Letter to the Editor
Diagnostic of Nodular Pulmonary Amyloidosis With Electromagnetical Navigation Bronchoscopy (ENB) and Cryobiopsy
Amiloidosis nodular pulmonar: diagnóstico con Navegación Electromagnética Bronquial (NEB) y criobiopsia
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(B) PET-CT: fibro-interstitial changes in both anterior segments of the upper lobes with intense fluorodeoxyglucose uptake (right SUVmax 7.0 and left SUVmax 6.8) (white arrows). (C) Chest radiography: extensive consolidations in apical segments of both upper lobes. (D) Pathology: extensive tissue calcification, associated with fibrosis and accompanied by chronic inflammatory infiltrate with foreign body-type gigantocellular reaction (black arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mercedes Carrasco Sánchez, Eduardo Solís García, Estefanía Llopis Pastor, Bairon Alfonso Paz Fernández, Mercedes García-Salmones Martín" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Mercedes" "apellidos" => "Carrasco Sánchez" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Solís García" ] 2 => array:2 [ "nombre" => "Estefanía" "apellidos" => "Llopis Pastor" ] 3 => array:2 [ "nombre" => "Bairon Alfonso" "apellidos" => "Paz Fernández" ] 4 => array:2 [ "nombre" => "Mercedes" "apellidos" => "García-Salmones Martín" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2659663624000043?idApp=UINPBA00004N" "url" => "/26596636/0000000600000001/v2_202406270528/S2659663624000043/v2_202406270528/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Diagnostic of Nodular Pulmonary Amyloidosis With Electromagnetical Navigation Bronchoscopy (ENB) and Cryobiopsy" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor</span>," "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Virginia Pajares, Albert Rafecas-Codern, Pere Serra-Mitjà, Irma Campazas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Virginia" "apellidos" => "Pajares" "email" => array:1 [ 0 => "vpajares@santpau.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Albert" "apellidos" => "Rafecas-Codern" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Pere" "apellidos" => "Serra-Mitjà" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Irma" "apellidos" => "Campazas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Respiratory Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pathology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Amiloidosis nodular pulmonar: diagnóstico con Navegación Electromagnética Bronquial (NEB) y criobiopsia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 1874 "Tamanyo" => 337515 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) PET/TC detecting hypermetabolic lung nodule in the lateral subsegment of the middle lobe (1.9<span class="elsevierStyleHsp" style=""></span>mm, SUVmax 4.36). (b) Lung nodule located with Electromagnetic Navigation Bronchoscopy (ENB). (c) Hematoxylin–eosin stain: Transbronchial crybiopsy showing alveolated lung parenchyma with nodular deposits of pink amorphous material, predominantly in vascular walls. (d) Congo red stain (20×) under polarized light. The amorphous material shows apple green birefringence.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read with interest the Clinical Image recently published by Cuenca S. et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> in the Open Respiratory Archives.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the same way of the authors, we agree that the lung amyloidosis involvement is relatively uncommon. Amyloidosis is a heterogeneous group of diseases characterized by the deposition of amyloid fibrils in the extracellular matrix of tissues and organs.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Pulmonary amyloidosis is frequently characterized by the AL amyloid subtype and can be located or associated with systemic involvement, presenting in a nodular, diffuse interstitial, or tracheobronchial pattern.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Nodular pulmonary amyloidosis (nodular amyloidoma) can appear incidentally in a chest radiologic diagnosis, it is often asymptomatic and also does not usually require surgical resection. The main differential diagnosis is lung cancer and the specific histological diagnosis must be established. Histologically, amyloidoma nodules are normally well circumscribed and are composed of homogenous eosinophilic material with aggregates of lymphocytes and plasma cells within or adjacent to the nodules.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cuenca S. et al., <a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> present a case of an ex-smoker patient with prostate cancer. The complementary study with Positron Emission Tomography–computed (PET/CT) showed a lung hypermetabolic nodule in the left upper lobe and mediastinal lymph nodes. Bronchoscopy and EBUS were performed without a conclusive result and the final diagnosis was established with surgical biopsy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We present a case with a nodular pulmonary amyloidosis diagnosed by cryobiopsy with Electromagnetical Navigation Bronchoscopy (ENB).