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Lymph nodes potentially amenable to sampling by EBUS, TBNA, or EBUSTBNA are indicated on the current lymph node map proposed by the International Association for the Study of Lung Cancer. The lymph node stations that are potentially amenable to TBNA, as originally illustrated by Wang et al (18,23), correspond to stations 4, 5, 7, 10, and 11, but TBNA is most often used to sample subcarinal lymph nodes (station 7). EUS-NA may be used to sample stations 5, 7, 8, and 9; EBUS-TBNA can be used to sample stations 2, 4, 7, 10, 11, and 12, and occasionally some high mediastinal nodes in station 1. L = left, R = right.
Source publication
A widening spectrum of increasingly advanced bronchoscopic techniques is available for the diagnosis and treatment of various bronchopulmonary diseases. The evolution of computed tomography (CT)-multidetector CT in particular-has paralleled these advances. The resulting development of two-dimensional and three-dimensional (3D) postprocessing techni...
Contexts in source publication
Context 1
... 1994, Wang proposed a system of lymph node mapping for the staging of bronchogenic carci- noma with TBNA that integrated the standard bronchoscopic examination with axial CT infor- mation regarding suspected pathologic nodes (23). This map identified 11 nodal stations accessible by TBNA and remains in harmony with the re- gional classification of lymph node staging for lung cancer (Fig 5). Using the Wang system, Harrow Wang et al (18,23), correspond to stations 4, 5, 7, 10, and 11, but TBNA is most often used to sample subcarinal lymph nodes (sta- tion 7). ...
Context 2
... malignant endobronchial lesions such as in- filtrating non-small cell lung cancer or carcinoid, bronchoscopic techniques are usually used as al- ternative or complementary strategies to surgery, radiation therapy, or chemotherapy (particularly for poor surgical candidates) (57) (Figs 15, 16). In contrast, techniques such as laser resection can preferentially be used in the treatment of benign central airway conditions such as amyloidosis (52), Figure 15. ...
Context 3
... malignant endobronchial lesions such as in- filtrating non-small cell lung cancer or carcinoid, bronchoscopic techniques are usually used as al- ternative or complementary strategies to surgery, radiation therapy, or chemotherapy (particularly for poor surgical candidates) (57) (Figs 15, 16). In contrast, techniques such as laser resection can preferentially be used in the treatment of benign central airway conditions such as amyloidosis (52), Figure 15. Bronchoscopic palliative treatment of suspected non-small cell lung cancer in a 68-year-old man. ...
Context 4
... laser ablation, electro- cauterization, argon plasma coagulation, and stent insertion provide more rapid relief, they are pri- marily used to restore airway patency, unlike cryo- therapy, photodynamic therapy, and brachyther- apy, which require more time to achieve recanali- zation after initial removal of endobronchial tissue (57). It is often necessary to combine approaches to achieve an optimal therapeutic result (Figs 15, 17). An increased understanding of the biologic behavior of both malignant and nonmalignant disease has helped to better define the choice of therapy selected, allowing the interventional pul- monologist to offer individually tailored solutions. ...
Context 5
... advantages of CT, and more recently multidetector CT, reside not only in its ability to depict the fistulous tract along its entire length (thereby identifying potential sites for therapy) but also to highlight possible underlying causes of the lesion (Figs 25, 26). Specific diagnosis of a bronchopleural fistula at CT requires di- rect visualization of a fistulous tract between colleagues observed that multidetector CT accu- rately detected 29 (97%) of 30 bronchoscopically evident complications in 21 patients who had undergone airway stent insertion, including 13 for benign indications and eight for malignant disease (67). ...
Context 6
... fistula connecting an airway to the pleura or to peripheral air-filled cavities is a recognized complication of thoracic surgery (eg, lobectomy Figure 25. Bronchopleural fistula aris- ing from the left main bronchus stump after pneumonectomy for non-small cell lung cancer in a 75-year-old woman. ...
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There is increasing recognition of tracheobronchomalacia (TBM) in patients with respiratory complaints, though its true incidence in the adult population remains unknown. Most of these patients have an acquired form of severe diffuse TBM of unclear etiology. The mainstays of diagnosis are dynamic (inspiratory and expiratory) airway computed tomogra...
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Introduction:
Rigid bronchoscopy has been proven to be an excellent tool for the diagnosis and management of several causes of central airway obstruction (CAO). The invasive treatment of silicone bronchobrachial stenting has been performed in children and adults with CAO, and satisfying results were obtained in previous studies. However, there are...
