from pleura was 2.1 (range, 0-2.8) cm. "Bronchus sign" was present in 12 (60%) of the lesions. Totally, 12 lesions (60%) were invisible on fluoroscopy. CBCT identified atelectasis obscuring the target in 4 cases (20%). Eleven patients (55%) underwent 1 CBCT scan and 9 patients (45%) 2. The mean estimated effective dose (E) to patients resulting from CBCT ranged between 8.6 and 23 mSv, depending on utilized conversion factors. Both pre-CBCT navigation and diagnostic yield were 50%. Additional post-CBCT maneuvers increased navigation yield to 75% (P=0.02) and diagnostic yield to 70% (P=0.04). One patient developed a pneumothorax. Conclusions CBCT-guided bronchoscopy is associated with an acceptable radiation dose. CBCT may potentially increase both navigation and diagnostic yield of thin/ultrathin bronchoscopy for peripheral lung nodules. The above findings as well as the incidental but relevant finding of intra-procedural atelectasis need to be confirmed in larger prospective studies. Trial registration This study is registered in ClinicalTrials.gov as number NCT02978170.
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Affiliation(s)
- Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mona Sarkiss
- Department of Anesthesiology and Preoperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aaron K Jones
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - John Stewart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alda Tam
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Ong P, Grosu HB, Debiane L, Casal RF, Eapen GA, Jimenez CA, Noor L, Ost DE. Long-term quality-adjusted survival following therapeutic bronchoscopy for malignant central airway obstruction. Thorax 2018; 74:141-156. [DOI: 10.1136/thoraxjnl-2018-211521] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 08/28/2018] [Accepted: 09/03/2018] [Indexed: 01/04/2023]
Abstract
BackgroundWhile therapeutic bronchoscopy has been used to treat malignant central (CAO) airway obstruction for >25 years, there are no studies quantifying the impact of therapeutic bronchoscopy on long-term quality-adjusted survival.MethodsWe conducted a prospective observational study of consecutive patients undergoing therapeutic bronchoscopy for CAO. Patients had follow-up at 1 week and monthly thereafter until death. Outcomes included technical success (ie, relief of anatomic obstruction), dyspnoea, health-related quality of life (HRQOL) and quality-adjusted survival.ResultsTherapeutic bronchoscopy was performed on 102 patients with malignant CAO. Partial or complete technical success was achieved in 90% of patients. At 7 days postbronchoscopy, dyspnoea improved (mean ∆Borg-day-7=−1.8, 95% CI −2.2 to −1.3, p<0.0001) and HRQOL improved (median prebronchoscopy 0.618 utiles, 25%–75% IQR 0.569 to 0.699, mean ∆utility-day-7+0.047 utiles, 95% CI +0.023 to 0.071, p=0.0002). Improvements in dyspnoea and HRQOL were maintained long-term. Compared with the prebronchoscopy baseline, HRQOL per day of life postbronchoscopy improved (mean ∆utility-long-term+0.036 utiles, 95% CI +0.014 to 0.057, p=0.002). Median quality-adjusted survival was 109 quality-adjusted life-days (QALDs) (95% CI 74 to 201 QALDs). Factors associated with longer quality-adjusted survival included better functional status, treatment-naïve tumour, endobronchial disease, less dyspnoea, shorter time from diagnosis to bronchoscopy, absence of cardiac disease, bronchoscopic dilation and receiving chemotherapy.ConclusionsTherapeutic bronchoscopy improves HRQOL as compared with baseline, resulting in approximately a 5.8% improvement in HRQOL per day of life. The risk-benefit profile in these carefully selected patients was very favourable.Trial registration numberResults; NCT03326570.
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Aldana G, Jimenez CA, Moran C. Unusual cause of sinusitis and cough. BMJ Case Rep 2018; 2018:bcr-2018-225829. [PMID: 30030254 PMCID: PMC6058159 DOI: 10.1136/bcr-2018-225829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Grecia Aldana
- Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos A Jimenez
- Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Cesar Moran
- Pathology Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Navarro EP, Posso-Osorio I, Naranjo-Escobar J, Moncada PA, Jimenez CA, Tobón GJ. Adult onset still’s disease and pigment cast nephropathytriggered by Chikungunya virus. J Nephropathol 2018. [DOI: 10.15171/jnp.2019.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Implication for health policy/practice/research/medical education: Despite Chikungunya virus was considered a benign illness, it is very important to recall thatsevere atypical manifestations can occur generating high morbidity rates. Early detection ofthese complications may help clinicians to improve clinical outcomes.
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Affiliation(s)
- Erika-Paola Navarro
- GIRAT: Grupo de investigación en Reumatología, Autoinmunidad y Medicina Traslational, Universidad Icesi, Fundación Valle del Lili, Cali, Colombia
| | - Iván Posso-Osorio
- GIRAT: Grupo de investigación en Reumatología, Autoinmunidad y Medicina Traslational, Universidad Icesi, Fundación Valle del Lili, Cali, Colombia
| | - Juan Naranjo-Escobar
- GIRAT: Grupo de investigación en Reumatología, Autoinmunidad y Medicina Traslational, Universidad Icesi, Fundación Valle del Lili, Cali, Colombia
| | | | | | - Gabriel J. Tobón
- GIRAT: Grupo de investigación en Reumatología, Autoinmunidad y Medicina Traslational, Universidad Icesi, Fundación Valle del Lili, Cali, Colombia
- Laboratory of Immunology, Fundación Valle Del Lili, Cali, Colombia
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Sagar AES, Jimenez CA, Shannon VR. Clinical and Histopathologic Correlates and Management Strategies for Inflammatory Myofibroblastic tumor of the lung. A case series and review of the literature. Med Oncol 2018; 35:102. [PMID: 29869302 DOI: 10.1007/s12032-018-1161-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 05/11/2018] [Accepted: 05/30/2018] [Indexed: 11/29/2022]
Abstract
Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm that may arise in soft tissues of nearly every organ. Although IMTs are the most common lung tumors in pediatric populations, these tumors are extremely rare in adults, constituting less than 1% of adult lung tumors. IMTs are characterized by proliferating spindle cells with variable inflammatory component. The biological behavior of lung IMTs in adults is highly unpredictable, which confounds diagnosis and treatment. We retrospectively investigated patients with pulmonary lesions and the histopathologic diagnosis of inflammatory myofibroblastic tumor or its synonymous names (Plasma Cell Granuloma, xanthogranuloma, inflammatory pseudotumor, fibroxanthoma, and fibrous histiocytoma) at the MD Anderson Cancer Institute in the period between August 2000 and August 2016. We describe 7 adult cases of IMT of the lung that were diagnosed at MD Anderson Cancer Center. These cases highlight the tumor's variability in terms of clinical presentation, histopathology, and biologic behavior, and underscore the challenges in the management of these rare lung neoplasms.
