Ultrasound-guided transthoracic needle biopsy of the lung: sensitivity and safety variables

OBJECTIVES

Variables affecting the performance of ultrasound-guided transthoracic needle biopsy (US-TTNB) are not well established. We examined clinical and imaging variables affecting the sensitivity and the complication rates of US-TTNB.

METHODS

We retrospectively reviewed a consecutive series of 528 US-TTNBs performed from 2008 to 2017. Univariate analyses were used to assess the influence of clinical and imaging variables on sensitivity and complication rates. Multivariate logistic regression was used to account for possible confounding variables.

RESULTS

In 397 malignant lesions, the sensitivity of US-TTNB was 72% (95% CI 68-77%; 285/397). The overall pneumothorax rate was 15% (95% CI 12-18%; 77/528), leading to a chest tube in 2% (95% CI 1-3%; 9/528). Multivariate analysis showed that increasing pleural contact length (up to 30 mm) was associated with increased sensitivity (OR 1.08 per mm; 95% CI 1.04-1.12; p < 0.001), and pleural contact length (OR 0.98 per mm; 95% CI 0.97-0.99; p = 0.013), lesion size (OR 0.98 per mm; 95% CI 0.96-0.99; p = 0.006), and core needle diameter of 18G (OR 0.47 as compared with 20G; 95% CI 0.26-0.83; p = 0.010) were associated with a decreased pneumothorax rate. Graphical inspection of cubic splines showed that the probability of a positive biopsy rose sharply with increasing pleural contact length up to 30 mm and was stable thereafter. A similar, but inverse, relationship was observed for the probability of a pneumothorax.

CONCLUSION

Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. Lesion size also predicts pneumothorax rates.

KEY POINTS

• US-TTNB has a high sensitivity and a low complication rate for pleural and pulmonary lesions with pleural contact. • Pleural contact length is a key variable predicting the sensitivity of US-TTNB and pneumothorax rate after US-TTNB. • This study suggests that relying on US-TTNB may not be optimal for lesions < 10 mm for which the risk of pneumothorax is as high as the chance of obtaining diagnosis.

Interaction Between Balloon-Expandable Valves and Coronary Ostia: Angiographic Analysis and Impact on Coronary Access

OBJECTIVES

We sought to evaluate the position of balloon-expandable valves in relation to the coronary ostia using an angiographic- and computed tomography (CT)-based analysis, and to determine the impact of valve position on coronary angiography (CA)/percutaneous coronary intervention (PCI) feasibility and results.

METHODS

A total of 533 patients who received a Sapien XT or Sapien 3 valve were included in the angiographic analysis. Of these, 49 benefited from an opportunistic electrocardiography-gated CT after transcatheter aortic valve replacement (TAVR) and were included in the CT analysis.

RESULTS

Regarding the left coronary artery (LCA) ostium, the top of the transcatheter heart valve (THV) frame was infraostial in 49% of cases, and the valve totally covered the LCA ostium in 27% of patients. The stent frame of the Sapien 3 valve completely covered the LCA ostium more frequently than the Sapien XT valve (43% vs 12%, respectively; P<.001) and the relative implantation depth was significantly less ventricular in the Sapien 3 group than in the Sapien XT group (28.0 ± 12.3% vs 36.8 ± 12.6%, respectively; P<.001). The CT evaluation found similar results to angiographic evaluation. A total of 53 patients (10%) underwent CA (± PCI) following TAVR, and valve position did not influence CA performance/quality and PCI results.

CONCLUSIONS

The stent frame of balloon-expandable Sapien valves exceeded the coronary ostia in about one-fourth of patients, and this percentage was >40% with the new-generation Sapien 3 valve. However, THV position did not affect the feasibility, quality, and results of CA/PCI post TAVR.

Prediction of lung cancer risk at follow-up screening with low-dose CT: a training and validation study of a deep learning method

Background

Current lung cancer screening guidelines use mean diameter, volume or density of the largest lung nodule in the prior computed tomography (CT) or appearance of new nodule to determine the timing of the next CT. We aimed at developing a more accurate screening protocol by estimating the 3-year lung cancer risk after two screening CTs using deep machine learning (ML) of radiologist CT reading and other universally available clinical information.

Methods

A deep machine learning (ML) algorithm was developed from 25,097 participants who had received at least two CT screenings up to two years apart in the National Lung Screening Trial. Double-blinded validation was performed using 2,294 participants from the Pan-Canadian Early Detection of Lung Cancer Study (PanCan). Performance of ML score to inform lung cancer incidence was compared with Lung-RADS and volume doubling time using time-dependent ROC analysis. Exploratory analysis was performed to identify individuals with aggressive cancers and higher mortality rates.