</p><p id="par0025" class="elsevierStylePara elsevierViewall">A 74-year-old woman, ex-smoker with mild and limited haemoptysis was referred to our Interventional Pulmonologist Unit to study the peripheral pulmonary nodule observed in a thoracic computed tomography (CT) scan. Lung cancer was suspected and complementary explorations were indicated. Pulmonary function tests demonstrated a diffusion capacity for carbon monoxide (DLCO) 50% of the predicted. PET/CT revealed a 1.9<span class="elsevierStyleHsp" style=""></span>mm nodule (SUVmax 4.36) in the lateral subsegment of the middle lobe without mediastinal involvement and no lesions in other organs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). The patient was discussed in the Tumor Board and it was decided that the first diagnostic approach would be with ENB to minimize the risk of pneumothorax. ENB was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b) and transbronchial needle aspiration (TBNA) and biopsies were obtained with 1.1<span class="elsevierStyleHsp" style=""></span>mm flexible cryoprobe. Rapid On Site Examination (ROSE) observed inflammatory cells in fine needle aspiration (FNA) samples. Final histological examination of the cryobiopsies revealed homogenous eosinophilic amorphous material (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c) with red-green birefringence under cross-polarized light with Congo red staining (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d) and the diagnosis of amyloidosis was established. The echocardiogram, serum plasma cell profile and protein electrophoresis were normal and the absence of systemic amyloidosis was confirmed. The patient was diagnosed with localized AL amyloid and remains asymptomatic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnostic of lung peripheral nodules without endobronchial involvement is a challenge. The screening in lung cancer strategies and the access of population to advance CT scan have increased the number of patients with lung peripheral nodules. The diagnostic yield using virtual bronchoscopy (VB), radial endobronchial ultrasound (r-EBUS), and ultrathin bronchoscopes remains suboptimal.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Transthoracic needle aspiration (TTNA) is a technique with good diagnostic yield but with high incidence of pneumothorax. In the last decade, Electromagnetic Navigation Bronchoscopy (ENB) has become in minimally invasive technique with optimal diagnostic yield to perform biopsies with vision in real time.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conlusion, the use of the novel ENB with different tools is a minimally invasive method that allows to improve the diagnosis strategies of peripheral lung nodules and avoid or plan the surgical approach.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">Informed consent was obtained from the patient for publication of the clinical data and images present in this manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">No external funding has been needed for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors’ contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Virginia Pajares, Albert Rafecas-Codern and Pere Serra-Mitjà have collected the clinical information and they have wroten the manuscript. Irma Campazas has performed pathological diagnosis and has described pathological findings.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest directly or indirectly related to the contents of the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Informed consent" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors’ contributions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 1874 "Tamanyo" => 337515 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) PET/TC detecting hypermetabolic lung nodule in the lateral subsegment of the middle lobe (1.9<span class="elsevierStyleHsp" style=""></span>mm, SUVmax 4.36). (b) Lung nodule located with Electromagnetic Navigation Bronchoscopy (ENB). (c) Hematoxylin–eosin stain: Transbronchial crybiopsy showing alveolated lung parenchyma with nodular deposits of pink amorphous material, predominantly in vascular walls. (d) Congo red stain (20×) under polarized light. The amorphous material shows apple green birefringence.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nodular pulmonary amyloidosis: a rare clinical entity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Cuenca Peris" 1 => "A. Flor Pérez" 2 => "C. López Valdivia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.opresp.2023.100243" "Revista" => array:5 [ "tituloSerie" => "Open Respir Arch" "fecha" => "2023" "volumen" => "5" "paginaInicial" => "100243" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/37496879" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Amyloidosis of the lung" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Khoor" 1 => "T.V. Colby" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5858/arpa.2016-0102-RA" "Revista" => array:6 [ "tituloSerie" => "Arch Pathol Lab Med" "fecha" => "2017" "volumen" => "141" "paginaInicial" => "247" "paginaFinal" => "254" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28134587" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary AL amyloidosis: a review and update on treatment options" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.N. Moy" 1 => "M. Mirza" 2 => "B. Moskal" 3 => "N. Asado" 4 => "B. Shah" 5 => "J. Bitran" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Ann Med Surg" "fecha" => "2022" "volumen" => "80" "paginaInicial" => "104060" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.S. Wang Memoli" 1 => "P.J. Nietert" 2 => "G.A. Silvestri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-1764" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "142" "paginaInicial" => "385" "paginaFinal" => "393" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21980059" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic yield and safety of navigation bronchoscopy: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.E.P. Kops" 1 => "P. Heus" 2 => "D.A. Korevaar" 3 => "J.A.A. Damen" 4 => "D.L. Idema" 5 => "R.L.J. Verhoeven" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.lungcan.2023.107196" "Revista" => array:5 [ "tituloSerie" => "Lung Cancer" "fecha" => "2023" "volumen" => "180" "paginaInicial" => "107196" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/37130440" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/26596636/0000000600000001/v2_202406270528/S265966362300070X/v2_202406270528/en/main.assets" "Apartado" => array:4 [ "identificador" => "92947" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/26596636/0000000600000001/v2_202406270528/S265966362300070X/v2_202406270528/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S265966362300070X?idApp=UINPBA00004N" ]
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