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ABSTRACT: OBJECTIVE: Pulmonary fissures completeness predicts efficacy in endobronchial valves (EBV) implantation, a new lobar volume reduction therapy for severe emphysematous patients. We assessed the incidence of incomplete fissures and the interobserver agreement in its evaluation with MDCT, in severe emphysematous patients prior to EBV implantation. MATERIALS AND METHODS: Volumetric thin-section CT scans of 35 patients (CODP GOLD 3/4, heterogeneous emphysema) were retrospectively reviewed by 2 pneumologists, 1 general and 2 experienced chest radiologists, independently and blinded for treatment outcome, and the pulmonary fissures were classified as either complete or incomplete. Interobserver agreement was assessed with Kappa index (KI). RESULTS: Agreement between all readers for the left oblique, right oblique and horizontal fissure was, respectively, moderate (KI=0.53), fair (KI=0.37) and moderate (KI=0.42). Highest agreement (99/105 fissures) was observed among experienced radiologists, being for left oblique, right oblique and horizontal, respectively, almost perfect (KI=0.79), perfect (KI=1.0) and moderate (KI=0.52). These 2 reviewers found that all of 35 patients had at least one incomplete fissure, with a proportion of incomplete fissures assigned as 74/65%, 85/85% and 91/88%, respectively for the left oblique, right oblique and horizontal fissures. CONCLUSIONS: Pneumologists and radiologists agreed fairly to moderately in fissures analysis, while the experienced chest radiologists reached the highest clinically adequate agreement of 94%. We believe that clinical routine visual analysis of the fissures integrity can be done with a good degree of confidence in MDCT images, and experienced readers might be required. Also, a higher than expected incidence of incomplete fissures was described in our studied population.
European journal of radiology 07/2012; · 2.65 Impact Factor
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Nicolas Kahn,
Michael Meister, Ralf Eberhardt,
Thomas Muley,
Philipp A Schnabel,
Christian Bender,
Marc Johannes,
Denise Keitel,
Holger Sültmann,
Felix J F Herth,
Ruprecht Kuner
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ABSTRACT: Early detection of malignancies in the lung by less-invasive methods aims at achieving efficient intervention and subsequently a reduction of the high mortality rate. We investigated whether biomarker analysis in endobronchial epithelial-lining fluid (ELF) collected by bronchoscopic microsampling (BMS) may be useful for a definitive preoperative diagnosis.
ELF was collected from subsegmental bronchi close to the indeterminate pulmonary nodule, which was detected by computed tomography, and from the contralateral lung. Diagnosis was confirmed by transbronchial biopsy or surgery. The study includes 142 ELF samples from 51 non-small-cell lung cancer patients and 20 benign cases. Microarray analysis was done with a patient subset (n = 15) to narrow down genes associated with a malignant phenotype. Thirteen potential biomarkers have been further analyzed by quantitative real-time polymerases chain reaction in an independent patient cohort (n = 56).
All patients underwent BMS without complications. Gene-expression analyses by microarrays and quantitative real-time polymerases chain reaction could be reliably applied to ELF samples, and resulted in potential biomarkers for malignant pulmonary nodules. Four genes (tenascin-C, [C-X-C motif] ligand 14, S100 calcium binding protein A9, and keratin 17) were found to be upregulated in ELF of non-small-cell lung cancer patients with adenocarcinoma or squamous cell carcinoma. Combined analysis of tenascin-C expression and the nodule size improved the prediction of malignancy in this patient cohort.
Our study suggests that the analysis of specific biomarkers in ELF collected by BMS could be a potentially useful adjunct to other diagnostic techniques aiming at the preoperative diagnosis of malignant pulmonary nodules.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 06/2012; 7(6):1001-8. · 4.55 Impact Factor
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ABSTRACT: One-way endobronchial valves (EBV) have been shown to relieve symptoms of emphysema, particularly in patients without collateral ventilation (CV) between the target and adjacent lobes. In this study, we investigated the ability of the bronchoscopic Chartis Pulmonary Assessment System(TM) to predict treatment response by determining the presence of CV.EBV patients (n=80) underwent a pre-treatment Chartis assessment. Before and 30 days after implantation, high-resolution CT scans were taken to determine target lobe volume reduction (TLVR). A pre- to post-treatment reduction of ≥350 mL was defined as significant. In addition, clinical outcomes (FEV1, 6-minute walk test and SGRQ) were compared over the same time period.Of the 51 patients classified as having an absence of CV according to their Chartis reading, 36 showed a TLVR ≥350 mL. Twenty-nine patients were classified as having CV, and of these 24 did not meet this TLVR cut-off. Chartis showed an accuracy level of 75% in predicting whether or not the TLVR cut-off would be reached. Those predicted to respond showed significantly greater TLVR (p < 0.0001) and FEV1 improvement (p=0.0013) than those predicted not to respond.Chartis is a safe and effective method of predicting response to EBV treatment.
