Table of Contents
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FOREWORD
PREFACE
ACKNOWLEDGEMENTS
List of Contributors
LIST OF ABBREVIATIONS
Section A
Linear EBUS Not so Black and White - Principles of Staging Assessment in Non-Small Cell Lung Cancer via EBUS
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Systematic Approach to Mediastinal Node Staging with Linear EBUS
Presentation
Comorbidities
Chest Imaging
Intervention
EBUS-TBNA Procedural Steps
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Linear EBUS: Can Ultrasonographic Features of the Lymph Nodes be Used to Predict Malignancy?
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
How to Deal with Mush – Tackling the Necrotic Lymph Node During Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration?
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Endoscopic Ultrasound with Bronchoscope‐Guided Fine Needle Aspiration Case Series
Case A Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Case B Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Case C Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Linear EBUS Guided Trans-Vascular Needle Aspiration (EBUS-TVNA)
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Radial EBUS Novel Flexible Ultrathin Cryoprobe in the Biopsy of SPN under Radial Endobronchial Ultrasound Guidance
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Radial Endobronchial Ultrasound Guided Transbronchial Biopsy of SPN
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Manual Bronchial Branch Reading Technique in the Localization of Peripheral Pulmonary Lesion
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
USG Chest & Guided Procedures Peripheral Lung Mass with Ultrasound Assisted Percutaneous Lung Biopsy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Chest Wall and Pleural Lesion with Ultrasound Assisted Percutaneous Biopsy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Lung Mass with Ultrasound Guided Percutaneous Biopsy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Ultrasound Guided Percutaneous Biopsy of Mediastinal Mass
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Ultrasound Guided Percutaneous Trucut Biopsy of Chest Wall Mass
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Navigation Bronchoscopy (Biopsy, Dye Marking, Fiducial Marking) One-Stop Lung Nodule Biopsy and Fiducial Marker Placement with Electromagnetic Navigation Bronchoscopy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Electromagnetic Navigation Bronchoscopy Lung Nodule Dye-Marking for Re-Do Thoracoscopic Surgery
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Robotic Bronchoscopy Robotic Bronchoscopy for Peripheral Pulmonary Nodule
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Videos
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Evaluation of Cough and Left Lower Lobe “Pneumonia”
Presentation
Comorbidities
Chest Imaging
Initial Testing
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Cone Beam CT Cone Beam CT for the Diagnosis of Small Peripheral Pulmonary Nodules: It’s Not Always Lung Cancer
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Two for the Price of One
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Procedural Images
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
One View is Not Enough
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Procedural Images
Learning Points
CONSENT FOR PUBLICATION
CONFLICTS OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Cellvizio Optical Lung Biopsy
Abstract
Presentation
Comorbidities
Chest Imaging
Intervention
Image Interpretation
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Incidental Finding of Latent Tuberculosis in the Evaluation of Locally Advanced Colon Cancer
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Cryobiopsy in DPLD Transbronchial Lung Cryobiopsy to Diagnose Chronic Hypersensitivity Pneumonitis
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Transbronchial Lung Cryobiopsy to Diagnose Eosinophilic Pneumonia
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
A Case of Unilateral Interstitial Lung Disease – Transbronchial Lung Cryobiopsy Solved the Mystery
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Section B
Benign Central Airway Obstruction
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Micro Laryngeal Tube (MLT/MLS) Guided Debulking of Tracheo-Bronchial Lesions – An Alternative Option to Rigid Bronchoscopy
Intervention
Complications
Post-Intervention
Learning Points
Advantages of MLT/MLS Tube
Disadvantages of Using an MLT/MLS Tube
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Multidimensional Approach for Tracheobronchial Papillomatosis Lesions
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Endoscopic Treatment for Inflammatory Myofibroblastic Tumor of the Trachea
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Endoscopic Treatment of Pulmonary Mucormycosis in an Immunocompetent Patient
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Emergent Endoscopic Treatment for TB-Associated Tracheal Stenosis Mimicking Asthma in a Young Adult
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Mechanical ‘Coring’ as Part of Multimodality Treatment in Critical Post-TB Tracheal Stenosis
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Multimodal Endoscopic Management of Multi-Level Post-TB Tracheal Stenosis
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Bronchoscopic Management of Post-Intubation Tracheal Stenosis (PITS) in a COVID-19 treated Patient
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Malignant Central Airway Obstruction
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Recurrent Mucoepidermoid Carcinoma of the Bronchus
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Videos
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Typical Low-Grade Carcinoid Tumour Causing Central Airway Obstruction
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Debulking of Tumour (Muco-Epidermoid Carcinoma) Involving Right Main Bronchus Causing Complete Collapse of Right Middle and Lower Lobes
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Massive Haemoptysis Secondary to a Bleeding Pseudo-Aneurysm
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Haemorrhage Post Biopsy of a Bronchial Carcinoid: What can be Done when Airway Interventions are Unsuccessful?
