Electromagnetic navigation bronchoscopy (ENB) is a minimally invasive technology that guides endoscopic tools to pulmonary lesions. ENB has been evaluated primarily in small, single-center studies; ...thus, the diagnostic yield in a generalizable setting is unknown.
NAVIGATE is a prospective, multicenter, cohort study that evaluated ENB using the superDimension navigation system (Medtronic, Minneapolis, Minnesota). In this United States cohort analysis, 1215 consecutive subjects were enrolled at 29 academic and community sites from April 2015 to August 2016.
The median lesion size was 20.0 mm. Fluoroscopy was used in 91% of cases (lesions visible in 60%) and radial endobronchial ultrasound in 57%. The median ENB planning time was 5 minutes; the ENB-specific procedure time was 25 minutes. Among 1157 subjects undergoing ENB-guided biopsy, 94% (1092 of 1157) had navigation completed and tissue obtained. Follow-up was completed in 99% of subjects at 1 month and 80% at 12 months. The 12-month diagnostic yield was 73%. Pathology results of the ENB-aided tissue samples showed malignancy in 44% (484 of 1092). Sensitivity, specificity, positive predictive value, and negative predictive value for malignancy were 69%, 100%, 100%, and 56%, respectively. ENB-related Common Terminology Criteria for Adverse Events grade 2 or higher pneumothoraces (requiring admission or chest tube placement) occurred in 2.9%. The ENB-related Common Terminology Criteria for Adverse Events grade 2 or higher bronchopulmonary hemorrhage and grade 4 or higher respiratory failure rates were 1.5% and 0.7%, respectively.
NAVIGATE shows that an ENB-aided diagnosis can be obtained in approximately three-quarters of evaluable patients across a generalizable cohort based on prospective 12-month follow-up in a pragmatic setting with a low procedural complication rate.
Background and ObjectiveSystemic antibiotics are the best treatment options for lung abscesses. However, up to 37% of lung abscesses do not respond to antibiotics and may require additional ...interventions. Percutaneous transthoracic tube drainage (PTTD), endoscopic catheter drainage (ECD) and surgical resection are additional options available when first line therapy with systemic antibiotics are unsuccessful. In this narrative review, we summarize all available interventional procedures, techniques, complications, safety, and contraindications.MethodsA literature search was performed using Medline/PubMed from January 1980 to October 2023. Key words: "lung abscess", "pulmonary abscess", "endoscopic drainage", "percutaneous drainage", "tube drainage". Pediatric patients were excluded from this study.Key Content and FindingsPTTD and ECD are fairly safe procedures. Performing PTTD or ECD without delay may shorten the duration of hospital stay. This may lower the burden on health care. Moreover, draining abscesses may relieve discomfort in the clinical symptoms associated with abscesses. The primary factor in choosing ECD over PTTD is the location of the abscess, and the presence of a bronchial airway leading to the abscess for successful ECD. ECD has lower rate of complications and mortality; and similar success rate compared to PTTD. While mortality has been reported with PTTD, ECD appears to be safer according to present data.ConclusionsPTTD and ECD are safe procedures, with low complication rates. ECD has a lower complication rate than PTTD does.
Substantial improvements in the early detection and treatment of breast cancer have led to improvements in survival, but breast cancer remains a significant cause of morbidity and mortality in women. ...In 2012, the mammalian target of rapamycin (mTOR) inhibitor everolimus was approved by the U.S. Food and Drug Administration for the treatment of advanced breast cancer in patients resistant to endocrine therapy. Although everolimus is generally well tolerated, mTOR inhibitor‐associated pneumonitis is one of the most common adverse drug events leading to treatment discontinuation. To date, the underlying pathophysiology of this toxicity is unclear, and this uncertainty may hinder the optimization of management strategies. However, experiences from breast cancer and renal cell carcinoma clinical trials indicate that mTOR inhibitor‐associated pneumonitis can be effectively managed by early detection, accurate diagnosis, and prompt intervention that generally involves everolimus dose reductions, interruptions, or discontinuation. Management can be achieved by a multidisciplinary approach that involves the collaborative efforts of nurses, oncologists, radiologists, infectious disease specialists, pulmonologists, clinical pharmacists, and pathologists. Comprehensive education must be provided to all health care professionals involved in managing patients receiving everolimus therapy. Although general recommendations on the management of mTOR inhibitor‐associated pneumonitis have been published, there is a lack of consensus on the optimal management of this potentially serious complication. This article provides an overview of mTOR inhibitor‐associated pneumonitis, with a focus on the detection, accurate diagnosis, and optimal management of this class‐related complication of mTOR inhibitor therapy.
Implications for Practice
This article summarizes the pathogenesis, clinical presentation, incidence, detection, and optimal management of everolimus‐related noninfectious pneumonitis in breast cancer. In particular, this article provides a detailed overview of the important aspects of the detection, accurate diagnosis, and appropriate management of mammalian target of rapamycin inhibitor‐associated pneumonitis. In addition, this article emphasizes that effective management of this adverse drug event in patients with breast cancer will require a multidisciplinary approach and collaboration among various health care professionals.