Findings

In the PanCan validation cohort, ML showed excellent discrimination with a 1-, 2- and 3-year time-dependent AUC values for cancer diagnosis of 0·968±0·013, 0·946±0·013 and 0·899±0·017. Although high ML score cohort included only 10% of the PanCan sample, it identified 94%, 85%, and 71% of incident and interval lung cancers diagnosed within 1, 2, and 3 years, respectively, after the second screening CT. Furthermore, individuals with high ML score had significantly higher mortality rates (HR=16·07, p<0·001) compared to those with lower risk.

Interpretation

ML tool that recognizes patterns in both temporal and spatial changes as well as synergy among changes in nodule and non-nodule features may be used to accurately guide clinical management after the next scheduled repeat screening CT.

Predicting Malignancy Risk of Screen-Detected Lung Nodules-Mean Diameter or Volume

OBJECTIVE

In lung cancer screening practice low-dose computed tomography, diameter, and volumetric measurement have been used in the management of screen-detected lung nodules. The aim of this study was to compare the performance of nodule malignancy risk prediction tools using diameter or volume and between computer-aided detection (CAD) and radiologist measurements.

METHODS

Multivariable logistic regression models were prepared by using data from two multicenter lung cancer screening trials. For model development and validation, baseline low-dose computed tomography scans from the Pan-Canadian Early Detection of Lung Cancer Study and a subset of National Lung Screening Trial (NLST) scans with lung nodules 3 mm or more in mean diameter were analyzed by using the CIRRUS Lung Screening Workstation (Radboud University Medical Center, Nijmegen, the Netherlands). In the NLST sample, nodules with cancer had been matched on the basis of size to nodules without cancer.

RESULTS

Both CAD-based mean diameter and volume models showed excellent discrimination and calibration, with similar areas under the receiver operating characteristic curves of 0.947. The two CAD models had predictive performance similar to that of the radiologist-based model. In the NLST validation data, the CAD mean diameter and volume models also demonstrated excellent discrimination: areas under the curve of 0.810 and 0.821, respectively. These performance statistics are similar to those of the Pan-Canadian Early Detection of Lung Cancer Study malignancy probability model with use of these data and radiologist-measured maximum diameter.

CONCLUSION

Either CAD-based nodule diameter or volume can be used to assist in predicting a nodule's malignancy risk.

Transcatheter valve-in-valve overexpansion for treating a large dysfunctional tricuspid bioprosthesis

Transcatheter valve-in-valve implantation within dysfunctional surgical bioprosthesis has become an alternative to redo open-heart surgery. However, suitability for valve-in-valve implantation in the tricuspid position is often limited by large surgical valve sizes. We report a case of a transcatheter tricuspid valve-in-valve implantation with a 29-mm balloon-expandable prosthesis within a 33-mm failed bioprosthesis (exceeding manufacturer's sizing recommendations). Overexpansion of a 29-mm SAPIEN XT valve by 1-ml overfilling of the deployment balloon was successfully performed, with no valve dislocation/embolization or residual tricuspid regurgitation. This case illustrates the feasibility of tricuspid valve-in-valve procedures in selected patients with large failed tricuspid bioprostheses.

Participant selection for lung cancer screening by risk modelling (the Pan-Canadian Early Detection of Lung Cancer [PanCan] study): a single-arm, prospective study

BACKGROUND

Results from retrospective studies indicate that selecting individuals for low-dose CT lung cancer screening on the basis of a highly predictive risk model is superior to using criteria similar to those used in the National Lung Screening Trial (NLST; age, pack-year, and smoking quit-time). We designed the Pan-Canadian Early Detection of Lung Cancer (PanCan) study to assess the efficacy of a risk prediction model to select candidates for lung cancer screening, with the aim of determining whether this approach could better detect patients with early, potentially curable, lung cancer.

METHODS

We did this single-arm, prospective study in eight centres across Canada. We recruited participants aged 50-75 years, who had smoked at some point in their life (ever-smokers), and who did not have a self-reported history of lung cancer. Participants had at least a 2% 6-year risk of lung cancer as estimated by the PanCan model, a precursor to the validated PLCOm2012 model. Risk variables in the model were age, smoking duration, pack-years, family history of lung cancer, education level, body-mass index, chest x-ray in the past 3 years, and history of chronic obstructive pulmonary disease. Individuals were screened with low-dose CT at baseline (T0), and at 1 (T1) and 4 (T4) years post-baseline. The primary outcome of the study was incidence of lung cancer. This study is registered with ClinicalTrials.gov, number NCT00751660.

