佐田 諭己

Abstract Background During endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA), the sonographic findings of B‐mode imaging, as well as endobronchial elastography, can be obtained noninvasively and used for the prediction of nodal metastasis. Methods Patients with lung cancer or suspected lung cancer who underwent EBUS‐TBNA were recorded prospectively and reviewed retrospectively. Both the B‐mode sonographic and elastographic findings were independently evaluated for each lymph node. The sonographic features were classified according to previously published criteria. If oval shape, indistinct margins, homogenous echogenicity, and the absence of coagulation necrosis sign were all observed by B‐mode imaging, then the lymph node was judged to be benign by sonographic imaging. In addition, if the stiffer area comprised more than 31% of the entire lymph node area, then the lymph node was judged to be malignant by elastography. We compared the results of these imaging‐based predictions with the pathological diagnoses. Results The prevalence of nodal metastasis was 78/228 (34.2%). B‐mode sonography predicted 95.8% of benign lymph nodes, and elastography predicted 72.1% of malignant lymph nodes. By combining the two modalities, 59 of 71 (83.1%) lymph nodes judged as malignant by both analyses were pathologically proven to be malignant, and 101 of 105 (96.2%) lymph nodes judged as benign by both analyses were pathologically proven to be benign. Conclusion The combination of elastography and sonographic findings showed good sensitivity and a high negative predictive value, which may facilitate selecting the most suspicious lymph nodes for biopsy. Key points Significant findings of the study. The combination of endobronchial elastography and sonography resulted in a higher diagnostic yield than either modality alone for predicting benign and malignant lymph nodes in patients with lung cancer. What this study adds. The combination of endobronchial elastography and sonography will help clinicians identify the most suspicious lymph nodes for puncturing during EBUS‐TBNA, which may improve the efficiency of EBUS‐TBNA.

肺動脈損傷は肺葉切除の際の重大な合併症の一つであるが、その対処法は各外科医の経験や考え方による。我が国の実態を調査するために日本呼吸器外科学会の評議員719名にアンケートを依頼した。アンケートに回答を頂き集計し得たのは418名(58.1%)であった。肺動脈処理の手技や損傷時の対応について貴重な共有すべき結果が得られた。肺葉切除は、鏡視下が81.8%で行われており、肺動脈処理は、右肺動脈A1+3:自動縫合器93.0%、左肺動脈A3:自動縫合器83.3%、右肺動脈A2b:中枢結紮+エナジーデバイス(もしくは結紮用クリップ)65.6%であった。肺動脈損傷と修復は、90%以上の呼吸器外科医が経験していた。半数が500ml以上の出血時で創の拡大を行っており、約1/4が止血操作の際に補助循環装置の使用経験を有していた。肺葉切除における呼吸器外科医の汎用している手技が今回のアンケート調査で示された。(著者抄録)

Obtaining biopsy specimens for pathologic diagnosis of primary cardiac tumors is challenging because of their anatomic location and the risk of tumor embolization. Due to the difficulty of histologic diagnosis and limited treatment strategies, it is not uncommon for patients to be treated based on radiologic findings alone. However, a firm pathologic diagnosis may permit more appropriate treatment selection, especially for those with primary cardiac lymphoma. Endoscopic ultrasound with bronchoscope-guided fine-needle aspiration is a minimally invasive modality for sampling mediastinal lymph nodes and mediastinal lesions adjacent to the esophagus. In this case report we present 2 patients with cardiac tumors that were successfully and safely diagnosed by endoscopic ultrasound with bronchoscope-guided fine-needle aspiration.

<p>背景．EBUS-TBNA施行後の脳梗塞に対し，遺伝子組み換え組織型プラスミノゲン活性化因子（rt-PA）による血栓溶解療法を施行した症例を経験した．症例．77歳男性．左肺癌に対し左肺上葉切除後1年で，呼吸困難を主訴に入院となった．胸部CT上心囊水の貯留，＃7リンパ節の腫大を認めた．悪性心囊水は認めなかった．＃7リンパ節に対しEBUS-TBNAを施行し，炎症による反応性リンパ節腫大と診断した．EBUS施行後，病棟での経過観察中（EBUS施行後8時間）に左片麻痺が出現し，脳梗塞が疑われた．脳MRIを施行し，急性期脳梗塞に矛盾しない所見を認め，ICU管理のもとで経静脈的にrt-PA投与を行った．rt-PA療法に伴う気道出血などの合併症は認めなかった．左片麻痺は徐々に改善し，EBUS施行後第21病日にリハビリ目的に転院となった．考察．生検後脳梗塞発症症例に対してのrt-PA療法は慎重投与の適応とされる．EBUS-TBNA施行後にrt-PA療法を行った報告はこれまでなく，文献的考察も含めて報告する．</p>

&lt;b&gt;&lt;i&gt;Background:&lt;/i&gt;&lt;/b&gt; Elastography is a relatively new technology that can generate images reflective of tissue stiffness (elasticity). Neoplastic tissue is usually stiffer than normal structures. &lt;b&gt;&lt;i&gt;Objectives:&lt;/i&gt;&lt;/b&gt; The aim of this study was to evaluate the feasibility and utility of elastography when combined with convex-probe endobronchial ultrasound (CP-EBUS) for predicting and localizing metastatic lymph nodes during endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA). &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; Consecutive results of endobronchial elastography of lymph nodes performed using EBUS- TBNA were prospectively collected and retrospectively analyzed. Elastography images were acquired as JPEG images and also recorded as video clips. Stiff area ratios [(stiff areas as blue pixels) / (lymph node areas as region of interest pixels)] for each lymph node determined by elastography were collated with the results of pathological diagnosis. We also performed elastography of surgically resected lymph nodes and compared image findings with pathological sections. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; We evaluated 49 lymph nodes in 21 patients by CP-EBUS. There were 16 metastatic nodes (10 lung cancer metastases and 6 metastases from extrathoracic malignancies). Mean stiff area ratios were significantly greater for metastatic lymph nodes (0.478) than for benign nodes (0.216; p = 0.0002). Using a cutoff value of 0.311 for stiff area ratios, the sensitivity and specificity for predicting metastatic disease were 0.81 and 0.85, respectively. The stiff area was histologically compatible with metastatic distribution in surgically resected lymph nodes. &lt;b&gt;&lt;i&gt;Conclusions:&lt;/i&gt;&lt;/b&gt; Endobronchial elastography is feasible for lymph nodes when combined with CP-EBUS. Stiff area ratios are useful for predicting metastatic lymph nodes, which may be an efficient guide for TBNA.