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Objective To assess how often transbronchial biopsy (TBBx) added unique positive findings apart from other synchronous bronchoscopic sampling techniques including the bronchoalveolar lavage–immunocompromised host (BAL-ICH) panel that justified changes in management in an array of immunocompromised patients with new pulmonary radiographic abnormalities. Methods We retrospectively reviewed all bronchoscopies performed at Mayo Clinic Rochester between January 2012 and December 2017; on the basis of the physician’s selection of a BAL-ICH panel, we identified 192 immunocompromised patients who underwent bronchoscopy with both a BAL-ICH panel and TBBx. The results of the BAL-ICH panel and TBBx were compared and subsequent management decisions analyzed from clinical notes. We identified changes in immunosuppressive agents, antibiotics, chemotherapy, goals of care, and decisions on further evaluation and procedures. We assessed whether the TBBx findings added information not identified on the BAL-ICH panel and other bronchoscopic sampling methods performed during the same procedure that justified subsequent management changes. Results Of 192 bronchoscopic procedures performed on immunocompromised patients with acute and subacute pulmonary radiographic abnormalities, management changes justified by the unique positive results of the TBBx occurred 28% (51/192) of the time. Those immunocompromised by solid malignant neoplasms and receiving active immunosuppressive therapy had management changes justified 62.1% (18/29) of the time by the TBBx results. No additional fungal organisms were identified on TBBx that were accounted for on the BAL-ICH panel. Conclusion Transbronchial biopsy may add information to other bronchoscopic findings in immunocompromised patients, especially those with solid malignant neoplasms receiving active immunosuppressive treatment. These potential benefits must be weighed against the risks inherent to the procedure.

There is no unanimity in the literature regarding the value of transbronchial biopsies (TBBs) performed at a scheduled time after lung transplantation (surveillance TBBs [SBs]), compared to biopsies performed for suspected clinical acute rejection (clinically indicated TBBs [CIBs]). This study exposes an assessment of our experience over the last 4 years through a retrospective analysis of the data collected.In our center, SBs are performed at 3, 6, and 12 months after a transplant. Data from 110 patients who underwent a TBB were collected from January 2013 to November 2017. Clinical and functional data along with the histologic results and complications were collected.Overall 251 procedures were performed: 223 for surveillance purposes and 28 for clinical indications. The SBs diagnostic rate was 84%. A grade 2 acute rejection (AR) was detected in 9 asymptomatic patients, all of whom were medically treated, with downgrading of AR documented in all cases. The rate of medical intervention in the SB group was 8%. The CIBs diagnostic rate was 96%. The rate of AR detected by CIBs was significantly higher than by SBs (36% versus 4%; P .0001). Overall the major complication rate was 4%; no patients required transfusions and no mortality occurred in the patient cohort.The surveillance protocol did not eliminate the necessity of CIBs, but in 8% of patients early rejection was histologically assessed. The correlation between histologic and clinical data allows a more careful approach to transplanted patients.

The efficacy of transbronchial needle aspiration (TBNA) with endobronchial ultrasonography using a guide sheath (EBUS-GS) for cases of peripheral pulmonary lesions (PPLs) has not been well established. The purpose of this study was to evaluate the efficacy of TBNA with EBUS-GS for PPLs.We evaluated 130 patients suspected to have lung cancer who underwent transbronchial brushing (brushing), transbronchial biopsy (TBB), and TBNA with EBUS-GS. The pathological diagnostic yields of TBNA were compared to that of TBB and brushing. The histological diagnosis of TBNA was compared to that of surgical specimens. The results of epidermal growth factor receptor (EGFR) gene mutation in TBNA samples were compared to that in TBB or surgical specimens.The diagnostic yields of this study were 62.9% for brushing, 80.0% for TBB, and 77.1% for TBNA. Histological diagnosis was 84.8% for TBB and/or TBNA and pathological diagnosis was 86.7% for all the procedures. TBB and TBNA had significance higher than brushing (p0.05). TBB and TBNA had a tendency of higher diagnostic yields than brushing if EBUS probe was adjacent to PPLs (p = 0.058). Histological evaluations were obtained from TBNA specimens from 50 of 105 patients (47.6%) and these were identical to those of surgical specimens from 29 of 32 patients (90.6%). The results of EGFR gene mutation in TBNA specimens were identical to the same tissue obtained by surgery or TBB.TBNA with EBUS-GS for PPLs was a useful tool for accurate diagnosis and EGFR gene mutation analysis. This method may improve diagnostic accuracy and be useful for molecular testing. This study was approved by the institutional review board (Date of approval: May 27, 2013, approval number: 2816) of Tokyo Women's Medical University Hospital.