摘要
在乳腺癌早期检测和治疗中取得的重大改善使生存率有所提高, 但是乳腺癌仍然是导致女性病损和死亡的一个重要原因。2012年, 美国食品药品监督管理局批准将哺乳动物雷帕霉素靶蛋白（mTOR）抑制剂依维莫司用于在内分泌疗法耐药性患者中治疗晚期乳腺癌。尽管依维莫司的耐受性普遍良好, 但是mTOR抑制剂相关性非感染性肺炎是导致治疗停止的最常见不良药物事件之一。迄今为止, 此毒性的基础病理生理学尚不明确, 而此不确定性可能会阻碍管理策略的优化。然而, 从乳腺癌和肾细胞癌临床试验中获得的经验表明, 通过早期检测、准确诊断和及时干预（通常包括减少依维莫司剂量以及中断或停止给药）可有效管理mTOR抑制剂相关性非感染性肺炎。可通过多学科方法管理疾病, 该方法需要护士、肿瘤医师、放射科医师、传染病专科医生、肺病医生、临床药剂师和病理学家的协同努力。必须向接受依维莫司的患者管理中涉及的所有医疗保健专业人士提供全面教育。尽管已发布了对mTOR抑制剂相关性非感染性肺炎管理的一般建议, 但是对于此可能发生的严重并发症的最佳管理, 人们尚未达成共识。本文概述了mTOR抑制剂相关性非感染性肺炎, 重点是针对mTOR抑制剂治疗中此类别相关性并发症的检测、准确诊断和最佳管理。
对临床实践的提示：本文总结了乳腺癌患者中依维莫司相关性非感染性肺炎的发病机理、临床表现、发病率、检测和最佳管理。本文特别概述了哺乳动物雷帕霉素靶蛋白抑制剂相关性非感染性肺炎的检测、准确诊断和恰当管理的重要方面。此外, 本文还着重指明, 在乳腺癌患者中有效管理此不良药物事件需要多学科方法和各种医疗保健专业人士的合作。
Evidence‐based guidelines that assist in the early detection, accurate diagnosis, and effective management of mTOR inhibitor‐associated pneumonitis are limited. This article provides a comprehensive summary of the pathogenesis, clinical presentation, incidence, detection, and optimal management of mTOR inhibitor‐associated pneumonitis in breast cancer.
Cytokines and Alcohol Crews, Fulton T.; Bechara, Rabih; Brown, Lou Ann ...
Alcoholism, clinical and experimental research,
April 2006, Letnik:
30, Številka:
4
Journal Article
Recenzirano
Cytokines are multifunctional proteins that play a critical role in cellular communication and activation. Cytokines have been classified as being proinflammatory (T helper 1, Th1) or ...anti‐inflammatory (T helper 2, Th2) depending on their effects on the immune system. However, cytokines impact a variety of tissues in a complex manner that regulates inflammation, cell death, and cell proliferation and migration as well as healing mechanisms. Ethanol (alcohol) is known to alter cytokine levels in a variety of tissues including plasma, lung, liver, and brain. Studies on human monocyte responses to pathogens reveal ethanol disruption of cytokine production depending upon the pathogen and duration of alcohol consumption, with multiple pathogens and chronic ethanol promoting inflammatory cytokine production. In lung, cytokine production is disrupted by ethanol exacerbating respiratory distress syndrome with greatly increased expression of transforming growth factor β (TGFβ). Alcoholic liver disease involves an inflammatory hepatitis and an exaggerated Th1 response with increases in tumor necrosis factor α (TNFα). Recent studies suggest that the transition from Th1 to Th2 cytokines contribute to hepatic fibrosis and cirrhosis. Cytokines affect the brain and likely contribute to changes in the central nervous system that contribute to long‐term changes in behavior and neurodegeneration. Together these studies suggest that ethanol disruption of cytokines and inflammation contribute in multiple ways to a diversity of alcoholic pathologies.
Newer navigational bronchoscopy technologies render peripheral lung lesions accessible for biopsy and potential treatment. We investigated whether photodynamic therapy (PDT) delivered via ...navigational bronchoscopy is feasible and safe for ablation of peripheral lung tumors.
Two studies evaluated PDT in patients with solid peripheral lung tumors followed by clinical follow-up (nonresection study, N=5) or lobectomy (resection study, N=10). Porfimer sodium injection was administered 40 to 50 hours before navigational bronchoscopy. Lesion location was confirmed by radial probe endobronchial ultrasonography. An optical fiber diffuser was placed within or adjacent to the tumor under fluoroscopic guidance; laser light (630 nm wavelength) was applied at 200 J/cm of diffuser length for 500 seconds. Tumor response was assessed by modified Response Evaluation Criteria in Solid Tumors at 3 and 6 months postprocedure (nonresection study) and pathologically (resection study).
