Retrospective analysis of radial EBUS outcome for the diagnosis of peripheral pulmonary lesion: sensitivity and complications

BACKGROUND

The purpose of the current study was to clarify the sensitivity and complication rate of the radial (endobronchial ultrasound, EBUS) without the use of guide-sheath (GS) and fluoroscopy for lung cancer (LC), by measuring the distance from the orifice of the bronchus to the pulmonary lesion, as well as to analyze factors that can predict the diagnostic outcome.

MATERIALS AND METHODS

A total of 147 patients with peripheral pulmonary lesions (PPL) underwent radial EBUS-guided transbronchial biopsy (TBB) in between August 1, 2013, and August 31, 2014. We analyzed retrospectively radiological data, diagnostic work-up in everyday clinical settings, final diagnosis and complication rates, as well as factors influencing the diagnostic outcome.

RESULTS

Around 63.9% of PPLs were visualized by ultrasound. A definitive malignant diagnosis was established in 39 patients (26.5%) using radial EBUS. In the remaining 108 patients, additional procedures were performed. We missed LC diagnosis in 40 cases that results in a sensitivity of 49%. For malignant lesions visualized by radial EBUS, the sensitivity was 60%, compared with 24% for not visualized lesions. For malignant lesions, logistic regression was performed to identify the factors that had significant influence on visualization of the lesion and on diagnostic yield. Logistic regression analysis showed significant odds ratios (OR) for visualization depending on location of the lesion; upper lobe lesions were identified more frequent with OR of 3.85 (95% CI 1.42 - 10.98, p=0.009). Size above 30 mm had a non-significant OR of 2.11 (95% CI 0.80-5.73, p=0.134) for visualization.Diagnostic yield was only significantly influenced by visualization with the radial EBUS, OR 3.70 (95% CI 1.35-11.02, p=0.014). Location (p=0.745) and size above 30 mm (p=0.308) showed no significant increase in diagnostic yield.Other lesion characteristics defined on computed tomography, such as distance to carina and pleura, did not show any significant influence on the diagnostic yield. The complications rate was low with three cases of pneumothorax.

CONCLUSION

Radial EBUS has definitely its place in the diagnostic work-up of PPL, especially for the lesions that can be visualized by radial ultrasound. However, prospective randomized controlled studies are necessary to raise the diagnostic yield and to define factors that can predict the outcome, which will consequently enable selection of the 'right' patients for this diagnostic procedure.

[COPD symptom screening can identify patients who require palliation]

This study developed and tested a collaboration model to improve the quality of palliative care for all patients with life-threatening illness who require palliation. Journal audit was performed on 79 in-hospital patients. European Organisation for Research and Treatment of Cancer, Quality of Life Question-naire (EORTC-QLQ-C15-PAL) symptom screening was found to be applicable to all patients with life-threatening illness. It was found important to document the patients' wishes for the end of life care and furthermore the electronic correspondence was found to contain relevant and sufficient information for the continuity of care.

[Electromagnetic navigated bronchoscopy can be applied for diagnosing peripherally located lung cancer in patients with severely reduced lung function]

Electromagnetic navigated (EMN) bronchoscopy is a new diagnostic method, which has been used in Denmark since 2008. It is a safe method for diagnosing lung cancer in patients with severely reduced lung function. The method allows diagnosis of peripherally located tumours. From September 2009 to January 2012, the procedure has been performed in 56 patients. In total, 67 tumour evaluations have been conducted. In 15 patients a cancer diagnosis was made. In two patients, pneumothorax occurred. The risk of pneumothorax as a consequence of the EMN procedure was 3%. This is in line with results and experiences from other studies.

F-18 FDG positron emission tomography in primary breast non-Hodgkin's lymphoma

A 50-year-old woman had an irregular, mobile, firm right breast mass that became progressively larger in the past 3 months that measured 18 x 15 cm at the time of examination. She had no nipple discharge or skin changes. A 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG PET) showed a ring-shaped breast uptake consisting of high peripheral glycolytic activity and a cold center most likely representing necrosis or hemorrhage despite the absence of a history of trauma, surgical intervention, chemotherapy, or radiation to the breast. Whole-body images did not show any evidence of lymph node involvement or distant metastases. These results were confirmed by computed tomography of the chest, abdomen, and pelvis. Cytologic examination of a fine-needle aspiration of the breast mass showed diffuse large B-cell, intermediate grade, non-Hodgkin's lymphoma. Although it occurs infrequently, primary breast lymphoma should be considered in patients with a breast mass that shows a ring-shaped FDG uptake. A PET scan, in contrast to other imagining techniques, offers the advantage of screening the entire body, excluding the presence of metastases, and confirming the primary origin of the breast lymphoma.