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Affiliation(s)
- Ala Eddin S Sagar
- Department of Pulmonary Medicine, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Vickie R Shannon
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
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22
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Abstract
Ethylene glycol toxicity is a known cause of anion gap metabolic acidosis, with the presence of an osmolar gap and the right clinical context suggesting to the diagnosis. Rapid recognition and early treatment is crucial. Unfortunately, ethylene glycol levels are not readily available and must be performed at a reference laboratory. We present a case where recognising the significance of the 'lactate gap' assisted in identifying ethylene glycol poisoning.
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Affiliation(s)
- A S Sagar
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Brandy J Mckelvy
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Affiliation(s)
- Ala-Eddin S Sagar
- Pulmonary, Critical Care and Sleep Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Erik Vakil
- Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos A Jimenez
- Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Reeba Mathew
- Pulmonary, Critical Care and Sleep Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
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24
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Landaeta M, Vial M, Jimenez CA, Debiane LG. Allergic bronchopulmonary mycosis presenting as a new lung mass. BMJ Case Rep 2017; 2017:bcr-2017-221591. [PMID: 29025778 DOI: 10.1136/bcr-2017-221591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Maria Landaeta
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Macarena Vial
- Pulmonary Department, Clinica Alemana de Santiago SA, Vitacura, Metropolitan Region, Chile
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Labib Gilles Debiane
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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25
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Vial MR, O'Connell OJ, Grosu HB, Hernandez M, Noor L, Casal RF, Stewart J, Sarkiss M, Jimenez CA, Rice D, Mehran R, Ost DE, Eapen GA. Diagnostic performance of endobronchial ultrasound-guided mediastinal lymph node sampling in early stage non-small cell lung cancer: A prospective study. Respirology 2017; 23:76-81. [PMID: 28857362 DOI: 10.1111/resp.13162] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [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: 11/02/2016] [Revised: 05/22/2017] [Accepted: 06/09/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Standard nodal staging of lung cancer consists of positron emission tomography/computed tomography (PET/CT), followed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) if PET/CT shows mediastinal lymphadenopathy. Sensitivity of EBUS-TBNA in patients with N0/N1 disease by PET/CT is unclear and largely based on retrospective studies. We assessed the sensitivity of EBUS-TBNA in this setting. METHODS We enrolled patients with proven or suspected lung cancer staged as N0/N1 by PET/CT and without metastatic disease (M0), who underwent staging EBUS-TBNA. Primary outcome was sensitivity of EBUS-TBNA compared with a composite reference standard of surgical stage or EBUS-TBNA stage if EBUS demonstrated N2/N3 disease. RESULTS Seventy-five patients were included in the analysis. Mean tumour size was 3.52 cm (±1.63). Fifteen of 75 patients (20%) had N2 disease. EBUS-TBNA identified six while nine were only identified at surgery. Sensitivity of EBUS-TBNA for N2 disease was 40% (95% CI: 16.3-67.7%). CONCLUSION A significant proportion of patients with N0/N1 disease by PET/CT had N2 disease (20%) and EBUS-TBNA identified a substantial fraction of these patients, thus improving diagnostic accuracy compared with PET/CT alone. Sensitivity of EBUS-TBNA however appears lower compared with historical data from patients with larger volume mediastinal disease. Therefore, strategies to improve EBUS-TBNA accuracy in this population should be further explored.
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Affiliation(s)
- Macarena R Vial
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Pulmonary Medicine, Interventional Pulmonology Unit, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Oisin J O'Connell
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mike Hernandez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laila Noor
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Pulmonary and Critical Care Medicine, Michael E. DeBakey Veterans Affairs, Baylor College of Medicine, Houston, TX, USA
| | - John Stewart
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mona Sarkiss
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Rice
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Reza Mehran
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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26
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O'Connell OJ, Almeida FA, Simoff MJ, Yarmus L, Lazarus R, Young B, Chen Y, Semaan R, Saettele TM, Cicenia J, Bedi H, Kliment C, Li L, Sethi S, Diaz-Mendoza J, Feller-Kopman D, Song J, Gildea T, Lee H, Grosu HB, Machuzak M, Rodriguez-Vial M, Eapen GA, Jimenez CA, Casal RF, Ost DE. A Prediction Model to Help with the Assessment of Adenopathy in Lung Cancer: HAL. Am J Respir Crit Care Med 2017; 195:1651-1660. [PMID: 28002683 DOI: 10.1164/rccm.201607-1397oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
RATIONALE Estimating the probability of finding N2 or N3 (prN2/3) malignant nodal disease on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with non-small cell lung cancer (NSCLC) can facilitate the selection of subsequent management strategies. OBJECTIVES To develop a clinical prediction model for estimating the prN2/3. METHODS We used the AQuIRE (American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education) registry to identify patients with NSCLC with clinical radiographic stage T1-3, N0-3, M0 disease that had EBUS-TBNA for staging. The dependent variable was the presence of N2 or N3 disease (vs. N0 or N1) as assessed by EBUS-TBNA. Univariate followed by multivariable logistic regression analysis was used to develop a parsimonious clinical prediction model to estimate prN2/3. External validation was performed using data from three other hospitals. MEASUREMENTS AND MAIN RESULTS The model derivation cohort (n = 633) had a 25% prevalence of malignant N2 or N3 disease. Younger age, central location, adenocarcinoma histology, and higher positron emission tomography-computed tomography N stage were associated with a higher prN2/3. Area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.82-0.89), model fit was acceptable (Hosmer-Lemeshow, P = 0.62; Brier score, 0.125). We externally validated the model in 722 patients. Area under the receiver operating characteristic curve was 0.88 (95% confidence interval, 0.85-0.90). Calibration using the general calibration model method resulted in acceptable goodness of fit (Hosmer-Lemeshow test, P = 0.54; Brier score, 0.132). CONCLUSIONS Our prediction rule can be used to estimate prN2/3 in patients with NSCLC. The model has the potential to facilitate clinical decision making in the staging of NSCLC.
