The different ways to establish a diagnosis : needle and forcep

printing supported by . Visit Chiesi at Stand B2.10 TUESDAY, SEPTEMBER 4TH 2012 P3594 The diagnostic yield and safety of fine needle aspiration of intrathoracic hydatid cysts: A three year retrospective study Obianuju B. Ozoh1,2, Coenraad F.N. Koegelenberg1, Raquel Brauns1, Elvis M. Irusen1, Florian von Groote-Bidlingmaier1 , Colleen A. Wright3, Mercia Louw3, Pawel T. Schubert3 , Chris T. Bolliger1. 1Medicine, University of Stellenbosch, Cape Town, South Africa; 2Medicine, University of Lagos, Nigeria; 3Anatomical Pathology, University of Stellenbosch, Cape Town, South Africa Background: Hydatid disease remains a clinically relevant entity in much of the developing word. A presumptive diagnosis may be confirmed by cytological analysis of liquid obtained by percutaneous aspiration of the cyst. There is, however, a paucity of data on the safety and diagnostic yield of this approach. Objectives: To assess ultrasound (US)-assisted transthoracic fine needle aspiration (TTFNA) of suspected thoracic hydatid cysts with regards to safety and diagnostic yield. Methods: We retrospectively included 11 cases (35.8±9.1 years, 7 females) who underwent US-assisted TTFNA over a three-year period and who were eventually confirmed to have histological proof (surgical resection) of hydatid cyst. Complications were reviewed, and the diagnostic yield of US-assisted TTFNA was compared with serology (using histology as the gold standard). Results: Cytology was diagnostic in 5/11 of cases (45.5%), compared to serology that was diagnostic in 6/8 cases (75%, p = 0.352). Cytology was diagnostic in one case with negative serology. A serious complication (empyema) was observed in one case. Conclusions: US-assisted FNA of thoracic hydatid cysts has a modest diagnostic yield. US-assisted FNA should be reserved for cases with indistinct imaging and/or a negative serology, given the risk of complications. P3595 EBUS-TBNA for diagnosis of granulomatous mediastinal lymphadenopathy Su Ying Low, Mariko S.Y. Koh, Thun-How Ong, Ghee-Chee Phua, Devanand Anantham. Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore Methods: Retrospective review of all patients who underwent EBUS-TBNA for suspected granulomatous mediastinal lymphadenopathy at Singapore General Hospital between 2008 and 2011. Results: Over 3 years 33/371(9%)patients underwent EBUS-TBNA for suspected granulomatous mediastinal lymphadenopathy – 18 for tuberculous(TB) and nontuberculous mycobacterial(NTM) lymphadenitis, 15 for sarcoidosis. Mean age 47±18 years, 54.5% male. Total of 49 lymph node stations were sampled, with station 7 the most frequent (43%). Median size of lymph node was 17mm(8-30), median number of passes per lymph node 2(1-5), and core biopsy obtained in 45(92%). Median follow-up was 9months(0.5-26). 13/18 patients had TB/NTM and EBUS-TBNA was diagnostic in 9. EBUS-TBNA cultures were positive in 6(67%), 1 showed acid-fast bacilli but cultures were negative, 2 had necrotizing granulomatous inflammation from biopsies and sputum cultures grew TB. Of the 4 false negatives, mediastinoscopy in 1 patient found NTM, 1 patient’s bronchial washings grew TB, and 2 patients responded to TB treatment. 14/15 patients had sarcoidosis and EBUS-TBNA was diagnostic in 9 with noncaseating granulomatous inflammation on histology. Of the 5 false negatives, 1 patient had a transbronchial lung biopsy consistent with sarcoidosis, the other 4 were diagnosed based on clinical history, response to treatment and follow-up. Sensitivities of EBUS-TBNA for TB/NTM, sarcoidosis and overall granulomatous mediastinal lymphadenopathy were 69%, 64%, 64%, NPV were 56%, 17%, 33%, and accuracies were 78%, 67%, 70% respectively. Conclusion: EBUS-TBNA can be useful in the diagnosis of suspected granulomatous mediastinal lymphadenopathy with a sensitivity and accuracy of >60%. P3596 EBUS-TBNA in a tertiary care center: Real life experience and quality assessment Philippe Nguyen, Michel Gagnon, Thomas Vandemoortele. Department of Pulmonology, Centre Hospitalier de l’Université de Montréal, Montreal, QC, Canada Introduction: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become the standard minimally invasive modality for sampling mediastinal lymph nodes. In this study, we evaluate our performance with the technique and propose a methodology that can be used in other center. Method: We included all EBUS-TBNA procedures performed in 2011 in our service. We proceeded to a thorough analysis of each case from a pragmatic perspective to evaluate the regional node sampling