Browsing by Author "Ost, David"
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Item Needle fracture during endobronchial ultrasound-guided transbronchial needle aspiration(American Thoracic Society, 2016) Vial, Macarena; O’Connell, John; Grosu, Horiana; Ost, David; Eapen, George; Jimenez, CarlosA 57-year-old man with new-onset hoarseness and markedly enlarged left paratracheal lymphadenopathy underwent an endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) that revealed non–small cell carcinoma. During the procedure, the needle broke inside the lymph node, and after several unsuccessful attempts to remove it, the procedure was terminated without any additional lymph node staging. The patient then self-referred to our institution, where he underwent a positron emission tomography–computed tomography scan and another EBUS-TBNA for completion of mediastinal staging.Item Non-small cell lung cancer transdifferentiation into small cell lung cancer: A case series(2018) Ahmed, Tahreem; Rodríguez Vial, Macarena; Ost, David; Stewart, John; Hasan, Muhammad A.; Grosu, Horiana B.Transdifferentiation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC) has been reported mostly in adenocarcinomas and has been described as a cause of acquired tyrosine kinase inhibitor (TKI) resistance. However, transdifferentiation has also been described in patients with different histologic characteristics and patients not exposed to TKIs and with no epidermal growth factor receptor (EGFR) mutation (the target of TKIs). To this date transdifferentiation remains poorly understood. We conducted a retrospective case series of patients who had biopsy-proven SCLC within 2 years after a diagnosis of NSCLC or in the same location as the known primary NSCLC. We found that 0.2% of lung cancer patients at our institution experienced transdifferentiation. Among these, 30 had adenocarcinoma and 16 had squamous cell carcinoma. In 27 of the 30 patients with adenocarcinoma (90%), SCLC was found in the same location as the known primary. In 14 of the 30 patients (47%), SCLC occurred within 2 years after the NSCLC diagnosis. In 12 of the 16 patients with squamous cell carcinoma (75%), SCLC was found in the same location as the known primary. In 8 of these 16 patients (50%), SCLC occurred within 2 years after the NSCLC diagnosis. Few patients with adenocarcinoma and none with squamous cell carcinoma were treated with TKIs or had an EGFR mutation. In conclusion the findings in the current study suggest that the discovery of SCLC histology after treatment of NSCLC may be more common than thought suggesting that further study is warranted to evaluate the phenomenon of transdifferentiation.Item Pleural touch preparations and direct visualization of the pleura during medical thoracoscopy for the diagnosis of malignancy(American Thoracic Society, 2017) Grosu, Horiana; Vial-Rodriguez, Macarena; Vakil, Erik; Casal, Roberto; Eapen, George; Morice, Rodolfo; Stewart, John; Sarkiss, Mona; Ost, DavidRATIONALE: During diagnostic thoracoscopy, talc pleurodesis after biopsy is appropriate if the probability of malignancy is sufficiently high. Findings on direct visual assessment of the pleura during thoracoscopy, rapid onsite evaluation (ROSE) of touch preparations (touch preps) of thoracoscopic biopsy specimens, and preoperative imaging may help predict the likelihood of malignancy; however, data on the performance of these methods are limited. OBJECTIVES: To assess the performance of ROSE of touch preps, direct visual assessment of the pleura during thoracoscopy, and preoperative imaging in diagnosing malignancy. METHODS: Patients who underwent ROSE of touch preps during thoracoscopy for suspected malignancy were retrospectively reviewed. Malignancy was diagnosed on the basis of final pathologic examination of pleural biopsy specimens. ROSE results were categorized as malignant, benign, or atypical cells. Visual assessment results were categorized as tumor studding present or absent. Positron emission tomography (PET) and computed tomography (CT) findings were categorized as abnormal or normal pleura. Likelihood ratios were calculated for each category of test result. RESULTS: The study included 44 patients, 26 (59%) with a final pathologic diagnosis of malignancy. Likelihood ratios were as follows: for ROSE of touch preps: malignant, 1.97 (95% confidence interval [CI], 0.90-4.34); atypical cells, 0.69 (95% CI, 0.21-2.27); benign, 0.11 (95% CI, 0.01-0.93); for direct visual assessment: tumor studding present, 3.63 (95% CI, 1.32-9.99); tumor studding absent, 0.24 (95% CI, 0.09-0.64); for PET: abnormal pleura, 9.39 (95% CI, 1.42-62); normal pleura, 0.24 (95% CI, 0.11-0.52); and for CT: abnormal pleura, 13.15 (95% CI, 1.93-89.63); normal pleura, 0.28 (95% CI, 0.15-0.54). CONCLUSIONS: A finding of no malignant cells on ROSE of touch preps during thoracoscopy lowers the likelihood of malignancy significantly, whereas finding of tumor studding on direct visual assessment during thoracoscopy only moderately increases the likelihood of malignancy. A positive finding on PET and/or CT increases the likelihood of malignancy significantly in a moderate-risk patient group and can be used as an adjunct to predict malignancy before pleurodesis.Item What exactly is a centrally located lung tumor? Results of an online survey(American Thoracic Society, 2017) Casal, Roberto; Vial, Macarena; Miller, Russell; Mudambi, Lakshmi; Grosu, Horiana B.; Eapen, George A.; Jimenez, Carlos A.; Morice, Rodolfo C.; Cornwell, Lorraine; Ost, DavidRATIONALE: Accurate mediastinal staging is a cornerstone in the management of patients with lung cancer. For patients with radiographically normal mediastinum, current lung cancer guidelines recommend invasive mediastinal staging when tumors are centrally located. However, definitions of central tumors are nonspecific, and there are discrepancies among guidelines (e.g., some use the inner one-third of the hemithorax, whereas others use the inner two-thirds). OBJECTIVES: To describe the definitions of central tumors used by pulmonologists and thoracic surgeons in their practices. METHODS: An online questionnaire was e-mailed to members of the American Association for Bronchology and Interventional Pulmonology and members of the Cardiothoracic Surgery Network. MEASUREMENTS AND MAIN RESULTS: A total of 218 participants completed our survey (12% response rate). Most common definitions for central tumors were: inner one-third of the hemithorax (55%), in contact with hilar structures (29%), and inner two-thirds of the hemithorax (15%). Of note, 29% of participants chose a definition fabricated specifically for this survey and not supported by guidelines. Regarding the method to delineate the thirds of the hemithorax, 182 (84%) participants chose a system of concentric lines arising in the hilum, whereas 31 (14%) chose straight lines in the sagittal plane of the chest. We found strikingly similar responses in members of both societies. CONCLUSIONS: A uniform definition of tumor centrality is currently lacking, and should be formulated. Studies using objective measurements that evaluate the ability of these different definitions of central lung tumors to predict N2 disease are needed to construct a clear and evidence-based definition.