The paper presents an algorithm proposed by the authors in order to obtain a theoretical model of the bronchial and used to test the virtual bronchoscopy procedure implemented in an innovative system for bronchoscopy with electromagnetically tracked and steerable biopsy forceps. The procedure is based on the Weibel theoretical model of the human tracheobronchial tree with new features added by the authors. The algorithm can be an important helping tool in the development of sophisticated algorithms for bronchoscopy applications and may be further implemented in clinical studies of navigated bronchoscopy.

We report a rare case of primary pulmonary synovial sarcoma that underwent spontaneous regression after a transbronchial biopsy. A 38-year-old woman with a well-demarcated solitary mass shadow on chest roentgenogram was referred to us. A transbronchial biopsy was performed, and immunohistochemical results as well as detection of SYT-SSX1 (SYnovial sarcoma Translocation-Synovial Sarcoma X chromosome breakpoint) transcripts resulted in a diagnosis of synovial sarcoma. A right lower lobectomy was performed during video-assisted thoracoscopic surgery. Pathologic examination revealed widespread coagulative necrosis with feeding arterioles occluded by organized thrombi. To our knowledge, this is the first report of a case of spontaneous regression of primary pulmonary synovial sarcoma.

Purpose TBB histologic assessment of CLAD status, particularly late post-LTx, is typically clinically unhelpful. Microarray analyses using the Molecular Microscope Diagnostic System (MMDx) in kidney & heart recipients are proving useful in providing mechanistic targets that inform therapeutic interventions, and could show similar promise in LTx. Methods LTx recipients with clinical instability- typically a falling FEV1 and symptoms- had bronchoscopic lavage with microbiologic & cytologic analyses and TBB [4-6 bites analyzed via histology, I TBB bite by MMDx microarray (Alberta Transplant Applied Genomic Center, Edmonton)]. The MMDx uses weighted equations to reflect probabilities of 4 idealized archetypes [Normal, T-cell rejection (TCMR), antibody-mediated rejection (ABMR), Injury]. One month post-TBB a clinical diagnosis was determined, & subsequent change in FEV1 was reassessed 6 months post-TBB. Clinicians were blinded to MMDx scores. Results 48 of 50 LTx who underwent TBB assessment at 1463±1296d post-LTx, (FEV1 32-118% predicted), had an assessable TBB for MMDx. Clinical diagnoses at 1 month post-TBB were CLAD n=21, infection n=17, ABMR n=5, TCMR n=4 & effusion n=1. TBB ISHLT grade was A0 n=46, A1 n=1, B0 n=11, B1 n=1; all others Ax and/or Bx. At 6 months post-TBB, using the highest of the 4 MMDx archetype scores, 1/12 (8%) Normal, 7/14 (50%) TCMR, 5/19 (26%) ABMR & 0/3 (0%) Injury recipients, had rapidly progressive CLAD. 15 patients had DSA>500, 9/15 were in ABMR group- 4 with rapidly progressive CLAD. In 31 patients without a clinical diagnosis of infection at 1 month, 11% Normal, 58% TCMR, 60% ABMR & 0% Injury group recipients went on to have rapidly progressive CLAD. Longer term follow-up (mean of 450±168d) in the TCMR arm and ABMR arm noted there were n=4 & 3 and n=2 & 1 deaths/re-LTx respectively, with 1 other re-LTx in the Normal group: all were CLAD related. Conclusion The MMDx score on single bite TBB specimens provided potentially useful mechanistic, therapeutic & prognostic detail in LTx recipients with clinical instability, whilst TBB histology was not clinically helpful in this cohort. The apparent association or confounding of infection, DSA and a predominant ABMR phenotype is notable. A prospective trial of MMDx directed therapy may be indicated.

