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Excisional biopsies are typically used to diagnose lymphoma, but data suggest that endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is equally effective. In this study, we determined whether EBUS-TBNA could accurately diagnose and subtype lymphoma.The cases of patients who had undergone EBUS-TBNA for suspected lymphoma were retrospectively reviewed. EBUS-TBNA results were categorized as lymphoma, specific nonlymphoma diagnosis, granulomatous inflammation, or adequate or inadequate lymphocytes with no specific diagnosis. To quantify the ability of EBUS-TBNA to diagnose lymphoma, we used likelihood ratios. To quantify the ability of EBUS-TBNA to diagnose and subtype lymphoma, we calculated sensitivity and specificity. For this analysis, lymphoma that could be subtyped on the basis of EBUS-TBNA was classified as a true positive; lymphoma that could not be subtyped was classified as a false negative.Of the 181 patients included, 75 (41.5%) were ultimately diagnosed with lymphoma. EBUS-TBNA was able to establish a diagnosis of lymphoma in 63 patients (84%). Granulomatous inflammation diagnosed on the basis of EBUS-TBNA was associated with a low likelihood of lymphoma being present (likelihood ratio, 0.00; 95% confidence interval [CI], 0.00-0.276). Adequate lymphocytes were associated with a low likelihood of lymphoma (LR, 0.25; 95% CI, 0.14-0.49). EBUS-TBNA was able to establish a diagnosis and subtype the lymphoma in 67% (95% CI, 0.45-0.88) of patients with de novo lymphoma and 81% (95% CI, 0.70-0.91) of patients with relapsed lymphoma.EBUS-TBNA is an effective, minimally invasive diagnostic test for patients with suspected lymphoma and can provide valuable clinical information, even with "negative" results.

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.To determine whether the type of sedation influences the diagnostic yield of EBUS-TBNA, its complication rates, and patient tolerance.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.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%) (P0.001). Most patients stated they "definitely would" undergo this procedure again in both groups (P = 0.355).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).

Background Non-palpable thyroid nodules can be difficult to access by conventional ultrasound-guided fine needle aspiration, particularly when they are intrathoracic. Many of these patients are subject to multiple follow up scans or invasive diagnostic procedures such as mediastinoscopy or surgical resection. We aim to describe the feasibility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for diagnosis of thyroid lesions. Methods All EBUS-TBNA performed at our institutions from February 2010 to February 2013 were screened, and those in which a thyroid biopsy was performed were reviewed. Results We identified 12 cases of EBUS-TBNA thyroid biopsy. Nine patients had an indication for EBUS in addition to their thyroid lesions. The median age was 64 years (range 44 to 84 years), and 10 patients were male. Median lesion size was 22.5 mm (range, 10 to 43 mm). Five lesions were strictly intrathoracic. All cases were sampled with a 22G needle and rapid on-site cytologic examination. Adequate samples were obtained in all 12 cases. Malignancy was identified in 3 of the 12 patients (metastatic breast adenocarcinoma, large B-cell lymphoma, and metastatic lung adenocarcinoma). The remaining 9 samples were deemed to be benign nodules. Seven of these were confirmed by clinical follow-up (n = 3), biopsies (n = 3), or surgery (n = 1). There were no EBUS-related complications. Conclusions EBUS-TBNA might be a safe and effective alternative for sampling thyroid lesions, particularly useful for those located below the thoracic inlet. Further prospective studies are required to compare its diagnostic yield and safety profile with standard techniques.

A 39-year-old male non-smoking lumberyard worker from northern Mississippi was referred for evaluation of a left lower lobe mass. He had been treated 4 years earlier for papillary thyroid cancer with thyroidectomy and radioactive iodine ablation. Neck dissection after treatment showed 5/54 nodes with metastases and 3 nodes with granulomatous inflammation. He had been followed without evidence of recurrent malignancy until a CT obtained during a respiratory infection showed a left lower lobe mass extending to the hilum …

Ultrasonography can provide guidance for several diagnostic and therapeutic procedures, and is now considered the standard of care for the evaluation of patients with pleural diseases. Ultrasonography is a particularly useful tool in the evaluation of pleural effusion and pleural thickening, with advantages such as portability, low cost, and safety.

Regardless of its volume, hemoptysis is a concerning symptom. Mild hemoptysis and its significance in patients with solid malignancies has not been studied.We conducted a retrospective chart review of patients with solid malignancies who presented for evaluation of mild hemoptysis. In this population, we studied the impact of bronchoscopic findings and endobronchial therapies on overall survival and bleeding recurrence. Patients were categorized into four groups on the basis of the presence or absence of active bleeding and endobronchial disease at the time of initial bronchoscopy: active bleeding with endobronchial lesion (AB/EBL), active bleeding without endobronchial lesion (AB/no-EBL), absence of active bleeding but with endobronchial lesion (no-AB/EBL), and absence of active bleeding and endobronchial lesion (no-AB/no-EBL).Ninety-five of the 112 patients with solid malignancies and mild hemoptysis underwent bronchoscopies. There was a significantly lower median survival time for patients with bronchoscopic findings of active bleeding and endobronchial lesion compared with patients with no active bleeding and/or no endobronchial lesion (3.48 mo; 95% confidence interval [CI], 2.14-6.05). On a multivariate analysis, factors independently associated with improved survival were higher hemoglobin values (hazard ratio [HR], 0.78; 95% CI, 0.67-0.91) and cessation of hemoptysis without recurrence at 48 hours (HR, 0.43; 95% CI, 0.22-0.84). Variables independently associated with worse survival were disease stage (HR, 10.8; 95% CI, 2.53-46.08) and AB/EBL (HR, 3.20; 95% CI, 1.74-5.89).In patients with solid malignancies presenting with mild hemoptysis, bronchoscopic findings of AB/EBL are associated with decreased survival. Hemoptysis control without recurrence at 48 hours after endobronchial intervention may improve survival.