Effects of metastatic and non-metastatic mammary adenocarcinoma on tissue distribution of gallium-67 in the rat

The purpose of this work was to study the effect of metastatic and non-metastatic mammary adenocarcinoma on tissue distribution of gallium-67 (67 Ga) citrate in Fischer-344 female rats by the use of gamma counting techniques. The homogenate (0.1 mm) of a sample of metastatic and non-metastatic tumor was implanted by subcutaneous injection in the right footpad of each animal's hind extremity. The animals bearing metastatic tumor were studied 2-24 days and the non-metastatic group 2-30 days after the implantation of tumor homogenate. The control group consisted of four animals and tumor-bearing groups of seven to eight animals at each time point. All animals were injected with 1.11 MBq of 67Ga citrate by intravenous administration and sacrificed in halothane anesthesia 48 h later. The relative tissue uptake data are presented as arithmetical mean value with a standard error and graphically demonstrated as normalized data with respect to control. The results demonstrate that 67Ga citrate uptake was largely unaffected in most organs by the presence of either metastatic or non-metastatic tumor. Gallium-67 uptake, however, was significantly and consistently increased in the popliteal lymph nodes of the ipsilateral extremity of tumor implant in the metastatic group. No difference was observed in the non-metastatic tumor group. The findings of this experimental work indicate that the host reaction to the tumor does not modify the gallium uptake characteristics in the normal tissues of tumor-bearing animals.

Poisoning with 2,4-dichlorophenoxyacetic acid treated by hemodialysis

In this paper four patients are presented who had been poisoned by 2,4-dichlorophenoxyacetic acid (2,4-D). The first patient, aged 51 years, had attempted to commit suicide by taking orally 400 ml of a 40% solution of 2,4-D. He was admitted in a coma, 6.5 h after poisoning. Extracorporal hemodialysis was performed and the course of the illness was satisfactory. The second patient, aged 80 years, had accidentally drunk 100 ml of a 40% solution of 2,4-D. He was admitted in a coma a few hours after poisoning. Hemodialysis and resin hemoperfusion were performed and the course of the illness was satisfactory. Prior to the above therapy the patient had a 2,4-D serum concentration of 177 mg/100 ml. 2,4-D clearance was 56.3 ml/min during this therapy. The third patient, aged 24 years, had drunk 200 ml of a 40% solution of 2,4-D in a suicide attempt, and paraquat poisoning was also suspected. He was admitted 10 h after poisoning and immediately hemodialysis and hemoperfusion were carried out: the course of the illness was satisfactory. On admittance the concentration of 2,4-D in serum was 122.5 mg/100 ml, and clearance was 72.9 ml/min during treatment. The fourth patient, aged 50 years, had accidentally drunk 100-200 ml of a 40% solution of 2,4-D. He was admitted in a coma 3 h after poisoning. Hemodialysis was performed and the course of the illness was satisfactory. On admittance the concentration of 2,4-D in serum was 37 mg/100 ml and clearance was 68.7 ml/min.(ABSTRACT TRUNCATED AT 250 WORDS)

Digoxin-like substance in the serum of uremic patients before and after hemodialysis

Digoxin concentrations in serum samples were measured before and after hemodialysis of 31 uremic patients (pts) who either never took digoxin or who had not taken digoxin for at least 1 year. False positive digoxin was found in 22 of 31 patients (71%) before hemodialysis and in 14 of 31 patients (45%) after hemodialysis. The concentrations ranged from 0.1 to 0.5 nmol/L, mean value was 0.20 +/- 0.16 before hemodialysis and after hemodialysis ranged 0.1 to 0.4 nmol/L mean value was 0.11 +/- 0.14 nmol/L. The difference before and after hemodialysis is statistically significant. Some of the patients had a constant value before and after hemodialysis. None had a higher value after hemodialysis than they did before. Eight patients, who had positive serum digoxin before hemodialysis with concentrations up to 0.5 nmol/L, became negative after hemodialysis. Our results indicate that a digoxinlike substance in uremic serum could be at least partly dialyzable.

The lack of clinical value of laboratory parameters in predicting outcome in acute renal failure

In 55 patients with either the oliguric and nonoliguric form of acute renal failure, some laboratory parameters for the analysis of prerenal and intrinsic types of acute renal failure were examined. The parameters were analyzed within 7 days of the clinically known beginning of the illness. The parameters were analyzed as follows: sodium in urine, creatinine urine/plasma ratio, urine osmolality, osmolality urine/plasma ratio, renal failure index, and fractional excretion of filtered sodium. Hemodialysis was performed in 29 of the 55 patients. The oliguric form of acute renal failure was present in 49 of the 55 patients. In relation to renal failure index, prerenal acute renal failure was present in 7 patients and intrinsic acute renal failure in 48. It appears that in patients with a clinical diagnosis of prerenal acute renal failure, the urinary parameters do not separate them from those with acute tubular necrosis. It also appears that in patients with laboratory diagnosis of prerenal acute renal failure (i.e., a RFT less than 1.0), the response to treatment is unpredictable and in fact may have a worse prognosis than in those with a RFI greater than 1.0 (5/7 deaths vs 10/48 deaths).