European Respiratory Journal 05/2012; · 5.89 Impact Factor
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ABSTRACT: OBJECTIVES:: We evaluated quantitative acoustic measurements, as a simpler alternative to perfusion scintigraphy, for estimation of predicted postoperative (ppo) lung function after resection surgery in our patient population. METHODS:: Patients with lung cancer, considered as candidates for lung resection, were enrolled in the study. All patients underwent lung function testing and quantitative breath sound testing by vibration response imaging (VRI) on the same day. A subset of patients also had perfusion testing. Forced expiratory volume in 1 second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) predictions derived from VRI testing were compared with perfusion values and actual FEV1 values at 1 month postoperatively. RESULTS:: Fifty-three subjects (40 males; age 66±8 y) participated. There was high correlation between both methods for the calculation of ppoFEV1% (R=0.94; n=39) and ppoFEV (L) (R=0.90; n=39). PpoFEV1 were 58±18% versus 56±20% and 1.69±0.49 L versus 1.62±0.52 L, based on perfusion and VRI methods, respectively. In 92% (36/39) of calculations, the difference between the 2 methods was <10%. High correlations also existed between VRI and perfusion for the calculation of ppoDLCO% (R=0.95; n=37) and ppoDLCO mL/min/mm Hg (R=0.90; n=37). VRI predictions showed good correlation for the 34 patients with actual postoperative lung function (R=0.88 and R=0.80 for FEV1% and FEV1L, respectively). Accuracy of the VRI to predict surgical risk (<40% cutoff threshold for ppo values) compared with actual postoperative values was 85% (29/34). CONCLUSIONS:: Predictions of postoperative lung function using VRI agree well with radionuclide techniques and actual measured postoperative values. VRI may provide a noninvasive, simpler alternative for estimation of ppo values, particularly when perfusion testing is not readily available.
American journal of clinical oncology 04/2012; · 2.21 Impact Factor
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ABSTRACT: AbstractBackgroundIntrabronchial valve placement for endoscopic lung volume reduction is used for patients with severe lung emphysema. Different treatment approaches are unilateral valve placement with the goal of complete occlusion and subsequent atelectasis leading to true volume reduction versus bilateral partial closure aiming for redistribution of ventilation but avoiding atelectasis. In this prospective pilot trial we compared the efficacy of these treatment approaches.MethodsPatients with severe bilateral heterogeneous emphysema were randomized to 2 groups. In the first group patients received unilateral valves aiming for total occlusion of one lobe. In the other group valves were placed in 2 contralateral lobes with incomplete closure. In all cases one-way valves were placed via a flexible bronchoscope. Patients were followed at 30 and 90 days, endpoints being change in pulmonary function tests (PFT), 6-minute-walk-distance (6MWD) and dyspnea score (mMRC) as well as quality of life (SGRQ).ResultsTwenty-two patients were treated in this study, 11 patients in each arm. At 30 days and 90 days significant differences were seen in PFT and 6MWD, as well as in mMRC and SGRQ in favour of unilateral treatment. At 90 days FEV(1) was improved by 21.4 ±10.7% in this group, but not in the bilateral group (-0.03 ±13.9%; p=0.002). One patient in the unilateral group experienced a pneumothorax and 2 patients in the bilateral group were treated for transient respiratory failure.ConclusionsUnilateral intrabronchial valve placement with complete occlusion appears superior to bilateral partial occlusion.U.S National Institute of Health (NCT00995852; http://clinicaltrials.gov).
