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Introducción: Es difícil obtener un diagnóstico tisular de tumores pulmonares de localización central en pacientes que no presentan anormalidades endobronquiales, y por tanto es un problema diagnóstico de consideración. Objetivo: El objetivo de este estudio fue evaluar el desempeño del ultrasonido endobronquial lineal con biopsia transbronquial por aspiración con aguja (USEB-BTBA) para el diagnóstico de tumores pulmonares de localización central. Métodos: Realizamos una revisión sistemática (PROSPERO, CRD42017080968) y buscamos estudios que evaluaran el rendimiento y/o la sensibilidad de USEB-BTBA para el diagnóstico de tumores pulmonares de localización central, en MEDLINE, Embase, BIOSIS Previews y Web of Science hasta el 18 de noviembre de 2018. Evaluamos la calidad del estudio mediante QUADAS-2 y efectuamos un metaanálisis de efectos aleatorios. Resultados: En total se identificaron 5,657 manuscritos; de éstos, se consideraron 14 para el estudio, que incluyeron a 1,175 pacientes sometidos a USEB-BTBA para el diagnóstico de un tumor intrapulmonar. Todos los estudios mostraron un alto riesgo de sesgo o problemas de aplicabilidad, especialmente en la selección de los pacientes. El rendimiento promedio de USEB-BTBA para diagnosticar tumores pulmonares de localización central fue 0.89 (IC 95% 0.84-0.92), y la sensibilidad promedio para diagnosticar tumores malignos fue 0.91 (IC 95% 0.88-0.94). Entre los estudios que publican esta información ocurrieron complicaciones relacionadas con el USEB en 5.4% de los pacientes (42/721). Conclusión: El USEB-BTBA tiene alto rendimiento y sensibilidad para diagnosticar tumores pulmonares de localización central, y es segura en pacientes seleccionados. Se recomienda emprender estudios prospectivos para evaluar el uso rutinario de este procedimiento en el diagnóstico de tumores intrapulmonares.

Background: Endoscopic ultrasound routinely guides lymph node evaluation for the staging of a known or suspected lung cancer. Characteristics seen on B-mode imaging might help the observer decide on the lymph nodes of risk. The influence of nodal size on the predictivity of these characteristics and the agreement with which operators can combine these for malignancy risk prediction is to be determined. Objectives: We evaluated (1) if prospectively scored individual B-mode ultrasound features predict malignancy when further divided by size and (2) assessed if observers were able to reproducibly agree on still lymph node image malignancy risk. Methods: Lymph nodes as visualized by EBUS were prospectively scored for B-mode characteristics. Still B-mode images were furthermore collected. After collection, a repeated scoring of a subset of lymph nodes was retrospectively performed (n = 11 observers). Results: Analysis of 490 lymph nodes revealed the short axis size is an objective measure for stratifying risk of malignancy (ROC area under the curve 0.78). With ≥8-mm size, 210/237 malignant lymph nodes were correctly identified (89% sensitivity, 46% specificity, 61% PPV, and 81% NPV). Secondary addition of B-mode features in Conclusions: Lymph nodes of ≥8-mm size and preferably even smaller should be aspirated regardless of other B-mode features. Observer disagreement in scoring both small and large lymph nodes suggests it is infeasible to include subjective features for stratification. Future research should focus on (integrating) other (semi)quantitative values for improving prediction.

Introduction: Fluoroscopy guided Bronchoscopy is used for the diagnosis of peripheral pulmonary lesions (PPLs), but its performance is not optimal. Rapid On Site Examination (ROSE) of cytological samples allows real-time feedback of adequacy during a diagnostic exam. Little is known about whether ROSE can affect the diagnostic accuracy of bronchoscopy in diagnosing PPLs. Materials and Methods: Our retrospective study assessed the impact of ROSE on the yield of fluoroscopy guided trans-bronchial sampling for the diagnosis of PPLs in 160 patients referred to the Interventional Pulmonology of the University Hospital of Brescia (Italy) between August 2018 and July 2019. In 80 consecutive patients ROSE was not performed (NO-ROSE group up to January 2019). For the following 80 patients ROSE was systematically performed both for trans-bronchial needle aspiration and biopsies. Histology from surgical resection or follow up CT scan at 6 months were used as reference standard. Results: The accuracy of fluoroscopy guided bronchoscopy for the diagnosis of PPLs in the ROSE group is higher than in the NO-ROSE group (88%vs79%). Prevalence of malignancy was 81% in both groups. Sensitivity of bronchoscopy on lesions with bronchus sign was 87% in the ROSE group and 88% in the NO-ROSE group. PPLs were smaller in the ROSE group (30,2 ±14.0 vs 38.1±22.3 mm, p Conclusions: Our retrospective analysis suggests that ROSE may increase the diagnostic yield of fluoroscopy guided bronchoscopic sampling of PPLs.

Background: Systematic assessment of lymph node status by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is indicated in (suspected) lung cancer. Sampling is herein guided by nodal size and FDG-PET characteristics. Ultrasound strain elastography (SE) might further improve risk stratification. By imaging tissue deformation over time, SE computes relative tissue strain. In several tissues, a lower strain (deformation) has been associated with a higher likelihood of malignancy. Objectives: To assess if EBUS-SE can independently help predict malignancy, and when combined with size and FDG uptake information. Methods: This multicenter (n = 5 centers) prospective trial included patients with suspected or proven lung cancer using a standardized measurement protocol. Cytopathology combined with surgery or follow-up imaging (>6 months) were used as reference standard. Results: Between June 2016 and July 2018, 327 patients and 525 lymph nodes were included (mean size 12.3 mm, malignancy prevalence 0.48). EBUS-SE had an overall AUC of 0.77. A mean strain n = 370), triple negative and positive nodes went from a 42% a priori chance of malignancy to 9 and 73%, respectively. Conclusions: EBUS-SE can help predict lymph node malignancy and may be useful for risk stratification when combined with size and PET information.