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Airway Fistula Watanabe Spigot for Persistent Pyopneumothorax with Bronchopleural Fistula
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Airway Stent (Silicone) Management of Iatrogenic Tracheal Tear with Silicone Y-Stent under V-V ECMO
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Silicone Y-Stent for Extrinsic Central Airway Obstruction due to Hodgkin’s Lymphoma
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Silicone Y-Stent for Extrinsic Central Airway Obstruction due to Mediastinal Lymphadenopathy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Silicone Stent for Recurrent Post-Intubation Tracheal Stenosis
Presentation
Comorbidities
Chest Imaging
Airway Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Post Intubation Tracheal Stenosis: Hourglass Stent
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Airway Stent (Metallic)
Intervention
Complications
Post-Intervention
Learning Points
Indications for Airway Stenting in Malignant Conditions
Advantages of SEMS
Disadvantages of Using a SEMS
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Fully Covered Metallic Stent for Critical Tracheal Stenosis Secondary to Small Cell Lung Carcinoma
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Palliative Stenting in Malignant Tracheal Narrowing
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Removal of Partially Covered Self-Expandable Metallic Tracheal Stent in a Stepwise Approach
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
3D Printed Airway Stents
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Patient Specific 3D Printed Stent for Treatment of Central Airway Disease due to IgG-Related Lung Disease
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Excessive Dynamic Airway Collapse/Tracheo-bronchomalacia
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Tracheobronchomalacia
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Photodynamic Therapy
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Photodynamic Therapy for Tracheal Adenoid Cystic Carcinoma
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Photodynamic Therapy for a Left Lower Lobe Bronchial Carcinoid Tumor
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Microwave Ablation
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Bronchoscopic Microwave Ablations for Patients with Multiple Lung Nodules and Previous Lobectomy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Bronchial Thermoplasty
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Going Strong 6 Years Post-Bronchial Thermoplasty after Failure of Live Fish Treatment
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
The Bronchial Thermoplasty Revolution in the Treatment of Severe Asthma
Presentation
Comorbidities
Chest Imaging
Intervention
Session 1
Session 2
Session 3
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Bronchoscopic Lung Volume Reduction (BLVR)
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Sustained Benefits Out to 5 Years in an Emphysema Patient Following Zephyr Endobronchial Valve Therapy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Segmental Bronchoscopic Lung Volume Reduction with Thermal Vapour Ablation
Presentation
Comorbidities
Chest Imaging
Intervention
Planning
Treatment 1
Treatment 2
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Persistent Air Leak
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Endobronchial Valves for Persistent Air Leak
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Giant Bullae Treatment of Giant Bullous Emphysaema with Zephyr Endobronchial Valves
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Foreign Body Removal Bronchoscopic Retrieval of an Impacted Fish Bone
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Hijab Pin in the Airway
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Localised Bronchiectasis Caused by Foreign Body Aspiration
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Whole Lung Lavage for PAP Whole Lung Lavage for Pulmonary Alveolar Proteinosis
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
A Case of Pulmonary Alveolar Proteinosis with Good Response to Whole Lung Lavage
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Section C
Pleuroscopy: A Step by Step Approach
Therapeutic
Contraindications
Absolute Contraindications
Relative Contraindications
Equipment
Others
Pre-Procedural Preparation and Patient Monitoring
Steps
Potential Complications
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Pleuroscopic Adhesiolysis for Complex Pleural Effusion
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Pleuroscopy in Malignant Effusion. Is Pleural Fluid Cytology Enough?