Background Solitary pulmonary nodules (SPNs) frequently require transbronchial needle aspiration (TBNA) or biopsy to determine malignant potential, but have variable diagnostic yields. Confirming needle placement within SPNs during TBNA could significantly increase diagnostic yield. Optical coherence tomography (OCT) provides nondestructive, high-resolution, microstructural imaging with potential to distinguish SPN from parenchyma. We have developed needle-based OCT probes compatible with TBNA. Before OCT can play any significant role in guiding clinical TBNA, OCT interpretation criteria for differentiating SPN from lung parenchyma must be developed and validated. Methods OCT of SPN and parenchyma was performed on 111 ex vivo resection specimens. OCT criteria for parenchyma and SPN were developed and validated in a blinded assessment. Six blinded readers (two pulmonologists, two pathologists, and two OCT experts) were trained on imaging criteria in a 15-min training session prior to interpreting the validation data set. Results OCT of lung parenchyma displayed evenly spaced signal-void alveolar spaces, signal-intense backreflections at tissue-air interfaces, or both. SPNs lacked both of these imaging features. Independent validation of OCT criteria by the six blinded readers demonstrated sensitivity and specificity of 95.4% and 98.2%, respectively. Conclusions We have developed and validated OCT criteria for lung parenchyma and SPN with sensitivity and specificity > 95% in this ex vivo study. We anticipate that OCT could be a useful complementary imaging modality to confirm needle placement during TBNA to potentially increase diagnostic yield.

Summary Objectives To determine factors associated with diagnostic yield of ENB. Methods In 112 consecutive patients referred to our department between March 2010 and December 2010 the diagnostic work-up for solitary pulmonary lesions included a FDG-PET-CT scan, and ENB in combination with ROSE. The final diagnosis was confirmed by histopathological evaluation of specimen obtained either by ENB, or – if ENB was not diagnostic – by CT-guided fine needle aspiration or surgery. Results Thirty-seven (33%) subjects were female, mean age was 66.7 (±1.04) years. The mean diameter of lesions was 27mm (range: 6–46mm). In 83.9% the combination of PET-CT, ENB, and ROSE established a correct diagnosis, as defined by the definite histopathological result. 15.2% (17/112) of lesions were benign, and 84.8% (95/112) were malignant. For 112 procedures we observed a steep learning curve with a diagnostic yield of 80% and 87.5% for the first 30 and last 30 procedures, respectively. The diagnostic yield in lesions ≤20mm and >20mm in diameter was 75.6% and 89.6% ( p =0.06), respectively. No significant difference in diagnostic yield was seen depending on lung function, and the localization of the lesions. Two cases (1.8%) of pneumothorax were seen during and up to 24h after bronchoscopy, none of them required a chest tube. Conclusion Diagnostic yield increased with experience but was independent from the size of the lesion, the localisation in the lungs, and lung function. The diagnostic yield of ENB can be as high as for CT-guided transthoracic biopsies but carries a significantly lower complication rate.

Introduction In endobronchial ultrasound-guided transbronchial biopsy (EBUS-TBB), techniques using a thin bronchoscope or a guide sheath have been proposed for accurate biopsy instrument reinsertion into the bronchial route indicated by a radial ultrasonic probe. The purpose of this study was to compare the diagnostic yields of these techniques for peripheral pulmonary lesions. Methods Patients with suspected peripheral pulmonary lesions were included in this prospective, randomized, noninferiority study and assigned to undergo EBUS-TBB under fluoroscopic guidance using a prototype 3.4-mm thin bronchoscope or a 4.0-mm bronchoscope with a guide sheath. Results A total of 205 patients were enrolled and randomized, of whom 203 patients (101 thin bronchoscopic method; 102 guide sheath method) were included in the analysis. Diagnostic histologic specimens were obtained in 65% (41% for benign and 75% for malignant lesions) of the thin bronchoscopy group and 62% (25% for benign and 71% for malignant lesions) of the guide sheath group. Diagnostic performance of the thin bronchoscopic method was confirmed to be noninferior to the guide sheath method (difference in diagnostic yields, 3.6%; 90% confidence interval, −7.5 to 14.7%). Mean procedure time was significantly shorter in the thin bronchoscopy group than the guide sheath group (27 versus 33 minutes; p = 0.002). Complications including pneumothorax, moderate bleeding, and pneumonia occurred in 5% and 2% in the respective groups ( p = 0.28). Conclusions EBUS-TBB using the thin bronchoscope was noninferior to the guide sheath method for the diagnosis of peripheral pulmonary lesions and was associated with shorter procedural time.