yield and our ability to conclude the investigation by achieving diagnosis and staging, avoiding unnecessary surgery and allowing direction for management. Results: EBUS-TBNA was performed in 53 consecutive patients. The indication was suspicion of malignant disease in 46 patients (87%) and benign in 7 patients (13%). In total, 117 nodes were sampled. The overall sensitivity ranged from 76 to 91% and the negative predictive value ranged from 78 to 92%. The median size of nodes was 15 mm. If malignant cells were discovered, histological precision was obtained in 68%. EBUS-TBNA was clinically sufficient in 43 of the 53 patients (diagnostic yield = 81%) and prevented 18 out of 27 patients (67%) from undergoing surgery. No major complications were reported. Conclusion: The attained sensitivity and negative predicitive value are similar to what has been published. Thorough analysis of patient cases is key in improving performance with this technique, and we encourage all centers to analyze their practice periodically in order to maintain quality standards. Finally, in our establishment, EBUS-TBNA offers clinicians an additional step to simplify healthcare and probably reduce the economic burden of such investigations. P3597 Transesophageal ultrasound-guided fine needle aspiration (EUS-guided FNA) as first diagnostic step of intrapulmonary lesions Micaela Romagnoli1, Lucia Crociani1, Carlo Gurioli1 , Gian Luca Casoni1, Alessandra Dubini2, Sara Tomassetti1, Christian Gurioli1 , Claudia Ravaglia1, Venerino Poletti1 . 1Thoracic Diseases, Pulmonology Unit, Forlì, Italy; 2Pathology, Pathology, Forlì, Italy Background: Bronchoscopy fails to establish a diagnosis in up to 30% of patients with centrally located lung cancer. EUS-guided FNA has been used for the diagnosis of suspected lung cancer near or adjacent to the esophagus in patients who had undergone a non-diagnostic bronchoscopy. Aim: To prospectively assess the feasibility and yield of EUS-FNA as first diagnostic step in the diagnosis of intrapulmonary tumours located near or adjacent to the esophagus. Study design: Patients with a CT-scan of the chest revealing an intrapulmonary tumour located near or adjacent to the esophagus were enrolled. They underwent EUS-FNA (Olympus, GF UCT 160) under deep sedation. Results: Fourteen patients were included, and EUS-FNA diagnosed lung cancer in all cases (12 NSCLC, 2 SCLC) (yield=100%). No complications occurred. The subtyping of (N)SCLC was allowed by cytological specimens in 9 cases (65%), by cell blocks in 3 cases (21%), whereas NSCLC could not be subtyped in 2 cases (14%). Conclusions: EUS-guided FNA might represent the first diagnostic step in patients with intrapulmonary tumours located near or adjacent to the esophagus. P3598 Virtual bronchoscopic navigation combined with endbronchial ultrasound for diagnosing small peripheral pulmonary lesions Masafumi Misawa, Haruki Kobayashi, Kei Nakashima, Nobuhiro Asai, Naoko Katsurada, Hideki Makino, Norihiro Kaneko, Masahiro Aoshima. Pulmonary Department, Kameda Medical Center, Kamogawa-city, Japan Background: Flexible fiberoptic bronchoscope may be a valuable procedure to evaluate pulmonary nodules. However, a diagnostic yield has been reported as low as 34% for peripheral lesions less than 2 cm in size. Objectives: This case series study evaluated the value of the virtual bronchoscopic navigation (VBN) combined with endobronchial ultrasound (EBUS) for diagnosing peripheral pulmonary lesions. Methods: Enrolled subjects were patients with pulmonary lesions which were deemed too small and peripheral for a conventional bronchoscopic sampling, who were referred to Kameda Medical Center for diagnostic bronchoscopy between September 2010 and February 2012. VBN was utilized to produce a pathway into the target lesion. Once the fiberoptic bronchoscope was advanced as far as possible in this pathway, a guide sheath with EBUS probe was then advanced to the target lesion under fluoroscopy guidance. After visualization of the lesion by EBUS, the probe was removed leaving the guide sheath in place. Samplings were then performed through the guide sheath under fluoroscopic guidance. Results: Study subjects included 58 patients with 62 lesions, mean age 68 years. The mean lesion size was 20 mm in diameter. Bronchi seen on VB image were highly consistent with the actual structure. The sensitivity for diagnosing malignancy was 43% and negative predictive value was 61%. Overall accuracy for diagnosis of all lesions was 69%. Conclusion: VBN combined with EBUS is useful method for collecting samples from small