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Affiliation(s)
| | | | - Michael J Simoff
- 3 Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan; and
| | - Lonny Yarmus
- 4 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Benjamin Young
- 2 Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Yu Chen
- 3 Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan; and
| | - Roy Semaan
- 3 Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan; and
| | | | - Joseph Cicenia
- 2 Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Harmeet Bedi
- 3 Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan; and
| | - Corrine Kliment
- 4 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Liang Li
- 5 Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas
| | - Sonali Sethi
- 2 Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Javier Diaz-Mendoza
- 3 Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan; and
| | - David Feller-Kopman
- 4 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Juhee Song
- 5 Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas
| | - Thomas Gildea
- 2 Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Hans Lee
- 4 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Michael Machuzak
- 2 Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
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27
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Vial MR, Stewart J, Lazarus DR, Eapen GA, Ost DE, Grosu HB, Jimenez CA. Unusual aetiology of a hilar mass in a man with history of thyroid cancer. Thorax 2016; 71:1167-1168. [PMID: 27422794 DOI: 10.1136/thoraxjnl-2016-208748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/26/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Macarena R Vial
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.,Department of Pulmonary Medicine, Universidad del Desarrollo, Clínica Alemana de Santiago, Chile
| | - John Stewart
- Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Donald R Lazarus
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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28
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Vial MR, O'Connell JO, Grosu HB, Ost DE, Eapen GA, Jimenez CA. Needle Fracture during Endobronchial Ultrasound-guided Transbronchial Needle Aspiration. Am J Respir Crit Care Med 2016; 193:213-4. [PMID: 26378480 DOI: 10.1164/rccm.201507-1430im] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Macarena R Vial
- 1 Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and.,2 Department of Pulmonary Medicine, Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - John O O'Connell
- 1 Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Horiana B Grosu
- 1 Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - David E Ost
- 1 Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - George A Eapen
- 1 Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
| | - Carlos A Jimenez
- 1 Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas; and
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29
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Ost DE, Ernst A, Lei X, Kovitz KL, Benzaquen S, Diaz-Mendoza J, Greenhill S, Toth J, Feller-Kopman D, Puchalski J, Baram D, Karunakara R, Jimenez CA, Filner JJ, Morice RC, Eapen GA, Michaud GC, Estrada-Y-Martin RM, Rafeq S, Grosu HB, Ray C, Gilbert CR, Yarmus LB, Simoff M. Diagnostic Yield and Complications of Bronchoscopy for Peripheral Lung Lesions. Results of the AQuIRE Registry. Am J Respir Crit Care Med 2016; 193:68-77. [PMID: 26367186 DOI: 10.1164/rccm.201507-1332oc] [Citation(s) in RCA: 306] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE Advanced bronchoscopy techniques such as electromagnetic navigation (EMN) have been studied in clinical trials, but there are no randomized studies comparing EMN with standard bronchoscopy. OBJECTIVES To measure and identify the determinants of diagnostic yield for bronchoscopy in patients with peripheral lung lesions. Secondary outcomes included diagnostic yield of different sampling techniques, complications, and practice pattern variations. METHODS We used the AQuIRE (ACCP Quality Improvement Registry, Evaluation, and Education) registry to conduct a multicenter study of consecutive patients who underwent transbronchial biopsy (TBBx) for evaluation of peripheral lesions. MEASUREMENTS AND MAIN RESULTS Fifteen centers with 22 physicians enrolled 581 patients. Of the 581 patients, 312 (53.7%) had a diagnostic bronchoscopy. Unadjusted for other factors, the diagnostic yield was 63.7% when no radial endobronchial ultrasound (r-EBUS) and no EMN were used, 57.0% with r-EBUS alone, 38.5% with EMN alone, and 47.1% with EMN combined with r-EBUS. In multivariate analysis, peripheral transbronchial needle aspiration (TBNA), larger lesion size, nonupper lobe location, and tobacco use were associated with increased diagnostic yield, whereas EMN was associated with lower diagnostic yield. Peripheral TBNA was used in 16.4% of cases. TBNA was diagnostic, whereas TBBx was nondiagnostic in 9.5% of cases in which both were performed. Complications occurred in 13 (2.2%) patients, and pneumothorax occurred in 10 (1.7%) patients. There were significant differences between centers and physicians in terms of case selection, sampling methods, and anesthesia. Medical center diagnostic yields ranged from 33 to 73% (P = 0.16). CONCLUSIONS Peripheral TBNA improved diagnostic yield for peripheral lesions but was underused. The diagnostic yields of EMN and r-EBUS were lower than expected, even after adjustment.
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Affiliation(s)
| | - Armin Ernst
- 2 Department of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Boston, Massachusetts
| | - Xiudong Lei
- 3 Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Sadia Benzaquen
- 5 University Hospital of Cincinnati Veteran Affairs Medical Center, Cincinnati, Ohio
| | | | | | - Jennifer Toth
- 7 Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Daniel Baram
- 10 Mather Memorial Hospital, Port Jefferson, New York
| | | | | | | | | | | | | | - Rosa M Estrada-Y-Martin
- 13 Lyndon B. Johnson Hospital-The University of Texas Health Science Center Houston, Houston, Texas
| | - Samaan Rafeq
- 2 Department of Pulmonary and Critical Care Medicine, St. Elizabeth's Medical Center, Boston, Massachusetts
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30
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Nigo M, Vial MR, Munita JM, Jiang Y, Tarrand J, Jimenez CA, Kontoyiannis DP. Fungal empyema thoracis in cancer patients. J Infect 2016; 72:615-21. [PMID: 26945845 DOI: 10.1016/j.jinf.2016.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 11/17/2015] [Revised: 02/19/2016] [Accepted: 02/25/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Fungal empyema thoracis (FET) is a rare life-threatening infection. We sought to describe the clinical characteristics of FET in a large academic cancer center. METHODS We conducted a retrospective chart review of all cancer patients who had a fungal isolate from the pleural fluid culture between 1/2005 and 8/2013. RESULTS A total of 106 fungal isolates were identified in 97 patients. Yeasts accounted for 62% of the isolates whereas 38% were identified as molds. The most frequent pathogens were Candida spp. (58%) and Aspergillus spp. (12%). All patients with Aspergillus and 83% with Candida met criteria for proven fungal disease. Compared to the Aspergillus group, Candida FET was associated with recent abdominal or thoracic surgical procedures (44% vs. 0%, p = 0.01). Overall, 6-week mortality was high, with no significant differences between Candida and Aspergillus (31% vs. 45%, respectively [p = 0.48]). Only 1 out of 11 patients with uncommon molds died at 6 weeks, despite only 2 of them received appropriate antifungal therapy. CONCLUSIONS Development of FET carries a high mortality in cancer patients. A history of a recent surgical procedure is a risk factor for FET due to Candida. Isolation of uncommon molds is likely to represent a contamination of the pleural fluid.