Chest 03/2012; · 5.25 Impact Factor
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Daniela Gompelmann,
Claus Peter Heussel, Ralf Eberhardt,
Gregory Snell,
Peter Hopkins,
Kim Baker,
Christian Witt,
Arschang Valipour,
Manfred Wagner,
Franz Stanzel,
Jim Egan,
Armin Ernst,
Steven Kesten,
Felix J F Herth
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ABSTRACT: Bronchoscopic thermal vapor ablation (BTVA) ablates emphysematous tissue through a localized inflammatory response followed by contractive fibrosis and tissue shrinkage leading to lung volume reduction that should not be influenced by collateral ventilation. Objectives: To determine the correlation of clinical data from a trial of BTVA with fissure integrity visually assessed by computed tomography (CT).
We conducted a single-arm study of patients with upper lobe-predominant emphysema (n = 44). Patients received BTVA either to the right upper lobe or left upper lobe, excluding the lingula. Primary efficacy outcomes were forced expiratory volume in 1 s (FEV(1)) and St. George's Respiratory Questionnaire (SGRQ) at 6 months. Lobar volume reduction from CT was another efficacy outcome measurement. The fissure of the treated lobe was analyzed visually on preinterventional CT. Incompleteness of the small fissure, the upper half of the right large fissure and the whole left large fissure were estimated visually in 5% increments, and the relative amount of fissure incompleteness was calculated. Pearson correlation coefficients were calculated for the association between fissure incompleteness and change in efficacy outcomes (baseline to 6 months) of BTVA.
A total of 38 out of 44 patients (86%) had incompleteness in the relevant fissure. Calculated relevant fissure incompleteness was a mean of 13% of fissure integrity (range 0-63). Correlation coefficients for the association of incompleteness with outcomes were as follows: FEV(1) = 0.17; lung volume reduction = -0.27; SGRQ score = -0.10; 6-min walk distance = 0.0; residual volume (RV) = -0.18, and RV/total lung capacity = -0.14.
Lobar fissure integrity has no or minimal influence on BTVA-induced lung volume reduction and improvements in clinical outcomes.
Respiration 03/2012; 83(5):400-6. · 2.26 Impact Factor
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ABSTRACT: We proposed to assess the feasibility of low mechanical index (MI) contrast enhanced ultrasound (CEUS) in the characterisation of thoracic lesions. Fifty patients were prospectively examined by CEUS and images acquired on a low MI (0.17-0.24) setting following injection of SonoVue. From region-of-interest (ROI) generated signal intensity (SI) time curves, the maximum SI, bolus arrival time (BAT), time to peak intensity (TTP), wash-in slope and mean transit time (MTT) were calculated. Using the Wilcoxon rank test; parameters and threshold values for positive differentiation were determined. In addition, for the parameters that allowed positive differentiation between malignant and benign lesions receiver operator curves (ROC) were obtained. The wash-in slope, TTP and MTT (p = 0.0003, <0.0001, 0.02) allowed positive differentiation. The sensitivity and specificity was 93% and 78%, with 6.87 s(-1) threshold value for the wash-in slope, 78% and 89% with 11.84 s threshold for the TTP and 48% and 89% with 78.6 s threshold for the MTT. CEUS is a useful tool for differentiating malignant and benign thoracic lesions.
Ultrasound in medicine & biology 09/2011; 37(11):1747-54. · 2.02 Impact Factor
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ABSTRACT: AeriSeal Emphysematous Lung Sealant is a novel endoscopic lung-volume reduction therapy designed to reduce hyperinflation and improve pulmonary function and quality of life in patients with advanced emphysema. The device is administered to the subsegmental bronchus via a catheter as a 20 ml volume of liquid-foam. It flows into the peripheral airways and alveoli where it polymerizes and functions as a tissue glue, forming a film of material on the lung surface that seals the target region to cause durable absorption atelectasis. The AeriSeal System received CE mark approval for the treatment of patients with advanced upper lobe predominant and homogeneous emphysema based upon favorable results from clinical studies, and is commercially available in Europe. Patient and treatment site selection algorithms have been developed to simplify product use and optimize outcomes. This manuscript summarizes how the device is used, its mechanism of action and clinical trial results supporting its safety and efficacy.