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
‘TB or Not TB?’- A Call for Pleuroscopy when Investigations are not Confirmatory
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Flexi-Rigid Pleuroscope-Guided Cryobiopsy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Transthoracic Ultrasound and Veress Needle Assisted Pleuroscopy in a Patient with Minimal Pleural Effusion
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Medical Thoracoscopy with “Induction Pneumothorax”
Case Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Rigid Thoracoscopy in Undiagnosed Exudative Pleural Effusion
Abstract
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Grains of Sago in the Chest: Rigid Thoracoscopy for TB Pleural Effusion
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Indwelling Pleural Catheter for Benign Pleural Effusion: A Patient with Lupus Pleurisy
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
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REFERENCES
Indwelling Pleural Catheter for Malignant Pleural Effusion. Managing Symptomatic Loculations
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Indwelling Pleural Catheter for Malignant Pleural Effusion with Spontaneous Pleurodesis
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Indwelling Pleural Catheter: A Step by Step Approach (Figs. 2-8)
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Complication of Indwelling Pleural Catheter in a Patient with Advanced Breast Cancer
Abstract
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Removal of Indwelling Pleural Catheter for Complicated Pleural Infection
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Malposition of Indwelling Pleural Catheter into the Liver
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Intrapleural Fibrinolytics Alternative Regimen of Intrapleural Fibrinolytics with Alteplase and Pulmozyme for Complex Effusion in a Post-Surgery Patient
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Intrapleural Fibrinolytics with Alteplase and Pulmozyme for Complex Tuberculous Effusion
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Chest Ultrasonography Parapneumonic Effusion with Collapsed Consolidated Lung
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCE
Rapid Detection of Pneumothorax by Thoracic Sonography
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Point of Care Thoracic Ultrasound (Diaphragm) in a Post-COVID-19 Patient
Presentation
Comorbidities
Chest Imaging
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENTS
REFERENCES
Section D
Foreign Body Removal (Different Techniques)
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Retrieval of Missed Foreign Bodies in Children: The Cryoextraction Method
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
A Flower in the Lung
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
A Successful Foreign Body Removal with an Adverse Outcome
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
A Plastic Cap in the Lung
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Transbronchial Lung Cryobiopsy in DPLD
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
A Rare Case of “Brown Lung Induration”
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Bronchoscopic Airway Stenosis Repair
Intervention
Complications
Post-Intervention
Learning Points
Videos
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Bronchoscopic Repair of Post Intubation Tracheal Stenosis
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Neonate with Noisy Breathing and Choking Spells
Intervention
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Congenital Tracheal Stenosis and Successful Slide Tracheoplasty
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Recurrent Tracheal Stenosis and Tracheomalacia
Intervention
Complications
Post-Intervention
Learning Points
Videos
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Tracheobronchomalacia
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Post-Adenovirus Bronchiolitis Obliterans with Tracheobronchomalacia in a Young Child
Intervention
Complications
Post-Intervention
Learning Points
Video
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
Left Bronchomalacia Secondary to Vascular Compression
Intervention
Complications
Post-Intervention
Learning Points
Videos
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCES
Central Airway Obstruction
Intervention
Complications
Post-Intervention
Learning Points
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
ACKNOWLEDGEMENT
REFERENCE
A Case-Based Approach to Interventional Pulmonology: A Focus on Asian Perspectives
Edited by
Jamalul Azizi Abdul Rahaman
Department of Pulmonology Serdang Hospital Malaysia
&
Tinku Joseph
Division of Interventional Pulmonology Amrita Institute of Medical Sciences, Kochi, Kerala India
BENTHAM SCIENCE PUBLISHERS LTD.
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FOREWORD
My friend Jamalul has got a brilliant idea of writing a very original interventional pulmonology (IP) book based on clinical case scenarios. Today, evidence-based medicine and statistics are ruling our daily practice. Thus, each case is unique and each patient, somehow, follows his/her own way regardless of what the theory predicts or commands.
The Asian perspective is also of great importance given the differences in the etiologies compared to other regions of the world. Asia is the leading region in terms of population and the high incidence of certain airway and lung diseases is an amazing source for fundamental and clinical research.