Citations
... The SEMS was accustomed according to the airway 3D reconstruction and the bronchoscopic manifestation. The airway 3D reconstruction at the end of inspiration enabled the diameter detection of the stenosed segment and the adjacent normal airway (15,16). The SEMS diameter was 2 mm smaller than the average normal diameter of the target airway in patients with malignant CAO; the SEMS diameter was 2 mm greater than the average normal diameter of the target airway in patients with malignant TEF, reducing the possibility of stent migration. ...
Background
Self-expanding metallic stent (SEMS) is a palliative therapy for patients with malignant central airway obstruction (CAO) or tracheoesophageal fistula (TEF). Despite this, many patients experience death shortly after SEMS placement.AimsWe aimed to investigate the effect of SEMS on the palliative treatment between malignant CAO and malignant TEF patients and investigate the associated prognostic factors of the 3-month survival.Methods
We performed a single-center, retrospective study of malignant CAO or TEF patients receiving SEMS placement. Clinical data were collected using the standardized data abstraction forms. Data were analyzed using SPSS 22.0. A two-sided P-value <0.05 was statistically significant.Results106 malignant patients (82 CAO and 24 TEF) receiving SEMS placement were included. The body mass index (BMI), hemoglobin levels, and albumin levels in the malignant TEF group were lower than in the malignant CAO group (all P < 0.05). The procalcitonin levels, C-reactive protein levels, and the proportion of inflammatory lesions were higher in the malignant TEF group than in the malignant CAO group (all P < 0.05). The proportion of symptomatic improvement after the SEMS placement was 97.6% in the malignant CAO group, whereas 50.0% in the malignant TEF group, with a significant difference (P = 0.000). Three months after SEMS placement, the survival rate at was 67.0%, significantly lower in the malignant TEF group than in the malignant CAO group (45.8% vs. 73.2%, P = 0.013). Multivariate analysis revealed that BMI [odds ratio (OR) = 1.841, 95% certificated interval (CI) (1.155-2.935), P = 0.010] and neutrophil percentage [OR = 0.936, 95% CI (0.883–0.993), P = 0.027] were the independent risk factors for patients who survived three months after SEMS placement.Conclusions
We observed symptom improvement in malignant CAO and TEF patients after SEMS placement. The survival rate in malignant TEF patients after SEMS placement was low, probably due to aspiration pneumonitis and malnutrition. Therefore, we recommend more aggressive treatment modalities in patients with malignant TEF, such as strong antibiotics, nutrition support, and strategic ventilation. More studies are needed to investigate the prognostic factors in patients with malignant airway disorders receiving SEMS placement.
... Single projection radiographs and single or bi-plane fluoroscopy have offered little utility in defining the 3-D co-localization of biopsy tool to nodules (14)(15)(16). While CT offers multiplanar 3-D information, its size, radiation dose (~1.5 mSv for an average sized patient in a low-dose chest CT protocol), and cost significantly limits its utility (17). Cone-beam CT (CBCT) has been investigated for intraoperative imaging and employs a large area detector that results in a lower radiation dose compared to fan-beam helical scanners but suffers from lower image quality and artifacts near the field of view edge (18)(19)(20)(21)(22). Current CBCT systems lack respiratory gating capabilities, require ~180 o mechanical X-ray source and detector rotation around the patient with typical scan times of ~30 s, and require the procedure room to be vacated during scanning times (19). ...
Background:
Screen detected and incidental pulmonary nodules are increasingly common. Current guidelines recommend tissue sampling of solid nodules >8 mm. Bronchoscopic biopsy poses the lowest risk but is paired with the lowest diagnostic yield when compared to CT-guided biopsy or surgery. A need exists for a safe, mobile, low radiation dose, intra-procedural method to localize biopsy instruments within target nodules. This retrospective cross sectional reader feasibility study evaluates the ability of clinicians to identify pulmonary nodules using a prototype carbon nanotube radiation enabled stationary digital chest tomosynthesis system.
Methods:
Patients with pulmonary nodules on prior CT imaging were recruited and consented for imaging with stationary digital chest tomosynthesis. Five pulmonologists of varying training levels participated as readers. Following review of patient CT and a thoracic radiologist's interpretation of nodule size and location the readers were tasked with interpreting the corresponding tomosynthesis scan to identify the same nodule found on CT.