peripheral pulmonary lesions and may help increase the diagnostic yield of transbronchial samplings in diagnosing small peripheral pulmonary lesions. P3599 Efficacy of transbronchial biopsies in diagnostics of smear-negative pulmonary TB Ilya Sivokozov, Olga Lovacheva. Endoscopy, CTRI RAMS, Moscow, Russian Federation Background: Around half of all cases of tuberculosis are smear-negative. In order to achieve the final diagnosis and to find a susceptibility profile of mycobacteria, bronchosopy is used. Aim: To investigate the effectiveness of bronchosopy in the diagnosis of smearnegative TB. Materials and methods: We analyzed 99 cases of smear-negative, therapy-naive patients with pulmonary TB without cavity according to chest CT. All of them undergo a bronchoscopy with bronchial swabs with/without brush-biopsy of targeted bronchus. We analyzed further dataset: results of cytological examination of brush-biopsy (acid-fast bacilli detection, components of specific granuloma, 653s Thematic Poster Session Halle A-10 12:50 14:40 Abstract printing supported by . Visit Chiesi at Stand B2.10printing supported by . Visit Chiesi at Stand B2.10 TUESDAY, SEPTEMBER 4TH 2012 caseous necrosis) and results for all available material of luminescent microscopy, PCR, BACTEC MGIT 960, and classical Lowenstein-Jensen (LY)culture. Results: Brush-biopsy was performed in 81/99 pts (81.2%), cytology revealed acid-fast bacilli in 14/81 (17,3%), specific granuloma components were found in 12/81 (14.8%), caseous necrosis was found in 15/81 (18.5%). In summary, combining all three components, cytology revealed TB signs in 21/81 (25.9%) with brush. Luminescent microscopy of all biopsy types was positive in 6/81 (9.9%). PCR testing was positive in 60/99 pts (60.6%), whereas microbiology was less effective 15/99 (15.2%) for LY culture, and 42/99 (42.4%) for BACTEC. In summary, PCR and culture methods were strong enough to detect as much as 68/99 (68.7%) of all smear-negative TB-cases. Combining the cytology, genetics and culture data, 71/99 (71.8%) of cases were detected. Conclusion: Bronchoscopy with brush-biopsy with or without swabs is effective method of diagnostics for patients with smear-negative pulmonary TB. P3600 Intratumoral injection of tranexamic acid for control of biopsy-induced bleeding: Two years’ experience of a new bronchoscopic technique Adil Zamani. Pulmonary Medicine, Meram Medical Faculty, Konya University, Konya, Turkey Background: Significant bleeding may occur following forceps biopsy or brushing of necrotic or hypervascular tumors in the airways. In some cases, such methods as endobronchial instillation of iced saline lavage and epinephrine may fail to control the bleeding. Objectives: To describe and assess the efficacy of a new bronchoscopic technique using intratumoral injection of tranexamic acid (IIT) for control bleeding during biopsy procedure. Method: IIT was performed in those patients who had endoscopically visible tumoral lesions with continued active bleeding following the first attempt of bronchoscopic sampling (forceps biopsy or endobronchial needle aspiration). Tranexamic acid (TEA) in dose of 250-500 mg was injected through a 22-gauge Wang cytology needle (MW-122) into the lesion. After 2-3 minutes of waiting, multiple forceps biopsy specimens were obtained from the lesion. Results: Between Oct 2009 and Jan 2012, 14 male patients (mean age, 61 yrs; range, 41-80 yrs) underwent bronchoscopic IIT. Two patients with drug-eluting stents were on continuous dual antiplatelet therapy (aspirin plus clopidogrel). Multiple (3 to10; mean, 5.7) and deep biopsy specimens were obtained from the lesions without producing active bleeding. The following histopathologic diagnoses were made: squamous cell carcinoma (n=9), non-small cell lung cancer (n=3), and small cell carcinoma (n=2). There were no side effects observed with TEA. Conclusion: Bronchoscopic IIT is a useful and safe technique for controlling significant bleeding due to forceps biopsy procedure, and might be suggested as a prebiopsy injection for endobronchial necrotic or hypervascular tumors. P3601 Comparison of conventional forceps biopsy and cryobiopsy in endobronchial lesions HamidReza Jabbardarjani1, Ramin Sami1, Arda Kiani2, Mohammadreza Masjedi3. 