We report a case of lung adenocarcinoma presenting as pure ground glass opacity (GGO) and diagnosed by bronchoscopy with the use endobronchial ultrasound with a guide sheath (EBUS-GS). The lesion was indistinguishable by real-time fluoroscopy but simultaneous endobronchial ultrasound scanning of the involved lung segment showed a hyperechoic shadow that was subtly more intense than a typical snowstorm appearance when scanning normal alveolar tissue. Transbronchial biopsy from this area revealed adenocarcinoma with lepidic growth.On hindsight, it was the aforementioned ultrasound pattern that helped us decide the sampling site for EBUS-GS guided TBB when fluoroscopy was equivocal. We hypothesize that this pattern is specific for GGO and we name it the Blizzard Sign.

SummaryPulmonary Langerhans’ cell histiocytosis (PLCH) and lymphangioleiomyomatosis (LAM) are two rare cystic lung diseases of unknown aetiology and different pathogenesis. Although the diagnosis can be strongly suspected on the basis of the medical history and clinical and radiological features, at times a pathological confirmation of the diagnosis is necessary. Surgical lung biopsy is considered the gold standard in the diagnosis of both LAM and PLCH. However, bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBB) are less invasive procedures that can be useful in diagnosis. BAL has a high specificity but low sensitivity for PLCH, and in an appropriate clinical context it can be used to establish the diagnosis. However, even if a high percentage of pigment-laden macrophages are found in the BAL fluid of patients with LAM, no BAL findings are considered suggestive for the disease. TBB shows a low diagnostic yield (10–40%) in PLCH because of the small amount of tissue obtained and the patchy nature of the disease, although it may be of more use in LAM.

Objetivo Describir la actividad de una de las primeras unidades de endoscopia respiratoria (UER) de nuestro pais analizando las indicaciones y tecnicas de broncoscopia diagnostica y terapeutica, y si se han modificado a lo largo de los anos. Material y metodos Estudio transversal de todas las broncoscopias realizadas en nuestra UER desde 01/1992 hasta 05/2009. Para analizar la evolucion de las indicaciones dividimos a la poblacion general en cuatro poblaciones agrupadas por orden cronologico segun la fecha de la exploracion. Para analizar las diferencias en la frecuencia de las distintas tecnicas a lo largo del tiempo empleamos el coeficiente Chi cuadrado de Pearson, aceptando como significativo un valor de p Resultados 30.359 exploraciones (1.785 exploraciones/ano); programadas 84,4% y urgentes 15,6%. De estas, 26.277 (86,5%) fueron diagnosticas, 2.668 (8,8%) terapeuticas y 1.414 (4,6%) intubaciones. Se ha producido un descenso estadisticamente significativo del numero de biopsias y cepillados bronquiales con un incremento significativo de las biopsias y punciones transbronquiales. Se han colocado 890 protesis endoluminales y se han realizado tratamientos con laser en 429 casos. El porcentaje de complicaciones ha sido escaso (0,5%) y la tolerancia de los pacientes con anestesia local fue considerada buena en el 91,1% de casos. Conclusiones El numero de broncoscopias realizadas en nuestra UER es elevado, en especial las terapeuticas. Las indicaciones y tecnicas realizadas se han modificado a lo largo de los anos de acuerdo con la evolucion de la tecnica y los cambios de incidencia de diferentes patologias neumologicas.

Background The diagnosis of centrally located intrapulmonary tumors not visible on bronchoscopy may be a challenge. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been shown to be useful for the evaluation of mediastinal lymph nodes. However, there have been no reports of the utility of EBUS-TBNA for the diagnosis of intrapulmonary tumors. Objectives The purpose of this study was to evaluate the usefulness of EBUS-TBNA for the diagnosis of intrapulmonary tumors located adjacent to the central airway. Methods From December 2002 to June 2007, 35 patients with pulmonary masses located close to the central airways were accessed by EBUS-TBNA. Conventional bronchoscopic biopsy before EBUS-TBNA was nondiagnostic in 25 of the 35 cases. Patients with endobronchial lesions were excluded from this study. Results EBUS-TBNA was performed in 19 peritracheal and 16 peribronchial lesions. Cytologic and/or histologic samples were diagnostic in 33 of 35 patients. The final diagnoses of the pulmonary masses were lung cancer in 26 cases (1 small cell lung cancer, 25 non-small cell lung cancer), metastatic lung tumors in 5, and BALT lymphoma in one. The sensitivity and the diagnostic accuracy of EBUS-TBNA for the diagnosis of unknown pulmonary masses was 94.1% and 94.3%, respectively. Conclusions Intrapulmonary lesions not assessable by conventional bronchoscopic procedures can easily be assessed and diagnosed by EBUS-TBNA as long as it is within the reach of the EBUS-TBNA scope. EBUS-TBNA is a real-time procedure with a high yield which can be applied for the diagnosis of lung tumors.