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Affiliation(s)
- Masayuki Nigo
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
| | - Macarena R Vial
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile; Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose M Munita
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA; Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Tarrand
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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31
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Ost DE, Ernst A, Grosu HB, Lei X, Diaz-Mendoza J, Slade M, Gildea TR, Machuzak M, Jimenez CA, Toth J, Kovitz KL, Ray C, Greenhill S, Casal RF, Almeida FA, Wahidi M, Eapen GA, Yarmus LB, Morice RC, Benzaquen S, Tremblay A, Simoff M. Complications Following Therapeutic Bronchoscopy for Malignant Central Airway Obstruction: Results of the AQuIRE Registry. Chest 2015; 148:450-471. [PMID: 25741903 DOI: 10.1378/chest.14-1530] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There are significant variations in how therapeutic bronchoscopy for malignant airway obstruction is performed. Relatively few studies have compared how these approaches affect the incidence of complications. METHODS We used the American College of Chest Physicians (CHEST) Quality Improvement Registry, Evaluation, and Education (AQuIRE) program registry to conduct a multicenter study of patients undergoing therapeutic bronchoscopy for malignant central airway obstruction. The primary outcome was the incidence of complications. Secondary outcomes were incidence of bleeding, hypoxemia, respiratory failure, adverse events, escalation in level of care, and 30-day mortality. RESULTS Fifteen centers performed 1,115 procedures on 947 patients. There were significant differences among centers in the type of anesthesia (moderate vs deep or general anesthesia, P < .001), use of rigid bronchoscopy (P < .001), type of ventilation (jet vs volume cycled, P < .001), and frequency of stent use (P < .001). The overall complication rate was 3.9%, but significant variation was found among centers (range, 0.9%-11.7%; P = .002). Risk factors for complications were urgent and emergent procedures, American Society of Anesthesiologists (ASA) score > 3, redo therapeutic bronchoscopy, and moderate sedation. The 30-day mortality was 14.8%; mortality varied among centers (range, 7.7%-20.2%, P = .02). Risk factors for 30-day mortality included Zubrod score > 1, ASA score > 3, intrinsic or mixed obstruction, and stent placement. CONCLUSIONS Use of moderate sedation and stents varies significantly among centers. These factors are associated with increased complications and 30-day mortality, respectively.
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Affiliation(s)
- David E Ost
- Pulmonary Department (Drs Ost, Grosu, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | | | - Horiana B Grosu
- Pulmonary Department (Drs Ost, Grosu, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiudong Lei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javier Diaz-Mendoza
- The Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Mark Slade
- Department of Thoracic Oncology, Papworth Hospital, Cambridge, England
| | - Thomas R Gildea
- Department of Pulmonary, Allergy, and Critical Care, Cleveland Clinic Foundation, Cleveland, OH
| | - Michael Machuzak
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Carlos A Jimenez
- Pulmonary Department (Drs Ost, Grosu, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Kevin L Kovitz
- University of Illinois Hospital & Health Sciences Center, Chicago, IL
| | - Cynthia Ray
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Sara Greenhill
- Chicago Chest Center Interventional Pulmonology, Elk Grove Village, IL
| | - Roberto F Casal
- Department of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, TX
| | - Francisco A Almeida
- Department of Pulmonary, Allergy, and Critical Care, Cleveland Clinic Foundation, Cleveland, OH
| | - Momen Wahidi
- Department of Internal Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Raleigh, NC
| | - George A Eapen
- Pulmonary Department (Drs Ost, Grosu, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Rodolfo C Morice
- Pulmonary Department (Drs Ost, Grosu, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sadia Benzaquen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH
| | - Alain Tremblay
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael Simoff
- The Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
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32
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Grosu HB, Morice RC, Sarkiss M, Bashoura L, Eapen GA, Jimenez CA, Faiz S, Lazarus DR, Casal RF, Ost DE. Safety of flexible bronchoscopy, rigid bronchoscopy, and endobronchial ultrasound-guided transbronchial needle aspiration in patients with malignant space-occupying brain lesions. Chest 2015; 147:1621-1628. [PMID: 25393333 DOI: 10.1378/chest.14-1704] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Bronchoscopy in patients with space-occupying brain lesions is anecdotally felt to carry a high risk of neurologic complications. METHODS We conducted a retrospective cohort study of patients with evidence of a malignant, space-occupying brain lesion who were referred for flexible or rigid bronchoscopy or endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The primary outcome of interest was the incidence of neurologic complications following the procedures in these patients. RESULTS Of the 103 enrolled patients, flexible bronchoscopy was performed in 41, rigid bronchoscopy in 12, and EBUS-TBNA in 50. Among these patients, 41 (40%) had evidence suggestive of increased intracranial pressure on imaging. Among all study patients, none (95% CI, 0-0.035) had neurologic, procedure-specific, or sedation-specific complications, and the level of care was not escalated in any of these patients. CONCLUSIONS On the basis of our findings, we recommend that procedures such as flexible or rigid bronchoscopy or EBUS-TBNA in patients with malignant space-occupying brain lesions should be considered reasonably safe as long as neurologic findings are stable.
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Affiliation(s)
- Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center.
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - Mona Sarkiss
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | - Saadia Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
| | | | - Roberto F Casal
- Department of Pulmonary Medicine, Michael DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center
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Ost DE, Ernst A, Grosu HB, Lei X, Diaz-Mendoza J, Slade M, Gildea TR, Machuzak MS, Jimenez CA, Toth J, Kovitz KL, Ray C, Greenhill S, Casal RF, Almeida FA, Wahidi MM, Eapen GA, Feller-Kopman D, Morice RC, Benzaquen S, Tremblay A, Simoff M. Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life. Chest 2015; 147:1282-1298. [PMID: 25358019 DOI: 10.1378/chest.14-1526] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is significant variation between physicians in terms of how they perform therapeutic bronchoscopy, but there are few data on whether these differences impact effectiveness. METHODS This was a multicenter registry study of patients undergoing therapeutic bronchoscopy for malignant central airway obstruction. The primary outcome was technical success, defined as reopening the airway lumen to > 50% of normal. Secondary outcomes were dyspnea as measured by the Borg score and health-related quality of life (HRQOL) as measured by the SF-6D. RESULTS Fifteen centers performed 1,115 procedures on 947 patients. Technical success was achieved in 93% of procedures. Center success rates ranged from 90% to 98% (P = .02). Endobronchial obstruction and stent placement were associated with success, whereas American Society of Anesthesiology (ASA) score > 3, renal failure, primary lung cancer, left mainstem disease, and tracheoesophageal fistula were associated with failure. Clinically significant improvements in dyspnea occurred in 90 of 187 patients measured (48%). Greater baseline dyspnea was associated with greater improvements in dyspnea, whereas smoking, having multiple cancers, and lobar obstruction were associated with smaller improvements. Clinically significant improvements in HRQOL occurred in 76 of 183 patients measured (42%). Greater baseline dyspnea was associated with greater improvements in HRQOL, and lobar obstruction was associated with smaller improvements. CONCLUSIONS Technical success rates were high overall, with the highest success rates associated with stent placement and endobronchial obstruction. Therapeutic bronchoscopy should not be withheld from patients based solely on an assessment of risk, since patients with the most dyspnea and lowest functional status benefitted the most.