FINDINGS

7059 queries came into the study coordinating centre and were screened for PanCan risk. 15 were duplicates, so 7044 participants were considered for enrolment. Between Sept 24, 2008, and Dec 17, 2010, we recruited and enrolled 2537 eligible ever-smokers. After a median follow-up of 5·5 years (IQR 3·2-6·1), 172 lung cancers were diagnosed in 164 individuals (cumulative incidence 0·065 [95% CI 0·055-0·075], incidence rate 138·1 per 10 000 person-years [117·8-160·9]). There were ten interval lung cancers (6% of lung cancers and 6% of individuals with cancer): one diagnosed between T0 and T1, and nine between T1 and T4. Cumulative incidence was significantly higher than that observed in NLST (4·0%; p<0·0001). Compared with 593 (57%) of 1040 lung cancers observed in NLST, 133 (77%) of 172 lung cancers in the PanCan Study were early stage (I or II; p<0·0001).

INTERPRETATION

The PanCan model was effective in identifying individuals who were subsequently diagnosed with early, potentially curable, lung cancer. The incidence of cancers detected and the proportion of early stage cancers in the screened population was higher than observed in previous studies. This approach should be considered for adoption in lung cancer screening programmes.

FUNDING

Terry Fox Research Institute and Canadian Partnership Against Cancer.

Giant Left Atrial Appendage Aneurysm Mimicking Mediastinal Mass and Associated with Incessant Atrial Arrhythmias

Left atrial appendage aneurysm (LAAA) is a rare entity. Clinical manifestations include arrhythmias and systemic embolization. We show here an example of a large and ectopic LAAA mimicking a mediastinal mass on chest X-ray and presenting with incessant atrial arrhythmias. Subsequent investigations leading to the correct diagnosis are described.

Self-expanding Portico Valve Versus Balloon-expandable SAPIEN XT Valve in Patients With Small Aortic Annuli: Comparison of Hemodynamic Performance

INTRODUCTION AND OBJECTIVES

The self-expanding Portico valve is a new transcatheter aortic valve system yielding promising preliminary results, yet there are no comparative data against earlier generation transcatheter aortic valve systems. The aim of this study was to compare the hemodynamic performance of the Portico and balloon-expandable SAPIEN XT valves in a case-matched study with echocardiographic core laboratory analysis.

METHODS

Twenty-two patients underwent transcatheter aortic valve implantation with the Portico 23-mm valve and were matched for aortic annulus area and mean diameter measured by multidetector computed tomography, left ventricular ejection fraction, body surface area, and body mass index with 40 patients treated with the 23-mm SAPIEN XT. Mean aortic annulus diameters were 19.6±1.3mm by transthoracic echocardiography and 21.4±1.2mm by computed tomography, with no significant between-group differences. Doppler echocardiographic images were collected at baseline and at 1-month of follow-up and were analyzed in a central echocardiography core laboratory.

RESULTS

There were no significant between-group differences in residual mean transaortic gradients (SAPIEN XT: 10.4±3.7mmHg; Portico: 9.8±1.1mmHg; P=.49) and effective orifice areas (SAPIEN XT: 1.36±0.27cm(2); Portico, 1.37±.29cm(2); P=.54). Rates of severe prosthesis-patient mismatch (effective orifice area<0.65cm(2)/m(2)) were similar (SAPIEN XT: 13.5%; Portico: 10.0%; P=.56). No between-group differences were found in the occurrence of moderate-severe paravalvular leaks (5.0% vs 4.8% of SAPIEN XT and Portico respectively; P=.90).

CONCLUSIONS

Transcatheter aortic valve implantation with the self-expanding Portico system yielded similar short-term hemodynamic performance compared with the balloon-expandable SAPIEN XT system for treating patients with severe aortic stenosis and small annuli. Further prospective studies with longer-term follow-up and in patients with larger aortic annuli are required.

Transcatheter mitral "valve-in-ring" implantation: a word of caution

Transcatheter mitral valve-in-valve and valve-in-ring procedures have emerged as a potential alternative for patients with failed mitral bioprosthesis or mitral valve repair who are at very high or prohibitive surgical risk. However, transcatheter mitral valve-in-ring implantation (TMViRI) remains a challenging procedure, partially because of the oval shape of mitral rings, which may lead to prosthesis dysfunction when the ring is not able to adopt the circular shape of the transcatheter valve. We present a case of failed TMViRI in a dysfunctional mitral homograft. The potential factors leading to procedural failure are discussed.