Bronchoscopy has been in clinical use for a long time with an excellent safety record. Unfortunately, the yield of bronchoscopic procedures for staging mediastinal lymph nodes as well as for the biopsy of peripheral lesions with conventional techniques has been disappointing. Transbronchial biopsy as well as transbronchial needle aspiration are generally performed without direct visualization, which partially explains this problem. The advent of endobronchial ultrasound has dramatically changed the environment, and, if used for guidance of transbronchial biopsy, lymph nodes can be reliable samples challenging the notion that mediastinoscopy should be the mediastinal staging procedure of choice. This article reviews technological background, application, and results of endobronchial ultrasound added to diagnostic bronchoscopy in the diagnosis and staging of patients with lung cancer.

Computed tomography (CT)-guided transbronchial biopsy (TBB) using an ultrathin bronchoscope with simulation by virtual bronchoscopy (VB) is effective for diagnosing small peripheral pulmonary lesions. However, we occasionally lose the proper bronchi to the lesion when a bronchoscope is inserted into peripheral bronchi with severe rotation. To overcome this problem, the virtual bronchoscopic navigation system that can display real-time VB images during TBB procedures in comparison with actual bronchi has been developed. We evaluated the usefulness of the virtual bronchoscopic navigation system for CT-guided TBB using an ultrathin bronchoscope (navigation method) to diagnose small peripheral pulmonary lesions, and compared the results to those with previous method that uses VB images in a simulation (simulation method). We performed CT-guided TBB using an ultrathin bronchoscope for 69 patients with 71 small peripheral pulmonary lesions (mean diameter, 13.7 mm) between November 2002 and November 2005 with the navigation method. CT-guided TBB with the navigation method was performed safely without any serious complications for all patients. Mean time to the initial scan, time to the first biopsy and total examination time were 5.3, 8.5 and 24.5 min, respectively. Fifty lesions (70%) were diagnosed by this procedure. Compared to simulation method, diagnostic sensitivity was higher in the navigation method, but the difference was not significant. However, the time to the first biopsy and total examination time were significantly shorter in the navigation method than in the simulation method (p

Introduction:The diagnostic yield of flexible bronchoscopy for peripheral pulmonary lesions is variable and often limited. Endobronchial ultrasonography (EBUS) has been reported to help localize a bronchoscopic occult pulmonary lesion and thereby improve the diagnostic yield of transbronchial biopsy (TBB).Methods:We evaluated the yield of EBUS-guided TBB in 50 consecutive patients with a bronchoscopic occult pulmonary lesion.Results:The mean diameter of the lesions was 36.6 mm (SD = 19.7 mm). We could visualize 74% of the bronchoscopic occult lesions with EBUS, and in these patients, a histologic diagnosis on TBB was obtained in 84%. However, the diagnostic yield was very poor for lesions

