岡地 祥太郎

BACKGROUND: Data regarding the diagnostic efficacy of radial endobronchial ultrasound (R-EBUS) findings obtained via transbronchial needle aspiration (TBNA)/biopsy (TBB) with endobronchial ultrasonography with a guide sheath (EBUS-GS) for peripheral pulmonary lesions (PPLs) are lacking. We evaluated whether intraoperative probe repositioning improves R-EBUS imaging and affects diagnostic yield and safety of EBUS-guided sampling for PPLs. METHODS: We retrospectively studied 363 patients with PPLs who underwent TBNA/TBB (83 lesions) or TBB (280 lesions) using EBUS-GS. Based on the R-EBUS findings before and after these procedures, patients were categorized into three groups: the improved R-EBUS image (n = 52), unimproved R-EBUS image (n = 69), and initial within-lesion groups (n = 242). The impact of improved R-EBUS findings on diagnostic yield and complications was assessed using multivariable logistic regression, adjusting for lesion size, lesion location, and the presence of a bronchus leading to the lesion on CT. A separate exploratory random-forest model with SHAP analysis was used to explore factors associated with successful repositioning in lesions not initially "within." RESULTS: The diagnostic yield in the improved R-EBUS group was significantly higher than that in the unimproved R-EBUS group (76.9% vs. 46.4%, p = 0.001). The regression model revealed that the improvement in intraoperative R-EBUS findings was associated with a high diagnostic yield (odds ratio: 3.55, 95% confidence interval, 1.57-8.06, p = 0.002). Machine learning analysis indicated that inner lesion location and radiographic visibility were the most influential predictors of successful repositioning. The complication rates were similar across all groups (total complications: 5.8% vs. 4.3% vs. 6.2%, p = 0.943). CONCLUSIONS: Improved R-EBUS findings during TBNA/TBB or TBB with EBUS-GS were associated with a high diagnostic yield without an increase in complications, even when the initial R-EBUS findings were inadequate. This suggests that repeated intraoperative probe repositioning can safely boost outcomes.

Bronchoscopic lung volume reduction (BLVR) with endobronchial valves is an established treatment for selected patients with advanced emphysema. A 74-year-old male patient with chronic obstructive pulmonary disease and severe dyspnea was scheduled to undergo BLVR targeting the right middle lobe bronchus based on high-resolution CT findings, which showed severe emphysematous changes with hyperinflation and fissure completeness of 98% in the right middle lobe. The physician conducted preoperative virtual reality (VR)-assisted planning using the patient's imaging data, enabling comprehensive visualisation of the bronchial tree, airway measurements, and procedural simulation. The Chartis system confirmed a 'no flow' pattern, supporting the absence of collateral ventilation. During the procedure, a size 5.5 valve was placed in the right B4/5 bronchus following VR and intraoperative assessments. The patient remained stable postoperatively without complications. VR enhanced procedural planning by improving airway assessment, optimising valve sizing, and reducing cognitive load, leading to increased efficiency and operator confidence. Further research is warranted to validate the utility of VR in bronchoscopic interventions.

Epithelioid hemangioendothelioma (EHE) with pleural involvement presents significant diagnostic challenges, particularly in terms of differentiating it from malignant pleural effusion caused by other types of cancer, such as lung carcinoma. While most cases of EHE follow an indolent course, some can deteriorate rapidly, particularly those with serosal involvement such as pleural metastasis. In this report, we describe a case in which semi-rigid thoracoscopic cryobiopsy under local anesthesia yielded adequate specimens safely for diagnosis of pleural dissemination of EHE. The patient was a 46-year-old woman who had been diagnosed with multifocal EHE affecting the liver and both lungs a decade earlier. After radiofrequency ablation for the hepatic lesions and 2 years of chemotherapy, she was monitored without specific treatment for approximately 8 years with no significant tumor progression. She presented to our department following a rapid increase in left-sided pleural effusion over the previous month. Based on the clinical course and imaging findings, the diagnosis was initially difficult. However, thoracoscopic cryobiopsy provided definitive confirmation of pleural EHE.