Results:
Fifty-five patients were scanned with stationary digital chest tomosynthesis. The median nodule size was 6 mm (IQR =4-13 mm). Twenty nodules (37%) were greater than 8 mm. The radiation entrance dose for s-DCT was 0.6 mGy. A significant difference in identification of nodules using s-DCT was seen for nodules <8 vs. ≥8 mm in size (57.7% vs. 90.9%, CI: -0.375, -0.024; P<0.001). Inter-reader agreement was fair, and better for nodules ≥8 mm [0.278 (SE =0.043)].
Conclusions:
With system and carbon nanotube array optimization, we hypothesize the detection rate for nodules will improve. Additional study is needed to evaluate its use in target and tool co-localization and target biopsy.
... CT chest with IV contrast can show the same findings as CT chest without IV contrast [45]. Additionally, CT chest with IV contrast can show important findings, such as necrotizing pneumonia, pulmonary abscess, and empyema that may be the underlying cause of the bronchopleural fistula [13,19,35,[46][47][48]. There is no evidence directly comparing CT chest without IV contrast and CT chest with IV contrast in diagnosis of bronchopleural fistula. ...
Pneumonia is one of the most common acute infections and the single greatest infectious cause of death in children worldwide. In uncomplicated, community-acquired pneumonia in immunocompetent patients, the diagnosis is clinical and imaging has no role. The first role of imaging is to identify complications associated with pneumonia such as pleural effusion, pulmonary abscess, and bronchopleural fistula. Radiographs are recommended for screening for these complications and ultrasound and CT are recommended for confirmation. The second role of imaging is to identify underlying anatomic conditions that may predispose patients to recurrent pneumonia. CT with intravenously administered contrast is recommended for this evaluation.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
... Clinical symptoms and types of VR are heterogeneous and nonspecific in pediatric patients, the diagnosis may be challenging and surgical management is controversial 19 . Some researchers had speculated that the type of VR and presence of tracheal stenosis were important factors in determining the approach to surgery 15,20 . Hong et al. reported quantitative evaluation of tracheal stenosis caused by PA sling and assessed the left PA re-implantation outcome 13 . ...
... As for congenital variants and aortic arch anomalies associated with CHD 3 , previous studies considered that approximately 12% of VRs were associated with cardiac pathology 20 . In our series, TOF was the most common disorder, followed by PDA, and other associated CHD such as atrial septal defect, VSD, and left superior vena cava or more complex malformation. ...
Clinically, early diagnosis and treatment is important for survival of pediatric with vascular ring (VR) associated with congenital heart disease (CHD), and accurate evaluation of VR is a prerequisite for repair surgical. The study aimed to assess the quantitative characteristics of tracheal compression in pediatrics with VR and CHD using dual-source computed tomography (DSCT), and further provided effective information for surgical decisions. A total of 49 VR patients with CHD and 56 controls were enrolled. The tracheal quantitative measurements (short diameter, long diameter, tracheal area and tracheal length) were obtained, and the degree of tracheal compression was assessed. Our results indicated that VR associated with CHD may cause more serious and complex symptoms, and the greater tracheal compression were found on DSCT when more severe symptoms were present (r = 0.84). The degree of tracheal compression was significantly different within the VR group between those with and without surgery (P = 0.002). Finally, there were good agreement among (1-long diameter ratio), (1-short diameter ratio) and (1-area ratio) in patients and controls, respectively. This study indicated that DSCT enables provides accurate quantitative tracheal compression information for VR pediatrics associated with CHD, and evaluation of the degree of tracheal compression by 1-area ratio may contribute to the repair surgical of VR.
... Ek olarak darlığın distalindeki hava yolunun açık olup olmadığı, lezyonun çapı -uzunluğu ve vasküler yapılar gibi diğer organlarla olan ilişkisini belirlemek de mümkün olmaktadır. Multiplanar rekonstrüksiyon (MPR) ve düşük yoğunluk projeksiyon görüntüleri, hava yolu tutulumunun derecesini değerlendirirken özellikle aksiyal, koronal eksenler ile üç boyutlu görüntüler tanı güvenirliğini arttırır, radyologlar, klinisyenler ve hastalar arasındaki iletişimi kolaylaştırır (21). ...
... Virtual bronchoscopy can be used prior to endobronchial procedures such as bronchial stent placement. Acute angles in the tracheo-bronchial tree can be studied extensively when planning stent deployment and when evaluating airway complications after stent placement (31,32). Virtual bronchoscopy can also be a useful method for monitoring the healing process (33,34) and evaluating the internal diameter of the bronchial stump prior to the application of sealants. ...