There were no deaths, discontinuations for adverse events, or serious or grade ≥3 adverse events related to study treatments. Photosensitivity reactions occurred in 8 of 15 patients: 6 mild, 1 moderate, 1 severe (elevated porphyrins noted in blood after treatment). Among 5 patients with clinical follow-up, 1 had complete response, 3 had stable disease, and 1 had progressive disease at 6 months follow-up. Among 10 patients who underwent lobectomy, 1 had no evidence of tumor at resection (complete response), 3 had 40% to 50% tumor cell necrosis, 2 had 20% to 35%, and 4 had 5% to 10%.
PDT for nonthermal ablation of peripheral lung tumors was feasible and safe in this small study. Further study is warranted to evaluate efficacy and corroborate the safety profile.
Endobronchial lipomas are rare benign lung tumors that can cause bronchial obstruction and parenchymal damage. While an uncommon etiology, they are often misdiagnosed due to a clinical presentation ...similar to obstructive pulmonary pathologies such as COPD and asthma. Upon review of English-language literature, under 50 cases of endobronchial lipomas were documented in the prior 10 years (2011-2021). There are no clear guidelines regarding the management of this particular entity, but typically interventional debulking is the treatment of choice. Here we present another unique case of endobronchial lipoma along with our diagnostic and therapeutic methodology. The patient underwent bronchoscopic debulking via a cryotherapy probe. Based on the histopathologic analysis, a diagnosis of endobronchial lipoma was made. Endobronchial lipomas must remain in any clinician's differential when a patient presents with dyspnea. We report the unique location of this lipoma based on our literature review and the importance of investigating endobronchial lesions due to a possible diagnosis of endobronchial lipoma.
Background Electromagnetic Navigation Bronchoscopy (ENB) (InReach iLogic system; superDimension Inc) is a relatively new discipline, with promising diagnostic and therapeutic applications in patients ...with lung lesions. Navigation is performed in a magnetic field and, therefore, has been considered relatively contraindicated in patients with pacemakers and automated implantable cardioverter-defibrillators (AICDs). Potential risks include altering the function and shutting off the device, device damage, lead displacement, and potential overheating. Over the past decade, there has been extensive literature about the safety of pacemakers in either the 1.5-T or 3-T magnetic fields used in current MRI scanners. Although the magnetic field used in ENB is significantly weaker, 0.0001 T or approximately equal to the earth's gravity, its safety in patients with pacemakers is yet to be elucidated. We present our initial experience with ENB in patients with cardiac implanted electrical devices. Methods Twenty-four procedures in 24 patients with lung lesions and permanent pacemakers were performed. A cardiac electrophysiologist and programmer were present during the procedure. At baseline, the pacers were interrogated, and ECG was recorded. Continuous cardiac monitoring was performed during the procedure, and at the end, the pacer settings and function were reinterrogated to check for any changes. Results The procedures were all successfully concluded. None of the patients suffered any arrhythmias or disruption to their pacemakers' function. Conclusion ENB appears to be safe when performed in patients with pacemakers and AICDs. Larger multicenter studies are needed to prove the final safety in this patient population.
ObjectiveFor the diagnosis of COVID-19, the yield of nasopharyngeal (NP) swabs is unclear, and bronchoalveolar lavage (BAL) is obtained to confirm the diagnosis. We assessed the utilisation of ...bronchoscopy for COVID-19 diagnosis in a multicenter study and compared the diagnostic yield of BAL versus NP swabs.MethodsThis retrospective study included all patients who were admitted with clinical presentation concerning for COVID-19 and underwent BAL from 1 March to 31 July 2020 at four tertiary care centres in North America. We also compared concordance of BAL with NP swabs for diagnosis of COVID-19 infection.ResultsFifty-three patients, with clinical suspicion for COVID-19 and admitted for respiratory failure, underwent bronchoscopy to collect BAL for SARS-CoV-2 testing. During the same period, 2039 bronchoscopies were performed on patients not infected with COVID-19. Of 42 patients with NP swabs and BAL collected within ≤7 days, 1 was NP swab negative but positive by BAL for SARS-CoV-2 (n=1/42 (2.4%)). Across a wide array of testing platforms, the overall agreement between NP swabs and BAL results was 97.6% (95% CI: 93.0% to 100%) with Cohen’s k of 0.90 (95% CI: 0.69 to 1.00). The sensitivity, specificity, positive and negative predictive values of NP swabs compared with BAL were 83.3% (95% CI: 53.5% to 100%), 100%, 100% and 97.3% (95% CI: 92.1% to 100%), respectively.ConclusionsBAL was used infrequently to assess COVID-19 in busy institutions. NP swabs have a high concordance with BAL for COVID-19 testing, but negative NP swabs should be confirmed with BAL when clinical suspicion is high.
We report the case of a patient with a prolonged bronchopleural fistula and empyema that were successfully treated by the placement of a removable, unidirectional endobronchial valve. This is the ...first report of the use of such a device for this indication.
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