1Tracheal Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran; 2Chronic Respiratory Diseases Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran; 3Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran Background and objectives: Forceps biopsy has long been the standard method of extracting samples from endobronchial lesions,however diagnostic yield of the specimen obtained by this method(72%)is not very desirable due to small size and artifact.Therefore,in order to increase the diagnostic yield in endobronchial lesions as well as diminish the complications we evaluated a new technique called cryobiopsy(using flexible cryoprobes to obtain frozen samples). Methods: All patients with endobronchial lesion except for vascular lesions referred to Intervention ward of Masih Daneshvari Hospital were included in this study.For each patient,6 specimen were obtained by conventional forceps,and 2 were extracted through cryobiopsy,one of them 3 seconds after freezing (CB3),and the other one 5 seconds after freezing(CB5).Bleeding during the procedure,and diagnostic yield of the samples were evaluated closely. Results: Of all 30 patients,diagnosis was achieved for 27 patients(90%).Diagnostic rate of forceps biopsies was 67%,while this rate was 80% and 78% for CB3 and CB5 respectively.Although there was no significant difference between these three rates, total diagnostic yield of both CB3 and CB5 together was significantly higher than conventional biopsy (P-value=0.016).Severe bleeding requiring APC to be controlled occurred in 2 cases during CB5,while no major hemorrhage happened during forceps biopsy. Conclusion: According to our results,obtaining at least two samples from endobronchial lesions by cryobiopsy technique can lead to a higher rate of diagnosis compared with 6 samples by forceps biopsy.However,duration of freezing(3 or 5 seconds)does not have a significant impact on the quality of specimen. P3602 Additional benefit of cryotechnique in transbronchial biopsies for histological diagnosis in interstitial lung disease (ILD) Henrik Wurps1, Sergej Griff2 , Wim Ammenwerth1, Torsten Blum1, Nicolas Schönfeld1, Thomas Mairinger2, Torsten T. Bauer1, Wolfram Grüning3. 1Klinik für Pneumologie, Lungenklinik Heckeshorn, HELIOS-Klinikum Emil v. Behring, Berlin, Germany; 2Institut für Pathologie, HELIOS-Klinikum Emil v. Behring, Berlin, Germany; 3Pneumologische Klinik, HELIOS Kliniken Schwerin, Mecklenburg-Vorpommern, Germany Background: Due to the small specimen size of transbronchial forcepsbiopsy, the histological diagnosis of interstitial lung disease is often difficult. In comparison transbronchial cryobiopsies were shown to be bigger and to contain more often and larger amount of alveolar tissue. Methods: Since 2009, all histological results of patients suspicious of ILD (clinical signs, pulmonary function, CT-scan-criteria) who underwent bronchocoscopy with transbronchial forcepsand cryobiopsy were analysed concerning the impact of the additional use of cryotechnique. Results: We evaluated data of 34 patients (age 60.0±13.2 years) who underwent forcepsand cryobiopsy. For 10 patients (29.4%) neither forcepsnor cryobiopsy assured a histological diagnosis. In 11 cases (32.4%) both methods ensured a diagnosis. In 12 cases (35.3%) a histological classification was found only in the cryobiopsy, in 1 case (2.9%) only in the forcepsbiopsy. Conclusion: By additiononal use of the cryoprobe in transbronchial biopsy, in this prospective case series up to today we were able to increase the amount of ensured histological diagnoses in ILD from 12/34 = 35,3% without cryobiopsy to 23/34 = 67,6% with cryobiopsy. This shows the high potential of cryotechnique as a tool in transbronchial biopsy in the diagnostic of ILD. P3603 In vivo probe-based confocal laser endomicroscopy in chronic diffuse parenchymal lung diseases Mathieu Salaun1,2, Stéphane Dominique1, Francis Roussel3, Anne Genevois4, Vincent Jounieaux5, Gérard ZALCMAN6, Luc Thiberville1,2 . 1Clinique Pneumologique, Rouen University Hospital, Rouen, France; 2Quant.I.F LITIS EA 4108, Rouen University, Rouen, France; 3Department of Cytology & Pathology, Rouen University Hospital, Rouen, France; 4Department of Radiology, Rouen University Hospital, Rouen, France; 5Department of Pneumology, Amiens University Hospital, Amiens, France; 6Department of Pneumology, Caen University Hospital, Caen, France Diagnosis of diffuse parenchymal lung diseases (DPLDs) is challenging and requires a multidisciplinary approach. Probe-based confocal laser endomicroscopy (pCLE) enables microimaging of the distal lung in vivo. Objective: To describe pCLE features in DPLD patients. Methods: pCLE was performed in 52 DPLD patients and 21 healthy volunteers (HV). Results were compared between HV and each of the pathologic groups, blindly to the diagnosis (Fisher’exact test and Bonferroni correction). The association between the pCLE and CTscan