... The first step in the diagnosis of a suspected lesion is the imaging of the chest and for this purpose chest CT scan is a valuable tool which has demonstrated high sensitivity and specificity rates [6]. Nevertheless, chest CT still has limitations and that is why over the years, various advanced techniques have been developed aiming to a more detailed assessment of the lungs and chest, using 2-D and 3-D reconstruction algorithms [7,8]. Moreover, an accurate histological diagnosis has to be obtained for the confirmation of the disease [9]. ...
... Chest CT scan is a valuable tool which has demonstrated high sensitivity and specificity rates [19]. Over the years, various advanced techniques have been developed aiming to a more detailed assessment of the lungs and chest, using 2-D and 3-D reconstruction algorithms [7]. With these techniques, a clinician can interpret more accurately the information obtained by the axial CT [8]. ...
Background: The purpose of this systematic review was to compare the diagnostic accuracy of axial thoracic CT, other imaging techniques and image reconstruction algorithms with the endoscopic findings of Fiberopptic Bronchoscopy (FOB), in patients with newly detected endobronchial lesions.
Methods: A systematic review of the literature for retrospective and prospective studies was performed. Articles considered included patients with endobronchial stenosis that were subjected to axial Computed Tomography of the chest with or without an image reconstruction technique, and Fiberoptic Bronchoscopy.
Results: 10 studies (6 prospective/4 retrospective) that were published in PubMed or CancerLit met the inclusion criteria. A total number of 633 patients were involved in the studies and an additional number of 53 patients were included as controls. All the patients were subjected to Fiberoptic Bronchoscopy (FOB) and imaging of the chest. The meta-analysis showed a high sensitivity for most imaging techniques, comparable with this of Fiberoptic Bronchoscopy, but with a significant Negative Predictive Value.
Conclusion: Even though the imaging techniques are a useful, fast and safe modality for the detection of endobronchial lesions, the high negative predictive value raises a concern on their sufficiency for the exclusion of lung cancer on high risk patients.
... CT (Fig. 17) is an important noninvasive tool to identify the location and size of this defect, and is considered superior to bronchoscopy [46]. On radiographs, a new or an increased pneumothorax, decrease in the air fluid level, lack of progressive fluid accumulation or a shift of the mediastinum away from the resected side after a pneumonectomy, is suggestive of BPF. ...
Evaluation for pneumothorax is an important indication for obtaining chest radiographs in patients who have had trauma, recent cardiothoracic surgery or are on ventilator support. By definition, a persistent pneumothorax constitutes ongoing bubbling of air from an in situ chest drain, 48 h after its insertion. Persistent pneumothorax remains a diagnostic dilemma and identification of potentially treatable aetiologies is important. These may be chest tube related (kinks or malposition), lung parenchymal disease, bronchopleural fistula, or rarely, oesophageal-pleural fistula. Although radiographs remain the mainstay for diagnosis and follow up of pneumothorax, computed tomography (CT) is increasingly being used for problem solving. Aetiology of persistent air leak determines the optimal treatment. For some, a simple repositioning of the chest tube/drain may suffice; others may require surgery. In this pictorial review, we will briefly describe the physiology of pneumothorax, discuss imaging features of identifiable causes for persistent pneumothorax and provide a brief overview of treatment options. Specific aetiology of a persistent air leak may often not be immediately discernible, and will need to be carefully sought. Accurate interpretation of imaging studies can expedite diagnosis and facilitate prompt treatment.
Key points
• Persistent pneumothorax is defined as a leak persisting for more than 2 days.
• Radiographs can identify chest-tube-related causes of pneumothorax.
• CT is the most useful test to identify other causes.
• Penetrating thoracic injury can cause fistulous communication resulting in a persistent pneumothorax.
• Discontinuity of visceral pleura identified by CT may indicate a bronchopleural fistula.
... There is a wide range of pathologic entities, both malignant and benign, for which CT imaging represents an essential component of both diagnosis and management. Indications for CT are generally in one of 2 broad categories: (1) symptomatic patients presenting with chronic cough, localized wheezing dyspnea, or hemoptysis, especially those with normal or nonlocalizing radiographs; and (2) cases in which there is endobronchial obstruction with or without associated atelectasis for which interventional bronchoscopic procedures are indicated, including for preprocedural planning as well as for postprocedural monitoring. 1,2 This article will first review optimal CT techniques for imaging the central airways. ...
