385 PULMONARY PROCEDURESsuspicious for lung cancer. 2 With the fi ndings of the NLST indicating a reduction in lung-cancer-specifi c mortality with CT scanning in at-risk people, the number of patients diagnosed with a PN could increase substantially if screening for lung cancer is broadly T he pulmonary nodule (PN) is becoming an increasingly common radiographic fi nding among patients in the United States. Nearly 45 million CT scan examinations are performed each year, and 11% to 30% (4.5-14 million) of those include an examination of the chest. 1 In the recently released National Cancer Institute-sponsored National Lung Screening Trial (NLST), . 25% of the group who underwent lowdose CT scans of the chest had examinations that were Background: The detection of pulmonary nodules (PNs) is likely to increase, especially with the release of the National Lung Screen Trials. When tissue diagnosis is desired, transthoracic needle aspiration (TTNA) is recommended. Several guided-bronchoscopy technologies have been developed to improve the yield of transbronchial biopsy for PN diagnosis: electromagnetic navigation bronchoscopy (ENB ), virtual bronchoscopy (VB), radial endobronchial ultrasound (R-EBUS), ultrathin bronchoscope, and guide sheath. We undertook this meta-analysis to determine the overall diagnostic yield of guided bronchoscopy using one or a combination of the modalities described here. Methods: We performed a MEDLINE search using "bronchoscopy" and "solitary pulmonary nodule." Studies evaluating the diagnostic yield of ENB, VB, R-EBUS, ultrathin bronchoscope, and/or guide sheath for peripheral nodules were included. The overall diagnostic yield and yield based on size were extracted. Adverse events, if reported, were recorded. Meta-analysis techniques incorporating inverse variance weighting and a random-effects meta-analysis approach were used. Results: A total of 3,052 lesions from 39 studies were included. The pooled diagnostic yield was 70%, which is higher than the yield for traditional transbronchial biopsy. The yield increased as the lesion size increased. The pneumothorax rate was 1.5%, which is signifi cantly smaller than that reported for TTNA. Conclusion: This meta-analysis shows that the diagnostic yield of guided bronchoscopic techniques is better than that of traditional transbronchial biopsy. Although the yield remains lower than that of TTNA, the procedural risk is lower. Guided bronchoscopy may be an alternative or be complementary to TTNA for tissue sampling of PN, but further study is needed to determine its role in the evaluation of peripheral pulmonary lesions.CHEST 2012; 142(2):385-393Abbreviations: ENB 5 electromagnetic navigation bronchoscopy; NLST 5 National Lung Screening Trial; PN 5 pulmonary nodule; R-EBUS 5 radial endobronchial ultrasound; TTNA 5 transthoracic needle aspiration; VB 5 virtual bronchoscopy

A ppropriate staging of lung cancer is critical, as it predicts prognosis and dictates treatment. Radiographic staging with CT scan and PET scan can offer clues to the extent of disease, but pathologic confi rmation of malignancy and determination of the TNM stage for non-small cell lung cancer (NSCLC) dictates the treatment choice. 1 In practice, mediastinal lymph node involvement most often differentiates those who are surgical candidates from those who are not. 2 The current methods available to adequately stage the mediastinum include mediastinoscopy, videoassisted thoracoscopy, endoscopic ultrasound (EUS), endobronchial ultrasound (EBUS), transthoracic needle aspiration, and transbronchial needle aspiration. The American College of Chest Physicians practice guidelines state that "tissue should be obtained by whatever method is easiest to perform" depending on the size and location of the lymph node, the availability of the technology, and expertise in the local facility. 1 EBUS and EUS have gained acceptance as dependable procedures to stage lung cancer with comparable accuracy to surgical methods. 1,[3][4][5] The use of ultrasound facilitates the direct visualization of the lymph node during biopsy and may offer information regarding nodal characteristics of malignant nodes.Purpose: Reliable staging of the mediastinum determines TNM classifi cation and directs therapy for non-small cell lung cancer (NSCLC). Our aim was to evaluate predictors of mediastinal lymph node metastasis in patients undergoing endobronchial ultrasound (EBUS). Methods: Patients with known or suspected lung cancer undergoing EBUS for staging were included. Lymph node radiographic characteristics on chest CT/PET scan and ultrasound characteristics of size, shape, border, echogenicity, and number were correlated with rapid on-site evaluation (ROSE) and fi nal pathology. Logistic regression (estimated with generalized estimating equations to account for correlation across nodes within patients) was used with cancer (vs normal pathology) as the outcome. ORs compare risks across groups, and testing was performed with two-sided a of 0.05. Results: Two hundred twenty-seven distinct lymph nodes (22.5% positive for malignancy) were evaluated in 100 patients. Lymph node size, by CT scan and EBUS measurements, and round and oval shape were predictive of mediastinal metastasis. Increasing size of lymph nodes on EBUS was associated with increasing malignancy risk ( P 5 .0002). When adjusted for CT scan size, hypermetabolic lymph nodes on PET scan did not predict malignancy. Echogenicity and border contour on EBUS and site of biopsy were not signifi cantly associated with cancer. In 94.8% of lymph nodes with a clear diagnosis, the ROSE of the fi rst pass correlated with subsequent passes. Conclusions: Lymph node size on CT scan and EBUS and round or oval shape by EBUS are predictors of malignancy, but no single characteristic can exclude a visualized lymph node from biopsy. Further, increasing the number of samples taken is unlikely to signifi cant...

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: EBUS-FNA samples are adequate for analysis of novel markers and pathways, including EMT, which may predict prognosis, responsiveness to therapy, and provide potential targets for new drug development. As the treatment of lung cancer shifts toward a more personalized approach, EBUS-FNA will likely play a central role in tissue acquisition for diagnosis, staging, and molecular analysis.

Pulmonary veno-occlusive disease (PVOD) is a rare entity that is usually mistaken with pulmonary arterial hypertension (PAH) but is considered class I′ of PAH. It is important to subclassify PVOD and distinguish it from PAH as treatment with vasodilators in PVOD patients is controversial and may be fatal. In this article, we describe a case of PVOD and how we diagnosed it.