OBJECTIVE: To analyze the individual and combined diagnostic yield and clinical utility of transbronchial needle aspiration and transbronchial biopsy in the histologic diagnosis of sarcoidosis in stages I and II. PATIENTS AND METHODS: We performed a prospective study enrolling all the patients admitted to our hospital between July 2001 and June 2006 with mediastinal lymph nodes of a diameter of over 10 mm and clinical and radiological indication of sarcoidosis. The patients underwent the following tests in the order specified: a transbronchial needle aspiration of 1 or more lymph nodes using a 19-gauge histology needle until 2 satisfactory specimens were obtained, a bronchoalveolar lavage, and 4 to 6 transbronchial biopsies. RESULTS: A total of 32 patients were enrolled during the study period. Of these, 26 were finally diagnosed with sarcoidosis. The mean (SD) age of the patients was 38.9 (10.6) years and there were 13 women (50%). The mean (SD) lymph node diameter was 23.5 (6.5) mm. The most common lymph node aspiration sites were the subcarinal station (9 patients, 34.6%) and a combination of the subcarinal and paratracheal stations (7 patients, 26.9%). Computed tomography scans of the chest revealed parenchymal involvement in 12 (46.2%) patients. Fifteen (57.7%) patients were diagnosed by transbronchial biopsy and 16 (61.5%) by transbronchial needle aspiration. These techniques were used in isolation in 7 (26.9%) and 8 (30.8%) patients, respectively (P>.05). Diagnosis was achieved with the combined results of transbronchial biopsy and needle aspiration in 23 (88.4%) patients. Overall, the diagnostic yield of the combined techniques was significantly higher than that of either one in isolation (P=.01 vs transbronchial biopsy and P=.02 vs needle aspiration). In patients with parenchymal involvement, yield was better for the combined techniques only in comparison with transbronchial biopsy (P=.01). Only 4 (15%) patients developed complications and 20 (76.9%) tolerated the procedures well. CONCLUSIONS: Diagnostic yield was significantly higher when transbronchial biopsy and transbronchial needle aspiration were used in combination than when used alone, particularly in patients without parenchymal involvement. There were few complications and tolerance was good.

Objectives: To evaluate the usefulness of the Sasada transbronchial angled forceps (STAF) in patients with peripheral pulmonary lesions (PPLs), which are difficult to manipulate with standard forceps. Methods: We have invented the STAF, a forceps with an angled tip. One hundred ten patients with PPLs that were difficult to reach with standard forceps were retrospectively evaluated. The patients first underwent bronchoscopy with a standard forceps and then with the STAF. The specimens obtained with standard forceps and those obtained with STAF were separately fixed and analyzed histologically. We compared the histologic diagnosis of the specimens obtained by STAF with that obtained by the specimens obtained with standard forceps. Statistical significance was calculated with the McNemar χ2 statistic. Results: The diagnostic yield of all lesions from the specimens obtained with STAF (86 of 110 lesions; 78.2%) was significantly higher than that of lesions from the specimens obtained with standard forceps (43 of 110 lesions; 39.1%; p Conclusions: The STAF was shown to be useful for obtaining specimens that were sufficient for histologic diagnosis from PPLs that were difficult to manipulate with standard forceps.

Este artículo completa las recomendaciones sobre el uso y aplicaciones del broncoscopio flexible en la infancia, del Grupo de Técnicas de la Sociedad Española de Neumología Pediátrica, incluyendo los procedimientos que, con fines diagnósticos y ocasionalmente terapéuticos, se aplican con mayor frecuencia durante la práctica de la broncoscopia flexible: el lavado broncoalveolar y las biopsias bronquial y transbronquial. Se realizan también recomendaciones para la práctica del lavado broncoalveolar no broncoscópico.Se revisan las indicaciones, contraindicaciones, recursos materiales, el cuidado y monitorización del paciente previo, durante y posterior al procedimiento, y las complicaciones de las técnicas. Estas recomendaciones pueden adoptarse, modificarse o rehusarse, según las necesidades clínicas de cada centro. : This article completes previous recommendations of the Techniques Group of the Spanish Society of Pediatric Pulmonologists on the practice of flexible bronchoscopy in children. We review the most frequently performed diagnostic and therapeutic procedures applied through the flexible bronchoscope: bronchoalveolar lavage, bronchial biopsy and transbronchial biopsy. Recommendations are also provided on the practice of nonbronchoscopic bronchoalveolar lavage.We review the indications and contraindications of these techniques, the equipment required, and the preparation and monitoring of the patient before, during and after the procedure. The complications of these techniques are also discussed. These recommendations may be adopted, modified or rejected according to clinical needs and constraints.

a b s t r a c t Granulomatosis with polyangiitis (Wegener) (GPA) was diagnosed in a 44 year-old-man who had a relapse 6 years after diagnosis with the "air crescent" sign on chest CT. Seven years after his diagnosis the patient presented a new relapse with cavitary lung disease, and high levels of anti-proteinase 3 antibodies, suggesting disease activity; however, a transbronchial biopsy showed histological findings of tuberculosis (TB). The association between TB and GPA is rarely informed; moreover TB and GPA have similar findings including both clinical and anti-proteinase 3 antibodies. © 2011 Elsevier Espana, S.L. All rights reserved.