... Indications for CT are generally in one of 2 broad categories: (1) symptomatic patients presenting with chronic cough, localized wheezing dyspnea, or hemoptysis, especially those with normal or nonlocalizing radiographs; and (2) cases in which there is endobronchial obstruction with or without associated atelectasis for which interventional bronchoscopic procedures are indicated, including for preprocedural planning as well as for postprocedural monitoring. 1,2 This article will first review optimal CT techniques for imaging the central airways. Following this, a classification of central airway disorders is presented with select illustrative examples. ...
... 4 Although controversial, routine acquisition of contiguous high-resolution images throughout the thorax is recommended as well. 2 Contiguous highresolution images with corresponding contiguous high-resolution coronal and sagittal images often prove essential for optimal imaging of the central airways both to enhance visualizing relationships between airways and adjacent mediastinal and hilar structures, as well as optimally visualizing select regions of interest, especially through lobar and proximal segmental airways. Additional advanced reconstruction techniques include curved multiplanar reconstructions, maximum intensity projection and minimum intensity projection (MINip) images ( Fig. 1), external rendering with either three-dimensional (3D) shaded surface displays or volumetric rendering, and internal virtual bronchoscopic rendering. ...
A wide variety of pathologic processes, both benign and malignant, affect the central airways. These processes may be classified into 4 distinct groups: anatomic variants, lesions that result in focal or diffuse airway narrowing, and those that result in multinodular airway disorder. Key to the accurate assessment of the central airways is meticulous imaging technique, especially the routine acquisition of contiguous high-resolution, 1-mm to 1.5-mm images. These images enable high-definition axial, coronal, and sagittal reconstructions, as well as advanced imaging techniques, including minimum intensity projection images and virtual bronchoscopy. Current indications most commonly include patients presenting with signs and symptoms of possible central airway obstruction, with or without hemoptysis. In addition to diagnosing airway abnormalities, computed tomography (CT) also serves a critical complementary role to current bronchoscopic techniques for both diagnosing and treating airway lesions. Advantages of CT include noninvasive visualization of the extraluminal extent of lesions, as well as visualization of airways distal to central airways obstructions. As discussed and illustrated later, thorough knowledge of current bronchoscopic approaches to central airway disease is essential for optimal correlative CT interpretation.
Copyright © 2015 Elsevier Inc. All rights reserved.
... This is less likely to be used as the sole diagnostic instrument. Studies have shown that ultrathin bronchoscopes can detect small airways as far as the 12th or 13th generation (about 2 mm) [12,13], but it is hard to provide higher-level information for diagnosis of bronchiolar diseases, such as acute bronchiolitis, bronchioloalveolar carcinoma, occlusive bronchiolitis, follicular bronchiolitis, diffuse panbronchiolitis, childhood asthma, and mineral dust airways diseases. Therefore, it is important to produce a new device, which can be used to directly examine the so-called ''silent'' or ''quiet'' zone [14], and could potentially provide new information for the diagnosis of bronchiolar diseases. ...
To assess the feasibility and safety of imaging canine peripheral airways (<1 mm) with an experimental micro-imaging fiber optic bronchoscope.
Twenty healthy dogs were scoped with a micro-imaging fiber optic bronchoscope (0.8 mm outer diameter). Images at various levels of the bronchioles, mucosal color, and tracheal secretions were recorded. The apparatus was stopped once it was difficult to insert. CT imaging was performed simultaneously to monitor progression. The safety of the device was evaluated by monitoring heart rate (HR), respiratory rate (RR), mean artery pressure (MAP), peripheral oxygen saturation (SpO2) and arterial blood gases (partial pressure of arterial carbon-dioxide, PaCO2, partial pressure of arterial oxygen, PaO2, and blood pH).
(1) According to the CT scan, the micro-imaging fiber was able to access the peripheral airways (<1 mm) in canines. (2) There was no significant change in the values of HR, MAP, pH and PaCO2 during the procedure (P>0.05). Comparing pre-manipulation and post-manipulation values, SpO2 (F = 13.06, P<0.05) and PaO2 (F = 3.01, P = 0.01) were decreased, whereas RR (F = 3.85, P<0.05) was elevated during the manipulation. (3) Self-limited bleeding was observed in one dog; severe bleeding or other complications did not occur.
Although the new apparatus had little effect on SpO2, PaO2 and RR, it can probe into small peripheral airways (<1 mm), which may provide a new platform for the early diagnosis of bronchiolar diseases.