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Affiliation(s)
- David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | | | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xiudong Lei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javier Diaz-Mendoza
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Mark Slade
- Department of Thoracic Oncology, Papworth Hospital, Cambridge, England
| | - Thomas R Gildea
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Kevin L Kovitz
- University of Illinois Hospital and Health Sciences Center, Chicago, IL
| | - Cynthia Ray
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Sara Greenhill
- Department of Pulmonary and Critical Care Medicine, Boston University, Boston, MA; Department of Interventional Pulmonology, Chicago Chest Center, Chicago, IL
| | - Roberto F Casal
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | | | - Momen M Wahidi
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Feller-Kopman
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sadia Benzaquen
- Department of Pulmonary and Critical Care, Baylor College of Medicine, Houston, TX; Department of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH
| | - Alain Tremblay
- Department of Pulmonary and Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael Simoff
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Reddy SM, Kopetz S, Morris J, Parikh N, Qiao W, Overman MJ, Fogelman D, Shureiqi I, Jacobs C, Malik Z, Jimenez CA, Wolff RA, Abbruzzese JL, Gallick G, Eng C. Phase II study of saracatinib (AZD0530) in patients with previously treated metastatic colorectal cancer. Invest New Drugs 2015; 33:977-84. [PMID: 26062928 DOI: 10.1007/s10637-015-0257-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/02/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Src has a critical role in tumor cell migration and invasion. Increased Src activity has been shown to correlate with disease progression and poor prognosis, suggesting Src could serve as a therapeutic target for kinase inhibition. Saracatinib (AZD0530) is a novel selective oral Src kinase inhibitor. METHODS Metastatic colorectal cancer patients who had received one prior treatment and had measurable disease were enrolled in this phase 2 study. Saracatinib was administered at 175 mg by mouth daily for 28 day cycles until dose-limiting toxicity or progression as determined by staging every 2 cycles. The primary endpoint was improvement in 4 month progression-free survival. Design of Thall, Simon, and Estey was used to monitor proportion of patients that were progression free at 4 months. The trial was opened with plan to enroll maximum of 35 patients, with futility assessment every 10 patients. RESULTS A total of 10 patients were enrolled between January and November 2007. Further enrollment was stopped due to futility. Median progression-free survival was 7.9 weeks, with all 10 patients showing disease progression following radiographic imaging. Median overall survival was 13.5 months. All patients were deceased by time of analysis. Observed adverse events were notable for a higher than expected number of patients with grade 3 hypophosphatemia (n = 5). CONCLUSION Saracatinib is a novel oral Src kinase inhibitor that was well tolerated but failed to meet its primary endpoint of improvement in 4 month progression-free survival as a single agent in previously treated metastatic colorectal cancer patients.
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Affiliation(s)
- S M Reddy
- Hematology-Oncology Fellow, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 463, Houston, TX, 77030, USA,
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Casal RF, Lazarus DR, Kuhl K, Nogueras-González G, Perusich S, Green LK, Ost DE, Sarkiss M, Jimenez CA, Eapen GA, Morice RC, Cornwell L, Austria S, Sharafkanneh A, Rumbaut RE, Grosu H, Kheradmand F. Randomized trial of endobronchial ultrasound-guided transbronchial needle aspiration under general anesthesia versus moderate sedation. Am J Respir Crit Care Med 2015; 191:796-803. [PMID: 25574801 PMCID: PMC4407485 DOI: 10.1164/rccm.201409-1615oc] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 12/30/2014] [Indexed: 12/25/2022] Open
Abstract
RATIONALE Data about the influence of the type of sedation on yield, complications, and tolerance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are based mostly on retrospective studies and are largely inconsistent. OBJECTIVES To determine whether the type of sedation influences the diagnostic yield of EBUS-TBNA, its complication rates, and patient tolerance. METHODS Patients referred for EBUS-TBNA were randomized (1:1) to undergo this procedure under general anesthesia (GA) or moderate sedation (MS). Pathologists were blinded to group allocation. MEASUREMENTS AND MAIN RESULTS The main outcome was "diagnostic yield," defined as the percentage of patients for whom EBUS-TBNA rendered a specific diagnosis. One hundred and forty-nine patients underwent EBUS-TBNA, 75 under GA and 74 under MS. Demographic and baseline clinical characteristics were well balanced. Two hundred and thirty-six lymph nodes (LNs) and six masses were sampled in the GA group (average, 3.2 ± 1.9 sites/patient), and 200 LNs and six masses in the MS group (average, 2.8 ± 1.5 sites/patient) (P = 0.199). The diagnostic yield was 70.7% (53 of 75) and 68.9% (51 of 74) for the GA group and MS group, respectively (P = 0.816). The sensitivity was 98.2% in the GA group (confidence interval, 97-100%) and 98.1% in the MS group (confidence interval, 97-100%) (P = 0.979). EBUS was completed in all patients in the GA group, and in 69 patients (93.3%) in the MS group (P = 0.028). There were no major complications or escalation of care in either group. Minor complications were more common in the MS group (29.6 vs. 5.3%) (P < 0.001). Most patients stated they "definitely would" undergo this procedure again in both groups (P = 0.355). CONCLUSIONS EBUS-TBNA performed under MS results in comparable diagnostic yield, rate of major complications, and patient tolerance as under GA. Future prospective multicenter studies are required to corroborate our findings. Clinical trial registered with www.clinicaltrials.gov (NCT 01430962).