Plasma pro-surfactant protein B and lung function decline in smokers

Plasma pro-surfactant protein B (pro-SFTPB) levels have recently been shown to predict the development of lung cancer in current and ex-smokers, but the ability of pro-SFTPB to predict measures of chronic obstructive pulmonary disease (COPD) severity is unknown. We evaluated the performance characteristics of pro-SFTPB as a biomarker of lung function decline in a population of current and ex-smokers. Plasma pro-SFTPB levels were measured in 2503 current and ex-smokers enrolled in the Pan-Canadian Early Detection of Lung Cancer Study. Linear regression was performed to determine the relationship of pro-SFTPB levels to changes in forced expiratory volume in 1 s (FEV1) over a 2-year period as well as to baseline FEV1 and the burden of emphysema observed in computed tomography (CT) scans. Plasma pro-SFTPB levels were inversely related to both FEV1 % predicted (p=0.024) and FEV1/forced vital capacity (FVC) (p<0.001), and were positively related to the burden of emphysema on CT scans (p<0.001). Higher plasma pro-SFTPB levels were also associated with a more rapid decline in FEV1 at 1 year (p=0.024) and over 2 years of follow-up (p=0.004). Higher plasma pro-SFTPB levels are associated with increased severity of airflow limitation and accelerated decline in lung function. Pro-SFTPB is a promising biomarker for COPD severity and progression.

Coronary obstruction following transcatheter aortic valve implantation: a systematic review

OBJECTIVES

This study sought to evaluate, through a systematic review of the published data, the main baseline characteristics, management, and clinical outcomes of patients suffering coronary obstruction as a complication of transcatheter aortic valve implantation (TAVI).

BACKGROUND

Very few data exist on coronary obstruction after TAVI.

METHODS

Studies published between 2002 and 2012, with regard to coronary obstruction as a complication of TAVI, were identified with a systematic electronic search. Only the studies reporting data on the main baseline and procedural characteristics, management of the complication, and clinical outcomes were analyzed.

RESULTS

A total of 18 publications describing 24 patients were identified. Most (83%) patients were women, with a mean age of 83 ± 7 years and a mean logistic European System for Cardiac Operative Risk Evaluation score of 25.1 ± 12.0%. Mean left coronary artery (LCA) ostium height and aortic root width were 10.3 ± 1.6 mm and 27.8 ± 2.8 mm, respectively. Most patients (88%) had received a balloon-expandable valve, and coronary obstruction occurred more frequently in the LCA (88%). Percutaneous coronary intervention was attempted in 23 cases (95.8%) and was successful in all but 2 patients (91.3%). At 30-day follow-up, there were no cases of stent thrombosis or repeat revascularization, and the mortality rate was 8.3%.

CONCLUSIONS

Reported cases of coronary obstruction after TAVI occurred more frequently in women, in patients receiving a balloon-expandable valve, and the LCA was the most commonly involved artery. Percutaneous coronary intervention was a feasible and successful treatment in most cases. Continuous efforts should be made to identify the factors associated with this life-threatening complication to implement the appropriate measures for its prevention.

A case-control study on occupational risk factors for sino-nasal cancer

OBJECTIVES

Sino-nasal cancer has been consistently associated with exposure to wood dust, leather dust, nickel and chromium compounds; for other occupational hazards, the findings are somewhat mixed. The aim of this study was to investigate the risk of sino-nasal epithelial cancer (SNEC) by histological type with prior exposure to suspected occupational risk factors and, in particular, those in metalworking.

METHODS

Between 1996 and 2000, incident cases were collected on a monthly basis from hospitals throughout the Piedmont region of Italy by the regional Sino-nasal Cancer Registry. A questionnaire on occupational history, completed by 113 cases and 336 hospital controls, was used to assign exposure to occupational hazards. The relationship between SNEC and cumulative exposure to these hazards was explored using unconditional logistic regression to statistically adjust for age, sex, smoking and co-exposures, allowing for a 10-year latency period.

RESULTS

The risk of adenocarcinoma was significantly increased with ever-exposure to wood dust (odds ratio; OR = 58.6), and to leather dust (OR = 32.8) and organic solvents (OR = 4.3) after controlling for wood dust, whereas ever-exposure to welding fumes (OR = 3.7) and arsenic (OR = 4.4) significantly increased the risk for squamous cell carcinoma. For each of these hazards, a significant increasing trend in risk across ordered cumulative exposure categories was found and, except for arsenic, a significantly increased risk with ever-exposure at low intensity. Treating cumulative exposure on a continuous scale, a significant effect of textile dusts was also observed for adenocarcinoma. For a mixed group of other histological types, a significant association was found with wood dust and organic solvents.

CONCLUSIONS

Some occupational risk factors for SNEC were confirmed, and dose-response relationships were observed for other hazards that merit further investigation. The high risk for adenocarcinoma with low-intensity exposure to wood dust lends support for a reduction in the occupational threshold value.

South American blastomycosis of epididymis

Reported herein is the first Brazilian case of epididymal involvement by South American blastomycosis, and apparently the second case to be reported in the world literature.