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Michela Bezzi



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    IBS20 - Endoscopic Solution to Iatrogenic Complications (Interactive Q and A) (Ticketed Session) (ID 60)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Now Available
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      IBS20.02 - Airway Stenosis (Now Available) (ID 3406)

      07:00 - 08:00  |  Presenting Author(s): Michela Bezzi

      • Abstract
      • Presentation
      • Slides

      Abstract

      Tracheal stenosis is suspected in individuals with risk factors presenting with signs and symptoms of airway narrowing. The condition may be suspected based on spirometry with a flow-volume loop and CT imaging of the neck and chest but fiberoptic bronchoscopy is required to confirm the presence and severity of tracheal stenosis. The symptoms of tracheal stenosis are similar to those of other conditions so it is important to carefully evaluate patients history. The symptoms of tracheal stenosis typically are wheezing, coughing or shortness of breath, cornage, upper respiratory infections, asthma that doesn’t respond to treatment.

      Benign tracheal stenoses are more commonly the result of an injury to the trachea due to prolonged intubation or tracheostomy but also Infections (tuberculosis), autoimmune disorders such as Granulomatosis with polyangiitisand amyloidosis or radiation therapy to the neck or chest. The morphological classification of airway stenosis includes granulomas, pseudoglottic stenosis, and “true stenosis” divided into web-like and complex stenoses.

      Web-like stenoses are circumferential strictures of the trachea involving the mucosa of a short segment (maximum 1 cm long)without any damage to the cartilages.

      Complex stenosesare sleeve strictures of the trachea more than 1 cm long, often associated with various degrees of cartilage involvement, malacia and inflammation.

      Several treatment options that can be used for tracheal stenosis depending on the cause, location and severity of the tracheal narrowing. Resection and anastomosis of the involved tract of the trachea is the gold standard treatment. Interventional Pulmonology (IP) offers minimally invasive techniques. Some IP treatment options can provide immediate relief but are considered temporary solutions, while others can provide a better long-term solution. Short-term treatment options for the condition include laser surgery and mechanical dilation with rigid scopes.Treatment options that are generally considered to work long term include stenting and tracheal reconstruction when only a short portion of the trachea is involved. Choice of procedure depends on the exact location and extent of the stenosis, but also on patient age and comorbidities.The most common treatment options for tracheal stenosis include:

      In 2007 Cavaliere et al. published the results of Laser Assisted Mechanical Dilation in 113 post-intubation tracheal stenoses

      Sex

      Age(Y)

      Cause of stenosis

      Type of stenosis

      M

      47

      50±21

      (12-84)

      Intubation

      38

      Tracheotomy

      35

      Web-like

      13

      Complex

      60

      Tab 1 - Patient carachterstics

      Therapeutic bronchoscopies were performed using rigid bronchoscopes (Efer, Dumon-Harrel type; FR) and general anesthesia.Endoscopic treatment was based on the use of three main techniques: laser photo-resection (multiple radial incisions), gentle dilation and removable silicon stents.

      tracheal stenoses.png

      Fig 1 Web like stenosis, Complex stenosis, Silicon stent

      therapeutic algorythm.png

      Most web-like stenoses were successfully treated with Laser Assisted Mechanical Dilation (LAMD) alone; among complex stenoses LAMD was sufficient to treat 13 patients (22%), whereas 47 patients (78%) required stent placement: 22 had their stent removed after one year and did not require any further therapy, 13 inoperable patients required permanent stent and 12 were referred to surgery after failure of multiple endoscopic treatments. No permanent complications secondary to endoscopic treatment were observed. Forty-eight patients (66%) obtained a stable, good result with the endoscopic procedure, 13 (18%) required a permanent stent while 12 patients (16%) were referred to surgery.

      These authors indicate that bronchoscopic treatment of post-intubation tracheal stenoses can be considered a safe first-line therapy, leaving some selected cases and the relapsing stenosis for surgical resection.