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Ost DE, Jimenez CA, Lei X, Cantor SB, Grosu HB, Lazarus DR, Faiz SA, Bashoura L, Shannon VR, Balachandran D, Noor L, Hashmi YB, Casal RF, Morice RC, Eapen GA. Quality-adjusted survival following treatment of malignant pleural effusions with indwelling pleural catheters. Chest 2014; 145:1347-1356. [PMID: 24480929 DOI: 10.1378/chest.13-1908] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Malignant pleural effusions (MPEs) are a frequent cause of dyspnea in patients with cancer. Although indwelling pleural catheters (IPCs) have been used since 1997, there are no studies of quality-adjusted survival following IPC placement. METHODS With a standardized algorithm, this prospective observational cohort study of patients with MPE treated with IPCs assessed global health-related quality of life using the SF-6D to calculate utilities. Quality-adjusted life days (QALDs) were calculated by integrating utilities over time. RESULTS A total of 266 patients were enrolled. Median quality-adjusted survival was 95.1 QALDs. Dyspnea improved significantly following IPC placement (P < .001), but utility increased only modestly. Patients who had chemotherapy or radiation after IPC placement (P < .001) and those who were more short of breath at baseline (P = .005) had greater improvements in utility. In a competing risk model, the 1-year cumulative incidence of events was death with IPC in place, 35.7%; IPC removal due to decreased drainage, 51.9%; and IPC removal due to complications, 7.3%. Recurrent MPE requiring repeat intervention occurred in 14% of patients whose IPC was removed. Recurrence was more common when IPC removal was due to complications (P = .04) or malfunction (P < .001) rather than to decreased drainage. CONCLUSIONS IPC placement has significant beneficial effects in selected patient populations. The determinants of quality-adjusted survival in patients with MPE are complex. Although dyspnea is one of them, receiving treatment after IPC placement is also important. Future research should use patient-centered outcomes in addition to time-to-event analysis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01117740; URL: www.clinicaltrials.gov.
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Affiliation(s)
- David E Ost
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center.
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | - Xiudong Lei
- Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine
| | | | - Horiana B Grosu
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | | | - Saadia A Faiz
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | - Lara Bashoura
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | - Vickie R Shannon
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | - Dave Balachandran
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | - Lailla Noor
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | - Yousra B Hashmi
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | | | - Rodolfo C Morice
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
| | - George A Eapen
- Department of Pulmonary Medicine, Department of Biostatistics, Section of Health Services Research, The University of Texas MD Anderson Cancer Center
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Affiliation(s)
- Timothy M Saettele
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
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Massarelli E, Onn A, Marom EM, Alden CM, Liu DD, Tran HT, Mino B, Wistuba II, Faiz SA, Bashoura L, Eapen GA, Morice RC, Jack Lee J, Hong WK, Herbst RS, Jimenez CA. Vandetanib and indwelling pleural catheter for non-small-cell lung cancer with recurrent malignant pleural effusion. Clin Lung Cancer 2014; 15:379-86. [PMID: 24913066 DOI: 10.1016/j.cllc.2014.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 02/13/2014] [Revised: 04/01/2014] [Accepted: 04/08/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION/BACKGROUND Non-small-cell lung cancer patients with malignant pleural effusion have a poor overall median survival (4.3 months). VEGF is a key regulator of pleural effusion production. It is unknown if pharmacological inhibition of VEGF signaling modifies the disease course of non-small-cell lung cancer patients with recurrent malignant pleural effusion. We report the final results of a single-arm phase II clinical trial of the VEGF receptor inhibitor, vandetanib, combined with intrapleural catheter placement in patients with non-small-cell lung cancer and recurrent malignant pleural effusion, to determine whether vandetanib reduces time to pleurodesis. PATIENTS AND METHODS Non-small-cell lung cancer patients with proven metastatic disease to the pleural space using pleural fluid cytology or pleural biopsy who required intrapleural catheter placement were eligible for enrollment. On the same day of the intrapleural catheter insertion, the patients were started on a daily oral dose of 300 mg vandetanib, for a maximum of 10 weeks. The primary end point was time to pleurodesis, with response rate as the secondary end point. Exploratory analyses included measurement of pleural fluid cytokines and angiogenic factors before and during therapy. RESULTS Twenty eligible patients were included in the trial. Eleven patients completed 10 weeks of treatment. Median time to pleurodesis was 35 days (95% confidence interval, 15-not applicable). Median time to pleurodesis in the historical cohort was 63 days (95% confidence interval, 45-86) when adjusted for Eastern Cooperative Oncology Group performance status ≤ 2. CONCLUSION Vandetanib therapy was well tolerated; however, it did not significantly reduce time to pleurodesis.
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Affiliation(s)
- Erminia Massarelli
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Amir Onn
- Institute of Pulmonary Oncology, Sheba Medical Center, Tel Aviv, Israel
| | - Edith M Marom
- Department of Diagnostic Radiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Christine M Alden
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Diane D Liu
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Hai T Tran
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Barbara Mino
- Department of Translational Molecular Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Ignacio I Wistuba
- Department of Translational Molecular Pathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - J Jack Lee
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Waun K Hong
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Roy S Herbst
- Section of Medical Oncology, Yale Comprehensive Cancer Center, Yale University School of Medicine, New Haven, CT
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX.
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Almeida FA, Casal RF, Jimenez CA, Eapen GA, Uzbeck M, Sarkiss M, Rice D, Morice RC, Ost DE. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest 2014; 144:1776-1782. [PMID: 23703671 DOI: 10.1378/chest.12-3046] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Evidence-based guidelines recommend mediastinal sampling as the first invasive test in patients with suspected lung cancer and mediastinal adenopathy. The goal of this study was to assess practice patterns and outcomes of diagnostic strategies in this patient population. METHODS We conducted a retrospective analysis of all patients in 2009 who had mediastinal adenopathy without distant metastatic disease to determine whether guideline-consistent care was delivered. Guideline-consistent care was defined as mediastinal lymph node sampling being performed as part of the first invasive procedure. RESULTS One hundred thirty-seven patients were included. Guideline-consistent care was provided in 30 cases (22%). Patients receiving guideline-consistent care had fewer invasive tests than patients with guideline-inconsistent care (1.3 ± 0.5 tests/patient vs 2.3 ± 0.5 tests/patient, respectively; P < .0001) and fewer complications (0 of 30, 0% vs 18 of 108, 17%; P = .01). Most of the complications (16 of 18) were related to CT image-guided needle biopsy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was sufficient to guide treatment decisions without any other invasive tests in 88 patients (64%). Although not all the complications and costs due to CT image-guided biopsies could have been avoided, roughly two-thirds could have been eliminated by just changing the testing sequence. CONCLUSION Quality gaps in lung cancer staging in patients with mediastinal adenopathy are common and lead to unnecessary testing and increased complications. In patients with suspected lung cancer without distant metastatic disease with mediastinal adenopathy, EBUS-TBNA should be the first test.