Proper interpretation of transbronchial biopsies is critical for appropriate patient management. Artifacts in lung tissue acquired during the biopsy procedure or subsequent processing may mimic "true" disease and potentially lead to incorrect diagnoses. In this study the interpretation of various artifacts in transbronchial biopsies will be correlated with the level of pathologist training and experience. Minced 1 to 2 mm fragments of normal lung tissue were processed to produce various tissue artifacts (atelectasis, sponge artifact, or bubble artifact). Seven hematoxylin-eosin–stained slides of various artifacts and three similar-appearing slides from "true" pulmonary diseases (lipoid pneumonia, usual interstitial pneumonia, and foreign body reaction) were evaluated by eight pathologists of different levels of training and experience. Most pathologists were unaware of the various artifacts in transbronchial biopsies and were occasionally able to differentiate them from true disease. Senior faculty frequently identified and correctly diagnosed the true pathology slides; however, they often failed to recognize artifacts. Junior faculty performed the best by correctly identifying the majority of true pathology and dismissed most artifacts. Junior and senior residents described the microscopic changes, but had more difficulty determining the significance of both true pathology and artifacts. Various artifacts in transbronchial biopsy specimens can create diagnostic dilemmas for all pathologists regardless of level of training. The elimination of these artifacts should reduce the possibility of biopsy misinterpretation. Ann Diagn Pathol 7:20-24, 2003. Copyright 2003, Elsevier Science (USA). All rights reserved.

La evaluacion de las enfermedades del mediastino continua siendo un reto en la actualidad. Ademas, en muchos casos el diagnostico anatomopatologico es imprescindible para decidir el tratamiento mas adecuado. La ultrasonografia endoscopica (USE) con y sin puncion aspirativa (PAAF) ha emergido en los ultimos anos en este contexto como una tecnica poco invasiva y muy eficaz solventando muchos problemas de las tecnicas radiologicas convencionales en la obtencion de material para el estudio histologico y obviando la necesidad de recurrir a tecnicas quirurgicas invasivas, todo ello con una morbilidad minima. Asi, la sensibilidad, la especificidad y la precision diagnostica de la USE-PAAF en el diagnostico de las adenopatias mediastinicas de origen incierto se situa alrededor o por encima del 90%. El papel de la USE-PAAF en la evaluacion del carcinoma de pulmon no esta aun tan bien establecido, pero todas las evidencias sugieren que es una buena tecnica de rescate cuando la puncion transbronquial no es diagnostica o incluso como exploracion inicial en el estudio de extension del mediastino independientemente de los resultados de la tomografia computarizada (TC). Estudios recientes sugieren ademas que la USE-PAAF es la tecnica diagnostica no quirurgica mas costeefectiva en el estudio de las enfermedades mediastinicas. Role of ultrasound-guided endoscopy in the evaluation of mediastinal lesions The evaluation of the mediastinum is still a challenge. In most cases, a pathologic study is mandatory for therapeutic decision-making. In this setting, endoscopic ultrasonography (EUS) without and with fine needle aspiration (FNA) is currently considered as a very useful and safe non-invasive technique since it overcomes most problems raising from standard radiologic techniques at the time of obtaining histologic confirmation. Moreover, it avoids the surgical approach for diagnosis in a significant number of patients. Thus, performance characteristics (sensitivity, specificity and accuracy) of EUS FNA in the diagnosis of mediastinal lymph nodes of unknown origin are higher than 90%. The place of EUS FNA in the staging of lung cancer is not well established yet, but available data suggest that it can play a major role in patients with negative transbronchial biopsy or even in the initial evaluation regardless of CT results. Finally, recent studies also suggest that EUS FNA is the most cost-effective non-surgical technique for the study of the mediastinum.

A 59-year-old man presented with severe paroxysms of cough associated with dyspnea. His CT scan showed diffuse bilateral ground glass opacifications. His bronchoalveolar lavage fluid was consistent with pulmonary alveolar proteinosis. Transbronchial biopsy, microbiological studies, and cytology did not identify any alternative diagnosis. The patient had a history of working as a textile loom technician for thirty-one years and had significant exposure to cotton dust. He responded well to whole lung lavage with improvement of symptoms, gas exchange, and CT scan. This patient represents the third reported case of pulmonary alveolar proteinosis associated with cotton dust exposure. We suggest that cellulose might be useful in animal models of pulmonary alveolar proteinosis.