features was assessed using multivariate analysis. Results: 9 of the 17 pCLE descriptors were significantly more frequent in DPLD patients than in HV (131 areas). pCLE differed in sarcoidosis (16 patients, 105 areas) by the presence of fluorescent bronchiolar cells, convoluted acinar elastic fibers, alveolar nodules; in idiopathic pulmonary fibrosis (n=8, 36 areas) by interalveolar septal fibers and a rigid acinar elastic network; hypersensitivity pneumonitis (n=6, 34 areas) by bronchiolar and alveolar cells; non-specific interstitial pneumonia (n=6, 38 areas) by fluorescent bronchiolar cells, septal fibers and a rigid network; asbestosis (n=10, 72 areas) by alveolar mouths <200 μm, axial fibers >20μm, septal fibers, and a rigid and dense acinar elastic network; systemic sclerosis (n=6, 38 areas) by fluorescent alveolar cells, septal fibers and a rigid network. HRCT honeycombing was associated to pCLE large alveolar mouths and a disorganized elastic network; both interlobular septa thickening and cysts were associated to the presence of septal fibers using pCLE Conclusion: pCLE could be added to the multidisciplinary discussion for the etiological diagnosis of DPLD. P3604 Retrospective study of transbronchial cryobiopsy (TCB) data in a case series of 20 patients with interstitial lung disease Sebastian Böing, Lars Hagmeyer, Sven Stieglitz, Christina Priegnitz, Winfried Randerath. Institute for Pneumology, University Witten/Herdecke, Solingen, Germany Introduction: So far surgical lung biopsies are the state-of-the-art technique to obtain histological data in patients with interstitial lung disease. We analyzed whether histological specimens obtained by TCB could contribute to establishing the definite diagnosis and whether the procedure is a safe one. Methods: A series of 20 patients showing interstitial patterns in high-resolution computertomography underwent the procedure of TCB. In all patients, 2-3 biopsies were sampled from different ipsilateral segments. Results: In 16/20 (80%) cases the pathological findings correlated well with the suspected diagnosis according to clinical, serological, radiological and bronchoalveolar lavage fluid evaluation findings. In 4/20 (20%) patients the diagnosis 654s Thematic Poster Session Halle A-10 12:50 14:40 Abstract printing supported by . Visit Chiesi at Stand B2.10printing supported by . Visit Chiesi at Stand B2.10 TUESDAY, SEPTEMBER 4TH 2012 remained doubtful after TCB so that these patients were subsequently forwarded to video-assisted thoracoscopic biopsy. In 3/4 (75%) of these cases the surgical lung biopsy and the TCB specimen showed the same histological pattern, therefore leading to a definite diagnosis. Regarding the safety of the studied procedure: in 4/20 (20%) patients an iatrogenic pneumothorax occurred after TCB, endobronchial bleeding was severe in 1/20 (5%) cases and moderate in 11/20 (55%) cases. Bleeding in all patients could be stopped by endoluminal application of adrenaline. Conclusions: TCB seems to be a suitable minimal-invasive tool in the diagnostic work-up of ILD-patients with a moderate periprocedural risk. P3605 Diagnostic accuracy of transthoracic needle aspiration (TTNA) in the evaluation of pulmonary nodules Carmen Manta1, Massimiliano Sivori1 , Vanna Balestracci1, Donatella Fini1, Roberto Tomè1, Ugo Giannoni2, Ilan Rosemberg2, Pier Aldo Canessa1. 1Pneumology, San Bartolomeo Hospital, Sarzana, La Spezia, Italy; 2Radiology, San Bartolomeo Hospital, Sarzana, La Spezia, Italy Percutaneous transthoracic needle aspiration (TTNA) biopsy is a diagnostic procedure used in pulmonary nodules where bronchoscopy does not reach. The aim of this study is to assess the value of TTNA in our field where the exams are performed by pneumologists. We assessed 108 consecutive patients who had a TTNA biopsy from January 2008 and December 2010 at our ward. All patients had previously undergone to bronchoscopy with a negative diagnostic result but with a strong clinical suspicion for malignant injury. During CT examination diameters of lesions were measured and the point of aspiration of cytological sample was pinpointed. The point of aspiration was in periphery or in the middle of the lesion. Cytological examinations diagnosed 70 (64.8%) malignant cases. Among 38 non malignant cytology, 29 patients were proved false negative cases. Sensitivity of TTNA was 71%, specificity 100%. Sensitivity of TTNA of central samples was 76.32%, peripheral 69.81%. We divided all patients into two groups: malignancy or benign nature of cytology. We processed a table with measures of diameters of nodules.