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Bristol, United Kingdom

Wijesuriya S.,Southmead Hospital | Chandratreya L.,Southmead Hospital | Medford A.R.,North Bristol Lung Center
Chest | Year: 2013

Chronic pulmonary thromboembolism (CPE) is a challenging diagnosis for clinicians. It is an often-forgotten diagnosis and can be difficult to detect and easily misdiagnosed. The radiologic features on CT pulmonary angiography are subtle and can be further compounded by pathologic mimics and unusual findings observed with disease progression. Diagnosis is important because CPE can lead to progressive pulmonary hypertension, morbidity, and mortality. Moreover, chronic thromboembolic pulmonary hypertension is the only category of pulmonary hypertension with an effective curative treatment in the form of pulmonary endarterectomy. Therefore, CPE must be considered and recognized early. The features of chronic pulmonary emboli on CT scans can be categorized into vascular or parenchymal findings. Endoluminal signs include totally or partially occlusive thrombi and webs and bands. Parenchymal features such as mosaic attenuation and pulmonary infarction are also noted, in addition to features of pulmonary artery hypertension. Additional findings have been noted, including cavitation of infarcts, microbial colonization of cavities, and bronchopleural fistulae. As CPE can be diagnosed at different stages of its disease pathway, such findings may not necessarily arouse suspicion toward a causative diagnosis of chronic embolism. To aid diagnosis for clinicians, this article describes the characteristic vascular and parenchymal CT scan features of chronic emboli, as well as important ancillary findings. We also provide an illustrative case series focusing on CT pulmonary angiography specifically as an imaging modality to highlight the progressive nature of CPE and its sequelae, as well as important radiologic mimics to consider in the differential diagnosis. © 2013 American College of Chest Physicians. Source

Medford A.R.,North Bristol Lung Center
Polskie Archiwum Medycyny Wewnetrznej | Year: 2010

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an advance in bronchoscopy. It is a staging tool for nonsmall cell lung cancer (NSCLC) but also allows diagnosis of unexplained mediastinal lymphadenopathy due to malignant and benign disease. It is a minimally invasive procedure that is used to stage suspected NSCLC with hilar nodes, discrete N2 or N3 disease, or bulky mediastinal disease. After a negative EBUS-TBNA result, if the pretest probability of lung cancer is high, a mediastinoscopy is still recommended, although in the light of recent trial data this is likely to change. EBUS-TBNA is expensive, which may limit its development in resource-rationed health care systems. Conventional (without ultrasound) transbronchial needle aspiration (TBNA) still has a useful role in lung cancer staging, especially where EBUS-TBNA is not available; it can help avoid unnecessary mediastinoscopies. Source

Medford A.R.L.,North Bristol Lung Center
Clinical Medicine, Journal of the Royal College of Physicians of London | Year: 2010

Endobronchial ultrasound has become increasingly used in the UK as a lung cancer staging and diagnostic tool. It has many applications especially in the mediastinal lymph nodes but also the vascular structures as well as the airway wall itself. It is superior to conventional transbronchial needle aspiration in lung cancer staging and diagnosis of mediastinal lymphadenopathy. With time it may well replace mediastinoscopy completely for staging lung cancer. There are, however, training issues and revenue-based tariff systems have been slow to reflect this innovation. Future developments may include routine use in the assessment of central pulmonary vasculature and assessment of airway wall remodelling. © Royal College of Physicians, 2010. All rights reserved. Source

Walters J.,North Bristol Lung Center | Maskell N.A.,University of Bristol
Recent Results in Cancer Research | Year: 2011

The incidence of mesothelioma continues to increase in the Western world and is likely to do so until 2011-2015. It commonly presents with breathlessness secondary to a pleural effusion, and whilst guidelines still advise thoracocentesis as the first line investigation, the sensitivity of this is low and a tissue diagnosis is usually required. Abrams needle biopsy also has a low diagnostic yield and high complication rate and is not recommended in guidelines on the investigation of mesothelioma. Computed tomography-guided biopsy or thoracoscopy both have a comparable sensitivity and low complication rates. Local anaesthetic thoracoscopy is increasingly used by respiratory physicians and has a comparable diagnostic sensitivity to Video-Assisted Thoracoscopic Surgery (VATS) without the need for a general anaesthetic. The requirement for prophylactic radiotherapy after pleural procedures in cases of mesothelioma is contentious, as the results from early trials suggesting it reduces tract seeding have been disputed by more recent trials. © 2011 Springer-Verlag Berlin Heidelberg. Source

Medford A.R.L.,North Bristol Lung Center
International Journal of Clinical Practice | Year: 2010

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal staging tool for lung cancer but also a diagnostic tool for mediastinal lesions near the airway. After a brief historic rationale, this article reviews the indications for EBUS-TBNA, provides an overview of practical, training and financial issues; reviews the evidence comparing the mediastinal staging tools and briefly discusses potential future applications. EBUS-TBNA is most commonly used for staging non-small cell lung cancer (NSCLC), but is also used for diagnosis of unexplained mediastinal lymphadenopathy of other causes. For staging before radical treatment, many centres still perform mediastinoscopy and this should be done to confirm negative EBUS-TBNA results in this setting and when the pre-test clinical probability of lung cancer is high. EBUS-TBNA may be used in the future for staging when the mediastinal nodes are normal according to radiological staging and also in re-staging. EBUS-TBNA can be learned with appropriate training and mentorship; it offers numerous advantages over mediastinoscopy; and it is less invasive and can reduce costs by avoiding unnecessary mediastinoscopies in many cases. © 2010 Blackwell Publishing Ltd. Source

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