Asia now possesses all the technical expertise to face this medical burden and IP experts, such as Jamalul, play a crucial role in training and spreading the knowledge. Jamalul honors me in calling me his mentor and, through me, he is part of the IP school of Marseille initiated by Jean-François Dumon, the father of interventional pulmonology. I can tell that he is a real member of this school which implies a passion for the art of bronchoscopy and IP procedures, mainly therapeutic bronchoscopy with the rigid bronchoscope.
Upon returning from Marseille, Jamalul pioneered rigid bronchoscopy amongst the pulmonologists in Malaysia. Over the past 14 years, he has dedicated himself to giving rigid bronchoscopy training to many local and overseas pulmonologists.
Tinku Joseph was one of Jamalul’s former students who is now doing excellent work and regularly teaching IP fellows. He started the first exclusive IP unit in Kerala state, India which performs basic and advanced bronchoscopic procedures. He is also a recipient of many international and national awards and was the first Indian doctor to win the best overall IP procedure award from the World Association for Bronchology and Interventional Pulmonology (WABIP).
Without passion, there is no positive energy in what anyone does. Without sustained motivation, there is no transmission of knowledge to the younger generation. Jamalul and Tinku Joseph have all the necessary passion and motivation to inspire our young colleagues and this book is certainly the cornerstone of this inspiration source.
Hervé Dutau
Associate Professor of Pulmonology
Head of the Thoracic Endoscopy Unit
Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Department
North University Hospital, Marseille, France
PREFACE
Our book primarily focuses on various aspects of Interventional Pulmonology (IP). To ensure an easy learning process, we have included many interesting diagnostic and therapeutic airway and pleural procedure cases. Leading experts in the field of IP from Asia, Canada and the US have contributed various cases.
Over the past 10 years, a lot of diagnostic and therapeutic innovations have taken place, paving the way for a significant boom in IP. The contents of our book have been divided into four different sections with a primary aim of case-based scenarios and solutions.
Section A consists of diagnostic IP procedures like linear and radial EBUS, navigation bronchoscopy, cryo lung biopsies and cone beam CT. We have included newer diagnostic modalities like cellvizio and robotic bronchoscopy as well.
Section B focuses on therapeutic rigid bronchoscopic procedures. Besides airway stenting and laser bronchoscopy, we have included recent interventions such as bronchial thermoplasty, bronchoscopic lung volume reduction, 3D printing and microwave ablation. Section C is dedicated to pleural procedures with the addition of the more recent ones such as indwelling pleural catheter (IPC) and fibrinolytics. Section D is dedicated to common paediatric IP procedures. The purpose of this book is not to provide the principles, theory or evidence of clinical practice of these procedures but to present actual case scenarios. We hope the book will complement the many IP books on the market that already cover the theory, principles and evidence of clinical practice.
Each case is presented with the history, including clinical, radiological, bronchoscopic/pleuroscopic findings and final outcomes. Many of these cases also have video illustrations as well. As a mark of respect to our patients, privacy identifiers have been intentionally omitted in the text and video presentations. Learning points are highlighted at the end of the case presentation.
Finally, we thank all the authors and co-authors for their hard work in making sure the work could be completed on time.
Jamalul Azizi Abdul Rahaman
Consultant Pulmonologist
Department of Pulmonology
Serdang Hospital
Malaysia
&
Tinku Joseph
Professor & Head of Interventional Pulmonology
Amrita Institute of Medical Sciences
Kochi, Kerala, India
ACKNOWLEDGEMENTS
Dr. Jamalul Azizi
I would like to thank my wife Suhani and our son Muhammad Izzat Al-Amin for allowing me to pursue my ambitions. It was not an easy job to complete the work during the COVID-19 pandemic. My gratitude to my mentor Dr. Hervé Dutau for inspiring me in the field of interventional pulmonology by imparting his skills and knowledge. A special thanks to Serdang Hospital where I work and the Malaysian Association for Bronchology and Interventional Pulmonology (MABIP) for their support building the interventional pulmonology subspecialty in Malaysia. Last but not least, my appreciation to Editor, Dr. Tinku Joseph for helping me with this project.