Expert Review of Medical Devices 05/2011; 8(3):307-12. · 2.63 Impact Factor
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ABSTRACT: BACKGROUND: Mediastinal lymph node staging for lung cancer remains one of the most important factors to determine patient outcome. METHODS: Noninvasive imaging techniques such as CT, MRI, PET and PET-CT provide some answers but no tissue diagnosis. RESULTS: The development of endo-oesophageal (EUS) and endobronchial ultrasound (EBUS) with fine-needle aspiration has provided the clinician with a tool to investigate the mediastinum and the adrenal gland with a safe, minimally invasive procedure that can be performed on an outpatient basis. CONCLUSION: The aim of this article was to give radiologists an overview of the techniques of EUS and EBUS and their role in the staging of lung cancer patients.
Insights into imaging. 04/2011; 2(2):133-140.
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Daniela Gompelmann, Ralf Eberhardt,
Claus-Peter Heussel,
Hans Hoffmann,
Hendrik Dienemann,
Maren Schuhmann,
Dittmar Böckler,
Philipp A Schnabel,
Arne Warth,
Ruben Lopez-Benitez,
Felix J F Herth
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ABSTRACT: Lung sequestration is a rare congenital pulmonary disorder and is usually diagnosed in children with recurrent pulmonary infections. Lung sequestrations are not commonly found to be a cause of respiratory symptoms in adults.
It was the aim of this study to show that pulmonary sequestration is rare in advanced age and can be accompanied by severe pulmonary symptoms.
We conducted a case series analysis of patient characteristics, symptoms, diagnosis and treatment of 11 adults with a lung sequestration at the Thoraxklinik Heidelberg between 2001 and 2009.
From 2001 to 2009, intralobar lung sequestration was diagnosed and treated in 11 adults aged 19 to 58 years with an average age of 39.9 ± 11.3 years and a male:female distribution of 5:6. In 3 patients (27.3%), the predominant symptom was hemoptysis. Recurrent pulmonary infections occurred in 1 patient (9.1%); pneumonia and lung abscess were detected in 2 patients (18.2%). In 3 cases (27.3%), dry cough was the predominant symptom, and in only 2 cases (18.2%), lung sequestration was asymptomatic. Eight patients (72.7%) were diagnosed by imaging techniques prior to surgery. In 3 cases (27.3%), diagnosis was made intraoperatively and by pathological examination. Surgical intervention included 7 lobectomies (63.6%), 3 wedge resections (27.3%) and 1 (9.1%) segmentectomy.
Lung sequestration in adults is rare, but it can cause severe pulmonary symptoms. In cases of recurrent pulmonary infections of identical localization or recurrent hemoptysis, lung sequestration should be considered in order for the diagnosis to be made rapidly. Surgical resection is the treatment of choice.
Respiration 02/2011; 82(5):445-50. · 2.26 Impact Factor
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ABSTRACT: Der Blick des Endoskopikers ist auf das Lumen und die innere Oberfläche der Atemwege beschränkt. Prozesse, die sich in den
verschiedenen Wandschichten ausbreiten oder die außerhalb des Lumens den Atemwegen anliegen, können nur an indirekten Zeichen
vermutet werden. Ein großer Teil pathologischer Prozesse an den Atemwegen erfasst auch die parabronchialen Strukturen. Besonders
bei malignen Prozessen ist das für das spätere Schicksal des Patienten entscheidend, und es besteht deshalb ein dringender
Bedarf, den Blick über die Tracheobronchialwand hinaus zu erweitern (Becker 1995). Die externe mediastinale Sonographie erreicht
die tiefe paratracheale und perihiläre Region kaum. Mit der transösophagealen Sonographie lassen sich die prätrachealen und
hilären Strukturen wegen der dazwischen liegenden Atemwege oder dem fehlenden anatomischen Kontakt kaum einsehen (Shannon et al. 1996). Deshalb haben wir seit 1989 begonnen, den endobronchialen Ultraschall zu erproben (◘ Abb. 6.1a–c)
◘ Abb. 6.1a–c.Ausschluss der Wandinfiltration. (TU Tumor, LN Lymphknoten, AOA Aorta ascendens, TR Trachea, ES Endosonde, In kleiner Lymphknoten, VC V. cava)
12/2010: pages 143-150;
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ABSTRACT: Although flexible bronchoscopy is the least invasive procedure for sampling, it is limited by its inability to reach lesions in the peripheral segments of the lung. Biopsy success is further compromised if the lesion is less than 30 mm in diameter or cannot be seen on fluoroscopy. We wanted to explore whether a new bronchoscopic navigation system could help access the peripheral lung airways and enable lesion sampling.