Effect of ionizing radiation on gastric secretion and gastric motility in monkeys

The prodromal syndrome of radiation sickness is characterized by nausea and vomiting but the pathophysiology and the treatment of this entity is largely unknown. We investigated this problem by determining the effects of ionizing radiation on gastric function with and without administration of the dopamine antagonist domperidone. We measured gastric electrical control activity (waves per minute), fractional emptying rate (percent per minute), acid output (microequivalents per minute), and plasma levels of immunoreactive beta-endorphin. Twelve conscious, chair-adapted rhesus monkeys were studied twice before, once immediately after, and once 2 days after a single 800-cGy (800 rads) 60Co total body irradiation. In addition to causing vomiting, total body irradiation transiently suppressed gastric electrical control activity, gastric emptying and gastric secretion, while increasing plasma levels of immunoreactive beta-endorphin. Domperidone had no effect on vomiting or gastric function either before or after irradiation, but it significantly increased plasma immunoreactive beta-endorphin.

Alterations in gastric mucus secretion in rhesus monkeys after exposure to ionizing radiation

The aim of the present study was to evaluate the effect of gamma-irradiation on soluble gastric mucus. Six conscious chair-adapted rhesus monkeys were studied once before and twice after exposure to ionizing irradiation (800 rads). Using a marker (99mTc-DTPA) dilution technique, acidic glycoprotein (AG), neutral glycoprotein (NG), ion, and fluid output were determined during a basal period and after the administration of an 80-ml water load. Irradiation significantly increased the outputs of both AG and NG during the basal period. After the water load, NG output remained elevated but irradiation abolished postload AG output thus inhibiting the normal rise in AG output stimulated by the load. Two days after irradiation NG output had returned to control levels whereas AG output was still suppressed. Sodium and potassium ion outputs were unaltered by irradiation. Chloride and fluid outputs were significantly inhibited on the day of irradiation but had returned to control levels within 3 days. These results indicate that irradiation produces significant changes in both the quantity and nature of the soluble mucus glycoproteins secreted into the gastric juice. It is suggested that these changes may compromise the protective ability of gastric mucus.

Effect of gamma-irradiation on the healing of gastric biopsy sites in monkeys. An experimental model for peptic ulcer disease and gastric protection

The acute effects of gamma-irradiation on the gastric mucosa have been studied in a primate model. Fiberoptic gastroscopies were performed in 6 rhesus monkeys in the basal state as well as 3 h and 3, 7, and 9 days after total body irradiation (800 rads). Gastric biopsy specimens (diameter 1 mm) obtained during each session were examined using light microscopy and scanning electron microscopy; in addition, subsequent healing of the biopsy sites was assessed visually. Gastric biopsy sites were completely healed in 3 days in the basal state; in contrast, ulcer craters (diameter 1 mm) were still present at the site of the biopsies 3, 7, and 9 days after the biopsies were performed in irradiated animals. Light microscopic examination of the biopsy specimens demonstrated only lymphocytic infiltration of the lamina propria. In contrast, scanning electron microscopic examination revealed that the size and number of microvilli of the gastric surface epithelial cells were increased on the day of irradiation compared to basal; 3-9 days later, numerous gastric surface epithelial cells were damaged or had disappeared so that bare areas of the lamina propria were visible in the specimens taken outside of the ulcer craters. These changes may reflect inadequate protection of insufficient regeneration of gastric mucosal cells which, in turn, would explain the persistence of ulcers after gastric biopsies were performed in irradiated monkeys.

Effects of a metastatic (13762) and nonmetastatic (R3230AC) mammary adenocarcinoma on radiocolloid localization in regional lymph nodes in Fischer 344 rats

Effects of a metastatic and nonmetastatic tumor on radiocolloid localization in regional lymph nodes in the rat were studied in order to examine further the hypothesis that suppression of radiocolloid uptake results from inhibition of macrophage phagocytic function by tumor products. On the basis of data obtained in the present model using homogenates of autologous spleen and two weakly immunogenic tumors introduced into the foot pad of rats, it is proposed that decreased radiocolloid uptake induced by a regional neoplasm may result from proliferation of nonphagocytic cellular elements within the regional lymph nodes and alterations in the cell population at the site of radiocolloid injection, which impede the transport of interstitially administered radiocolloid and its access to phagocytic macrophages, within primary and secondary regional lymph nodes. In its inception, therefore, suppression of radiocolloid uptake is not unique to neoplasia and may not directly reflect altered phagocytosis.

The predictive value of myocardial radioisotope scanning in animals treated with doxorubicin

Thirty-four New Zealand white rabbits were treated with doxorubicin and imaged weekly with Tc-99m pyrophosphate to define the value of abnormal myocardial images in predicting doxorubicin-induced cardiac toxicity. Increased myocardial uptake was detected in most animals on sustained treatment with doxorubicin. A greater proportion of the heart was involved with doxorubicin-related histologic changes in animals with strongly positive myocardial images than in treated animals with moderately positive or normal scans. The myocardial images returned to normal levels 2--6 wk after doxorubicin was discontinued. Five of seven rabbits that received doxorubicin after they had three moderately positive myocardial scans, died from congestive heart failure. Three rabbits whose doxorubicin was discontinued because of scan findings, survived for 6 wk or more before dying from renal failure. The three rabbits who received the highest total dose of doxorubicin died of renal failure without developing abnormal myocardial scans.