Dr. Tinku Joseph
Having an idea and turning it into a book is as hard as it sounds. To be honest, writing this book was harder than I thought and more rewarding than I could have ever imagined. None of this would have been possible without my supportive wife, Sania. From reading early drafts to giving me advice on the cover to keeping our little munchkin’s (Nichelle and Mikhail) out of my hair so I could edit, she was as important to getting this book done as I was. Thank you so much, dear.
I am eternally grateful to my parents, in-laws and brother for being my pillar of support throughout my life. Writing and editing a book, focusing on various aspects of Interventional Pulmonology was a surreal process and I express my sincere thanks to my mentor Dr. Jamalul Azizi for giving me an opportunity to be a part of this book. Also, a special thanks to my colleagues (especially Dr. Sreeraj) at Amrita hospital where I work, and to Mr. Sam who supported us in designing this book. I must thank God and my patients most of all, because without them I wouldn’t have been able to do any of this.
List of Contributors
Adnan MajidSection of Interventional Pulmonology, Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USAAisya Natasya MusaRespiratory Unit, Department of Internal Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), MalaysiaAjit NambiarDepartment of Pathology, Amrita Institute of Medical Sciences, Kochi, Kerala, IndiaAlejandro AragakiDepartment of Pulmonary, Allergy and Critical Care Medicine & Transplant Center, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USAAlex CheeDepartment of Medicine, University of Calgary, Calgary, CanadaAmanil'Ula HassanPaediatric Respiratory Unit, Serdang Hospital, Selangor, Selangor, MalaysiaAnantham DevanandSingHealth Duke-NUS Lung Centre, SingaporeAndrea Ban Yu-LinFaculty of Medicine, National University of Malaysia, Kuala Lumpur, MalaysiaAni Suraya Abd GhaniSerdang Hospital, Selangor, MalaysiaAnna Marie NathanDivision of Paediatric Respiratory & Sleep Medicine, Department of Paediatrics, University of Malaya Medical Centre, University of Malaya, Kuala Lumpur, MalaysiaBelgundi Preeti VidyasagarYashoda Hospitals, Secunderabad, IndiaCalvin S.H. NgDepartment of Surgery, The Chinese University of Hong Kong, N.T., Hong Kong SARChai Chan SinDivision of Respiratory Medicine, Sarawak General Hospital, Kuching, Sarawak, MalaysiaChristopher ManleyFox Chase Cancer Center, Philadelphia, PA 19111, USAChristopher RadchenkoDepartment of Pulmonary, Allergy and Critical Care Medicine & Transplant Center, Cleveland Clinic, Cleveland, Ohio, USAD. Kyle HogarthUniversity of Chicago, Chicago, USADayang Zuraini SahadanPaediatric Respiratory Unit, Serdang Hospital, Selangor, MalaysiaEg Kah PengDivision of Paediatric Respiratory & Sleep Medicine, Department of Paediatrics, University of Malaya Medical Centre, University of Malaya, Kuala Lumpur, MalaysiaElaine DumoulinDepartment of Medicine, University of Calgary, Calgary, CanadaGopanDepartment of Cardiac Anaesthesia, AMRITA Institute of Medical Sciences, Kochi, Kerala, IndiaHamdan LemanSerdang Hospital, Selangor, MalaysiaHari Kishan GonuguntlaYashoda Hospitals, Secunderabad, IndiaHema Yamini RamarmutyRespiratory Department, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, MalaysiaHuda Munirah AinuddinPaediatric Respiratory Unit, Serdang Hospital, Selangor, MalaysiaJamalul Azizi Abdul RahamanDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaJayaprakash BalakrishnanDepartment of Pulmonary Medicine, Trivandrum Medical College, Kerala, IndiaJouke AnnemaDepartment of Respiratory Medicine, Amsterdam UMC, Amsterdam, NetherlandsJoyce W.Y. ChanDepartment of Surgery, The Chinese University of Hong Kong, N.T., Hong Kong SARJuan Pablo UribeSection of Interventional Pulmonology, Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USAKai SwensonSection of Interventional Pulmonology, Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USAKhadijah Mohd NorDepartment of Otorhinolaryngology, University Putra Malaysia, Selangor, MalaysiaKhai Lip NgDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaKhairulamir ZainuddinAnesthesiology Department, KPJ Selangor Specialist Hospital, MalaysiaKho Sze ShyangDivision of Respiratory Medicine, Sarawak General Hospital, Kuching, Sarawak, MalaysiaKoh Gee TiongSerdang Hospital, Selangor, MalaysiaKyle