The LungPoint system produced a virtual bronchoscopic pathway indicating the bronchus into which the bronchoscope should be advanced. Virtual bronchoscopic images were displayed alongside and registered with actual bronchoscopic video. After performing broncoscopy with a standard bronchoscope for first examination, the thin bronchoscope was advanced to the target bronchus under direct visualization without fluoroscopy. A pilot study included consecutive patients at a tertiary teaching hospital with pulmonary peripheral lesions (<42 mm). Biopsies were taken later.
Study subjects included 25 patients (9 women and 16 men, mean age 67 years) with 25 lesions (mean size 28 mm). Using this navigation system, the bronchoscope could be advanced along the planned route in all cases. In 14 of the cases (56%), the bronchoscope could be advanced all the way to the lesion bronchus. The planning time was a median of 5 minutes, and the median examination time was 15 minutes. A definitive diagnosis was possible in 20 cases (80%). One patient experienced a small pneumothorax because of the biopsy that resolved without drainage. No other complications occurred.
This navigation system is useful for bronchoscopy for pulmonary peripheral lesions (NCT01067755).
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 10/2010; 5(10):1559-63. · 4.55 Impact Factor
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Thorax 09/2010; 65(9):842; author reply 842-3. · 6.84 Impact Factor
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ABSTRACT: We present a case of a 65-year-old man with recurrent hemoptysis and weight loss for 6 months. Thirty-two years earlier, lobectomy of the right lower lobe had been performed for abcessing pneumonia. Due to recurrent pulmonary infections after lobectomy the patient had to retire at the age of 46. A diagnostic procedure to explain the hemoptysis was performed. A computed tomogram revealed a suspicious formation in the bronchus intermedius, and the patient was referred to our department with the suspicion of lung cancer. During bronchoscopy an endobronchial mass was detected and extracted whole with a foreign-body forceps. Textile fibers of a sponge in the histology specimen led to the final diagnosis of gossypiboma (also known as textiloma). After removal of the gossypiboma no further pulmonary infections occurred.
Respiratory care 07/2010; 55(7):933-6. · 2.01 Impact Factor
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Respiration 03/2010; · 2.26 Impact Factor
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ABSTRACT: Technologic advances in bronchoscopy continue to improve the ability to perform minimally invasive, accurate evaluations of the tracheobronchial tree and to perform an ever-increasing array of diagnostic, staging, therapeutic, and palliative interventions. The role of both old and new diagnostic bronchoscopy will continue to evolve as further improvements are made in bronchoscopes, accessory equipment, and imaging technologies. The major challenge is the adoption of the many new bronchoscopic techniques into routine clinical practice. There is a need for well-designed studies to delineate the appropriate use of these interventions and to better define their limitations and cost effectiveness.
Clinics in chest medicine 03/2010; 31(1):87-100, Table of Contents. · 2.51 Impact Factor
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ABSTRACT: For mediastinal lymph nodes, biopsies must often be performed to accurately stage lung cancer. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) allows real-time guidance in sampling paratracheal, subcarinal, and hilar lymph nodes, and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can sample mediastinal lymph nodes located adjacent to the esophagus. Nodes can be sampled and staged more completely by combining these procedures, but to date use of two different endoscopes has been required. We examined whether both procedures could be performed with a single endobronchial ultrasound bronchoscope.
Consecutive patients with a presumptive diagnosis of non-small cell lung cancer (NSCLC) underwent endoscopic staging by EBUS-TBNA and EUS-FNA through a single linear ultrasound bronchoscope. Surgical confirmation and clinical follow-up was used as the reference standard.
Among 150 evaluated patients, 139 (91%; 83 men, 56 women; mean age 57.6 years) were diagnosed with NSCLC. In these 139 patients, 619 nodes were endoscopically biopsied: 229 by EUS-FNA and 390 by EBUS-TBNA. Sensitivity was 89% for EUS-FNA and 92% for EBUS-TBNA. The combined approach had a sensitivity of 96% and a negative predictive value of 95%, values higher than either approach alone. No complications occurred.