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 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.

The solitary pulmonary nodule (SPN) is frequently encountered on chest imaging and poses an important diagnostic challenge to clinicians. The differential diagnosis is broad, ranging from benign granulomata and infectious processes to malignancy. Important concepts in the evaluation of SPNs include the definition, morphologic characteristics via appropriate imaging modalities, and the calculation of pretest probability of malignancy. Morphologic differentiation of SPN into solid or subsolid types is important in the choice of follow-up and further management. In this first part of a two-part series, we describe the morphologic characteristics and various imaging modalities available to further characterize SPN. In Part 2, we will describe the determination of pretest probability of malignancy and an algorithmic approach to the diagnosis of SPN.

In this second part of a two-part series, we describe an algorithmic approach to the diagnosis of the solitary pulmonary nodule (SPN). An essential aspect of the evaluation of SPN is determining the pretest probability of malignancy, taking into account the significant medical history and social habits of the individual patient, as well as morphologic characteristics of the nodule. Because pretest probability plays an important role in determining the next step in the evaluation, we describe various methods the physician may use to make this determination. Subsequently, we outline a simple yet comprehensive algorithm for diagnosing a SPN, with distinct pathways for the solid and subsolid SPN.

The purpose of this review is to examine the literature on lung cancer screening with an emphasis on the prevalence of cancer in screen-detected nodules. On the basis of the evidence, we will then develop a practical approach to screen-detected lung nodules.The first large randomized controlled trial using low-dose computed tomography (LDCT) found that persons undergoing three annual screening examinations with LDCT had a 20% relative reduction in lung cancer mortality as compared with those screened with annual chest X-rays. The probability of cancer in screen-detected nodules depends on their size and whether the nodules are detected on prevalence or incidence screens. The probability of cancer in screen-detected nodules ranges from 2.4 to 5.2%. Management strategies for screen-detected nodules that have been used successfully include careful observation using serial CT imaging, CT-guided fine needle biopsy, and surgery in carefully selected cases. The most frequently used strategies involve serial CT imaging and CT-guided biopsy for larger nodules and those that demonstrate growth on follow-up.There is now evidence that LDCT in carefully selected high-risk populations can lead to better outcomes but the cost effectiveness of mass screening with LDCT is still unknown. Only patients at high risk for cancer should be screened.

A 76-year-old woman with history of multiple spinal surgeries was found to have chronic recurrent pleural effusion. Thoracentesis was performed, which showed a clear, "water-like" transudative fluid with a total protein level of 0.2 g/dL, glucose level equivalent to serum (118 mg/dL), low LDH level (76 U/dL), and low nucleated cell count. Given the appearance of the fluid, β-2-transferrin was checked, which confirmed the presence of cerebrospinal fluid in the pleural space. On the basis of the clinical presentation, pleural fluid analysis, clear appearance of the pleural fluid, and β-2-transferrin positivity, the patient was diagnosed with duropleural fistula.

A 36-year-old male with no medical history had sudden onset dyspnoea on minimal exertion. He was hemodynamically stable, chest x-ray was normal and computer tomography showed a saddle pulmonary embolus (PE). A transthoracic echocardiogram (TTE) revealed a large mobile thrombus in the right ventricle (RV) outflow tract and RV dilatation with …

We read with interest the article published by Fysh et al 1 in CHEST (April 2012) describing a high incidence (10%) of fractured, indwelling, pleural catheters (IPCs) and would like to comment on the much lower incidence of this complication as it is reported in the literature and in our experience with IPCs. Our review of seven publications on the subject, including a systemic review by Van Meter et al 2 comprising almost 2,000 IPCs, described only one case of a fractured IPC in a patient with mesothelioma and trapped lung. 3 In a review of our institutional database, we identifi ed only two fractured catheters out of 1,790 IPCs that we placed since 1998. While the cause of this signifi cant discrepancy in the rate of catheter fracture between the authors’ experience and ours is unclear, we would like to highlight several factors that could contribute to the variance

A 70-year-old man with mediastinal lymphadenopathy was referred to our centre for endobronchial ultrasound with transbronchial needle aspiration. During the bronchoscopic examination, two separate anatomical bronchial variances were observed: a supernumerary ‘true’ tracheal bronchus branching off from the distal right lateral wall of the trachea (figure 1A) and a displaced aberrant ‘tracheal’ bronchus arising from the distal lateral wall of the left main stem bronchus (figure 1B). There was a normal right upper lobe bronchus but the upper division truncus of the …

A 68-year-old woman with a history of laryngeal cancer status post-laryngectomy was referred to the emergency room for an abnormal chest CT scan. …