PottsUniversity of Chicago, Chicago, USALarry Ellee NyantiMedical Department, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, MalaysiaM.D. VarunnYashoda Hospitals, Secunderabad, IndiaMarcela AzevedoDepartment of Pulmonary, Allergy and Critical Care Medicine & Transplant Center, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USAMas Fazlin Mohamad JailainiFaculty of Medicine, National University of Malaysia, Kuala Lumpur, MalaysiaMeghana SubashAmrita Institute of Medical Sciences, Kochi, Kerala, IndiaMelvin Tay Chee KiangSingHealth Duke-NUS Lung Centre, SingaporeMichael A. PritchettFirstHealth of the Carolinas and Pinehurst Medical Clinic, Pinehurst, NC, USAMohamed Faisal Abdul HamidFaculty of Medicine, National University of Malaysia, Kuala Lumpur, MalaysiaMohammad Ashkan MoslehiDivision of Pediatric interventional pulmonology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, IranMohd Arif Mohd ZimRespiratory Unit, Department of Internal Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), MalaysiaMohd Faizul bin Abu SamahDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaMona Zaria NasaruddinDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaMuhammad Amin IbrahimRespiratory Unit, Department of Internal Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), MalaysiaMuhammad Farid FauadRespiratory Unit, Department of Internal Medicine, Faculty of Medicine, Universiti Teknologi MARA (UiTM), MalaysiaMuhammad Redzwan S. Rashid AliKPJ Johor Specialist Hospital, Johor Bahru, MalaysiaNai-Chien HuanDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaNg Boon HauFaculty of Medicine, National University of Malaysia, Kuala Lumpur, MalaysiaNik Nuratiqah Nik AbeedFaculty of Medicine, National University of Malaysia, Kuala Lumpur, MalaysiaPrince NtiamoahDepartment of Pulmonary, Allergy and Critical Care Medicine & Transplant Center, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USARushi RabariAmrita Institute of Medical Sciences, Kochi, Kerala, IndiaRainbow W.H. LauDepartment of Surgery, The Chinese University of Hong Kong, N.T., Hong Kong SARRosmadi IsmailSunway Medical Center, Selangor, MalaysiaSadia BenzaquenEinstein Medical Center, Jefferson University, Philadelphia, Pennsylvania, USASameer ArbatOne Healthcare, Nagpur, IndiaSangeta VadiveluDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaSaraiza Abu BakarDepartment of Otorhinolaryngology, Serdang Hospital, Selangor, MalaysiaSathish C. ReddyAMRITA Institute of Medical Sciences, Kochi, Kerala, IndiaShantini JaganathanDepartment of Otorhinolaryngology, Serdang Hospital, Selangor, MalaysiaShuanzeng WeiDepartment of Pathology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USASoo Chun IanUniversity of Malaya Medical Center, Kuala Lumpur, MalaysiaSreeraj NairAMRITA Institute of Medical Sciences, Kochi, Kerala, IndiaSuhashini GanapatyDepartment of Pathology, Serdang Hospital, Selangor, MalaysiaSyeda Samia RasheedYashoda Hospitals, Secunderabad, IndiaTang Jeat ThongDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaTess KramerDepartment of Respiratory Medicine, Amsterdam University Medical Center, NetherlandsThomas R. GildeaDepartment of Pulmonary, Allergy and Critical Care Medicine & Transplant Center, Respiratory Insti tute, Cleveland Clinic, Cleveland, Ohio, USATie Siew TeckDivision of Respiratory Medicine, Sarawak General Hospital, Kuching, Sarawak, MalaysiaTinku JosephChief of Interventional Pulmonology & Associate professor Department of Pulmonary Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, IndiaTushara MadathilDepartment of Cardiac Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala, IndiaWong Soo FenDepartment of Pulmonology, Serdang Hospital, Selangor, MalaysiaZakaria ZahariTunku Azizah Hospital, Kuala Lumpur, Malaysia
Section A
Diagnostic Interventional Pulmonology
Linear EBUS Not so Black and White - Principles of Staging Assessment in Non-Small Cell Lung Cancer via EBUS
Tay Chee Kiang Melvin1, *,Soo Chun Ian2,Anantham Devanand1
1 SingHealth Duke-NUS Lung Centre, Singapore
2 University of Malaya Medical Center, Kuala Lumpur, Malaysia
*Corresponding author Tay Chee Kiang Melvin: SingHealth Duke-NUS Lung Centre, Singapore; Tel: ????; Fax: ????; E-mail:
[email protected]Presentation
A 76-year-old woman presents with cough and dyspnea for 2 months. No constitutional symptoms or family history of malignancy.