Introduction: Obtaining a tissue diagnosis of centrally located lung tumors in patients presenting without endobronchial abnormalities is challenging, and therefore a considerable diagnostic problem. Objective: The objective of this study was to evaluate the performance of linear endobronchial ultrasound guided-transbronchial-needle aspiration (EBUS-TBNA) for the diagnosis of centrally located lung tumors. Methods: We performed a systematic review (PROSPERO, CRD42017080968) and searched MEDLINE, Embase, BIOSIS Previews, and Web of Science till November 18, 2018 for studies that evaluated the yield and/or sensitivity of EBUS-TBNA for diagnosing centrally located lung tumors. We assessed the study quality using QUADAS-2 and performed random-effects meta-analysis. Results: A total of 5,657 manuscripts were identified; of these 14 were considered for the study, including 1,175 patients who underwent EBUS-TBNA for diagnosing an intrapulmonary tumor. All studies had a high risk of bias or applicability concerns, predominately regarding patient selection. The average yield of EBUS-TBNA for diagnosing centrally located lung tumors was 0.89 (95% CI 0.84–0.92) and average sensitivity for diagnosing malignant tumors was 0.91 (95% CI 0.88–0.94). Among studies reporting this information, EBUS-related complications occurred in 5.4% of patients (42/721). Conclusion: EBUS-TBNA has a high yield and sensitivity for diagnosing centrally located lung tumors and is safe in selected patients. Prospective studies are recommended to evaluate the routine use of this procedure for diagnosing intrapulmonary tumors.

Endobronchial ultrasound (EBUS) has revolutionized the field of bronchoscopy because it allows to observe peribronchial structures and distal peripheral lung lesions. The use of EBUS was first described by Hurte and Hanrath in 1992. EBUS technology exists in two forms: radial and convex transducer probes. The radial EBUS probe has a 20-MHZ (12-30 MHz available) rotating transducer that can be inserted together with or without a guide sheath through the working channel (2.0-2.8 mm) of a standard flexible bronchoscope. The transducer rotates and produces a 360-degree circular image around the central position of the probe. There are two types of radial EBUS probes: "peripheral" probes, used to identify parenchymal lung lesions, and "central" probes, with balloon sheaths, used for the assessment of airway walls and peribronchial lymph nodes.

Background: The short-axis diameter cut off of adequacy for EBUS-TBNA samples is not well established. This measure can be even more important during a EBUS/EUS systematic staging where many lymphnodes can be detected and it is essential to select which nodes should be punctured also considering the probability of obtaining an adequate sample. Aim: To determine a lymphnode short-axis diameter (SAD) cut off predictive of adequacy for EBUS-TBNA sampling during endosonographic systematic staging. Methods: We retrospectively reviewed 66 nodes measured and sampled during 16 systematic EBUS mediastinal staging procedures for NSCLC. SAD were measured during EBUS in patients referred for lung cancer staging and the adequacy of specimens at EBUS-TBNA assessed. A sample was considered adequate if at least 40 lymphocytes were present under x40 magnification. EBUS systematic staging was performed under deep sedation by 3 different operators with more than 4-year experience with EBUS-TBNA. Results: The mean SAD of the sampled mediastinal and hylar nodes is 8,1mm (3-20mm). EBUS-TBNA provided satisfactory samples from 52 nodal stations (79%) and an adequacy of 100% was reached for a short-axis diameter cut-off of 7 mm. Conclusion: In our first experience of mediastinal systematic staging EBUS-TBNA has an adequacy of 100% when lymphnodes with SAD³7 mm are sampled. Adequacy drops to 51% when SAD

Introduction: In selected cases, the management of cavities in tubercolosis consists in the combination of anti-TB chemotherapy and adjuvant lung resection. Method: We hypothesized that lung collapse therapy using one-way endobronchial valves may be effective in the treatment of TB with cavities. We report our early experience with 3 MDR-TB, 1 patient with Atypical Mycobacteriosis, and 1 TB patient with DRESS (Drug Rush Eosinophilia and Systemic Symptoms) Syndrome in whom TB cavity collapse was attempted using Zephyr valves (Pulmonx Inc., Redwood City, CA, USA). All except the one with DRESS syndrome, were treated with optimal anti-TB chemotherapy. Outcome: The insertion of Zephyr valves was achieved by standard bronchoscopy without complications. Two to three valves were inserted to isolate a cavity, and in most cases to exclude the whole lobe. 4 out of 5 patients were sputum + at the time of the procedure. A cavity collapse was observed in 4 out of 5 cases. All of the patients improved in clinical status and sputum smear was negative at last FU. There were no short and long-term complications related to this treatment. View this table: TABLE 1 - Conclusion: Our early experience shows that creating a hypoventilation and hypo-oxygenation zone by closing the TB cavities using Zephyr endobronchial valves is feasible and appears to provide long term clinical benefits.