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Affiliation(s)
- Francisco A Almeida
- Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Roberto F Casal
- Department of Pulmonary and Critical Care Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mateen Uzbeck
- The Department of Pulmonary Medicine, Our Lady of Lourdes and Beaumont Hospitals, Dublin, Ireland
| | - Mona Sarkiss
- Department of Anesthesia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Rice
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Grosu HB, Eapen GA, Morice RC, Jimenez CA, Casal RF, Almeida FA, Sarkiss MG, Ost DE. Stents are associated with increased risk of respiratory infections in patients undergoing airway interventions for malignant airways disease. Chest 2014; 144:441-449. [PMID: 23471176 DOI: 10.1378/chest.12-1721] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Long-term complications of therapeutic bronchoscopy include infections and airway restenosis due to tumor. No studies have compared the incidence rates of infection in patients with stents with those without stents. We hypothesized that patients with stents would have a higher incidence of lower respiratory tract infections than would patients without stents. METHODS We conducted a retrospective cohort study, covering the period September 2009 to August 2011, of patients who had therapeutic bronchoscopy for malignant airways disease. Outcomes recorded were lower respiratory tract infection and airway restenosis by tumor. RESULTS Seventy-two patients had therapeutic bronchoscopy for malignant airways disease. Twenty-four of these patients had one or more stents placed. Twenty-three of the 72 patients (32%) developed lower respiratory tract infections. Stents were associated with an increased risk of infection (hazard ratio [HR], 3.76; 95% CI, 1.57-8.99; P = .003). The incidence rate of lower respiratory tract infection was 0.0057 infections per person-day in patients with stents vs 0.0011 infections per person-day in patients without stents. The incidence rate difference, 0.0046 infections per person-day, was significant (95% CI, 0.0012-0.0081; P = .0002). Restenosis due to tumor overgrowth was associated with more severe obstruction at baseline (obstruction ≥ 50% vs < 50% preprocedure; HR, 13.71; 95% CI, 1.75-107.55; P = .013). CONCLUSION Therapeutic bronchoscopy with stent placement is associated with a higher risk of infection than is therapeutic bronchoscopy alone. If ablative techniques reopen the airway and there is a good chance that the tumor may respond to chemotherapy and/or radiation, a strategy of initially holding off on stenting may be warranted.
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Affiliation(s)
- Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roberto F Casal
- Department of Pulmonary Medicine, Baylor College of Medicine, Houston, TX
| | - Francisco A Almeida
- Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Mona G Sarkiss
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Casal RF, Iribarren J, Eapen G, Ost D, Morice R, Lan C, Cornwell L, Almeida FA, Grosu H, Jimenez CA. Safety and effectiveness of microdebrider bronchoscopy for the management of central airway obstruction. Respirology 2013; 18:1011-5. [PMID: 23520982 DOI: 10.1111/resp.12087] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [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: 11/29/2012] [Revised: 01/27/2013] [Accepted: 01/29/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE Microdebrider bronchoscopy is a relatively new modality for the management of central airway obstruction (CAO) of both benign and malignant origin. Our objective was to describe our experience with this technique, with special attention to its safety and effectiveness. METHODS We retrospectively reviewed cases of therapeutic bronchoscopies using microdebrider for CAO from two institutions (M.D. Anderson Cancer Center and Michael E. Debakey VA Medical Center, Houston) from August 2008 through February 2012. RESULTS We identified 51 cases. Malignant CAO was detected in 36 cases (71%): non-small-cell lung cancer (n = 22), melanoma (n = 3), small-cell-lung cancer (n = 2), thyroid cancer (n = 2), esophageal carcinoma (n = 2), breast cancer (n = 2), and others (n = 3). Benign diseases included: papillomas (n = 8), granulation tissue (n = 3), and others (n = 4). Obstruction was purely endoluminal in 32 cases (63%). Pre-treatment obstruction was severe in 25 cases (49%), moderate in 20 cases (39%) and mild in 6 (12%). Lesions were located in the trachea (n = 23), main stem bronchi (n = 25), and bronchus intermedius (n = 8), with some patients having more than one lesion. After tumor debulking with microdebrider, the residual airway obstruction was insignificant (n = 27 cases; 53%), mild (n = 23 cases; 45%), and moderate (n = 1; 2%). No major complications were encountered, only 2 patients had mild adverse events: one case of pneumomediastinum, and one self-expandable stent damage requiring its removal. Two patients (4%) died within 30 days of causes unrelated to the procedure or the CAO. CONCLUSIONS Microdebrider bronchoscopy is a potentially safe and effective way to manage central airway obstruction of both malignant and benign origin.
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Affiliation(s)
- Roberto F Casal
- Department of Pulmonary and Critical Care Medicine, The Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX 77030, USA.
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Eapen GA, Shah AM, Lei X, Jimenez CA, Morice RC, Yarmus L, Filner J, Ray C, Michaud G, Greenhill SR, Sarkiss M, Casal R, Rice D, Ost DE. Complications, consequences, and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: Results of the AQuIRE registry. Chest 2013; 143:1044-1053. [PMID: 23117878 DOI: 10.1378/chest.12-0350] [Citation(s) in RCA: 221] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Few studies of endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA) have been large enough to identify risk factors for complications. The primary objective of this study was to quantify the incidence of and risk factors for complications in patients undergoing EBUS-TBNA. METHODS Data on prospectively enrolled patients undergoing EBUS-TBNA in the American College of Chest Physicians Quality Improvement Registry, Evaluation, and Education (AQuIRE)database were extracted and analyzed for the incidence, consequences, and predictors of complications. RESULTS We enrolled 1,317 patients at six hospitals. Complications occurred in 19 patients (1.44%;95% CI, 0.87%-2.24%). Transbronchial lung biopsy (TBBx) was the only risk factor for complications,which occurred in 3.21% of patients who underwent the procedure and in 1.15% of those who did not (OR, 2.85; 95% CI, 1.07-7.59; P 5 .04). Pneumothorax occurred in seven patients(0.53%; 95% CI, 0.21%-1.09%). Escalations in level of care occurred in 14 patients (1.06%;95% CI, 0.58%-1.78%); its risk factors were age . 70 years (OR, 4.06; 95% CI, 1.36-12.12; P 5 .012),inpatient status (OR, 4.93; 95% CI, 1.30-18.74; P 5 .019), and undergoing deep sedation or general anesthesia (OR, 4.68; 95% CI, 1.02-21.61; P 5 .048). TBBx was performed in only 12.6% of patients when rapid on site cytologic evaluation (ROSE ) was used and in 19.1% when it was not used ( P 5 .006).Interhospital variation in TBBx use when ROSE was used was significant ( P , .001). CONCLUSIONS TBBx was the only risk factor for complications during EBUS-TBNA procedures.ROSE significantly reduced the use of TBBx.