Comorbidities
Active smoker of 40 pack-years, hypertension.
Chest Imaging
CXR showed a rounded retrocardiac opacity (Fig. 1). Chest computed tomography (CT) revealed enlarged left hilar, left lower paratracheal, subcarinal and right paratracheal lymph nodes (Figs. 2a-c). There was a 7.2cm heterogeneous mass in the left lower lobe (Fig. 2d). There were no other significant CT findings.
Intervention
Systematic endobronchial ultrasound (EBUS) assessment for hilar and mediastinal lymphadenopathy using convex-probe EBUS (BF-UC180F, Olympus) under topical airway anesthesia (Lignocaine 1% instilled via “spray-as-you-go” technique) and moderate sedation (Midazolam and Fentanyl). Linear EBUS assessment began in the right hilum (Station 10R) and continued up into the mediastinum with the right lower and upper paratracheal nodes (Stations 4R & 2R respectively).
Fig. (1))
Rounded retrocardiac opacity on CXR.
On EBUS, there was no lymph node ≥ 5mm in the short axis at Station 10R. However, enlarged nodes (short-axis diameter approximately 1cm) were visualized at a location cranial to the intersection between the caudal margin of the left brachiocephalic vein and the trachea. Endobronchial ultrasoundguided trans-bronchial needle aspiration (EBUS-TBNA) was performed on a Station 2R node using 22G ViziShot aspiration needle (NA-201SX-4022, Olympus). 4 passes were made, with rapid on-site cytologic examination (ROSE) confirming malignant cells and adequate cellular yield. The procedure was halted at this time.
Post-Intervention
EBUS-TBNA Station 2R histologic results – gross description: multiple clumps of tissue measuring 0.7 x 0.6 x 0.1cm; microscopic description: clusters of epithelial cells with up to moderate nuclear atypia. On immunochemistry, the atypical cells show positivity for deltaNp63 (p40) whilst being negative for thyroid transcription factor 1 (TTF1), in keeping with squamous cell carcinoma.
Fig. (2))(a) 2R lymph node at level of left brachiocephalic vein on CT thorax (Note: For most instances, the aortic arch would not be visualized at this level as it typically lies more caudal to the left brachiocephalic vein).
Fig. (2))(b) Small 4R lymph nodes and large 4L lymph nodes.
Fig. (2))(c) Subcarinal lymph node.
Fig. (2))(d) Left lower lobe mass in the superior segment.
Learning Points
EBUS-TBNA is often used for both diagnosis and staging of non-small cell lung cancer during the same procedure [1]. Thorough pre-procedural planning is pivotal to the success of achieving the two aims.Generally, the approach to the staging examination is to sample the highest station lymph nodes first, i.e., N3 level nodal stations, followed by N2 level, and lastly N1 level.A good understanding and appreciation of the relationship between anatomic landmarks and the various nodal stations during EBUS, and accurate classification of the latter (according to the latest edition of the International Association for the Study of Lung Cancer lymph node map) are crucial as nodal status impacts surgical candidacy.The choice between systematic assessment (≥ 3 passes per node or ROSE at stations 2R, 2L, 4R, 4L, and 7) versus selective assessment (short-axis diameter ≥ 1cm by CT/ultrasound or < 3 passes or no ROSE) in staging examination remains somewhat contentious. Nonetheless, it is our practice to sample any lymph node ≥ 5mm in the short axis, and to perform ≥ 4 passes per station to ensure adequate yield for molecular testing.Video
EBUS TBNA of station 2R lymph node.
CONSENT FOR PUBLICATION
Not applicable.
CONFLICT OF INTEREST
The authors declare no conflict of interest, financial or otherwise.