The diagnosis in cases of mediastinal and/or hilar lymphadenopathy with no lung parenchymal involvement is often difficult. We undertook this study to assess the diagnostic value of flexible bronchoscopy (FOB) especially transbronchial needle aspiration (TBNA) and transbronchial lung biopsy (TBLB) in these patients.Forty eight patients with hilar and/or mediastinal lymphadenopathy without any parenchymal lung lesions, managed between 2000 to 2004 at a tertiary care centre who underwent FOB were evaluated retrospectively.Out of 48 patients, FOB showed widening of carina in six, widening of secondary carina in four, bulge in airways because of extrinsic compression in seven and endobronchial nodule in two patients. It was normal in rest 29 patients. TBNA was done in all patients and TBLB in 13 patients where clinico-radiologic findings were consistent with stage 1 sarcoidosis. FOB established diagnosis in 18 patients (caseating granuloma in eight, noncaseating granuloma in nine, and AFB culture positive in one). It was inconclusive in other patients. One patient developed pneumothorax requiring intercostal tube drainage.FOB especially TBNA has an important role in the diagnosis of hilar and mediastinal lymphadenopathy and should be considered before other invasive procedures.

Summary A diagnosis of Churg–Strauss syndrome forme fruste was made from the histology of a transbronchial biopsy sample taken from a 49-year-old woman. Her case history supports the generally accepted hypothesis of the patho-mechanism of the disease, i.e., ongoing corticosteroid therapy can control the underlying disease, which manifests shortly after withdraw the corticosteroid therapy.

Transbronchial biopsy has become the procedure of choice for the diagnosis of acute lung rejection after transplantation, but the sensitivity of the technique in this setting remains unknown. In this study, 14 mongrel dogs underwent left lung transplantation, after which triple-drug immunosuppression was given for 5 days and then all immunosuppression was stopped. All animals had clear chest radiographs at this time. Transbronchial biopsy was performed in nine lung regions (two to six pieces of lung tissue were obtained per region, with a mean of 4.3 pieces per region) before the animals were killed 2 to 4 days later, at which time varying degrees of rejection had occurred. Rejection was graded histologically on a scale of 0 to 3 (0 = no rejection, 1 = mild rejection, 2 = moderate rejection, 3 = severe rejection) in each piece of lung tissue obtained at transbronchial biopsy. After the dogs were put to death, the true state of lung rejection was determined by histologic examination of the entire lung. We calculated the sensitivity of transbronchial biopsy with 95% confidence intervals. Five pieces of lung tissue were needed to yield a sensitivity of 92% (82%, 100%) to identify mild rejection in the entire lung with transbronchial biopsy. Three pieces of lung tissue were needed to yield a sensitivity of 92% (84%, 100%) to identify the presence of moderate to severe rejection in the entire lung (that is, rejection that requires pulse therapy) on transbronchial biopsy. These results indicate that three to five pieces of lung tissue that are suitable for diagnostic purposes obtained at transbronchial biopsy are adequate for the diagnosis of acute pulmonary rejection after lung transplantation.

To evaluate the utility of the CT bronchus sign in making a choice between transbronchial biopsy (TBB) and transthoracic needle aspiration (TTNA) as the first diagnostic procedure in a patient with a solitary pulmonary nodule (SPN), we reviewed the results of TBB and TTNA in 26 patients who had a bronchogenic carcinoma less than 3 cm, studied with thin-section CT. The patients were divided into two groups. Group 1 included ten cases with a third- to fifth-order bronchus sign. Group 2 included two cases with a sixth-order bronchus sign and 14 cases with absence of a bronchus sign. TBB was performed in all the patients; conversely, TTNA was carried out in 22 patients. In group 1, TBB gave a diagnostic yield in eight (80 percent) of ten patients, while TTNA was positive in three (42 percent) of seven patients (p>0.05). Conversely, in group 2, results of TBB were normal in all the patients, while TTNA gave a diagnosis in 10 (66 percent) of 15 patients (p