The two procedures can easily be performed with a dedicated linear endobronchial ultrasound bronchoscope in one setting and by one operator. They are complementary and provide better diagnostic accuracy than either one alone. The combination may be able to replace more invasive methods as a primary staging method for patients with lung cancer.
Chest 02/2010; 138(4):790-4. · 5.25 Impact Factor
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ABSTRACT: Although the treatment of choice for stage I lung cancer patients is surgery, a lot of patients have a high comorbidity and are medically inoperable. Bronchoscopy, as a central technique in diagnosing lung cancer, has the potency to apply endoscopic therapy to small lung lesions in a minimally invasive way in patients with high risk for surgery. Unfortunately, bronchoscopy cannot always reach lesions in the peripheral lung, in particular the smaller lesions. Therefore, new guidance techniques like virtual bronchoscopy and electromagnetic navigation are now available and instead of using the systems as a diagnostic tool, these techniques may provide an option for therapeutic interventions to inoperable lung tumor patients. With endoscopic fiducial marker placement for robotic radiosurgery and endoluminal high-dose brachytherapy, local radiotherapy of peripheral lung tumors becomes feasible, reducing radiotherapy-induced toxicity. Radiofrequency tissue ablation through the working channel of a flexible bronchoscope may be a chance of making a diagnosis and a curative treatment in one endoscopic session. However, technical improvements of the ablation probes are currently necessary to expand the sizes of ablated areas. Even though the technologies are very attractive and pilot data are extremely encouraging, more studies establishing selection criteria and best utility are needed.
Respiration 01/2010; 79(4):265-73. · 2.26 Impact Factor
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ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a category of diseases characterized by chronic airflow obstruction and hyperinflation. The GOLD committee and the American Thoracic Society/European Respiratory Society have published detailed, evidence-based reviews of management approaches, providing stepped-care algorithms for pharmacologic and nonpharmacologic therapy. Over the past several decades, much effort was spent in designing additional nonpharmacologic approaches to ameliorate symptoms in these patients. Three endoscopic lung volume reduction principles have shown promise and reached later-stage clinical trials in patients with heterogeneous emphysematous diseases. These include so-called blocking devices (valves), nonblocking devices (coils) and irreversible nonblocking techniques (bronchoscopic thermal vapor ablation, polymeric lung volume reduction) designed to collapse and remodel hyperinflated lung. For homogeneous diseases the formation of airway bypass tracts designed to facilitate emptying of damaged lung regions with long expiratory times is being investigated.
Respiration 01/2010; 79(1):5-13. · 2.26 Impact Factor
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ABSTRACT: Unfortunately, flexible bronchoscopy, the least invasive bronchoscopic procedure, is of limited value for obtaining tissue from lesions in the peripheral segments of the lung. Biopsy success is further compromised if the lesion is less than 3 cm in diameter. The main limitation of flexible bronchoscopy is the difficulty in reaching peripheral lesions with the accessory tools. In this paper, we will discuss a new bronchoscopic advance in the diagnosis and treatment of lung cancer. Once extended beyond the tip of the bronchoscope, these tools are difficult to guide to the desired location. Localizing the lesion under fluoroscopy is difficult, and alternative diagnostic guidance methods, such as computer tomography-guided bronchoscopy and endobronchial ultrasound, are more demanding. Therefore, new methods for navigation and localization are needed. One of these new technologies is electromagnetic navigation bronchoscopy. The aim of this special report is to provide an analysis of the published literature. A literature search was constructed and performed on PubMed to identify the literature from 2000 to 2008. The search words were 'electromagnetic navigation', 'coin lesion', 'solitary pulmonary nodule' and 'lung cancer'. We review a number of recent studies that utilize electromagnetic navigation and guidance, and analyze their performance characteristics for clinical applications of the technology. Electromagnetic navigation is likely to play an increasing and integral role in the diagnosis and staging of lung cancer in the near future. Electromagnetic registration may impact both the staging and diagnosis of peripheral lesions.
Expert Review of Respiratory Medicine 10/2009; 3(5):469-73.