ACKNOWLEDGEMENTS
Declared none.
REFERENCE
[1]Kinsey C.M., Arenberg D.A.. Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging.Am. J. Respir. Crit. Care Med.2014189664064910.1164/rccm.201311-2007CI24484269
Systematic Approach to Mediastinal Node Staging with Linear EBUS
Hema Yamini Ramarmuty1, *
1 Respiratory Department, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
*Corresponding author Hema Yamini Ramarmuty: Respiratory Department, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia; Tel: ????; Fax: ????; E-mail:
[email protected]Presentation
A 64-year-old lady presented with chronic cough, loss of weight and loss of appetite for 8 months duration.
Comorbidities
Hypertension for the past 4 years. She is a non-smoker.
Chest Imaging
CXR showed a large left lung mass. This was confirmed with a CECT thorax which demonstrated a left hilar mass, measuring 9.7 X 9.6cm with enlarged and necrotic mediastinal nodes (Figs. 1a and b).
Intervention
Convex-probe endobronchial ultrasound (CP-EBUS) through a size 4 laryngeal mask airway (LMA) under general anaesthesia (total intravenous anaesthesia).
The mediastinal nodes were assessed using a systematic approach. The 2L node and 4L (N2) node (Fig. 1a) were less than 1cm in size. The station 11R node (Fig. 1b) measured 8mm while the station 7 (N2) node (Fig. 1c) was 30mm with heterogeneous opacity. The station 4R (N3) node (Fig. 1d) measured around 11mm with distinct margins and was heterogeneous in nature. We were unable to assess the left hilar nodes as the left main bronchus was narrowed. We proceeded to sample the station 4R node.
EBUS-TBNA Procedural Steps
1. The 22G EBUS-TBNA needle is introduced into the working channel of the CP-EBUS scope.
2. The sheath is then adjusted to the desired position (till it is visible on the endoscopic image).
3. Once the sheath is seen, the length of the needle is adjusted and the needle is advanced into the lesion. Doppler examination is performed before advancing the needle to avoid unintentional puncture of vessels. Once the needle is within the lesion, the inner stylet is used to clear the tip of the internal lumen. The stylet is removed and negative pressure is applied using a syringe.
4. Subsequently, the needle is moved back and forth within the lesion.
5. The needle is retrieved and the stylet is used to push out the aspirated material on to a glass slide. This is then smeared, air-dried and fixed with a Diff-Quik stain.
6. Rapid On-Site Evaluation (ROSE), which is performed by an on-site cytopathologist will aid in confirming the adequacy of material thus reducing the duration of the procedure and the amount of unnecessary biopsy. More samples are sent in a saline pot for cell block.
In this patient, a total of 4 passes were performed at station 4R node (Fig. 3). ROSE showed clusters of malignant cells. We then switched to a flexible fibreoptic bronchoscope and proceeded with a thorough examination of the airways. She was found to have widening of the main carina angle and total stenosis of the right middle lobe. Mucosa over the left main bronchus (LMB) appeared oede-matous and congested. Nodular deposits were seen at the entrance of the LMB. The scope could not be advanced further into the LMB to visualise the left upper lobe and left lower lobe segments as it was narrowed. A 1.1mm flexible cryoprobe was used to obtain biopsies from the nodular deposits at the LMB (Fig. 4).
Complications
There were no procedure related adverse effects. The patient was discharged home the next day with no complications.
Post-Intervention
ROSE showed atypical cells suspicious for malignancy. Final pathology results revealed adenocarcinoma. She was diagnosed with stage IIIc (T4N3M0) adenocarcinoma and was referred to the oncologists for further management.
Fig. (1))(a) Axial CT thorax shows enlarged right lower paratracheal node (station 4R).
Axial CT thorax shows a left hilar mass and an enlarged station 7 node.
4L node is 8mm and is seen below the aorta and above the pulmonary artery (PA). The margins are indistinct. The 11Rs node is 8mm. The right interlobar artery is seen next to it. Enlarged station 7 node measuring 30mm. The 4R node is 11mm with clear margins, SVC (Superior vena cava) is seen below it.
EBUS needle is seen within the 4R node.
Flexible cryoprobe used to obtain biopsy from the nodular mucosa at the entrance of the LMB.