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Affiliation(s)
- George A Eapen
- University of Texas MD Anderson Cancer Center, Houston, TX.
| | | | - Xiudong Lei
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Joshua Filner
- Kaiser Permanente Sunnyside Medical Center, Clackamas, OR
| | | | | | | | - Mona Sarkiss
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - David Rice
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- University of Texas MD Anderson Cancer Center, Houston, TX
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Yarmus LB, Akulian J, Lechtzin N, Yasin F, Kamdar B, Ernst A, Ost DE, Ray C, Greenhill SR, Jimenez CA, Filner J, Feller-Kopman D. Comparison of 21-gauge and 22-gauge aspiration needle in endobronchial ultrasound-guided transbronchial needle aspiration: results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry. Chest 2013; 143:1036-1043. [PMID: 23632441 DOI: 10.1378/chest.12-1205] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit. METHODS We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge. RESULTS A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P < .001). CONCLUSIONS There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.
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Affiliation(s)
| | | | | | | | | | - Armin Ernst
- St. Elizabeth's Medical Center, Brighton, MA
| | - David E Ost
- University of Texas MD Anderson Cancer Center, Houston, TX
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Affiliation(s)
- Roberto F Casal
- Department of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX.
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Affiliation(s)
- Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Faiz SA, Bashoura L, Lei X, Sampat KR, Brown TC, Eapen GA, Morice RC, Ferrajoli A, Jimenez CA. Pleural effusions in patients with acute leukemia and myelodysplastic syndrome. Leuk Lymphoma 2013; 54:329-35. [PMID: 22812422 DOI: 10.3109/10428194.2012.713478] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pleural effusions are rarely observed in patients with acute myelogenous leukemia (AML), acute lymphocytic leukemia (ALL) and myelodysplastic syndrome (MDS)/myeloproliferative neoplasm (MPN). Therefore the underlying etiology of pleural effusions and the efficacy and safety of pleural procedures in this population has not been well studied. In a retrospective review of cases from 1997 to 2007, we identified 111 patients with acute leukemia or MDS/MPN who underwent pleural procedures. Clinical characteristics were reviewed, and survival outcomes were estimated by Kaplan-Meier methods. A total of 270 pleural procedures were performed in 111 patients (69 AML, 27 ALL, 15 MDS/MPN). The main indications for pleural procedures were possible infection (49%) and respiratory symptoms (48%), and concomitant clinical symptoms included fever (34%), dyspnea (74%), chest pain (24%) and cough (37%). Most patients had active disease (61%). The most frequent etiology of pleural effusions was infection (47%), followed by malignancy (36%). Severe thrombocytopenia (platelet count < 20 × 10(3)/µL) was present in 43% of the procedures, yet the procedural complication rate was only 1.9%. Multivariate analysis revealed that older age, AML, MDS/MPN and active disease status were associated with a shorter median overall survival. Infection and malignant involvement are the most common causes of pleural effusion in patients with acute leukemia or MDS. After optimizing platelet count and coagulopathy, thoracentesis may be performed safely and with high diagnostic yield in this population. Survival in these patients is determined by the response to treatment of the hematologic malignancy.
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Affiliation(s)
- Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030-1402, USA.
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Grosu HB, Jimenez CA, Morice RC, Ost D, Sarkiss MG, Eapen GA. Cryptogenic Bronchial Stenosis. Am J Respir Crit Care Med 2013; 187:327. [DOI: 10.1164/rccm.201206-1023im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - David Ost
- Department of Pulmonary Medicine and
| | - Mona G. Sarkiss
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Casal RF, Staerkel GA, Ost D, Almeida FA, Uzbeck MH, Eapen GA, Jimenez CA, Nogueras-Gonzalez GM, Sarkiss M, Morice RC. Randomized clinical trial of endobronchial ultrasound needle biopsy with and without aspiration. Chest 2013; 142:568-573. [PMID: 22156610 DOI: 10.1378/chest.11-0692] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (EBUS-TBNA) is performed with a dedicated 22- or 21-gauge needle while suction is applied. Fine-needle sampling without suction (capillary sampling) has been studied for endoscopic ultrasound and for biopsies at various body sites and has resulted in similar diagnostic yield and fewer traumatic samples. However, the role of EBUS-guided transbronchial needle capillary sampling (EBUS-TBNCS) is still to be determined. METHODS Adults with suspicious hilar or mediastinal lymph nodes (LNs) were included in a single-blinded, prospective, randomized trial comparing EBUS-TBNA and EBUS-TBNCS. The primary end point was the concordance rate between the two techniques in terms of adequacy and diagnosis of cytologic samples. The secondary end point was the concordance rate between the two techniques in terms of quality of samples. RESULTS A total of 115 patients and 192 LNs were studied. Concordance between EBUS-TBNA and EBUS-TBNCS was high, with no significant difference in adequacy (88% vs 88%, respectively [P ± .858]; concordance rate, 83.9% [95% CI, 77.9-88.8]); diagnosis (36% vs 34%, respectively [P ± .289]; concordance rate, 95.8% [95% CI, 92-92.8]); diagnosis of malignancy (28% vs 26%, respectively [P ± .125]; concordance rate, 97.9% [95% CI, 94.8-99.4]); or sample quality (concordance rate, 83.3% [95% CI, 73.3-88.3]). Concordance between EBUS-TBNA and EBUS-TBNCS was high irrespective of LN size (≤ 1 cm vs > 1 cm). CONCLUSIONS Regardless of LN size, no differences in adequacy, diagnosis, or quality were found between samples obtained using EBUS-TBNA and those obtained using EBUS-TBNCS. There is no evidence of any benefit derived from the practice of applying suction to EBUS-guided biopsies. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00886847; URL: www.clinicaltrials.gov
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Affiliation(s)
- Roberto F Casal
- Department of Pulmonary and Critical Care Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX.
| | - Gregg A Staerkel
- Department of Pathology, Division of Anatomic Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Francisco A Almeida
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Mateen H Uzbeck
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Mona Sarkiss
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rodolfo C Morice
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Affiliation(s)
- Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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