      1.Shapshay SM, Beamis JF, Jr, Hybels RL, Bohigian RK. Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation. Ann Otol Rhinol Laryngol. 1987;96:661–664.

      2. Bacon JL, Patterson CM, Madden BP. Indications and interventional options for non-resectable tracheal stenosis. J Thorac Dis. 2014;6:258–70.

      3. Galluccio G, Lucantoni G, Battistoni P, Paone G, Batzella S, Lucifora V et al. Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up. Eur J Cardiothorac Surg. 2009;35:429–33.

      4. Murgu SD, Colt HG, Mukai D, Brenner M. Multimodal imaging guidance for laser ablation in tracheal stenosis. Laryngoscope. 2010;120:1840–6.

      5. Cavaliere S, Bezzi M, Toninelli C, Foccoli P
Management of post-intubation tracheal stenoses using the endoscopic approach. Follow-up of 73consecutive patients over a four-year period.
Monaldi arch Chest Dis 2007 Jun; 67(2):73-80

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    OA01 - Advanced Diagnostic Approaches for Intrathoracic Lymph Nodes and Peripheral Lung Tumors (ID 117)

    • Event: WCLC 2019
    • Type: Oral Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Now Available
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      OA01.01 - Predictive Value of EBUS Strain Elastography in Mediastinal Lymph Node Staging; The E-Predict Multicenter Study Results (Now Available) (ID 1620)

      10:30 - 12:00  |  Author(s): Michela Bezzi

      • Abstract
      • Presentation
      • Slides

      Background

      Systematic assessment of lymph nodal involvement by EBUS-TBNA is indicated for suspected and proven lung cancers. Nodal size and PET characteristics help guide which lymph nodes to sample. Especially smaller lymph nodes remain challenging, since PET is of limited value due to low resolution. Additional ultrasound B-mode features such as lymph node size, margin or node heterogeneity have shown variable predictive outcomes. Ultrasound strain elastography (EBUS-SE) is a promising technique. By monitoring tissue deformation over time using ultrasound imaging, a relative tissue strain can be computed. Lower tissue strain is shown to correlate to malignancy. Using a standardized measurement procedure (RespirationDOI: 10.1159/000494143), we aimed to assess the value of strain elastography for predicting lymph node malignancy in addition to size information.

      Method

      This multicenter prospective international trial [NCT02488928] included patient with suspected or proven lung cancer in five hospitals. Measurements were obtained following to a standardized operating procedure using Pentax-Hitachi EBUS systems. Nodal cytopathology combined with follow up imaging (>6 months) or surgery were used as reference standard. If uncertainty in outcome remained, nodes were excluded in final analysis.

      Result

      EBUS-SE was performed in 416 patients and 525 lymph nodes (June 2016 – July 2018). Final diagnoses showed 272 benign and 253 malignant nodes. Mean lymph node size was 12.3 mm. B-mode size and mean strain correlated to risk of malignancy with AUC of 78% and 76.8% (95% CI 0.73-0.81). Using a clinical work-up setting with 10mm and 8mm size cut-offs for aspiration, short axis size higher than 8 or 10mm resulted in respective sensitivity of 85% and 72%, specificity of 52% and 71%, PPV of 62% and 70% and NPV of 79% and 73%. Addition of strain elastography (mean<90) to EBUS-short-axis size (<10mm) increased overall sensitivity from 72% to 90% and NPV from 73% to 81%. More nodes were found false positive, specificity decreased from 71% to 42% and PPV went from 70% to 59%. Addition of strain (mean<78) to EBUS-size (<8mm) increased sensitivity from 85% to 94% and NPV from 79% to 85%. Specificity decreased from 52% to 32% and PPV from 63% to 55%.

      Conclusion

      EBUS strain elastography is of added value in guiding nodal sampling. Strain and size combined can help identify more malignant nodes, although it will ultimately also lead to more false positive sampling. Strain information may especially be of potential value in nodes of small size, where PET resolution is limited.

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